Behavioral Management of Paradoxical Vocal Fold Motion

Paradoxical vocal fold motion (PVFM), or vocal cord dysfunction (VCD), is a non-organic, behavioral, upper airway disorder primarily characterized by adduction of the true vocal folds during respiration. Recognition of this condition is becoming more prevalent amongst physicians, resulting in an increased number of referrals to speech-language pathologists (SLPs) for assessment and treatment. Diagnosis of PVFM requires a multidisciplinary approach. Treatment for PVFM is also multi-factorial, but is primarily designed to train abduction of the vocal folds during the breathing cycle, allowing easy movement of breath to and from the lungs without laryngeal constriction. Behavioral management is the preferred and most common approach to treatment and may include relaxed throat breathing and laryngeal control exercises during trigger-specific training.

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When Inspiratory Stridor Is Not Paradoxical Vocal Fold Motion/Inducible Laryngeal Obstruction: A Case Study of Diaphragm Flutter

Perspectives of the ASHA Special Interest Groups ◽

10.1044/2021_persp-21-00039 ◽

2021 ◽

pp. 1-5

Author(s):

Mary J. Sandage ◽

C. P. Billingsley ◽

Jeanne L. Hatcher ◽

Brian Petty ◽

J. Tod Olin

Keyword(s):

Differential Diagnosis ◽

Vocal Fold ◽

Multidisciplinary Approach ◽

Clinical Course ◽

Inspiratory Stridor ◽

Laryngeal Obstruction ◽

Assessment And Treatment ◽

Vocal Fold Motion ◽

Paradoxical Vocal Fold Motion

Purpose This case study describes the clinical course for an individual referred to a speech-language pathologist (SLP) for assessment and treatment of paradoxical vocal fold motion/inducible laryngeal obstruction (PVFM/ILO) who was ultimately diagnosed with diaphragm flutter. This case presentation describes the critical importance of a multidisciplinary approach to identify conditions in the differential diagnosis of PVFM/ILO, which may lead to timely diagnosis and treatment of such conditions. Method Using a case study format with links to pre- and posttreatment videos, the clinical course of a 20-year-old woman presenting with persistent inspiratory stridor and cough during waking time was delineated. Data used to determine the differential diagnosis included careful clinical observation, extensive medical history, and endoscopic laryngeal assessment. Results Using a multidisciplinary approach with professionals from three different treatment centers, the diagnosis of diaphragm flutter was affirmed and successful medical management with an empiric trial of Baclofen was initiated with complete resolution of the dyspnea, cough, and inspiratory stridor over 3 weeks. Conclusions This case study describes a rare condition in the differential diagnosis of PVFM/ILO called diaphragm flutter, characterized by persistent inspiratory stridor and cough that interrupted connected speech and swallowing. SLPs who specialize in the assessment and treatment of PVFM/ILO may encounter this condition. Clinician awareness of the clinical profile for diaphragm flutter is critical for rapid referral to the appropriate medical specialists to achieve timely symptom relief. Supplemental Material https://doi.org/10.23641/asha.14781867

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Medical Comorbidities for Paradoxical Vocal Fold Motion (Vocal Cord Dysfunction) in the Military Population

Journal of Voice ◽

10.1016/j.jvoice.2009.03.007 ◽

2010 ◽

Vol 24 (6) ◽

pp. 728-731 ◽

Cited By ~ 12

Author(s):

Joyce Gurevich-Uvena ◽

Joseph M. Parker ◽

Thomas M. Fitzpatrick ◽

Matthew J. Makashay ◽

Michelle M. Perello ◽

...

Keyword(s):

Vocal Cord ◽

Vocal Fold ◽

Vocal Cord Dysfunction ◽

Military Population ◽

Medical Comorbidities ◽

The Military ◽

Vocal Fold Motion ◽

Paradoxical Vocal Fold Motion

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

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2016.06.045 ◽

2017 ◽

Vol 69 (1) ◽

pp. 18-23 ◽

Cited By ~ 14

Author(s):

Nizhoni Denipah ◽

Christopher M. Dominguez ◽

Erik P. Kraai ◽

Tania L. Kraai ◽

Paul Leos ◽

...

