1. SPPA 640 Voice Disorders Paradoxical Vocal Fold Motion a.k.a….  Munchausen’s Stridor  Psychogenic Stridor  Functional Inspiratory Stridor  Functional upper airway obstruction  Atypical asthma  Factitious asthma  Emotional laryngeal wheezing  vocal cord dysfunction  Adult spasmodic croup  Functional abduction paresis  Emotional laryngospasm  Episodic laryngeal dyskinesia  pseudoasthma

2. SPPA 640 Voice Disorders Paradoxical Vocal Fold Motion (PVFM): What is it?  Primarily a breathing impairment upper airway (extrathoracic) obstruction vocal folds adducting (closing) when they should be abducting (opening) Inspiration, expiration or both occurs in isolation, or with asthma

3. SPPA 640 Voice Disorders Paradoxical Vocal Fold Motion  Etiology Unknown psychological factors are implicated but well controlled studies are lacking

4. SPPA 640 Voice Disorders Paradoxical Vocal Fold Motion  Commonly induced by Stress Exercise gastroesophageal reflux (nocturnal) Post-nasal drip Respiratory irritants cold air panic associated with asthma

5. SPPA 640 Voice Disorders PVFM: Patient Characteristics  More common in girls/women 3-4/1 female/male ratio  Children, adolescents, adults 20-40 years  Diagnosis of uncontrolled asthma  Anomalous findings for severe asthma Brugman & Newman, (1993) Kuppersmith et al. (1993)

6. SPPA 640 Voice Disorders PVFM: Some Characteristics May see  Hx of asthma treatment  Previous emergency intubation (rare)  Hx of tracheotomy (rare)  Chronic steroid use  Hoarseness and other voice changes

7. SPPA 640 Voice Disorders Assessment of PVFM  Team approach including Speech pathology Otolaryngology Pulmonary function Gastroenterology (GERD/LPR) Allergy Psychiatry

8. SPPA 640 Voice Disorders PVFM: Signs Clinical  Stridor  rapid breathing  accelerated pulse rate  anxiety/panic  Auscultation identifies the larynx as site of obstruction

9. SPPA 640 Voice Disorders PVFM: Signs Laryngoscopy  Adduction of anterior 2/3’s of TVFs during inspiration  small posterior diamond shaped glottic chink  Mediolateral compression of ventricular folds  Exam normal when asymptomatic

10. SPPA 640 Voice Disorders PVFM: Signs Laryngoscopic Assessment (SLP & ENT)  Tidal breathing (rest)  Forced inspiration, forced expiration  Panting  Sniffing  Repeated rapid deep inspirations  Exercise challenge

11. SPPA 640 Voice Disorders PVFM: Signs Pulmonary Function (Spirometry) When symptomatic… PVFM  Forced vital capacity: normal  Forced expiratory volume in 1 sec: normal  Inspiratory flow: reduced  Expiratory flow/inspiratory flow ratio: elevated  Bronchodilator treatment: limited improvement Asthma  Forced vital capacity: normal  Forced expiratory volume in 1 sec: reduced  Expiratory flow/inspiratory flow: normal or reduced  Bronchodilator treatment: marked improvement

12. SPPA 640 Voice Disorders Tilles (2003)

13. SPPA 640 Voice Disorders PVFM: Bronchoprovocation Methacholine challenge Induces small airway narrowing A negative response will help exclude asthma

14. SPPA 640 Voice Disorders PVFM: Provocation Exercise challenge Helpful for eliciting symptoms in certain clients Does not differentiate asthma and PVCD Allows signs/symptoms to be observed so that a Dx may be made

15. SPPA 640 Voice Disorders PVFM: Psychosocial Characteristics Reports of  Perfectionism  Obsessive-compulsive features  Anxiety disorders (panic)  Somatization disorder  Difficulty expressing anger, sadness and fear  Conversion reaction (??) Rate of psychopathology no different from severe asthmatics Mathers-Schmidt (2001)

16. SPPA 640 Voice Disorders Mathers-Schmidt (2001)

17. SPPA 640 Voice Disorders PVFM: Management Education  Review normal airway function  Review test results  Discuss possible precipitants stress, exercise, GERD, panic etc

18. SPPA 640 Voice Disorders PVFM: Management  Quick controls (+/- endoscopic feedback) Sniffing, 3 quick sniff in, slow controlled exhalation on /s/ or /sh/, lips pursed Manual lowering of larynx Panting: shallow and limited number of times (but not with asthma)

19. SPPA 640 Voice Disorders PVFD: Management  Teach relaxed throat breath, awareness of laryngeal muscle tension Flatten tongue, drop jaw, inhale through nose and exhale on /s/  Abdominal breathing pattern  Controlled exhalation  General relaxation exercises (audiotapes)  Stress management, counseling  Antireflux protocol  Biofeedback using endoscope