eMedicine Specialties > Allergy and Immunology > Asthma

Vocal Cord Dysfunction

Author: Praveen Buddiga, MD,, Physician, Allergy, Asthma and Immunology, Baz Allergy, Asthma and Sinus Center, Fresno, California
Contributor Information and Disclosures

Updated: Jul 10, 2009

Introduction

Background

Vocal cord dysfunction (VCD), also commonly known as paradoxical vocal fold motion, can be characterized as an abnormal adduction of the vocal cords during the respiratory cycle (especially during the inspiratory phase) that produces airflow obstruction at the level of the larynx.1,2,3

VCD frequently mimics persistent asthma and is often treated with high-dose inhaled or systemic corticosteroids, bronchodilators, multiple emergency department visits, hospitalizations, and, in some cases, tracheostomies and intubation.2,4,5,6

The patients considered here have problems associated with abnormal vocal cord movement without an organic basis. Flow-volume loops obtained during symptomatic periods of wheezing show a limitation of inspiratory flow suggestive of variable extrathoracic obstruction (inspiratory loop flattening). Paradoxical vocal cord motion can be confirmed on laryngoscopy performed when patients are symptomatic.

The clinical history provides limited opportunity to distinguish between patients with VCD and patients with asthma because both groups present with symptoms of wheezing, cough, and dyspnea.7,8 The localization of airflow obstruction to the laryngeal area is an important clinical discriminatory feature in patients with VCD.

Another clinical clue may be that patients with VCD often seem to have refractory asthma with poor response to beta-agonists or inhaled corticosteroids.9,10 They do not usually report nocturnal awakening due to breathlessness.

Objectively, the data reveal absence of hypoxemia in this subset as compared to compromised persons with asthma.10

The hallmark of diagnosis is noted on direct rhinolaryngoscopy; a glottic chink is present along the posterior portion of the vocal cords, while the anterior portion of the vocal cords is adducted.

Pathophysiology

During the normal respiratory cycle, the vocal cords partially abduct with inhalation and partially adduct with end-exhalation. This phasic vocal cord movement is physiologic, and it allows the unimpeded movement of air inward to the lungs and outward to the atmosphere while maintaining the alveolar patency of the lungs by providing positive airway pressure during expiration (ie, positive end-expiratory pressure [PEEP]).

The larynx, therefore, serves as an upper airway valve to help keep the lungs expanded. For this function, the larynx is richly innervated, and its size is regulated by the activation of striated muscles that are under voluntary and reflexive control. Both laryngeal and respiratory motor neurons influence glottic size, and they, in turn, may be influenced by vagal reflex activity arising from pulmonary and laryngeal receptors.

The mechanisms that cause glottic chink narrowing or intermittent closing during inspiration independent of any changes in lower airway caliber are unknown. In affected patients, the integrated function of the vocal cords ceases episodically, leading to acute intermittent episodes of functional airway obstruction. The clinical signs and symptoms resemble those observed in disorders such as vocal cord paralysis, asthma, epiglottitis, laryngospasm, and angioedema secondary to anaphylaxis.

Recent case reports have described other causes of VCD, such as an inlet patch of heterotopic gastric mucosa in the upper esophagus11 and exposure to agents such as glutaraldehyde and chlorine inhalation by swimmers or divers.

VCD appears to be part of the spectrum of airway disorders caused by occupational exposures, including irritant exposures and psychological stressors, at the World Trade Center disaster. A recent study evaluating the role of formal psychological testing in patients with paradoxical vocal cord dysfunction found a pattern consistent with conversion disorder in some patients; however, a subset of patients did not appear to be associated with psychopathology.12

To summarize, the exact cause of this condition is not clearly evident.10 A hypothesis is that mediation of the vagus nerve may alter the laryngeal tone and lower the threshold for stimuli to produce vocal cord spasm or to precipitate the abnormal adduction of vocal cords. Recent literature suggests a greater emphasis on organic causes such as gastroesophageal reflux and laryngopharyngeal reflux since the laryngopharynx is highly sensitive to gastric acid irritation.

Frequency

United States

This condition is observed in up to 10% of patients at referral centers seeking evaluation of asthma that is unresponsive to aggressive therapy. The literature reveals a high incidence of VCD in persons with psychiatric conditions (eg, depression, obsessive-compulsive disorder, borderline personality disorder, neuroses induced by childhood sexual abuse),1,13 persons with an increased body mass index6 and medical personnel. VCD may complicate true asthma in a small number of patients.

Mortality/Morbidity

Mortality rates are unknown, but morbidity is often significant from years of corticosteroid use, resulting in iatrogenic Cushing-like syndrome, bone density loss, and growth suppression in the pediatric population.10

Sex

This condition is predominantly observed in females.12 The authors' review of the published literature indicates a female-to-male ratio of approximately 3:1.