Keyword(s):

Vocal Cord ◽

Vocal Fold ◽

Vocal Cord Dysfunction ◽

Acute Management ◽

Vocal Fold Motion ◽

Paradoxical Vocal Fold Motion

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Visual biofeedback for paradoxical vocal fold motion (PVFM)

Journal of Otolaryngology - Head and Neck Surgery ◽

10.1186/s40463-021-00495-0 ◽

2021 ◽

Vol 50 (1) ◽

Author(s):

Rachelle Alyce LeBlanc ◽

Daniel Aalto ◽

Caroline C. Jeffery

Keyword(s):

Vocal Fold ◽

Medication Use ◽

Vocal Folds ◽

Asthma Medication ◽

Secondary Outcome ◽

Post Intervention ◽

Visual Biofeedback ◽

Vocal Fold Motion ◽

Paradoxical Vocal Fold Motion

Abstract Objectives Paradoxical vocal fold motion (PVFM) is a common condition where the vocal folds inappropriately adduct during inspiration. This results in dyspnea and occasionally significant distress. The condition is thought to be primarily functional, with behavioural therapy considered mainstay in the non-acute setting. However, practice variations and limited access to speech language pathology (SLP) services can pose management challenges. We aimed to examine the efficacy of surgeon performed visual biofeedback as first-line treatment for PVFM. Study design Prospective, non-randomized, non-comparative clinical study. Methods Adult patients referred for possible PVFM and congruent laryngoscopy findings over a two-year period were included. Patients were excluded if they presented in acute distress, had alternate diagnosis to explain symptomology and/or coexisting untreated lower respiratory pathology. Patients underwent immediate surgeon-performed visual biofeedback on the same visit day. The primary outcome of interest was change in Dyspnea Index (DI) scores pre- and post-intervention 3 months follow-up. The secondary outcome measured was change in asthma medication use from baseline to follow-up. Results Of 34 patients presenting, 25 met inclusion criteria. Of these, 72% were female with an average age of 36.9 ± 14.1. Approximately 48% of patients had a diagnosis of well-controlled asthma at presentation and co-morbid psychiatric diagnoses were common (52%). Pre- and post-intervention analysis showed significant improvement in DI scores (p < 0.001) and reduction in bronchodilator use (p = 0.003). Conclusion This is a prospective study that evaluates the role of visual biofeedback in PVFM patients. Our data suggests that visual biofeedback effectively reduces short-term subjective symptoms and asthma medication use. Level of evidence 3 Graphical abstract

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Vocal Cord Dysfunction/Paradoxical Vocal Fold Motion

Primary Care Clinics in Office Practice ◽

10.1016/j.pop.2007.09.005 ◽

2008 ◽

Vol 35 (1) ◽

pp. 81-103 ◽

Cited By ~ 43

Author(s):

Marcy Hicks ◽

Susan M. Brugman ◽

Rohit Katial

Keyword(s):

Vocal Cord ◽

Vocal Fold ◽

Vocal Cord Dysfunction ◽

Vocal Fold Motion ◽

Paradoxical Vocal Fold Motion

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Paradoxical Vocal Fold Motion in Children and Adolescents

Language Speech and Hearing Services in Schools ◽

10.1044/0161-1461(2004/034) ◽

2004 ◽

Vol 35 (4) ◽

pp. 353-362 ◽

Cited By ~ 39

Author(s):

Mary J. Sandage ◽

Sherri K. Zelazny

Keyword(s):

Behavioral Interventions ◽

Vocal Fold ◽

Behavioral Treatment ◽

Vocal Folds ◽

School Nurses ◽

Management Evaluation ◽

Adolescent Population ◽

Speech Language Pathologist ◽

Vocal Fold Motion ◽

Paradoxical Vocal Fold Motion

Paradoxical vocal fold motion (PVFM) is a complex adductory disorder of the vocal folds that frequently is mistaken for asthma. PVFM typically requires behavioral intervention by a trained speech-language pathologist for complete resolution of the symptoms. Once thought to be limited to adults, PVFM has been increasingly documented and successfully treated in the child and adolescent population. Understanding PVFM requires thorough knowledge of the differential diagnoses, the clinical features of PVFM, the differentiation of PVFM from asthma, the medical professionals involved in the diagnosis and treatment, and the behavioral interventions that are commonly prescribed. Teachers, school nurses, and coaches may be the first professionals to see the symptoms in children and assume that they have asthma. Successful referral, diagnosis, and behavioral treatment requires a team of individuals in the child’s community, including the school speech-language pathologist, who can work together to ensure identification and resolution of the symptoms. This article discusses etiologies, differential diagnosis, referral, medical management, evaluation, and behavioral treatment of the child or adolescent with PVFM.

