Download Paradoxical Vocal Fold Motion (PVFM)

Paradoxical Vocal Fold Motion (PVFM)
a.k.a. VCD
Thomas Murry, PhD
Weill Cornell Medical College
New York, New York
Paradoxical Vocal Fold Motion (PVFM)
a.k.a. VCD
In accordance with Weill Cornell Medical
College Policy:
I have no financial or other
conflicts to disclose with regard to the
information I will present today.
Paradoxical Vocal Fold Motion
a.k.a. VCD: Historical Overview
Paradoxical Vocal Fold Motion PVFM



A disorder of abnormal adductory vocal fold
motion that usually occurs during inspiration.
During episodes of PVFM, the vocal folds
partially or fully adduct, restricting the passage
of air to the lungs. Also known as VCD.
Common patient symptoms


Shortness of breath, cough, choking, voice changes
May have other multiple complaints
What are we talking about?
 History: Shortness of breath
- 18 months, cough, choking
sensation.
 No asthma, bronchitis or
pulmonary dysfunction
 Unchanged with PPI X 4
months
History of PVFM: Early Observations

Dunglison, R. – 1842 Described disorders of laryngeal muscles
brought on by “hysteria in females” Called it “hysterical croup”
 Flint, A. The Principles and Practices of Medicine, 1842 reported in 2
adult males “laringusmus stridulus”
 Mackenzie, M. -1869 First visual observation of vocal folds closing
during inspiration in hysteric adults with stridor. First to attribute stridor
to “paradoxic closure.”

Osler, W. –1902 The Principles and Practices of Medicine 4th Ed.
Defined a stridorous condition “spasm of the muscles may occur with
violent inspiratory efforts and may even lead to cyanosis”
Cause was considered “purely psychogenic”
 Patterson, R. et. al 1974 “Munchausen’s stridor”
33 y.o. woman, 15 hospital admissions. No single diagnosis
Does this remind you of the early days of Spasmodic Dysphonia ?
Since Then: Terms to describe abnormal vocal fold
movement in the absence of other medical diseases
Munchausen stridor
Nonorganic stridor
Nonorganic upper airway obstruction
Paradoxical vocal cord adduction
Paradoxical vocal fold dysfunction (preferred by speech pathologists;
Patel 2004)
Paradoxical vocal fold motion
Paradoxical vocal cord movement
Paroxysmal laryngospasm
Paroxysmal vocal cord dysfunction
Paroxysmal vocal cord motion
Pseudoasthma
Adductor breathing dystonia
Adult spasmodic croup
Asthma-like disorder (Lowhagen, 2002)
Asthmatic extra thoracic upper airway obstruction
Atypical asthma
Benign paradoxical vocal cord motion
Bilateral abductor vocal cord paresis
Emotional laryngeal wheezing
Emotional laryngospasm
Episodic laryngeal dyskinesia
Episodic laryngospasm
Episodic paroxysmal laryngospasm
Exercise-induced laryngomalacia
Exercise-induced laryngospasm of emotional origin
Expiratory laryngeal stridor
Factitious asthma
False croup
Familial Munchausen stridor
Fictitious asthma
Functional abduction paresis
Functional breathing disorder
Functional laryngeal dyskinesia
Functional stridor
Functional upper airway obstruction
Functional vocal cord paralysis
Glottic dysfunction
Hysteric croup
Hysterical stridor
Inspiratory vocal cord dysfunction
Irritable larynx syndrome
Irritant-associated vocal cord dysfunction
Laryngeal asthma
Laryngeal dysfunction
Laryngeal dyskinesia
Laryngeal respiratory dystonia
Laryngeal spasm
Laryngeal stridor
Laryngismus fugax
Laryngismus stridulous
Laryngoneurosis
Munchausen syndrome presenting as bronchospasm
Pseudo-steroid-resistant asthma
76 terms
Are they really
the same
disease!!
Psychogenic laryngeal dysfunction
Psychogenic respiratory distress
Psychogenic stridor
Psychogenic stridor caused by a conversion disorder
Psychogenic upper airway obstruction
Psychogenic wheezing
Psychosomatic stridor
Psychosomatic wheezing
Respiratory glottic spasm
Reversible upper airway obstruction
Sleep-related laryngospasm
Spasmodic croup
Spasmodic croup in the adult
Stress-inducible functional laryngospasm (Schmidt M, 1985)
Suffocative laryngismus
Thymic asthma
Upper airway dysfunction syndrome
Upper airway obstruction misdiagnosed as asthma
Variable extrathoracic obstruction
Variable vocal cord dysfunction
Vocal cord dysfunction masquerading as asthma
Vocal cord dyskinesia
Vocal cord malfunction
Brugman, Chest, 2009
Direct Laryngeal Evidence



