Outcomes of Paradoxical Vocal Cord Motion Diagnosed in Childhood.

OBJECTIVES: To explore long-term patient reported outcome (PRO) measures of pediatric paradoxical vocal cord motion (PVCM) including ease of diagnosis, management, symptom duration and effect on quality of life. METHODS: All children >8 years of age diagnosed with PVCM at a tertiary pediatric hospital between 2006 and 2017 were invited to complete a survey addressing study objectives. RESULTS: 21/47 eligible participants could be contacted and 18/21 (86%) participated. 78% were female with a mean age at diagnosis of 11.6 and 15.0 years at survey completion. Common PVCM symptoms reported were dyspnea (89%), globus sensation (56%), and stridor (50%). The median time to diagnosis was 3 months (IQR 2-5 months). Nearly all reported being misdiagnosed with another condition, usually asthma, until being correctly diagnosed usually by an otolaryngologist. Participants reported undergoing 3.7 diagnostic studies (range 0-8); pulmonary function testing was most common. Of numerous treatments acknowledged, breathing exercises were common (89%) but only reported helpful by 56%. Use of biofeedback was recalled in 1/3 of subjects but reported helpful in only 14% of them. Anti-reflux, allergy, anticholinergics, inhalers and steroids were each used in >50%, but rarely reported effective. PVCM was reportedly a significant stressor when initially diagnosed but despite 2/3 of participants still reporting ongoing PVCM symptoms, the perceived stress significantly decreased over time (Z = 3.26, P = 0.001). CONCLUSIONS: This first PVCM PRO study endorses that diagnosis is often delayed and prescribed treatments often viewed as ineffective. While biofeedback and breathing exercises may be critical for short-term control of PVCM episodes, lifestyle changes and stress reduction are likely necessary for long-term management. Increased awareness and improvements in management are needed for this condition.

Perceptual Clinical Features in Exercise-Induced Laryngeal Obstruction (EILO): Toward Improved Diagnostic Approaches.

INTRODUCTION: Athletes with exercise-induced laryngeal obstruction (EILO) (previously commonly referred to as paradoxical vocal fold motion disorder, or paradoxical vocal fold motion, among other terms) are often misdiagnosed, resulting in prolonged, and at times inappropriate, clinical management. The high prevalence of misdiagnosis is largely due to a lack of universal consensus of key clinical features indicating EILO and a dearth of validated quantitative approaches to accurately detect episodic laryngeal breathing disorders (ELBD) from other pathologies. Additionally, mechanisms underlying EILO clinical presentation are poorly understood, further confounding identification and management of the condition. Therefore, the objectives of this study were twofold. The first was to identify patient-centered perception of symptoms that could distinguish adolescent athletes with EILO from athletes without the condition, at baseline (rest) and during an exercise challenge (provocation), and to quantify symptom severities for use as preliminary diagnostic benchmarks. The second objective was to investigate the merit of one commonly proposed mechanism in the EILO literature-stress reactivity (temperament)-by comparing personality traits in athletes with and without EILO. METHODS: Twelve (12) athletes diagnosed with EILO and 14 healthy athletic volunteers without the condition were asked to rate the severity of their present symptoms using a 0-100 continuous visual analog scale. Participants then underwent an exercise challenge with simultaneous laryngoscopy and were asked to complete the same set of symptom severity ratings experienced during rigorous exercise. Finally, participants completed the Fear subscale on the early adolescent temperament questionnaire-revised (EATQ-R) to measure self-perceived levels of stress reactivity. RESULTS: There were significant group differences for inspiratory and expiratory dyspnea with exercise (P = 0.01). Symptoms of stridor (EILO: P = .01; control: P = .001) and throat tightness (EILO: P = .01, control: P = .01) were statistically different between rest and exercise in both groups. However, no group differences were found on these two parameters (P > .05). Other symptoms from the list of previously purported symptoms indicative of ELBD (e.g. cough, dysphonia) were infrequently reported in the exercise variant. Additionally, measurements of stress reactivity on the EATQ-R Fear subscale were similar between the two athletic groups. Interestingly, EATQ-R Fear Subscale scores for both groups were significantly higher compared to typical adolescents in the U.S. population (P < .001, respectively). DISCUSSION: Results suggest dyspnea severity, particularly when experienced during an exercise-induced ELBD (EILO) episode, is the most sensitive symptom parameter to distinguish individuals with EILO from those without the condition. These findings confirm previous literature describing episodic laryngeal breathing disorders in clinical cohorts. Results also showed symptoms of throat tightness and stridor is more prevalent during exercise, compared to rest. However, the level of their severity occurred variably across both groups of athletes and may point to a less robust indication of pathology. Finally, similarities to stress reactivity between the two athletic groups imply certain temperaments historically attributed to patients with EILO may instead better reflect temperaments in competitive young athletes, in general. CONCLUSION: Study findings highlight the importance of using normative comparisons in the study of episodic laryngeal breathing disorders to prevent overgeneralization of characteristics to clinical cohorts. Results also speak of the clinical utility of exercise challenge to improve specificity of EILO diagnosis.

