Transcript Paradoxical Vocal Fold Movement

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
Definition Of PVFM
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Inappropriate adduction of the vocal folds
during inhalation
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Two physiological variants:
1. Adduction of true and false folds
throughout the breathing cycle
2. Adduction during deep inspiration and
slight abduction on expiration
Epidemiology
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incidence / prevalence unclear
– may be as high as 40% of patients with asthma
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age of onset: 9+ years
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usually female
Etiology
May be...
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Coexistent with asthma
 Precipitated by emotional events
 Occurring with or without organic
conditions
(Mathieson, 2001)
Types (in order of prevalence)
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Gastroesophageal reflux
Psychogenic stridor
Respiratory-type laryngeal dystonia
Drug-induced laryngeal dystonic reactions
Asthma-associated laryngeal dysfunction
Abnormalities that affect the brainstem
(Koufman, 1994)
Signs & Symptoms
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sensation of throat being closed
dramatic episodes of breathing difficulty
stridor
pt. struggles to inspire
shortness of breath
‘wheezing’
cough
Triggers
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shouting or coughing
physical exercise
acid reflux
breathing cold air
irritants (smoke, pollen, etc.)
psychosocial issues
neurological issues
(ASHA, 2001)
Diagnosis - History
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Throat tightness
 voice changes during attack
 little/no improvement with asthma Tx
 no night awakening secondary to attack
Physical Exam
‘clean wheeze’
 ask pt. to pant (may improve symptoms)
 ask pt. to hold breath
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Pulmonary
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normal lung volume
 relatively normal expiratory flows
Laryngoscopy
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“crucial in making the diagnosis” (Koufman, 1994)
Classic Pattern
 VF adduction of anterior two-thirds during
inspiration
 Posterior glottal chink during closure on
inspiration
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50% will have normal VF motion when
asymptomatic
Laryngoscopic Examination
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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)
Differential Features
Pattern
Duration
Hoarseness
Airway Support
Needed
Reflux
Paroxysmal
Minutes
Usually
Almost never
Dystonia
Daytime
Hours
Rarely
Sometimes
Psychogenic
Paroxysmal
Variable
Never
Sometimes
Brainstem
Continual
Continual
Sometimes
Usually
(Koufman, 1994)
Confused Diagnoses
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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!
Behavioral Treatment
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Understanding anatomy and physiology of
the laryngeal system
– learn to control vocal fold movement
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Performing relaxation exercises
– differential relaxation of excess tension in upper
body
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Focusing
– focal breathing on face rather than neck
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Reducing precipitators
– daily log to chart precipitators of PVFM episodes
Additional Treatment
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Heliox - 80% helium, 20% oxygen
– relieves most severe symptoms
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Psychological intervention
References
ASHA (2001). Paradoxical vocal fold movement. Retrieved from: http://www.asha.org/speech/
disabilities/vocal_fold.cfm.
Buddiga, P. & O’Connell, M. (2002). Vocal cord dysfunction. Retrieved from:
http://www.emedicine.com/med/topic3563.htm.
Colton, R. & Casper, J. (1990). Understanding Voice Problems: A Physiological Perspective for
Diagnosis and Treatment. Baltimore: Williams & Wilkins.
Koufman, J. (1994). The differential diagnosis of paradoxical vocal cord movement. The Visible
Voice, 3(3). Retrieved 4/3/03 from: http://www.bgsm.edu/voice/ paradoxical.html.
Mathieson. (2001). Greene & Mathieson’s The Voice & Its Disorders. (6th Ed.) Philadelphia: Whurr
Publishers.
Roussel, N. (n.d.). Vocal cord dysfunction: Role of the SLP in management. Retrieved 4/3/03 from
University of Louisiana at Lafayette: http://www.usc.loisiana.edu/~ncr3025/roussel/codi504/
VCD.html
Shreve, M. (1997). Vocal cord dysfunction. Retrieved from University of Minnesota:
http://www.peds.umn.edu/divisions/pccm/pulm/shreve/VCD.html
Stemple, J., Glaze, L., & Klaben, B. (2000). Clinical Vocal Pathology: Theory and Management. (3rd
ed.). Singular Publishing.
Von Berg, S. (n.d.) Unmasking voices disorders: Paradoxical vocal fold movement. Retrieved 4/3/03
from ASHA Website: http://www.asha.org
Weiss, T. & Quinn, F. (2001). Vocal cord dysfunction: Paradoxical vocal cord motion - a thorough
review. Grand Rounds Presentation, UTMB Dep. of Otolaryngology. Retrieved from:
http://www.utmb.edu/Grnds/Vocal-Cord-2001-07/VCD-2.hmt#_ednref1