Download PVFM

Paradoxical Vocal Fold Motion
a.k.a….
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Munchausen’s Stridor
Psychogenic Stridor
Functional Inspiratory
Stridor
Functional upper airway
obstruction
Atypical asthma
Factitious asthma
Emotional laryngeal
wheezing
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vocal cord dysfunction
Adult spasmodic croup
Functional abduction
paresis
Emotional
laryngospasm
Episodic laryngeal
dyskinesia
pseudoasthma
SPPA 640 Voice Disorders
Paradoxical Vocal Fold Motion (PVFM):
What is it?
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Primarily a breathing impairment
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upper airway (extrathoracic) obstruction
vocal folds adducting (closing) when they should be
abducting (opening)
Inspiration, expiration or both
occurs in isolation, or with asthma
SPPA 640 Voice Disorders
Paradoxical Vocal Fold Motion
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Etiology
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Unknown
psychological factors are implicated but well
controlled studies are lacking
SPPA 640 Voice Disorders
Paradoxical Vocal Fold Motion
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Commonly induced by
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Stress
Exercise
gastroesophageal reflux (nocturnal)
Post-nasal drip
Respiratory irritants
cold air
panic associated with asthma
SPPA 640 Voice Disorders
PVFM: Patient Characteristics
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More common in girls/women
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3-4/1 female/male ratio
Children, adolescents, adults 20-40 years
Diagnosis of uncontrolled asthma
Anomalous findings for severe asthma
SPPA 640 Voice Disorders
Brugman & Newman, (1993)
Kuppersmith et al. (1993)
PVFM: Some Characteristics
May see
 Hx of asthma treatment
 Previous emergency intubation (rare)
 Hx of tracheotomy (rare)
 Chronic steroid use
 Hoarseness and other voice changes
SPPA 640 Voice Disorders
Assessment of PVFM
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Team approach including
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Speech pathology
Otolaryngology
Pulmonary function
Gastroenterology (GERD/LPR)
Allergy
Psychiatry
SPPA 640 Voice Disorders
PVFM: Signs
Clinical
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Stridor
rapid breathing
accelerated pulse rate
anxiety/panic
Auscultation identifies the larynx as site of
obstruction
SPPA 640 Voice Disorders
PVFM: Signs
Laryngoscopy
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Adduction of anterior 2/3’s of TVFs during
inspiration
small posterior diamond shaped glottic
chink
Mediolateral compression of ventricular
folds
Exam normal when asymptomatic
SPPA 640 Voice Disorders
PVFM: Signs
Laryngoscopic Assessment (SLP & ENT)
 Tidal breathing (rest)
 Forced inspiration, forced expiration
 Panting
 Sniffing
 Repeated rapid deep inspirations
 Exercise challenge
SPPA 640 Voice Disorders
PVFM: Signs
Pulmonary Function (Spirometry)
When symptomatic…
PVFM
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Forced vital capacity: normal
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Forced expiratory volume in 1 sec: normal
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Inspiratory flow: reduced
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Expiratory flow/inspiratory flow ratio: elevated
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Bronchodilator treatment: limited improvement
Asthma
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Forced vital capacity: normal
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Forced expiratory volume in 1 sec: reduced
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Expiratory flow/inspiratory flow: normal or reduced
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Bronchodilator treatment: marked improvement
SPPA 640 Voice Disorders
SPPA 640 Voice Disorders
Tilles (2003)
PVFM: Bronchoprovocation
Methacholine challenge
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Induces small airway narrowing
A negative response will help exclude asthma
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PVFM: Provocation
Exercise challenge
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Helpful for eliciting symptoms in certain clients
Does not differentiate asthma and PVCD
Allows signs/symptoms to be observed so that a Dx
may be made
SPPA 640 Voice Disorders
PVFM: Psychosocial Characteristics
Reports of
 Perfectionism
 Obsessive-compulsive features
 Anxiety disorders (panic)
 Somatization disorder
 Difficulty expressing anger, sadness and fear
 Conversion reaction (??)
Rate of psychopathology no different from severe
asthmatics
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Mathers-Schmidt (2001)
Mathers-Schmidt (2001)
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PVFM: Management
Education
 Review normal airway function
 Review test results
 Discuss possible precipitants
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stress, exercise, GERD, panic etc
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PVFM: Management
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Quick controls (+/- endoscopic feedback)
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Sniffing, 3 quick sniff in, slow controlled
exhalation on /s/ or /sh/, lips pursed
Manual lowering of larynx
Panting: shallow and limited number of times (but
not with asthma)
SPPA 640 Voice Disorders
PVFD: Management
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Teach relaxed throat breath, awareness of laryngeal
muscle tension
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Flatten tongue, drop jaw, inhale through nose and exhale on /s/
Abdominal breathing pattern
Controlled exhalation
General relaxation exercises (audiotapes)
Stress management, counseling
Antireflux protocol
Biofeedback using endoscope
SPPA 640 Voice Disorders