Predictors of voice therapy efficacy in vocal cord dysfunction at a tertiary care center.

OBJECTIVE: Vocal cord dysfunction is inappropriate adduction of vocal cords during inspiration that causes dyspnea and is commonly mistaken for exercise-induced asthma. To improve diagnostic accuracy, this study aims to identify demographics associated with vocal cord dysfunction and to determine their impact on the efficacy of voice therapy in improving vocal cord function. STUDY DESIGN: Retrospective chart review. SETTING: Single tertiary care institution between January 2015 and December 2021. METHODS: 184 patients who underwent voice therapy for vocal cord dysfunction were included. The primary outcome was patient self-reported percent improvement of symptoms. The secondary outcome was number of voice therapy treatments. RESULTS: The mean duration of symptoms was 2 ± 3 years. The mean number of voice therapy treatments was 2.2 ± 1.5. Of the 107 (58.2 %) patients with documented perceived breathing improvement percentages recorded, the mean maximal percent improvement was 72.5 ± 21.5 %. Mean maximal percent improvement of symptoms increased with each voice therapy treatment (p = 0.01). This association remained significant when controlling for comorbid conditions such as allergic rhinitis with postnasal drip, anxiety, asthma, and gastroesophageal reflux disease in multivariate analysis (p = 0.005). Patients with asthma had significantly higher maximum percent breathing improvement compared to those without asthma (p = 0.026). Similarly, patients who played sports had significantly higher maximum percent breathing improvement compared to those who did not (p = 0.022). CONCLUSION: Patient perceived breathing improvement with voice therapy is higher among those with concomitant asthma and those who play sports. Voice therapy is a safe and effective first line treatment of vocal cord dysfunction even when controlling for comorbid conditions.

Treatment effectiveness for Vocal Cord Dysfunction in adults and adolescents: A systematic review.

OBJECTIVE: To determine whether treatment effectiveness can be established for a range of vocal cord dysfunction (VCD) interventions in adolescents and adults. DESIGN: A systematic review of the literature and risk of bias appraisal was completed using the Joanna Briggs Institute Critical Appraisal Tools. Data were qualitatively synthesized in the broad intervention groups of glottic airway and respiratory retraining, pharmacological therapies, airway device therapies and psychological therapies. DATA SOURCES: Nine electronic databases, two clinical trial registries and the grey literature were searched from inception to September 2021 for articles on VCD interventions or equivalent terms. ELIGIBILITY CRITERIA: Studies were included if they were randomized controlled trials, non-randomized controlled trials, quasi-experimental pre- and post-test studies and within-subject repeated measure designs, participants were 13 years or older, VCD was diagnosed using laryngoscopy or CT larynx, VCD intervention was provided and outcome measures reported on VCD symptoms. RESULTS: The search yielded no randomized controlled trials. There were 17 quasi-experimental studies that met the eligibility criteria, and these studies reported on glottic airway and respiratory retraining, botulinum toxin injections, inspiratory muscle strength training and amitriptyline; all were associated with VCD symptom reduction. In addition, 2 within-subject repeated measure studies reported inspiratory muscle strength training and respiratory retraining to be effective in reducing symptoms in participants with exertional VCD. The included studies were reported in full-text publications (11) and conference proceedings (8). There was a high risk of bias and low quality of evidence across all intervention areas. CONCLUSION: Glottic airway and respiratory retraining, botulinum toxin injections, low-dose amitriptyline and inspiratory muscle strength training devices have been associated with symptom reduction in adults and adolescents with vocal cord dysfunction. Limited objective data exist to support the effectiveness of these interventions, and robust controlled trials are needed in this area. Systematic Review Registration: CRD42018092274 (PROSPERO).

Vocal Cord Dysfunction: Rapid Evidence Review.

