Diagnostic Considerations

Laryngomalacia, vocal cord paresis, and CNS causes must be differentiated from vocal cord dysfunction (VCD).^[27]Additionally, VCD is often misdiagnosed as asthma.

Antenatal prolapse must also be considered.^[28]

Table 1. Differential diagnosis of laryngeal movement disorders^{[29, 30, 31]} (Open Table in a new window)

VCD
Psychogenic	Somatoform disorder, conversion disorder, abuse, anxiety disorder, depression, Munchausen syndrome, malingering
Exercise	Exercise
Irritant	Extrinsic (chemical irritants, olfactory stimuli) Intrinsic (GERD, laryngopharyngeal reflux rhinits/post nasal drip, sinusitis)
Laryngospasm	Intubation, airway manipulation, IgE mediated, nocturnal aspiration
Vocal Cord Paresis/Paralysis	Prolonged intubation, recurrent laryngeal or vagus nerve damage during chest or thyroid surgery, idiopathic
Infectious	Epiglottis, bronchiolitis, laryngotracheobronchitis (croup), laryngitis, pharyngeal abscess, diphtheria, pertussis, laryngeal papillomatosis
Neoplastic	Head and neck malignancy, cystic hygroma, hemangioma, rhabdomyosarcoma, teratoma, lymphoma, papilloma
Endocrine	Thyroid goiter

Differential Diagnoses

Allergic and Environmental Asthma
Anaphylaxis
Asthma
Bilateral Vocal Fold Paralysis
Epiglottitis
Exercise-Induced Asthma
Foreign body obstruction
Laryngeal abnormalities (eg, neoplasm, polyps, cyst)
Laryngeal edema from C1INH deficiency or ACE inhibitor use
Laryngeal spasm
Unilateral Vocal Fold Paralysis
Upper Respiratory Tract Infection
Vocal Polyps and Nodules