Rogers, J. et al. 1978 Case Report
Paradoxical motion of the vocal folds observed at
rest in patients with shortness of breath and cough
refractory to typical asthma treatment
 No obvious neurological disorders
 No vocal fold pathology- only chronic cough
“Paradoxical Movement of Vocal Cords”
Rogers, J. Stell, P.
J. Laryngol. Otol, 1978
Christopher, Wood, Eckert, Blager et al. 1983

Vocal Cord Dysfunction Presenting As Asthma

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
Patients with a history of failed treatments for asthma (with S.O.B.)
Subjects with cough, laryngospasm and “choking”
Little or no evidence of GERD
Anxiety level similar in severity to other voice/speech disorders
RESULTS:
 Endoscopic examination at rest
 No evidence of airway obstruction or laryngeal pathology

Conclusion VCD/PVFM: A movement/breathing disorder
related to abnormalities of the larynx
New Eng. J. Med; 308, 1983: 1566-70
Since Then . . . (1983-2010)
 Strong interest in PVFM/VCD by ENT, Pulm. Allergy, GI and
SLP
 . Lakin RC. et al. 1984 Chest

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Newman, KB et al. 1994 Sem. In Crit. Care Med.
Andrianopoulos Gallivan, et al 2000 J. Voice
Altman, Simpson 2002 Oto. HNS
Poelmans, 2004 J. Digestive Dis. Sci. 2004
Mathers-Schmidt, BA et al. 2005 J. Voice
Sacre-Haouri, JA 2006 Rev. Aler. Mex.
Cukier-Blaj, et al. 2009 Laryngoscope
and others . . .
Studies of demographics, pulmonary function,
laryngeal function, reflux related issues , treatments
Recent Data
Improved SLN response correlated with reduced
PVFM, cough and patient self-assessment of LPR
 PVFM may represent a compensatory motor response of
efferent fibers in the RLN acting in response to hyposensitivity
of the Afferent fibers of the SLN
 Motor system actively participates in the protective system of the
airway
Typical Case Histories
 Exact onset of PVFM often unknown





Post URI
Post intubation
Post blunt trauma to head/neck
Tension – speaking, activity
Exercise induced at times, other times relieved
by exercise
 Mouth breather
 Other - UNKNOWN
PVFM Demographics
 Under-recognized
 Mean time to diagnosis 4.5 years
Patel, Merati 2004 O-HNS
 Often confused with asthma
 Problems caused from misdiagnosis
 Inappropriate medical interventions
 Intubation
 Tracheotomy
Vertigan, AE. et al 2006 J. Voice
Demographics and Clinical Features of PVFM/VCD Populations
In previously diagnosed asthma/pulmonary disorders
Total
Adults
Pediatrics
1,209 (76%)
3.2:1
42
19-82
…
2.9
389 (24%)
2.5:1
14
0.02-18
…
2.4
Number of patients
Female:Male
Median age (yr)
Age range (yr)
Duration of symptoms (mo)
Hospitalizations
(mean/patient)
1,598
2.9:1
29
0.02-82
29
2.7
ICU admissions
42
18
24
Patients intubated
75
55
20
Patient with tracheotomy
23
16
7
Loss of consciousness or cyanosis
20
14
6
History of asthma elicited
Asthma documented
72
39
572
47
299
24
Brugman, Chest 2009
A Clinician’s Dilemma