Vocal cord dysfunction (i.e., vocal cords closing when they should be opening, particularly during inspiration) should be suspected in patients presenting with inspiratory stridor or wheezing; sudden, severe dyspnea (without hypoxia, tachypnea, or increased work of breathing); throat or chest tightness; and anxiety, particularly in females. Common triggers include exercise, asthma, gastroesophageal reflux disease, postnasal drip, upper or lower respiratory tract infection, and irritants. Nasolaryngoscopy and pulmonary function testing, with provocative exercise and methacholine, can help diagnose vocal cord dysfunction and are helpful to evaluate for other etiologies. Conditions that can trigger vocal cord dysfunction should be optimally treated, particularly asthma, gastroesophageal reflux disease, and postnasal drip, while avoiding potential irritants. Therapeutic breathing maneuvers and vocal cord relaxation techniques are first-line therapy for dyspnea that occurs with vocal cord dysfunction. A subset of vocal cord dysfunction leads to dysphonia, as opposed to dyspnea, secondary to abnormal laryngeal muscle spasms (vocal cord closure is less severe). OnabotulinumtoxinA injections may be helpful for spasmodic dysphonia and for treating dyspnea in certain cases, although evidence is limited.

Multidisciplinary team clinic for vocal cord dysfunction directs therapy and significantly reduces healthcare utilization.

BACKGROUND AND OBJECTIVE: Multidisciplinary team (MDT) clinics use an integrated approach to individualize care of complex medical conditions. Vocal cord dysfunction (VCD) is a challenging condition that is likely to benefit from MDT clinics but this has not been researched. METHODS: A prospective observational cohort study of a novel VCD MDT clinic was conducted in patients with suspected VCD. Relevant questionnaires, medical history, physical examination, spirometry, dynamic computerized tomography (CT) larynx and laryngoscopy were utilized and patients were allocated to treatment pathways depending on putative diagnosis. Speech pathology intervention with laryngeal retraining (LR) was offered and if LR therapy failed botulinum toxin injection was offered. Primary outcome was reductions in healthcare utilization. RESULTS: Overall, 80 consecutive patients were included in analyses. A definitive diagnosis of VCD was made in 56 of 80 (70%) patients. After LR (n = 35), emergency department (ED)/hospital admissions declined significantly in the subsequent 12 months (P = 0.001). General practice visits also reduced (P < 0.001). Botulinum toxin injections were administered in 21 patients unresponsive to LR therapy and both general practice and ED/hospital visits declined (P < 0.001 and P = 0.01, respectively) after injection. CONCLUSION: A multidisciplinary approach to VCD confers benefit and can be used to allocate appropriate management leading to a reduction in healthcare utilization.

Pathophysiology of Fibrosis in the Vocal Fold: Current Research, Future Treatment Strategies, and Obstacles to Restoring Vocal Fold Pliability.

Communication by voice depends on symmetrical vibrations within the vocal folds (VFs) and is indispensable for various occupations. VF scarring is one of the main reasons for permanent dysphonia and results from injury to the unique layered structure of the VFs. The increased collagen and decreased hyaluronic acid within VF scars lead to a loss of pliability of the VFs and significantly decreases their capacity to vibrate. As there is currently no definitive treatment for VF scarring, regenerative medicine and tissue engineering have become increasingly important research areas within otolaryngology. Several recent reviews have described the problem of VF scarring and various possible solutions, including tissue engineered cells and tissues, biomaterial implants, stem cells, growth factors, anti-inflammatory cytokines antifibrotic agents. Despite considerable research progress, these technical advances have not been established as routine clinical procedures. This review focuses on emerging techniques for restoring VF pliability using various approaches. We discuss our studies on interactions among adipose-derived stem/stromal cells, antifibrotic agents, and VF fibroblasts using an in vitro model. We also identify some obstacles to advances in research.

Acute Management of Paradoxical Vocal Fold Motion (Vocal Cord Dysfunction).

Paradoxical vocal fold motion disorder, also commonly termed vocal cord dysfunction, is a poorly understood cause of acute upper airway obstruction. Patients with paradoxical vocal fold motion frequently present to the emergency department (ED) with acute respiratory distress and stridor. Lack of familiarity with this disorder may lead to delayed diagnosis or misdiagnosis and unnecessary intubations or surgical airway procedures. Although long-term management of paradoxical vocal fold motion is well described, there is a paucity of information about acute evaluation and management. This article aims to summarize the ED presentation and management of paradoxical vocal fold motion.

