VCD/PVFM: Role of the SLP in Management

CODI 504 Voice Disorders
Lecture 8: VOCAL CORD DYSFUNCTION: Role of the SLP in Management

1. Background of the Condition

First reported in 1983 by physicians at National Jewish Medical and Research Center (Christopher, et al, 1983)
Condition causes asthma like symptoms
Cause is vocal fold closure or adduction during inhalation
Prevalence of VCD is unknown - estimates as high as 40% of patients thought to have asthma ( Landwehr, et al., 1996)

2. Background (cont.)

Also referred to as paradoxical vocal cord movement (PVCM)
Normal phasic motion of vocal cords
Two variants based on physiology
Adduction of true and ventricular vocal folds throughout breathing cycle with both inspiratory & expiratory stridor
Adduction during deep inspiration and slight abduction on expiration (Kellman & Leopold, 1982)
Persistence and degree of inappropriate glottic closure varies

3. Etiology

Etiology also varies across patients
Originally thought to be psychogenic - a type of conversion disorder
Original study identified 5 patients with symptoms of asthma, non-responsive to standard treatment, chronic hx of repeated “attacks” across 1 -13 years
All had history of psychological problems
Referred to speech pathology and counseling

4. Etiology II

Experts now postulate other etiologies (Bless & Swift, 1995)
Hyper-reactivity of upper airway
Neurogenic
Psychological
Pharmacological
In children and adolescents links are being made to exercise-induced bronchospasms ( Landwehr, et al., 1996)) & cystic fibrosis (Rusakow, et al., 1991)
In adults exposure to inhaled irritants & GERD are thought to be associated with the condition (Perkner, et al., 1998)

5. Etiology III

In both populations, physical and sexual abuse has also been identified as possible etiology (Freedman, et al., 1991; Fuller, 2000)
VCD can and often does co-exist with asthma
Classic Signs/Symptoms

Primary symptoms are non-vocal
Throat tightness and/or chest tightness
Shortness of breath
Cough
Wheezing (stridor)
Swallowing difficulty
Voice symptoms, if present, may range from chronic or intermittent weak hoarse voice to aphonia

7. Diagnosis of VCD

Difficult because of the overlap of symptoms with asthma
Careful case history
Pulmonary tests negative for asthma; flow volume loop, especially for inspiration, is flat
Lack of improvement of symptoms with asthma tx including oral steroids
Laryngoscopy using flexible scope

Adduction of vocal folds during inspiration
Posterior glottal chink during closure on inspiration

8. Triggers of VCD

Upper respiratory infections
Fumes & odors
Cigarette smoke
Singing
Emotional upset
Post-nasal drip
Exercise

9. VCD and GERD

James A Koufman, M.D. (Wake Forest University Center for Voice Disorders)
gastroesophageal or laryngopharyngeal reflux is most common cause of VCD (at least in adults)
Attacks are the result of direct contact of gastric fluids with laryngopharyngeal structures
Symptoms

Sudden-onset , noisy, obstructed breathing, “choking” episodes,
May deny heartburn but report other symptoms of laryngopharyngeal reflux including hoarseness, difficulty swallowing, sensation of lump in the throat, chronic throat clearing or cough, too much throat mucous and/or “post-nasal drip”

10. Psychogenic Causes of VCD

Almost all are teenagers
Occurs with sudden onset and offset
May have difficulty expressing anger, sadness & pleasure
Obsessive-compulsive personality, passive-dependent personality or a borderline personality
Exercise, physical activity and stressful situations trigger VCD
Significant subgroup may be female athletes

11. Neurogenic & Pharmacological Etiologies

Respiratory-type adductor laryngeal dystonia

Hyperadduction during inspiration w/o significant voice problems
Respond to botulinum toxin

Brainstem abnormalities

VCD along with bilateral abductor paralysis, apnea
Severe closed head injury, Chiari malformations, brainstem strokes

Drug-induced laryngeal dystonic reactions

Associated with use of neuroleptic drugs; anesthetics
Stridor along with other extrapyramidal symptoms
Symptoms are temporary & can be reversed

12. VCD and Asthma

Subset of asthma patients also have VCD
If inspiratory stridor is present, VCD should be considered
Blager study (1998) - pt.’s description of site of constriction may be predictive
Presence of PVCM on transnasal fiberoptic exam is diagnostic

13. Treatment of VCD

Acute attacks may require hospitalization
Breathe mixture of helium (70%) and oxygen (30%)
Begin at 5 minutes - gradually reduce time (Blager, 1996)
Severe cases may require tracheotomy
Specific breathing techniques taught by speech pathologist
Counseling/verbal support
Psychological treatment/hypnosis
If coming off of large amounts of corticosteroids will need close supervision of physician

14. Speech Therapy for VCD

Florence Blager (National Jewish Medical)
Support - acknowledge real nature of respiratory distress
Practice breathing exercises during normal periods to prepare for attacks
Diaphragmatic breathing
Wide-open throat breathing
Focus on exhalation
Create self-awareness/ownership of the breathing sequence

15. Relaxed Throat Breathing

Sit with hand on abdomen
Make hand go out and in with exhalation
Inhale with relaxed throat, with tongue relaxed on floor of mouth, and lips gently closed
Exhale easily on /s/ - gradually extending exhalation
Do at least 5 breaths several times a day and at any sign of tension, tightness or stridor
Rationale

focus on breathing reduces tendency to panic & increase tension;
nasal inhalation increases full glottal abduction;
attention to exhalation relaxes system

16. Summary

VCD or PVCM is a sometimes confusing condition affecting the larynx
Occurs when there is inappropriate closure of the vocal cords during inhalation
Respiratory obstruction can be intermittent or continuous; mild or severe depending on the cause
Symptoms are similar to those of asthma
Behavioral therapy along with counseling is effective for most cases