Vocal Cord Dysfunction Workup

  • Author: Praveen Buddiga, MD; Chief Editor: Michael A Kaliner, MD   more...
 
Updated: Feb 7, 2011
 

Laboratory Studies

Laboratory studies may be indicated to exclude other diagnoses.

Eosinophil count

Eosinophilia may suggest the diagnosis of asthma if levels are greater than 5%, but absence of this sign does not clearly exclude the diagnosis, especially if the patient has been frequently treated with oral corticosteroids.

Elevated eosinophil counts may also be observed in skin diseases such as atopic dermatitis and in clinical entities such as pulmonary infiltrates with eosinophilia, allergic bronchopulmonary aspergillosis (ABPA), Churg-Strauss syndrome, and parasitic diseases.

Vocal cord dysfunction (VCD), itself, is not associated with an elevated blood eosinophil count.

Serum immunoglobulin E (IgE) assay

Elevated serum IgE is observed in allergic individuals, but it is not specific for asthma.

This elevation may be observed in other syndromes such as ABPA and Churg-Strauss syndrome. Its presence may indicate a concomitant diagnosis of asthma even though its absence is not exclusionary.

VCD by itself is not associated with an elevated serum IgE level.

Arterial blood gases (ABG)

ABG findings reveal an alveolar-arterial gradient (ie, the alveolar-arterial oxygen difference), which is a measure of oxygen delivery from the lungs to blood, that is usually within reference ranges in the subset of patients with VCD.

In patients with acute asthma, ABG findings may be abnormal, indicative of hypoxemia.

C1 inhibitor and C4 levels

These levels should be evaluated to exclude hereditary angioedema.

This is especially useful if episodes have been prolonged (1-4 d) or if angioedema in other areas or unexplained abdominal pain has occurred in or out of association with episodes of dyspnea.

Next

Imaging Studies

Chest radiography

Radiographic findings are usually normal, or radiographs may show hyperinflation in asthmatic individuals.

Chest radiography may be used to evaluate other pulmonary diseases or structural laryngeal and cardiac abnormalities that may explain or support the patient's respiratory symptoms.

Previous
Next

Other Tests

Pulmonary function test

Spirometric testing supports the diagnosis of VCD in symptomatic individuals.[21] This study is used to identify individuals with asthma or other pulmonary abnormalities, including upper airway obstruction. In patients without coexisting asthma, spirometric findings are usually within the reference range during an episode.[10] If flows are decreased during an episode, forced vital capacity (FVC) decreases in tandem with forced expiratory volume in the first second (FEV1), which is not consistent with classic airflow limitation.

Flow-volume loops are the most useful tool in discriminating between VCD and asthma. Flow-volume loops typically demonstrate inspiratory loop flattening, ie, an inspiratory flow decrease during symptomatic periods suggestive of VCD. In addition, during VCD symptoms, an abrupt drop and rise in the expiratory flow volume loop may be observed in the absence of coughing.

Flow volume loops. Flow volume loops.

Results of routine measurement of airflow obstruction (ie, FEV1, peak expiratory flow rate) can be within reference ranges in VCD if the vocal cords close only on inspiration. If vocal cord closure occurs during both inspiration and expiration, FEV1 can decrease along with the decrease in FVC, making the FEV1/FVC ratio within the reference range. This distinguishes isolated VCD from VCD concomitant with asthma, in which the FEV1 is proportionately decreased more than the FVC, representing airflow limitation.

Methacholine provocation

A patient with VCD shows no bronchial hyperresponsiveness on methacholine challenge unless he or she has concomitant asthma.

This challenge is therefore most helpful in excluding the diagnosis of asthma. It may also be helpful in confirming that a patient with VCD has coexisting asthma.

Exercise provocation

In a patient in whom exercise or strenuous activity is a primary trigger, a graded exercise challenge on a bicycle ergometer or treadmill is helpful to establish a diagnosis.

Allergy skin testing

Perform skin tests to determine the existence of an allergic or environmental trigger or condition (eg, allergic rhinitis, allergic asthma).

Previous
Next

Procedures

Laryngoscopy

The criterion standard for the diagnosis of VCD is direct visualization of the paradoxical adduction of the true vocal cords during inspiration.[2, 22, 21]

The classic textbook picture is the adduction of the anterior two thirds of the vocal cords with a posterior diamond-shaped chink through which air flows during the inspiratory phase.

Laryngoscopic views of the vocal cords. Laryngoscopic views of the vocal cords.

If the patient is not symptomatic at the time of laryngoscopy or rhinoscopy, typical vocal cord changes may often be induced by exercise, hyperventilation, or a maximal forced expiratory effort followed by rapid inspiration. These maneuvers may increase the sensitivity of the test.[23, 24, 25]

Previous
Proceed to Treatment & Management
 
 
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 and American College of Allergy, Asthma and Immunology

Disclosure: Glaxo Smith Kline Honoraria Speaking and teaching; Meda Honoraria Speaking and teaching; Teva Honoraria Speaking and teaching

Specialty Editor Board

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: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

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 Management position

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St 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: Alcon Consulting fee Consulting; Greer Consulting fee Consulting; Sanofi Consulting fee Consulting; Schering/Merck Consulting fee Consulting; Teva Consulting fee Consulting; Meda Honoraria Speaking and teaching; Ista Consulting

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. Christopher KL, Morris MJ. Vocal cord dysfunction, paradoxic vocal fold motion, or laryngomalacia? Our understanding requires an interdisciplinary approach. Otolaryngol Clin North Am. Feb 2010;43(1):43-66, viii. [Medline].

  14. 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].

  15. 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].

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

  17. 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].

  18. 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].

  19. Morris MJ, Christopher KL. Diagnostic criteria for the classification of vocal cord dysfunction. Chest. Nov 2010;138(5):1213-23. [Medline].

  20. Bittleman DB, Smith RJ, Weiler JM. Abnormal movement of the arytenoid region during exercise presenting as exercise-induced asthma in an adolescent athlete. Chest. Aug 1994;106(2):615-6. [Medline].

  21. 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].

  22. 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].

  23. 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].

  24. Deckert J, Deckert L. Vocal cord dysfunction. Am Fam Physician. Jan 15 2010;81(2):156-9. [Medline].

  25. Doshi DR, Weinberger MM. Long-term outcome of vocal cord dysfunction. Ann Allergy Asthma Immunol. Jun 2006;96(6):794-9. [Medline].

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

  27. 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].

  28. 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].

  29. 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].

  30. 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].

  31. 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].

  32. Parsons JP, Benninger C, Hawley MP, Philips G, Forrest LA, Mastronarde JG. Vocal cord dysfunction: beyond severe asthma. Respir Med. Apr 2010;104(4):504-9. [Medline].

  33. 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].

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

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

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

  37. 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.

  38. 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].

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

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

  41. 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].

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

  43. 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].

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

  45. 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].

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

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

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

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

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

  51. 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].

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

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

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

  55. 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].

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

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

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

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

 
Previous
Next
 
Flow volume loops.
Laryngoscopic views of the vocal cords.
Vocal cord dysfunction treatment plan.
Relaxed throat breathing exercises.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
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.