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.

[Paradoxical vocal fold motion, a real breathing problem : diagnosis and treatment]. / Adduction paradoxale des cordes vocales, un vrai problème respiratoire : diagnostic et traitement.

The paradoxical vocal fold motion (PVFM) is a temporary total inability to breathe, which is important to rule out from other more or less important breathing difficulties encountered in asthma. Overtreatment for asthma instead of treatment for PVFM can lead to iatrogenic complications which can be averted by early and correct diagnosis. This article presents a list of symptoms and related disorders, enabling to more easily diagnose PVFM, as well as its specifics treatments and a « Block-unblock maneuver ¼ not yet described in the literature, allowing the patient to respond to the crisis and to prevent future crises.

L'adduction paradoxale des cordes vocales (PVFM ­ paradoxical vocal fold motion) est une incapacité momentanée totale de respirer qu'il faut distinguer des difficultés de respiration plus ou moins importantes que l'on rencontre dans l'asthme. Les symptômes ressemblant à ceux de l'asthme, il en résulte des traitements médicamenteux à hautes doses pouvant entraîner des morbidités iatrogènes qu'il faut absolument essayer d'éviter. Cet article présente une liste de symptômes et troubles associés, permettant de poser plus facilement le diagnostic, ainsi que les traitements spécifiques dont une « manœuvre de blocage-déblocage ¼, permettant au patient de réagir et d'éviter de nouvelles crises.

The VCDQ--a Questionnaire for symptom monitoring in vocal cord dysfunction.

BACKGROUND: Vocal cord dysfunction (VCD) typically involves abnormal adduction of the vocal cords during inspiration, mimics the symptoms of asthma and leads to the prescription of ineffective medications. OBJECTIVE: We aimed to develop a clinical tool to monitor symptoms and response to treatment in confirmed VCD. METHODS: We collated symptoms of VCD from focus groups comprising patients and healthcare professionals; phrases describing these symptoms were assessed for face validity and internal correlation and rated for importance. The resultant 12-item questionnaire (VCDQ) rated the impact of each on a 5-point Likert scale (total score range 12-60) and was tested for reliability, concurrent validity and performance in 31 patients with endoscopically confirmed VCD (± asthma), 29 asthmatics with no history of VCD and 14 healthy controls. We assessed response to speech and language therapy and the minimal important difference by measuring the VCDQ pre- and post- therapy in a 20 new patients. RESULTS: The VCDQ had excellent test-retest reliability and differentiated VCD vs. healthy (Mann-Whitney U-test: z = -5.390, P < 0.001) and asthma (z = -5.730, P < 0.001). All patients improved post-therapy, assessed both by a global rating of change score (GRCS) and by the VCDQ [median (IQR) score pre-therapy 50.5 (48.0 - 54.8), post-therapy 35.0 (29.3 - 41.8), P < 0.001]. The minimal important difference in the VCDQ associated with a rating of 'minimally better' on the GRCS was 4 points. CONCLUSIONS AND CLINICAL RELEVANCE: The VCDQ is a valid and responsive tool suitable for measuring changes in symptoms in patients with VCD. It also gives insight into which symptoms are important to patients and could guide future therapy refinements. Future assessments of novel therapies for this condition should use an appropriately validated tool such as the VCDQ to measure response.

Vocal cord dysfunction in bronchial asthma. A review article.

