1. Paradoxical Vocal Fold Movement (PVFM) Also know as... Vocal Cord Dysfunction Vocal Cord Malfunction Laryngeal Dyskinesia Inspiratory Adduction Paroxysmal Laryngospasm Functional Airway Obstruction Adductor Laryngeal Breathing Disorder Fogerty 4/8/03

2. Definition Of PVFM Inappropriate adduction of the vocal folds during inhalation Two physiological variants: 1. Adduction of true and false folds throughout the breathing cycle 2. Adduction during deep inspiration and slight abduction on expiration

3. Epidemiology incidence / prevalence unclear –may be as high as 40% of patients with asthma age of onset: 9+ years usually female

4. Etiology May be... Coexistent with asthma Precipitated by emotional events Occurring with or without organic conditions (Mathieson, 2001)

5. Types (in order of prevalence) Gastroesophageal reflux Psychogenic stridor Respiratory-type laryngeal dystonia Drug-induced laryngeal dystonic reactions Asthma-associated laryngeal dysfunction Abnormalities that affect the brainstem (Koufman, 1994)

6. Signs & Symptoms sensation of throat being closed dramatic episodes of breathing difficulty stridor pt. struggles to inspire shortness of breath ‘wheezing’ cough

7. Triggers shouting or coughing physical exercise acid reflux breathing cold air irritants (smoke, pollen, etc.) psychosocial issues neurological issues (ASHA, 2001)

8. Diagnosis - History Throat tightness voice changes during attack little/no improvement with asthma Tx no night awakening secondary to attack

9. Physical Exam ‘clean wheeze’ ask pt. to pant (may improve symptoms) ask pt. to hold breathPulmonary normal lung volume relatively normal expiratory flows

10. Laryngoscopy “crucial in making the diagnosis” (Koufman, 1994) Classic Pattern VF adduction of anterior two-thirds during inspiration Posterior glottal chink during closure on inspiration 50% will have normal VF motion when asymptomatic

11. Laryngoscopic Examination alternatively phonate /i/ and sniff, rapidly take deep breaths cough, throat clear, chuckle count to fifty, rapidly and loudly read a written passage in a loud voice sing (Koufman, 1994)

12. Differential Features (Koufman, 1994)

13. Confused Diagnoses Asthma Other causes of laryngeal obstruction –bilateral vocal fold paralysis –laryngeal stenosis Abduction may be inconsistent, incomplete, inappropriate in PVFM, but must occur for a diagnosis Many patients have inappropriately received intubation or tracheostomy. Sometimes multiple times!

14. Behavioral Treatment Understanding anatomy and physiology of the laryngeal system –learn to control vocal fold movement Performing relaxation exercises –differential relaxation of excess tension in upper body Focusing –focal breathing on face rather than neck Reducing precipitators –daily log to chart precipitators of PVFM episodes

15. Additional Treatment Heliox - 80% helium, 20% oxygen –relieves most severe symptoms Psychological intervention

16. References