Multiple systems interaction

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
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
Laryngeal: Sensory/Motor hypersensitivity
Pulmonary: Asthma/Pulmonary obstruction
Phonatory: Speech vs non-speech breathing
Behavioral: Psychological/Psychiatric/Habituation
Digestive: Gastroesophageal disorder
Rhinoallergenic: Pollution/Irritants
Multiple diagnoses/treatments: May be dependent on the specialist consulted
Overlapping Conditions
 PVFM, Chronic Cough, Shortness of Breath
 Focus is laryngeal, not pulmonary
 Findings of one often seen in others
 Cause and effect not well understood
 Triggers may be similar
 Triggers may be many
 Reflux treatment alone fails in high percentage of
cases
PVFM
 Blager: Conceptual Model
 Vulnerable neuro-phonatory-behavioral system
impacted by


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Long-term functional maladaptive breathing pattern
Laryngeal irritation/injury
Educational Issues – high achiever
May include activity/exercise induced breathing
dysfunction
Christopher, Wood, Blager NEJM, 1983
PVFM: What To Look For

Shortness of breath without exercise

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Intermittent c/o voice changes-hoarseness

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May be BETTER or WORSE with exercise
ENT may see no pathologies in larynx except
abnormal motion (Flexible endoscopy)
Cough or S.O.B. after talking
Choking sensation unrelated to eating
Little or no sustained response to typical
medications

PPI, Steroids, Allergy, Inhalers
PVFM: What To Look For

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Multiple complaints
Sudden changes

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S.O.B. without activity
S.O.B. with activity that improves as activity continues

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Cycling, Running Swimming
Cough despite normal swallow
Intermittent complaints of reflux or bad taste in
mouth
Overwhelming need to want to “take a breath”
Assessments



Spirometry
Endoscopy
Trial treatments
Keep in mind:
1. Most people have had this problem for
some time with many diagnoses that
have not resolved the problem.
2. PVFM is not exclusionary – other neuro.
allergenic or laryngeal issues may be present
Flow Volume Spirometry
Expiratory
phase
Normal
FIV.5
PVFM – characteristic
flattened inspiratory loop
Murry et al 2006
FIV
Dynamic Voice Assessment
Using Flexible Endoscopy

Breathing
 Oral
 Nasal
 challenge
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Sustained phonation
Speaking
Singing
Coughing
Laughing
Dysphonia complaint
30-35% of patients
Flexible endoscopy

Normal
24 y.o. without symptoms

PVFM
28 y.o. with S.O.B.
No other symptoms
Primary Treatment
Respiratory Retraining
 Behavioral
 Dramatic improvement with a specialized type of voice
therapy in patients presenting with asthma symptoms
 Movement of vocal folds observed during symptom –free
periods
 Pulmonary function tests showed no airway disease or
obstruction
 Conclusion: A movement/breathing disorder
related to abnormalities of the larynx
Christopher KL Wood, RP New Eng. J Med. 1983: 1566-1570
Treole, K. et.al J. Voice. 1999 Mar;13(1):143-52.
Murry, T. et.al Laryngoscope. 2004: 1341-1345
Murry, T. et. al Ann. Otol.Rhinol.Laryngol. 2006;115(10):754-758.
Behavioral Therapy:
Respiratory Retraining
Not traditional voice therapy
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Approx 65% have no voice complaints
Underlying basis of treatment exercises
1. Unforced breathing rhythm
2. Breathing location– lower thoracic
3. Breathing rate – change speeds
4. Combine with voice in certain pts.
Christopher KL Wood, RP New Eng. J Med. 1983: 1566-1570
Murry, T Oswarczak, V Ann. Otol. Rhinol. Laryngol 2006: 115(10):754-758
Murry, T Sapienza, C. Oto. Clinics of N.A. 2010
PVFM: Behavioral Treatment
 Respiratory Retraining
 Passive inhalation - do not force air in
 Focus on slower inhalation/exhalation
 Begin with rhythmic breathing
 Walking Pattern – combines breathing with
movement
 Exhale on an even walking rhythm
 Without/with sound
 Advance from low to high resistance
 Option to use inspiratory resistance breather device
Respiratory Retraining