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Paradoxical vocal fold motion: respiratory retraining to manage long-term symptoms

Jornal da Sociedade Brasileira de Fonoaudiologia ◽

10.1590/s2179-64912012000100014 ◽

2012 ◽

Vol 24 (1) ◽

pp. 80-85 ◽

Cited By ~ 6

Author(s):

Victoria Hatzelis ◽

Thomas Murry

Keyword(s):

Vocal Fold ◽

Laryngopharyngeal Reflux ◽

Extended Period ◽

Vocal Folds ◽

Post Treatment ◽

Shortness Of Breath ◽

Patient Reported ◽

Vocal Fold Motion ◽

Paradoxical Vocal Fold Motion

Paradoxical vocal fold motion (PVFM) is a laryngeal disorder characterized by abnormal adduction of the vocal folds during respiration. It is caused by a multitude of etiologies and their interactions. In the current study, a 24-year-old female patient with a 12-year complaint of shortness of breath was diagnosed with paradoxical vocal fold motion following nasal endoscopy, spirometry testing and detailed case history analysis. She had no history or indication of laryngopharyngeal reflux or chronic cough. She performed respiratory retraining exercises three to four times daily for a period of four weeks, and continued daily exercises for two additional months as needed. After four weeks of treatment, abnormal vocal fold adduction continued to be seen on endoscopy and the patient was mildly symptomatic. One month post-treatment, there was no abnormal vocal fold adduction and the patient reported rare shortness of breath. At three months post-treatment, there was no abnormal vocal fold adduction and the patient no longer reported shortness of breath. She reported normal breathing with no symptoms one year later. The results suggest that non-pulmonary related shortness of breath treated with respiratory retraining can effectively eliminate dyspnea in patients with long term breathing difficulties caused by paradoxical vocal fold motion. Resolution may require treatment over an extended period of time.

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The Effect of Exercise on Respiratory Resistance in Athletes With and Without Paradoxical Vocal Fold Motion Disorder

American Journal of Speech-Language Pathology ◽

10.1044/2015_ajslp-14-0110 ◽

2015 ◽

Vol 24 (3) ◽

pp. 470-479 ◽

Cited By ~ 4

Author(s):

Sally J. K. Gallena ◽

Nancy Pearl Solomon ◽

Arthur T. Johnson ◽

Jafar Vossoughi ◽

Wei Tian

Keyword(s):

Repeated Measures ◽

Vocal Fold ◽

Female Athletes ◽

Exercise Duration ◽

Treadmill Running ◽

Respiratory Resistance ◽

The Difference ◽

Airflow Perturbation Device ◽

Vocal Fold Motion ◽

Paradoxical Vocal Fold Motion

Purpose An investigational, portable instrument was used to assess inspiratory (R i ) and expiratory (R e ) resistances during resting tidal breathing (RTB), postexercise breathing (PEB), and recovery breathing (RB) in athletes with and without paradoxical vocal fold motion disorder (PVFMD). Method Prospective, controlled, repeated measures within-subject and between-groups design. Twenty-four teenage female athletes, 12 with and 12 without PVFMD, breathed into the Airflow Perturbation Device for baseline measures of respiratory resistance and for two successive 1-min trials after treadmill running for up to 12 min. Exercise duration and dyspnea ratings were collected and compared across groups. Results Athletes with PVFMD had lower than control R i and R e values during RTB that significantly increased at PEB and decreased during RB. Control athletes' R e decreased significantly from RTB to PEB but not from PEB to RB, whereas R i did not change from RTB to PEB but decreased from PEB to RB. Athletes without PVFMD ran longer, providing lower dyspnea ratings. Conclusion Immediately following exercise, athletes with PVFMD experienced increased respiratory resistance that affected their exercise performance. The difference in resting respiratory resistances between groups is intriguing and could point to anatomical differences or neural adaptation in teenagers with PVFMD. The Airflow Perturbation Device appears to be a clinically feasible tool that can provide insight into PVFMD and objective data for tracking treatment progress.

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