Age

This condition predominates in people aged 20-40 years, but it can occur in people aged 6-83 years. Recent literature suggests an increase of this condition in children and adolescents.

Clinical

History

  • Wheezing
  • Cough
  • A feeling of tightness in the throat
  • Hoarseness and voice change
  • Stridor
  • Shortness of breath
  • Dyspnea on exertion
  • Inspiratory difficulty
  • Sudden episodes of shortness of breath
  • Unresponsiveness to bronchodilators and corticosteroids

Physical

  • Laryngeal auscultation may reveal harsh stridulous sounds during symptoms.
  • Wheezing may be heard in the chest (transmitted from the upper airway).

Causes

Problems associated with vocal cord dysfunction (VCD) include the following:

  • Gastroesophageal reflux disease, laryngopharyngeal reflux
  • Upper airway inflammation due to allergies (rhinitis), sinusitis, or recurrent viral infections
  • Strenuous exercise14,15,16
  • Occupational or other exposure to irritant fumes17,9,3
  • Environmental allergens and/or pollutants
  • Psychogenic causes (eg, severe emotional stress)

More on Vocal Cord Dysfunction

Overview: Vocal Cord Dysfunction
Differential Diagnoses & Workup: Vocal Cord Dysfunction
Treatment & Medication: Vocal Cord Dysfunction
Follow-up: Vocal Cord Dysfunction
Multimedia: Vocal Cord Dysfunction
References
[ CLOSE WINDOW ]

References

  1. Anbar RD, Hehir DA. Hypnosis as a diagnostic modality for vocal cord dysfunction. Pediatrics. Dec 2000;106(6):E81. [Medline].

  2. Bahrainwala AH, Simon MR. Wheezing and vocal cord dysfunction mimicking asthma. Curr Opin Pulm Med. Jan 2001;7(1):8-13. [Medline].

  3. Huggins JT, Kaplan A, Martin-Harris B, Sahn SA. Eucalyptus as a specific irritant causing vocal cord dysfunction. Ann Allergy Asthma Immunol. Sep 2004;93(3):299-303. [Medline].

  4. Byrd RP Jr, Krishnaswamy G, Roy TM. Difficult-to-manage asthma. How to pinpoint the exacerbating factors. Postgrad Med. Nov 2000;108(6):37-40, 45-6, 49-50 passim. [Medline].

  5. Hayes JP, Nolan MT, Brennan N, FitzGerald MX. Three cases of paradoxical vocal cord adduction followed up over a 10- year period. Chest. Sep 1993;104(3):678-80. [Medline].

  6. Vlahakis NE, Patel AM, Maragos NE, Beck KC. Diagnosis of vocal cord dysfunction: the utility of spirometry and plethysmography. Chest. Dec 2002;122(6):2246-9. [Medline].

  7. Christopher KL, Wood RP 2nd, Eckert RC, et al. Vocal-cord dysfunction presenting as asthma. N Engl J Med. Jun 30 1983;308(26):1566-70. [Medline].

  8. Hicks M, Brugman SM, Katial R. Vocal cord dysfunction/paradoxical vocal fold motion. Prim Care. Mar 2008;35(1):81-103, vii. [Medline].

  9. Galdi E, Perfetti L, Pagella F, et al. Irritant vocal cord dysfunction at first misdiagnosed as reactive airway dysfunction syndrome. Scand J Work Environ Health. Jun 2005;31(3):224-6. [Medline].

  10. Goldman J, Muers M. Vocal cord dysfunction and wheezing. Thorax. Jun 1991;46(6):401-4. [Medline].

  11. Silvers WS, Levine JS, Poole JA, et al. Inlet patch of gastric mucosa in upper esophagus causing chronic cough and vocal cord dysfunction. Ann Allergy Asthma Immunol. Jan 2006;96(1):112-5. [Medline].

  12. Husein OF, Husein TN, Gardner R, et al. Formal psychological testing in patients with paradoxical vocal fold dysfunction. Laryngoscope. Apr 2008;118(4):740-7. [Medline].

  13. Freedman MR, Rosenberg SJ, Schmaling KB. Childhood sexual abuse in patients with paradoxical vocal cord dysfunction. J Nerv Ment Dis. May 1991;179(5):295-8. [Medline].

  14. McFadden ER Jr, Zawadski DK. Vocal cord dysfunction masquerading as exercise-induced asthma. a physiologic cause for "choking" during athletic activities. Am J Respir Crit Care Med. Mar 1996;153(3):942-7. [Medline].

  15. Morris MJ, Deal LE, Bean DR, et al. Vocal cord dysfunction in patients with exertional dyspnea. Chest. Dec 1999;116(6):1676-82. [Medline].