Practice several times per day
Exhale
Inhale
LT
RT
RT
LT
Use steps to increase
the resistance
PVFM: Summary
 True cause(s) of PVFM often not known
 Develop a high index of suspicion based on the
profile and case history
 Misdiagnosis – common


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Functional disorder
Asthma
Psychological
Allergies
Swallowing disorder
GERD/LPR
Remember: PVFM
Not exclusionary
It isn’t there if you don’t know about it!
Anon.
Paradoxical Vocal Fold Motion (PVFM)
a.k.a. VCD: Historical Overview
Thomas Murry, PhD
Weill Cornell Medical College
New York, New York
Summary

PVFM – more and more the purview of the
ENT/SLP team
 Supporting documentation from pulmonologist
 Flow loop spirometry –inspiratory and expiratory
 Flexible laryngoscopy
Additional Historical Dilemma
 VCD – most likely term used by
pulmonologists, allergists, psychiatrists and
psychologists
 PVFM – most likely term used by
otolaryngologists and speech pathologists
 Is the diagnosis based on the tool used?
 Flow loop spirometry – Pulm. Aller.
 Flexible endoscopy - ENT
2010
Another New Diagnostic Term!

POLO
– Periodic Occurrence of Laryngeal Obstruction
 Combines VCD, PVFM and IARP (Intermittent arytenoid
region prolapse)
 Endoscopy – gold standard
 Exclude fixed obstructive airway lesions
Christopher, KL. Morris, MJ, 2010
Distinguishing Diagnostic Features
PVFM and ASTHMA
Symptom
Chest tightness
Throat tightness
Stridor with inspirati
Wheeze
Triggers
PVFM
RARE
Yes
Yes
NO
Exercise
Temp changes
Airway irritants
Stress
Emotional Changes
Asthma
YES
No
No
YES
Exercise
Temp changes
Airway irritants
Stress
Emotional Changes
Allergens
Distinguishing Diagnostic Features
PVFM and ASTHMA
PVFM
Response to steroids Usually none
Nocturnal symptoms
Rare
Female preponderance Yes
Age at Onset
All ages
Speech/Voice Related 30-35%
ASTHMA
Good response
Routine
No
Childhood
No
Recent common terminology
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Vocal cord dysfunction
(VCD)
Munchausen’s Stridor
Functional Airway
Obstruction
Paradoxical VC
dysfunction
Episodic Paroxysmal
Laryngospasm
Intermittent arytenoid
region prolapse (IARP)

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Factitious Asthma
Laryngospasm
PVC Motion/Movement
Psychogenic Stridor
Irritable Larynx
Syndrome (ILS)
Laryngeal Dyskinesia
Adductor breathing
dystonia
Episodic laryngeal
dyskinesia
Examples
Young Adult
Normally healthy
Episodic shortness of breath after talking-9 mo.
Fell at ice skating rink about the time of onset
49 y.o.
Cough
Worse with Asthma meds
Now with S. O. B. daily
No change with PPI bid 4
months
Typical Teen-Age Case: Hallie
• 14 yo female
• 2 year hx of intermittent stridor and
•
•
•
•
•
dyspnea-well tolerated
Symptoms started after URI (?)
Initially, only noted with extreme exertion
No symptoms at rest
No dysphonia
No improvement with Prevacid x 3 months
History: Hallie
• Extremely athletic prior to URI:
• Basketball
• Soccer
• Track and field
• Not allowed to compete due to shortness of
breath and dizziness when running
• Symptoms significantly affected her QOL
• While recovering from clavicle fracture
• Symptoms less but still present
• Otherwise healthy – non smoker, no other meds.
• Recently SOB accompanied by cough
Haille: 14 y.o.
Onset following sickness
First visit – Paradoxical movement:
Consistent on all inhalations
Quiet breathing
Speaking
Pre-Tx. At rest
Haille: 14 y.o.
Onset following URI
Pre-Tx. At rest
After 3 sessions
At Rest
After exercise
Assessment and Plan
• Diagnosis:
• Exercise and non exercise induced
paradoxical vocal fold movement
• PVFM seen at rest
• Previous treatments:
• PPI prescribed by Pediatrician
• BID 30-60 min before breakfast and dinner
• Unchanged since onset
Respiratory Retraining