Exercise-Induced Laryngeal Obstruction and Performance Psychology: Using the Mind as a Diagnostic and Therapeutic Target.

Exercise-induced laryngeal obstruction causes severe shortness of breath during exercise. Episodes are associated with severe distress. These patients and those with inducible laryngeal obstruction triggered by other factors have been noted to demonstrate mental health disorders, personality features that may be associated with symptoms, and dysfunctional stress responses. This literature review calls attention to the observation that patients with isolated exercise-induced laryngeal obstruction are generally mentally healthy. We review available metrics to assess traits and stress responses in performance psychology. We also discuss a therapeutic performance psychology framework.

The Vocal Fold Dysfunction Questionnaire: Validity and Reliability of the Persian Version.

OBJECTIVES: The aim of this study was to develop, validate, and assess the reliability of the Persian version of Vocal Cord Dysfunction Questionnaire (VCDQP). STUDY DESIGN: The study design was cross-sectional or cultural survey. MATERIALS AND METHODS: Forty-four patients with vocal fold dysfunction (VFD) and 40 healthy volunteers were recruited for the study. To assess the content validity, the prefinal questions were given to 15 experts to comment on its essential. Ten patients with VFD rated the importance of VCDQP in detecting face validity. Eighteen of the patients with VFD completed the VCDQ 1 week later for test-retest reliability. To detect absolute reliability, standard error of measurement and smallest detected change were calculated. Concurrent validity was assessed by completing the Persian Chronic Obstructive Pulmonary Disease (COPD) Assessment Test (CAT) by 34 patients with VFD. Discriminant validity was measured from 34 participants. The VCDQ was further validated by administering the questionnaire to 40 healthy volunteers. Validation of the VCDQ as a treatment outcome tool was conducted in 18 patients with VFD using pre- and posttreatment scores. RESULTS: The internal consistency was confirmed (Cronbach α = 0.78). The test-retest reliability was excellent (intraclass correlation coefficient = 0.97). The standard error of measurement and smallest detected change values were acceptable (0.39 and 1.08, respectively). There was a significant correlation between the VCDQP and the CAT total scores (P < 0.05). Discriminative validity was significantly different. The VCDQ scores in patients with VFD before and after treatment was significantly different (P < 0.001). CONCLUSIONS: The VCDQ was cross-culturally adapted to Persian and demonstrated to be a valid and reliable self-administered questionnaire in Persian-speaking population.

Measuring Quality of Life in Pediatric Paradoxical Vocal Fold Motion Using the SF-36v2.

OBJECTIVES: Paradoxical vocal fold motion (PVFM) consists of intermittent adduction of the vocal folds during inspiration, resulting in stridor and worsened by anxiety and stress. The purpose of this study was to assess the impact of PVFM on quality of life in our pediatric patient population. STUDY DESIGN: This is a prospective, descriptive survey study. METHODS: Thirty-nine consecutive patients (ages 12-17 years) presenting with a PVFM diagnosis for respiratory retraining sessions with speech-language pathology were recruited. Patients completed a brief demographic questionnaire and the Short Form 36, version 2, a validated tool for measuring health-related quality of life. RESULTS: There were 31 (79%) girls and 8 (21%) boys with a mean age of 15.5 years. Subjects reported regular participation in competitive extracurricular activities, including track or cross country (30.8%), swimming (17.9%), and cheerleading or dancing (15.4%). Of the patients in the study, 46.2% were straight-A students. On the SF-36 (population averages normalized to a score of 50), the general health of patients with PVFM was better than that of the general population (53.27); however, their physical health limited their role activities more severely (42.82). In addition, a greater proportion of the group with PVFM was at risk for first-stage depression screening when compared with the general population (28% versus 18%). CONCLUSIONS: We demonstrate a measurable detrimental impact of PVFM on health-related quality of life. This is consistent with previously published literature showing a preponderance of females with PVFM, most of whom are high achievers academically and athletically.

Functional Outcomes after Behavioral Treatment of Paradoxical Vocal Fold Motion in Adults.

OBJECTIVE: Paradoxical vocal fold motion (PVFM) is responsive to behavioral therapy, often resulting in a remission of symptoms, but little is known about whether treatment is beneficial with regard to PVFM-associated psychological symptoms or functional limitations. The goal of the study was to identify patient perceptions of the impact of treatment for PVFM and characteristics associated with treatment outcomes. METHODS: A survey was conducted of all adults who had received at least 1 session of treatment for PVFM in our outpatient clinic over a 2-year period. RESULTS: The 39 participants ranged in age from 18 to 82 and had received a median of 3 treatment sessions. At a median follow-up of 10 months following treatment, respondents reported improvements in a wide range of areas, including sports and leisure, daily activities, and social participation. The majority reported improvements in feelings of anxiety, helplessness, and control. Poorer outcomes were associated with more severe voice symptoms, fewer treatment sessions, and needing oral steroids for asthma control. CONCLUSION: There was a reduction in a wide range of activity limitations after treatment. Feelings of control were strongly associated with positive outcomes. The therapy appeared to be equally effective for adults with exercise-induced and environmental variants of PVFM.

