Friday, July 14, 2017

Paradoxical Vocal Cord Dysfunction


During the springtime, here in Missouri, we have a surge of paradoxical vocal cord dysfunction referrals (PVCD). PVCD is a neurological disorder that involves the vocal folds when exposed to a “trigger.” Patients with PVCD typically have complaints of difficulty breathing, tightness in the throat, and even at times syncope episodes. Some PVCD symptoms can be so extreme that hospitalization is required.

PVCD is complex and can be difficult to diagnose. Some patients with PVCD have been misdiagnosed with asthma and there are some patients that have PVCD and asthma. When a patient is having a PVCD event the vocal folds adduct (come together) during inhalation and sometimes exhalation. Picture A shows adducted vocal folds while picture B shows abducted vocal folds. Adducted vocal folds during respiration can cause difficulty breathing and a stridor.



In this blog post pseudonyms, triggers/contributory factors, evaluation process, treatment, and resources will be reviewed. This blog post is not meant to replace an evaluation. It is meant to provide cursory information regarding PVCD and resources for speech-language pathologists and patients.

Pseudonyms
A physician may diagnose you with PVCD. However, there are several pseudonyms. Listed are just a few of the pseudonyms for PVCD:
  • ·      Vocal cord dysfunction
  • ·      Pseudo-asthma or fictitious asthma
  • ·      Episodic laryngeal dyskinesia
  • ·      Munchausen’s stridor


Triggers and Contributory Factors
Most individuals with PVCD have recognized their own triggers. A trigger is something that can cause a PVCD event to occur. Some triggers or contributory factors may include the following:
  • ·      Gastroesophgeal reflux disease
  • ·      Stress
  • ·      Allergies
  • ·      Exercise induced
  • ·      Other environmental triggers such as strong odors, candles, or chemicals.


Evaluation Process
A thorough evaluation is critical to properly diagnose PVCD. A pulmonary function test, methacoline challenge, and laryngoscopy are common evaluations in determining PVCD. Pulmonary function tests are a group of tests that evaluate how well the lungs are working. A methacoline challenge can help in the differential diagnosis process. It can determine if an individual has asthma. Typically, if an individual has asthma there will be a “scooped out” expiratory curve. PVCD will present with a blunted inspiratory curve.



Laryngoscopy is a procedure where a small endoscope is placed through the nasal cavity and hovers in the hypopharynx. From this position the vocal folds can be visualized. Ideally, when evaluating for PVCD with laryngoscopy the evaluator (a speech-language pathologist, ENT, or pulmonologist) will attempt to stimulate a PVCD event. This can be done by having the patient exercise before or during the scope, introducing strong scents, or by having the patient complete an intense respiratory task such attempting to count to 100 on one breath.



Treatment
There are several methods to treat PVCD. Each individual is unique therefore treatment is not a “one size fits all.” A speech-language pathologist may help a patient learn breathing techniques such as inhaling through the nose and then exhaling with pursed lips. The speech-language pathologist may also educate on GERD management. Other team members might be needed to help manage PVCD such as a psychologist, allergist, ENT, dietician, and primary care physician.

Resources and CEU’s
I would highly recommend the following resources if you are interested in learning more about PVCD!


References

Ben-Joseph, E. P. (Ed.). (2013, March). Surgeries and Procedures: Laryngoscopy. Retrieved July 14, 2017, from http://kidshealth.org/en/parents/emmi-laryngoscopy.html

Deckert, J., & Deckert, L. (2010, January 15). Vocal Cord Dysfunction. Retrieved July 14, 2017, from http://www.aafp.org/afp/2010/0115/p156.html

Palla, J., & Friedman, A. D. (2016). Paradoxical Vocal Cord Motion in Pediatric Patients. Pediatric Annals, 45(5). doi:10.3928/00904481-20160331-01


Pruitt, B. (2013, February 5). Asthma or Vocal Cord Dysfunction? Retrieved July 14, 2017, from http://www.rtmagazine.com/2013/02/asthma-or-vocal-cord-dysfunction-2/

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