Cycle of breathing begins with exhalation


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Avoids tightening of the chest muscles
Breathing out/in is continuous but slow
Exhale/Inhale duration are equal
Cueing/Distractions may be added
Increase speed when appropriate
Rt
Lt
EX
IN
Rt
Lt
Respiratory Retraining

Practice several times per day
 Use walking to maintain a breathing rhythm
 First focus on easy exhalation
 Then increase speed and resistance
 Use of breathing resistance training devices is helpful
 Common everyday straw – also works
 Rhythmic breathing through nose and mouth
 Voice may be added
Exhale
Inhale
Respiratory Retraining
 Advantages
 Focuses on open airway, upper abdominal
relaxation
 Avoids shallow breathing
 Later adapted to high energy, rapid
rhythms and high resistance
 Bicycling, swimming, jogging, speaking
Many high level athletes have PVFM
Respiratory Retraining
 Advantages
 Patient in control of breathing
 Reduces anxiety when cough or shortness of breath
 Relaxation of the upper thorax and shoulders
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Easier when focus is on exhalation
Easier with movement (WALKING)
Conforms to existing data on normal breathing
Improves speech
PVFM: Treatment
 Advanced Respiratory Retraining
 Resistive breathing
 Sustained exhalation – open/closed mouth
 UUUUUUU
 Shhhhhhh
 Interrupted
Low resistance
Higher resistance
 MM MM MM MM MM
 Shh Shh SShh Shh Shh
Interrupt with easy nasal sniff
PVFM: Treatment
 Respiratory Retraining is not




YOGA
Relaxation Exercises
Hypnotism
Psychological counseling
 Respiratory retraining
 A conscious retraining of CNS dysfunction
 Modification of behavior for a laryngeal movement
disorder
 Equates to retraining stroke patient to move hands or feet
appropriately
Treatment: Reflux and PVFMD
FIGURE 1A
10
9
8
7
SEVERITY
6
OF
5
COUGH
4
3
2
1
0
Pre - Therapy
Post - Therapy
Female Female Female Female Male 1
1
2
3
4
SUBJECT
All subjects were on bid
PPI for at least 3 mo.
Murry, et.al,Laryngoscope, 2004; 114
Treatment: Reflux and PVFMD
FIGURE 1B
1
0.9
0.8
0.7
FIV 0.5/ 0.6
0.5
FIVC 0.4
0.3
0.2
0.1
0
Pre - Therapy
Post - Therapy
Fem ale Fem ale Fem ale Fem ale Male 1
1
2
3
4
SUBJECT
Murry, et.al, Laryngoscope, 2004: 114
Supplemental Treatments
 Dietary
 Reduce high acid/irritant intake

Caffeine, Alcohol, Vinegar
 Increase non acid intake

Water, non mint chewing gum, thin liquids
 Increase the act of swallowing
 Low probability of improvement if used alone
Irwin, R. French, C. et. al Pulm Pharm. Thera. 2002: 283-86.
Other Treatments: Botulinum Toxin (rare)

Severe PVFM 27 y.o. FVC= 78%
Failed Pulm. Med. therapy
Indications for Botox:
– Failure of voice
therapy and
pharmacotherapy to
stop symptoms
– Stridor or effortful
inhalation
– Effecting lifestyle
» Use QOL
assessment
OTHER TREATMENTS

