Paradoxical Vocal Fold Movement (PVFM)

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 breath Pulmonary • 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