  16. Wilson JJ, Theis SM, Wilson EM. Evaluation and management of vocal cord dysfunction in the athlete. Curr Sports Med Rep. Mar-Apr 2009;8(2):65-70. [Medline].

  17. Allan PF, Abouchahine S, Harvis L, Morris MJ. Progressive vocal cord dysfunction subsequent to a chlorine gas exposure. J Voice. Jun 2006;20(2):291-6. [Medline].

  18. Watson MA, King CS, Holley AB, Greenburg DL, Mikita JA. Clinical and lung-function variables associated with vocal cord dysfunction. Respir Care. Apr 2009;54(4):467-73. [Medline].

  19. Chiang WC, Goh A, Ho L, Tang JP, Chay OM. Paradoxical vocal cord dysfunction: when a wheeze is not asthma. Singapore Med J. Apr 2008;49(4):e110-2. [Medline].

  20. Kass JE, Castriotta RJ. Heliox therapy in acute severe asthma. Chest. Mar 1995;107(3):757-60. [Medline].

  21. Manthous CA, Hall JB, Caputo MA, et al. Heliox improves pulsus paradoxus and peak expiratory flow in nonintubated patients with severe asthma. Am J Respir Crit Care Med. Feb 1995;151(2 Pt 1):310-4. [Medline].

  22. Grillone GA, Blitzer A, Brin MF, et al. Treatment of adductor laryngeal breathing dystonia with botulinum toxin type A. Laryngoscope. Jan 1994;104(1 Pt 1):30-2. [Medline].

  23. Maillard I, Schweizer V, Broccard A, et al. Use of botulinum toxin type A to avoid tracheal intubation or tracheostomy in severe paradoxical vocal cord movement. Chest. Sep 2000;118(3):874-7. [Medline].

  24. Dworkin JP, Meleca RJ, Simpson ML, Garfield I. Use of topical lidocaine in the treatment of muscle tension dysphonia. J Voice. Dec 2000;14(4):567-74. [Medline].

  25. Bahrainwala AH, Simon MR, Harrison DD, et al. Atypical expiratory flow volume curve in an asthmatic patient with vocal cord dysfunction. Ann Allergy Asthma Immunol. Apr 2001;86(4):439-43. [Medline].

  26. Brancatisano T, Collett PW, Engel LA. Respiratory movements of the vocal cords. J Appl Physiol. May 1983;54(5):1269-76. [Medline].

  27. Diamond E, Kane C, Dugan G. Presentation and Evaluation of Vocal Cord Dysfunction. Chest. 2000;118(Suppl 4):199S.

  28. Higgins JC. The 'crashing asthmatic.'. Am Fam Physician. Mar 1 2003;67(5):997-1004. [Medline].

  29. Jain S, Bandi V, Zimmerman J, et al. Incidence of Vocal Cord Dysfunction in Patients Presenting to Emergency Room with Acute Asthma Exacerbation. Chest. 1999;116(Suppl 4):243S.

  30. Landwehr LP, Wood RP 2nd, Blager FB, Milgrom H. Vocal cord dysfunction mimicking exercise-induced bronchospasm in adolescents. Pediatrics. Nov 1996;98(5):971-4. [Medline].

  31. Link HW, Stillwell PC, Jensen VK, Laskowski DM. Vocal Cord Dysfunction in the Pediatric Age Group. Chest. 1998;114(Suppl 4):255S-256S.

  32. Martin R, Blager F, Gay M, et al. Paradoxical vocal cord motion in presumed asthmatics. Semin Respir Med. 1987;8:332-337.

  33. Maschka DA, Bauman NM, McCray PB Jr, et al. A classification scheme for paradoxical vocal cord motion. Laryngoscope. Nov 1997;107(11 Pt 1):1429-35. [Medline].

  34. McFadden ER Jr. Glottic function and dysfunction. J Allergy Clin Immunol. May 1987;79(5):707-10. [Medline].

  35. Murray DM, Lawler PG. All that wheezes is not asthma. Paradoxical vocal cord movement presenting as severe acute asthma requiring ventilatory support. Anaesthesia. Oct 1998;53(10):1006-11. [Medline].

  36. Newman KB, Dubester SN. Vocal Cord Dysfunction: Masquerader of Asthma. Semin Resp Crit Care Med. 1994;15:161-167.

  37. Newman KB, Mason UG 3rd, Schmaling KB. Clinical features of vocal cord dysfunction. Am J Respir Crit Care Med. Oct 1995;152(4 Pt 1):1382-6. [Medline].

  38. O'Connell MA, Sklarew PR, Goodman DL. Spectrum of presentation of paradoxical vocal cord motion in ambulatory patients. Ann Allergy Asthma Immunol. Apr 1995;74(4):341-4. [Medline].