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Psychological – rarely needed
Accupuncture
Counseling – rarely needed
Severe cases may require
 Helium therapy
 Traditional voice therapy
 Nissen Fundoplication – inflammatory based
PVFM
What Must Be Done

Complete assessment-including vocal
function
 Do not assume





Pulmonary work up including
inspiratory measures



Asthma
Allergy
Stress
Reflux
Chest X-Ray or Chest MRI
FEV 25%-75%
GI work up
Respiratory Retraining

Results seen in 3-4
sessions if identified
early
Recent exam
9 months later
after running
Is Reflux an Issue with PVFM?
Number of Patients With Paradoxical Vocal Fold Motion With
Normal and Abnormal Reflux Symptom Index Scores and
Laryngopharyngeal Sensitivity Thresholds.
Number
Normal RSI Normal LS
1
Normal RSI Abnormal LS
11
Normal LS Abnormal RSI
10
Abnormal RSI Abnormal LS 53
RSI = Reflux Symptom Index
Percentage
1.3
14.7
13.3
70.7
LS = Laryngopharyngeal Sensitivity.
Cukier-Blaj, et. al Laryngoscope, 2008
Unusual Presentation: Speaking Only
•
•
•
•
•
•
Female 55, foundation
director with cough only
when talking
Two pulm. assessmentsnormal
Chest CT and Xray normal
Regularly exercises
Tried PPI’s and various
asthma meds. for 2 years
PVFM + cough + MTD
TX: Respiratory retraining
Stop Asthma meds
Voice exercises
PPI +
Unusual Presentation: Speaking Only
•
•
•
•
•
Female 55, foundation
director with cough only
when talking
Two pulm. assessmentsnormal
Chest CT and Xray normal
Regularly exercises
Tried PPI’s and various
asthma meds. for 2 years
Outcome: After 4 sessions, all
symptoms eliminated
Treatment: Sniff, speak, sniff
Summary


PVFM may have numerous symptoms that require
comprehensive work up
Diagnosis:

Thorough history
 Endoscopy – Observe motion at rest
 Spirometry – Note inspiratory pattern
 Treatments:


Respiratory Retraining
Others-Remember, PVFM not exclusionary
Chronic Cough, Laryngospasm and
Paradoxical Vocal Fold Motion (PVFM)
Causes and Treatments
Thomas Murry, PhD
Weill Cornell Medical College
New York, New York
Respiratory Retraining
 Summary
 Education
 Oral posture





Wide open throat
Tongue lies flat in mouth
Lips closed
Relax Jaw
Don’t tighten stomach
 Focus on exhalation

Breathe out – don blow out
PVFM: Treatment
 Respiratory Retraining






Initially, keep the same rhythm
Increase rate
Increase resistance
Requires practice
Symptomatic/Non-symptomatic
Extend to running, cycling, etc.
PVFM Demographics
 Strong female predominance
 72-86% of patients female
 90% in the Med Col. Wisc. Series
 66% in Columbia series
 High school grades above average
 Organized sports
 Social stressors – not all
 Exercised-induced symptoms
 Cheerleading
 Phys. Ed. classes
PVFM Demographics
 In older adults
 50-55% female
 58% in Columbia study
 Laryngopharyngeal reflux
 Excess weight – rapid onset
 Diabetes
 Surgical intubation
 Those involved in
care taking occupations
PVFM Demographics



In children and young
adults:
Shortness of breath
Strong female predominance
 72-86% of patients female
 90% in the Med Col.
Wisc. Series
 42% in Columbia series
 School grades above
average
 Organized sports
 Social stressors – not all
 Exercised-induced
symptoms
Patel, R. et al. Oto HNS 2004

In older adults
 50-70% female
 68% in Columbia study
 Shortness of breath




Cough
Rapid weight onset
Surgical intubation
Involved in care taking
occupations
 Mild respiratory disorders
 Rare problems while
exercising
Murry, Tabaee, Aviv, L’Scope 2004