The forgotten cause of stridor in the emergency department

Abstract

Paradoxical Vocal Fold Movement Disorder is where the larynx exhibits paradoxical vocal cords closure during respiration, creating partial airway obstruction. Causes of vocal fold movement disorder are multifactorial, and patients describe tightness of throat, difficulty getting air in, have stridor, and do not respond to inhalers. We propose using transnasal laryngoscopy examination, which will show narrowing of vocal cords on inspiration, and The Pittsburgh Vocal Cord Dysfunction Index with a cutoff score of ≥4 to distinguish vocal fold movement disorder from asthma and other causes of stridor. Management of paradoxical vocal fold movement disorder involves a combination of pharmacological, psychological, psychiatric, and speech training. Paradoxical vocal fold movement disorder is a very treatable cause of stridor, so long as it is identified and other organic causes are excluded.

Current opinions for the management of asthma associated with ear, nose and throat comorbidities

“…The prevalence of VCD is up to 40% in patients with difficult-to-control asthma [136] and is associated with a poorer quality of life [103], but little is known about the true prevalence of VCD in severe asthma because most studies have examined selected patient groups [46]. VCD is often misdiagnosed as asthma, which leads to an inappropriate choice of treatment options for subjects with this condition and inappropriate stepping up of medications to generate a better therapeutic response for "unresponsive" asthma, which places the patient at risk for more potential adverse effects and greater medical costs [12,155]. In the study of TRAISTER et al [156], 42.4% of patients with VCD were misdiagnosed as asthma for an average 9 years.…”

“…The exact pathophysiology of VCD remains unknown [145,155]. Proposed theories include altered autonomic input from central brain regions polysynaptically linked to the larynx resulting in hyperkinetic laryngeal dysfunction [155].…”

“…The exact pathophysiology of VCD remains unknown [145,155]. Proposed theories include altered autonomic input from central brain regions polysynaptically linked to the larynx resulting in hyperkinetic laryngeal dysfunction [155]. A classification was proposed by FORREST et al [159] into primary VCD (75%), which is psychological, and secondary VCD (25%) to medical disorders divided into irritable larynx syndrome and neurological disorder.…”

“…The triggers that induce an episode of VCD are frequently similar to those that exacerbate asthma, including emotional stress, airway irritants, changes in humidity or extreme temperatures, respiratory infections and physical exercise [12,46,145]. Asthma and VCD have several common comorbidities, including chronic allergic and non-allergic rhinitis with post-nasal drip, gastro-oesophageal reflux disease, untreated sleep apnoea, smoking, anxiety and hyperventilation [12,145,155].…”

“…Symptoms are often episodic and reversible, with or without therapy [160]. The Pittsburgh VCD Index is a simple four-question questionnaire with a good predictive value to diagnose VCD (cut-off score ⩾4) and to distinguish VCD from asthma [46,145,155]. Patients with poorer asthma control, frequent exacerbations and emergency visits, and minimal response to corticosteroids should be investigated for VCD [46,145,160], and VCD should be included in the differential diagnosis of asthma [145].…”