  39. O'Hollaren MT. Masqueraders in clinical allergy: laryngeal dysfunction causing dyspnea. Ann Allergy. Nov 1990;65(5):351-6. [Medline].

  40. Paparella MM, Shumrick D, Gluckman J, Meyerhoff W. Otolaryngology: Head & Neck. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1991.

  41. Parker JM, Mooney LD, Berg BW. Exercise Tidal Loops in Patients with Vocal Cord Dysfunction. Chest. 1998;114(Suppl 4):256S.

  42. Patterson DL, O'Connell EJ. Vocal Cord Dysfunction: What have we learned in 150 years?. Insights in Allergy. 1994;9(6):1-12.

  43. Perkner JJ, Fennelly KP, Balkissoon R, et al. Irritant-associated vocal cord dysfunction. J Occup Environ Med. Feb 1998;40(2):136-43. [Medline].

  44. Powell DM, Karanfilov BI, Beechler KB, et al. Paradoxical vocal cord dysfunction in juveniles. Arch Otolaryngol Head Neck Surg. Jan 2000;126(1):29-34. [Medline].

  45. Reisner C, Nelson HS. Vocal cord dysfunction with nocturnal awakening. J Allergy Clin Immunol. Jun 1997;99(6 Pt 1):843-6. [Medline].

  46. Sandage MJ, Zelazny SK. Paradoxical vocal fold motion in children and adolescents. Lang Speech Hear Serv Sch. Oct 2004;35(4):353-62. [Medline].

  47. Schachter AJ. Vocal cord dysfunction may be functional. Chest. Jul 1998;114(1):351. [Medline].

  48. Selner JC, Staudenmayer H, Koepke JW, et al. Vocal cord dysfunction: the importance of psychologic factors and provocation challenge testing. J Allergy Clin Immunol. May 1987;79(5):726-33. [Medline].

  49. Sokol W. Vocal cord dysfunction presenting as asthma. West J Med. Jun 1993;158(6):614-5. [Medline].

  50. Soli CG, Smally AJ. Vocal cord dysfunction: an uncommon cause of stridor. J Emerg Med. Jan 2005;28(1):31-3. [Medline].

  51. Weir M, Ehl L. Vocal cord dysfunction mimicking exercise-induced bronchospasm in adolescents. Pediatrics. Jun 1997;99(6):923-4. [Medline].

  52. Wood RP 2nd, Milgrom H. Vocal cord dysfunction. J Allergy Clin Immunol. Sep 1996;98(3):481-5. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

vocal cord dysfunction, VCD, paradoxical vocal cord motion, laryngeal dyskinesia, abnormal adduction of the vocal cords during the respiratory cycle, airflow obstruction, variable extrathoracic obstruction, inspiratory loop flattening, depression, obsessive-compulsive disorder, borderline personality disorder, neuroses induced by childhood sexual abuse, asthma

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Praveen Buddiga, MD,, Physician, Allergy, Asthma and Immunology, Baz Allergy, Asthma and Sinus Center, Fresno, California
Praveen Buddiga, MD, is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, and American Medical Association
Disclosure: Glaxo Smith Kline  Honoraria Speaking and teaching

Medical Editor

Stephen Rosenfeld, MD, Professor Emeritus, Department of Medicine, Allergy, Immunology and Rheumatology Unit, University of Rochester School of Medicine and Dentistry
Stephen Rosenfeld, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American Federation for Clinical Research, Clinical Immunology Society, and Medical Society of the State of New York
Disclosure: Elan Ownership interest None; Invitrogen Ownership interest None; Merck Ownership interest None; Pfizer Ownership interest None; Medco Health Ownership interest None; Millipore Ownership interest None

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael R Simon, MD, MA, Clinical Professor Emeritus, Departments of Internal Medicine and Pediatrics, Wayne State University School of Medicine; Adjunct Staff, Division of Allergy and Immunology, Department of Internal Medicine, William Beaumont Hospital
Michael R Simon, MD, MA is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Physicians, American Federation for Medical Research, Michigan Allergy and Asthma Society, Michigan State Medical Society, Royal College of Physicians and Surgeons of Canada, and Society for Experimental Biology and Medicine
Disclosure: Secretory IgA, Inc. Ownership interest Board membership

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael A Kaliner, MD, Clinical Professor of Medicine, George Washington University School of Medicine; Chief, Section of Allergy and Immunology, Washington Hospital Center; Medical Director, Institute for Asthma and Allergy
Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, and Association of American Physicians
Disclosure: Abbott Consulting fee Consulting; Alcon Consulting fee Consulting; Glaxo Consulting fee Consulting; Greer Consulting fee Consulting; Sanofi Consulting fee Consulting; Schering Consulting fee Consulting; Teva  Consulting; Meda Honoraria Speaking and teaching

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.