Workup

Anbar RD, Hehir DA. Hypnosis as a diagnostic modality for vocal cord dysfunction. Pediatrics. 2000 Dec. 106(6):E81. [QxMD MEDLINE Link].
Bahrainwala AH, Simon MR. Wheezing and vocal cord dysfunction mimicking asthma. Curr Opin Pulm Med. 2001 Jan. 7(1):8-13. [QxMD MEDLINE Link].
Huggins JT, Kaplan A, Martin-Harris B, Sahn SA. Eucalyptus as a specific irritant causing vocal cord dysfunction. Ann Allergy Asthma Immunol. 2004 Sep. 93(3):299-303. [QxMD MEDLINE Link].
Malaty J, Wu V. Vocal Cord Dysfunction: Rapid Evidence Review. Am Fam Physician. 2021 Nov 1. 104 (5):471-475. [QxMD MEDLINE Link].
Watson MA, King CS, Holley AB, Greenburg DL, Mikita JA. Clinical and lung-function variables associated with vocal cord dysfunction. Respir Care. 2009 Apr. 54(4):467-73. [QxMD MEDLINE Link].
Christopher KL, Wood RP 2nd, Eckert RC, et al. Vocal-cord dysfunction presenting as asthma. N Engl J Med. 1983 Jun 30. 308(26):1566-70. [QxMD MEDLINE Link].
Goldman J, Muers M. Vocal cord dysfunction and wheezing. Thorax. 1991 Jun. 46(6):401-4. [QxMD MEDLINE Link].
Bucca C, Rolla G, Brussino L, De Rose V, Bugiani M. Are asthma-like symptoms due to bronchial or extrathoracic airway dysfunction?. Lancet. 1995 Sep 23. 346 (8978):791-5. [QxMD MEDLINE Link].
Truong A, Truong DT. Vocal Cord Dysfunction: An Updated Review. Otolaryngol. December 08, 2011. S1:002:
Byrd RP Jr, Krishnaswamy G, Roy TM. Difficult-to-manage asthma. How to pinpoint the exacerbating factors. Postgrad Med. 2000 Nov. 108(6):37-40, 45-6, 49-50 passim. [QxMD MEDLINE Link].
Hayes JP, Nolan MT, Brennan N, FitzGerald MX. Three cases of paradoxical vocal cord adduction followed up over a 10- year period. Chest. 1993 Sep. 104(3):678-80. [QxMD MEDLINE Link].
Vlahakis NE, Patel AM, Maragos NE, Beck KC. Diagnosis of vocal cord dysfunction: the utility of spirometry and plethysmography. Chest. 2002 Dec. 122(6):2246-9. [QxMD MEDLINE Link].
Hicks M, Brugman SM, Katial R. Vocal cord dysfunction/paradoxical vocal fold motion. Prim Care. 2008 Mar. 35(1):81-103, vii. [QxMD MEDLINE Link].
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. 2005 Jun. 31(3):224-6. [QxMD MEDLINE Link].
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. 2006 Jan. 96(1):112-5. [QxMD MEDLINE Link].
Husein OF, Husein TN, Gardner R, et al. Formal psychological testing in patients with paradoxical vocal fold dysfunction. Laryngoscope. 2008 Apr. 118(4):740-7. [QxMD MEDLINE Link].
Christopher KL, Morris MJ. Vocal cord dysfunction, paradoxic vocal fold motion, or laryngomalacia? Our understanding requires an interdisciplinary approach. Otolaryngol Clin North Am. 2010 Feb. 43(1):43-66, viii. [QxMD MEDLINE Link].
Freedman MR, Rosenberg SJ, Schmaling KB. Childhood sexual abuse in patients with paradoxical vocal cord dysfunction. J Nerv Ment Dis. 1991 May. 179(5):295-8. [QxMD MEDLINE Link].
Traister RS, Fajt ML, Petrov AA. The morbidity and cost of vocal cord dysfunction misdiagnosed as asthma. Allergy Asthma Proc. 2016 Mar. 37 (2):25-31. [QxMD MEDLINE Link].
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. 1996 Mar. 153(3):942-7. [QxMD MEDLINE Link].
Morris MJ, Deal LE, Bean DR, et al. Vocal cord dysfunction in patients with exertional dyspnea. Chest. 1999 Dec. 116(6):1676-82. [QxMD MEDLINE Link].
Wilson JJ, Theis SM, Wilson EM. Evaluation and management of vocal cord dysfunction in the athlete. Curr Sports Med Rep. 2009 Mar-Apr. 8(2):65-70. [QxMD MEDLINE Link].
Al-Alwan A, Kaminsky D. Vocal cord dysfunction in athletes: clinical presentation and review of the literature. Phys Sportsmed. 2012 May. 40(2):22-7. [QxMD MEDLINE Link].
Rundell KW, Weiss P. Exercise-induced bronchoconstriction and vocal cord dysfunction: two sides of the same coin?. Curr Sports Med Rep. 2013 Jan. 12(1):41-6. [QxMD MEDLINE Link].
Allan PF, Abouchahine S, Harvis L, Morris MJ. Progressive vocal cord dysfunction subsequent to a chlorine gas exposure. J Voice. 2006 Jun. 20(2):291-6. [QxMD MEDLINE Link].
CC Maskell, N Pargeter, J Fellows, A Mansur, R Howard. M11 A preliminary biopsychosocial model of Vocal Cord Dysfunction (VCD). Thorax. 2015. 70:A231-A232.
Morris MJ, Christopher KL. Diagnostic criteria for the classification of vocal cord dysfunction. Chest. 2010 Nov. 138(5):1213-23. [QxMD MEDLINE Link].
Bittleman DB, Smith RJ, Weiler JM. Abnormal movement of the arytenoid region during exercise presenting as exercise-induced asthma in an adolescent athlete. Chest. 1994 Aug. 106(2):615-6. [QxMD MEDLINE Link].
Hicks M, Brugman SM, Katial R. Vocal cord dysfunction/paradoxical vocal fold motion. Prim Care. 2008 Mar. 35 (1):81-103, vii. [QxMD MEDLINE Link].
Morrison M, Rammage L, Emami AJ. The irritable larynx syndrome. J Voice. 1999 Sep. 13 (3):447-55. [QxMD MEDLINE Link].
Dunn N, Katial R, Hoyte F. Vocal cord dysfunction: a review. Asthma Research and Practice. September 22, 2015. 1:9:
Balkissoon R, Kenn K. Asthma: vocal cord dysfunction (VCD) and other dysfunctional breathing disorders. Semin Respir Crit Care Med. 2012 Dec. 33(6):595-605. [QxMD MEDLINE Link].
Traister RS, Fajt ML, Landsittel D, Petrov AA. A novel scoring system to distinguish vocal cord dysfunction from asthma. J Allergy Clin Immunol Pract. 2014 Jan-Feb. 2(1):65-9. [QxMD MEDLINE Link].
Chiang WC, Goh A, Ho L, Tang JP, Chay OM. Paradoxical vocal cord dysfunction: when a wheeze is not asthma. Singapore Med J. 2008 Apr. 49(4):e110-2. [QxMD MEDLINE Link].
Newman KB, Mason UG 3rd, Schmaling KB. Clinical features of vocal cord dysfunction. Am J Respir Crit Care Med. 1995 Oct. 152(4 Pt 1):1382-6. [QxMD MEDLINE Link].