Comparative analysis of clinical profile: Chronic cough vs paradoxical vocal fold motion.

BACKGROUND: Ongoing contention surrounding typical demographic and clinical attributes of chronic cough (CC) and paradoxical vocal fold motion (PVFM) impedes timely diagnosis and optimum patient care. Designed to reduce preventable patient morbidity through improved recognition and differentiation, the current study aimed to determine representative clinical profiles for CC and PVFM, with identification of distinctive attributes from the general population and risk factors associated with each diagnosis. METHODS: Self-reported medical questionnaires, demographic and lifestyle attributes of CC and PVFM cases from a disease-specific outcomes database were compared to US population data and published normative values. Univariate comparison and multivariate regression modelling of age, sex, alcohol intake, smoking, Reflux Symptom Index (RSI), Voice Handicap Index (VHI), and Generalized Anxiety Disorder 7-item Scale (GAD-7) determined distinguishing features between the clinical groups, including odds ratios for presenting with CC versus PVFM. RESULTS: Clinical profiles developed from 283 (128 CC, 155 PVFM) adults (18-91 years) were significantly different from the general population across each demographic, lifestyle and clinical variable (all p < .01), with the exception of obesity. Age (55.39 ± 13.54 vs 45.07 ± 16.51 years, p < .01) and mean RSI score (21.5 ± 9.02 vs 18.1 ± 9.08, p < .01) most reliably distinguished CC from PVFM, with those aged 60-69 years (OR = 9.45) most likely to be diagnosed with CC. CONCLUSIONS: Standard clinical profiles of CC and PVFM are distinct from the general population, aiding determination of relative probabilities and risk factors in the differential diagnostic process. Variations between CC and PVFM were subtle, reliably distinguished by age and relative severity of laryngopharyngeal reflux symptomatology.

Hypnosis for Asthma and Vocal Cord Dysfunction in a Patient With Autism.

Wheezing in children often is the result of asthma, but vocal cord dysfunction (VCD) may cause stridor or sounds that sometimes are misattributed to the wheezing of asthma. The frequent comorbidity of asthma and VCD also adds to the difficulty in making a clear diagnosis. The challenges of evaluating and treating wheezing are complicated further in children with developmental disorders, such as autism, because of the difficulties of obtaining an adequate history and assessing the clinical response to treatment. This article presents a patient with multiple psychiatric problems, including autism, with severe recurrent wheezing as a result of vocal cord dysfunction and asthma. Hypnosis has previously proven efficacious for treating vocal cord dysfunction, and in this case, hypnotic techniques were major factors in successful symptom control.

Correlation among the dysphonia severity index (DSI), the RBH voice perceptual evaluation, and minimum glottal area in female patients with vocal fold nodules.

OBJECTIVES: To investigate the clinical significance and correlation of the dysphonia severity index (DSI), the RBH (roughness [R]; breathiness [B]; hoarseness [H]) perceptual voice quality evaluation, and minimum glottal area (MGA) in patients with vocal fold nodules and validate the practicality of the DSI further. METHODS: The DSI evaluation, the voice RBH perceptual evaluation, and the MGA were performed on 30 female patients with vocal fold nodules (the patient group) and 30 female volunteers with normal voices (the control group). The DSI determination was calculated using the following formula: DSI = 0.13 × MPT + 0.0053 × F(0)-High - 0.26 × I-Low - 1.18 × Jitter(%) + 12.4. The RBH evaluation was graded according to four scales. The MGA was measured by KayPENTAX Kips (7105) software. The differences among the DSI, the RBH grade, and MGA of the patients were compared. RESULTS: The median DSI values of the patient group and the control group were -0.81 and 3.79, respectively, and the difference was statistically significant (P < 0.01). The median MGA of the patient group and the control group were 355.5 and 121, respectively, and the difference was statistically significant (P < 0.01). DSI exhibited moderate negative correlation with R (rP = -0.686, P < 0.01), B (rP = -0.609, P < 0.01), and H (rP = -0.487, P < 0.01). MGA demonstrated moderate positive correlation with R (rP = 0.667, P < 0.01), B (rP = 0.545, P < 0.01), and H (rP = 0.449, P < 0.01), whereas MGA showed strong negative correlation with DSI (rP = -0.888, P < 0.01). CONCLUSIONS: The application of the DSI as an objective parameter to evaluate dysphonia in female patients with vocal nodules has significant clinical application and good correlation with MGA measurement.