Vocal Cord Dysfunction

Paula Barson, MA-CCC, SLP, and Joseph Piccione, DO, MS

Introduction/Etiology/Epidemiology

•Vocal cord dysfunction (VCD) can be described as inappropriate adduction or closure of the true vocal folds during inspiration and/or expiration and may result in upper-airway obstruction, stridor, or wheezing.

•VCD has been previously called

—Fictitious asthma

—Mimicking asthma

—Irritable larynx

—Laryngeal dysfunction

•Epidemiology

—Increasing prevalence in children and adolescents

—Can occur in children as young as 6 years of age

—Female-to-male ratio of approximately 3:1

—Often affects “high achievers” in academics and/or athletics

—Possible comorbid psychiatric conditions include

▪Anxiety

▪Depression

▪Obsessive compulsive disorder

▪Borderline personality disorder

Pathophysiology

•The vocal cords adduct, leaving only a small posterior glottic opening.

•Adduction occurs during inhalation and/or exhalation.

•The exact etiologic origin is unknown.

•The laryngeal reflexes are mediated by the vagus nerve.

—A change in laryngeal tone can lower the sensory threshold and induce laryngospastic reflexes.

•Triggers include

—Exercise (especially competitive events) associated with increased body tension of the chest, shoulders, and neck

—Strong smells (eg, perfumes, chlorine, certain foods)

—Respiratory tract irritants

—Allergens

—Singing

—Laughing

—Hot and/or cold air

—Postnasal drip

—Upper respiratory infections

—Psychological factors, including anxiety and stress

Clinical Features

•Sudden, episodic shortness of breath (resting or exertional)

•Intermittent hoarseness

•Most commonly associated with inspiratory stridor

•May have coexisting monophonic expiratory wheeze

•Chronic cough and/or frequent throat clearing

•Chest and/or throat tightness

•Difficulty with inhalation and/or exhalation

•Patient may describe “just having trouble getting air in”

•Patient may describe feeling like “breathing through a straw”

•No response to bronchodilators and/or corticosteroids

•May occur primarily indoors or outdoors for some individuals

•Commonly manifests during exercise

—Lack of response to treatment of exercise-induced bronchoconstriction with albuterol

—Description of “difficulty in getting air in” (with no cough, wheeze, etc) — In elite athletes, a minor degree of narrowing produces more limitation than might be expected

—Many teenagers with VCD fit the psychological profile, as well

Differential Diagnosis