Deckert J, Deckert L. Vocal cord dysfunction. Am Fam Physician. 2010 Jan 15. 81(2):156-9. [QxMD MEDLINE Link].
Doshi DR, Weinberger MM. Long-term outcome of vocal cord dysfunction. Ann Allergy Asthma Immunol. 2006 Jun. 96(6):794-9. [QxMD MEDLINE Link].
Guglani L, Atkinson S, Hosanagar A, Guglani L. A systematic review of psychological interventions for adult and pediatric patients with vocal cord dysfunction. Front Pediatr. 2014. 2:82. [QxMD MEDLINE Link]. [Full Text].
Kass JE, Castriotta RJ. Heliox therapy in acute severe asthma. Chest. 1995 Mar. 107(3):757-60. [QxMD MEDLINE Link].
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. 1995 Feb. 151(2 Pt 1):310-4. [QxMD MEDLINE Link].
Grillone GA, Blitzer A, Brin MF, et al. Treatment of adductor laryngeal breathing dystonia with botulinum toxin type A. Laryngoscope. 1994 Jan. 104(1 Pt 1):30-2. [QxMD MEDLINE Link].
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. 2000 Sep. 118(3):874-7. [QxMD MEDLINE Link].
Dworkin JP, Meleca RJ, Simpson ML, Garfield I. Use of topical lidocaine in the treatment of muscle tension dysphonia. J Voice. 2000 Dec. 14(4):567-74. [QxMD MEDLINE Link].
Wilson JJ, Theis SM, Wilson EM. Evaluation and management of vocal cord dysfunction in the athlete. Curr Sports Med Rep. 2009 Mar-Apr. 8(2):65-70. [QxMD MEDLINE Link].
Parsons JP, Benninger C, Hawley MP, Philips G, Forrest LA, Mastronarde JG. Vocal cord dysfunction: beyond severe asthma. Respir Med. 2010 Apr. 104(4):504-9. [QxMD MEDLINE Link].
Woolnough K, Blakey J, Pargeter N, Mansur A. Acid suppression does not reduce symptoms from vocal cord dysfunction, where gastro-laryngeal reflux is a known trigger. Respirology. 2013 Apr. 18(3):553-4. [QxMD MEDLINE Link].
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. 2001 Apr. 86(4):439-43. [QxMD MEDLINE Link].
Brancatisano T, Collett PW, Engel LA. Respiratory movements of the vocal cords. J Appl Physiol. 1983 May. 54(5):1269-76. [QxMD MEDLINE Link].
Diamond E, Kane C, Dugan G. Presentation and Evaluation of Vocal Cord Dysfunction. Chest. 2000. 118(Suppl 4):199S.
Higgins JC. The 'crashing asthmatic.'. Am Fam Physician. 2003 Mar 1. 67(5):997-1004. [QxMD MEDLINE Link].
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.
Landwehr LP, Wood RP 2nd, Blager FB, Milgrom H. Vocal cord dysfunction mimicking exercise-induced bronchospasm in adolescents. Pediatrics. 1996 Nov. 98(5):971-4. [QxMD MEDLINE Link].
Link HW, Stillwell PC, Jensen VK, Laskowski DM. Vocal Cord Dysfunction in the Pediatric Age Group. Chest. 1998. 114(Suppl 4):255S-256S.
Martin R, Blager F, Gay M, et al. Paradoxical vocal cord motion in presumed asthmatics. Semin Respir Med. 1987. 8:332-337.
Maschka DA, Bauman NM, McCray PB Jr, et al. A classification scheme for paradoxical vocal cord motion. Laryngoscope. 1997 Nov. 107(11 Pt 1):1429-35. [QxMD MEDLINE Link].
McFadden ER Jr. Glottic function and dysfunction. J Allergy Clin Immunol. 1987 May. 79(5):707-10. [QxMD MEDLINE Link].
Murray DM, Lawler PG. All that wheezes is not asthma. Paradoxical vocal cord movement presenting as severe acute asthma requiring ventilatory support. Anaesthesia. 1998 Oct. 53(10):1006-11. [QxMD MEDLINE Link].
Newman KB, Dubester SN. Vocal Cord Dysfunction: Masquerader of Asthma. Semin Resp Crit Care Med. 1994. 15:161-167.
O'Connell MA, Sklarew PR, Goodman DL. Spectrum of presentation of paradoxical vocal cord motion in ambulatory patients. Ann Allergy Asthma Immunol. 1995 Apr. 74(4):341-4. [QxMD MEDLINE Link].
O'Hollaren MT. Masqueraders in clinical allergy: laryngeal dysfunction causing dyspnea. Ann Allergy. 1990 Nov. 65(5):351-6. [QxMD MEDLINE Link].
Paparella MM, Shumrick D, Gluckman J, Meyerhoff W. Otolaryngology: Head & Neck. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1991.
Parker JM, Mooney LD, Berg BW. Exercise Tidal Loops in Patients with Vocal Cord Dysfunction. Chest. 1998. 114(Suppl 4):256S.
Patterson DL, O'Connell EJ. Vocal Cord Dysfunction: What have we learned in 150 years?. Insights in Allergy. 1994. 9(6):1-12.
Perkner JJ, Fennelly KP, Balkissoon R, et al. Irritant-associated vocal cord dysfunction. J Occup Environ Med. 1998 Feb. 40(2):136-43. [QxMD MEDLINE Link].
Powell DM, Karanfilov BI, Beechler KB, et al. Paradoxical vocal cord dysfunction in juveniles. Arch Otolaryngol Head Neck Surg. 2000 Jan. 126(1):29-34. [QxMD MEDLINE Link].
Reisner C, Nelson HS. Vocal cord dysfunction with nocturnal awakening. J Allergy Clin Immunol. 1997 Jun. 99(6 Pt 1):843-6. [QxMD MEDLINE Link].
Sandage MJ, Zelazny SK. Paradoxical vocal fold motion in children and adolescents. Lang Speech Hear Serv Sch. 2004 Oct. 35(4):353-62. [QxMD MEDLINE Link].
Schachter AJ. Vocal cord dysfunction may be functional. Chest. 1998 Jul. 114(1):351. [QxMD MEDLINE Link].
Selner JC, Staudenmayer H, Koepke JW, et al. Vocal cord dysfunction: the importance of psychologic factors and provocation challenge testing. J Allergy Clin Immunol. 1987 May. 79(5):726-33. [QxMD MEDLINE Link].
Sokol W. Vocal cord dysfunction presenting as asthma. West J Med. 1993 Jun. 158(6):614-5. [QxMD MEDLINE Link].
Soli CG, Smally AJ. Vocal cord dysfunction: an uncommon cause of stridor. J Emerg Med. 2005 Jan. 28(1):31-3. [QxMD MEDLINE Link].
Weir M, Ehl L. Vocal cord dysfunction mimicking exercise-induced bronchospasm in adolescents. Pediatrics. 1997 Jun. 99(6):923-4. [QxMD MEDLINE Link].
Wood RP 2nd, Milgrom H. Vocal cord dysfunction. J Allergy Clin Immunol. 1996 Sep. 98(3):481-5. [QxMD MEDLINE Link].