INTRODUCTION: Vocal cord dysfunction (VCD) is a condition in which the larynx exhibits paradoxical vocal cord adduction during inspiration, resulting in extra-thoracic variable airway obstruction. It has been described as a mimic of asthma, and hence, many patients with VCD are diagnosed as difficult-to-treat asthma and suffer significant morbidity as such. METHODS: In completing this review we searched the literature using the database from MEDLINE, PubMed, and the Cochrane library using the medical terms "vocal cord/vocal cord dysfunction and asthma". RESULTS: During the last few decades, many publications have described many conditions that may cause or coexist with VCD. In addition, the association between asthma and VCD was recognized. In this narrative review we provide an overview of the current knowledge about VCD and, in particular its relationship to asthma. We also provide a pragmatic diagnostic algorithm and treatment options based on our collaborative multi-disciplinary management of patients attending a difficult to control asthma clinic. CONCLUSION: Most VCD patients present with inadequately controlled asthma rather than the typical symptoms described in association with VCD. Careful diagnostic strategy as outlined in this review may be helpful in confirming the diagnosis.

Deep brain stimulation for vocal tremor: a comprehensive, multidisciplinary methodology.

Tremulous voice is a characteristic feature of a multitude of movement disorders, but when it occurs in individuals diagnosed with essential tremor, it is referred to as essential vocal tremor (EVT). For individuals with EVT, their tremulous voice is associated with significant social embarrassment and in severe cases may result in the discontinuation of employment and hobbies. Management of EVT is extremely difficult, and current behavioral and medical interventions for vocal tremor result in suboptimal outcomes. Deep brain stimulation (DBS) has been proposed as a potential therapeutic avenue for EVT, but few studies can be identified that have systematically examined improvements in EVT following DBS. The authors describe a case of awake bilateral DBS targeting the ventral intermediate nucleus for a patient suffering from severe voice and arm tremor. They also present their comprehensive, multidisciplinary methodology for definitive treatment of EVT via DBS. To the authors' knowledge, this is the first time comprehensive intraoperative voice evaluation has been used to guide microelectrode/stimulator placement, as well as the first time that standard pre- and post-DBS assessments have been conducted, demonstrating the efficacy of this tailored DBS approach.

Acute vocal fold dystonic reaction to propofol: a case report.

A 67-year old male underwent uneventful robotic-assisted thoracoscopic resection of a solitary pulmonary fibrous tumor. Immediately following extubation at the completion of the surgical procedure, the patient developed respiratory distress that did not resolve with treatment. Benadryl provided only temporary relief. Midazolam and hydromorphone were given for anxiolysis and analgesia respectively, which provided transient relief of symptoms. Propofol was given to decrease upper airway reflexes. Adequate reversal from nondepolarizing neuromuscular blockade was confirmed with nerve stimulator. A flexible laryngoscope was introduced nasally to visualize the vocal cords, which revealed intermittent tremulousness of the vocal cords, adduction of bilateral vocal cords to the midline, and minimal to absent opening with inspiration, without any apparent injury or blood, saliva, or vomit noted in or around the glottic opening. The patient was then given diazepam and reintubated. Given the patient's history of difficulty breathing after previous surgery and the lack of vocal cord movement, dystonic reaction to propofol was suspected. The patient remained intubated for two hours in the post-anesthesia care unit before being extubated uneventfully.

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.

[Pursed Lips Inspiration for Vocal Cord Dysfunction].

Paradoxical vocal cord motion (PVCM) during vocal cord dysfunction (VCD) generally occurs spasmodically and transiently. After we had experienced 36 cases of VCD and successfully treated with conservative treatment including "pursed lips inspiration" method, we experienced a boy who had persistent PVCM. It was observed his PVCM vanished when he breathed in through pursed lips, while it appeared again when he stopped pursed lips inspiration. An airway reflex has been reported where the negative pressure in the subglottic space resulting from the inspiratory effort against a narrowed glottis activates the vocal cord adductor. VCD is considered to have both acceleration of laryngeal closure reflex against airway stimuli and active adductive movement of vocal cords against negative pressure in the subglottic space as underlying factors. The pursed lips inspiration method enables VCD patients not only to accomplish slow and light breathing but also to decrease the difference in the pressure between the supra--and subglottic space by occluding the nasal cavity and voluntary puckering up of the mouth which generate negative pressure in the supraglottic space. This is the first report of the pursed lips inspiration method as a treatment for VCD. Pursed lips inspiration is a simple method which is easy to perform anytime, anywhere without any special equipment, and is considered to be worth trying for VCD.