Media Gallery

Flow volume loops.
Laryngoscopic views of the vocal cords.
Vocal cord dysfunction treatment plan.
Relaxed throat breathing exercises.

of 4

Table 1. Differential diagnosis of laryngeal movement disorders^[29, 30, 31]

Table 1. Differential diagnosis of laryngeal movement disorders ^{[29, 30, 31]}

VCD
Psychogenic	Somatoform disorder, conversion disorder, abuse, anxiety disorder, depression, Munchausen syndrome, malingering
Exercise	Exercise
Irritant	Extrinsic (chemical irritants, olfactory stimuli) Intrinsic (GERD, laryngopharyngeal reflux rhinits/post nasal drip, sinusitis)
Laryngospasm	Intubation, airway manipulation, IgE mediated, nocturnal aspiration
Vocal Cord Paresis/Paralysis	Prolonged intubation, recurrent laryngeal or vagus nerve damage during chest or thyroid surgery, idiopathic
Infectious	Epiglottis, bronchiolitis, laryngotracheobronchitis (croup), laryngitis, pharyngeal abscess, diphtheria, pertussis, laryngeal papillomatosis
Neoplastic	Head and neck malignancy, cystic hygroma, hemangioma, rhabdomyosarcoma, teratoma, lymphoma, papilloma
Endocrine	Thyroid goiter

Back to List

Author

Praveen Buddiga, MD, FAAAAI Founder, BUDDIGA Family Allergy Asthma & Skin Immunology; Assistant Clinical Professor, Fresno Medical Education Program, University of California, San Francisco, School of Medicine

Praveen Buddiga, MD, FAAAAI is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, California Medical Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: PFIZER; GLAXO-SMITH-KLINE; ASTRA-ZENECA; MYLAN; TEVA RESPIRATORY; ALCON OPHTHALMICS; MERCK RESPIRATORY.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Michael R Simon, MD, MA Clinical Professor Emeritus, Departments of Internal Medicine and Pediatrics, Wayne State University School of Medicine; Professor, Department of Internal Medicine, Oakland University William Beaumont 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, Society for Experimental Biology and Medicine

Disclosure: Have a 5% or greater equity interest in: Secretory IgA, Inc. ; siRNAx, Inc.<br/>Received income in an amount equal to or greater than $250 from: siRNAx, Inc.