Vocal chord disorder can be diagnosed as asthma

ORLANDO, Florida – Athletes with a vocal cord disorder that restricts breathing are more likely to be misdiagnosed and inappropriately treated for exercise-induced asthma, according to research presented today at the Triological Society’s 116th Annual Meeting.

Researchers at The Ohio State University Wexner Medical Center also examined interventions ranging from biofeedback to botox injections to help manage the condition – called paradoxical vocal fold motion disorder (PVFMD) – and found that vocal cord “retraining” therapy was effective at reducing or resolving breathing symptoms, allowing many athletes to stop using previously prescribed corticosteroid asthma inhalers.

The retrospective study examined 46 division one collegiate athletes, marathon and triathlon runners who were newly diagnosed with PVFMD, a condition brought on by stress, anxiety or increased exertion which causes the vocal cords to constrict and obstruct breathing. An estimated five percent of athletes have PVFMD, which can severely impact performance.

“There isn’t a lot in the literature about PVFMD in elite athletes, and our study shows that because of their high level of conditioning they may be more difficult to diagnose and treat than non-athletes.” said Brad deSilva, MD, the study’s lead investigator and residency program director for the Department of Otolaryngology-Head and Neck Surgery at Ohio State’s Wexner Medical Center.

For example, only 30 percent of the study group reported consistently experiencing PVFMD symptoms like coughing during exercise. However, in post-exertion testing using a flexible fiberoptic laryngoscope (FFL), researchers ultimately verified PVFMD diagnosis in all but six of the athletes. Additionally, in comparison to a control cohort of non-athletes with PVFMD, athletes were less likely to present with a history of reflux, laryngeal edema or psychiatric diagnosis.

The study presenters noted that the addition of the exercise trigger during FFL improved the researcher’s ability to detect PVFMD, and that clinicians may want to strongly consider FFL examination when dealing with an elite athlete patient with breathing issues, particularly because the respiratory sounds of PVFMD may be confused with asthma.

“PVFMD symptoms can often mimic asthma, and as many as 40 percent of people with asthma also have PVFMD – so it’s typical for an athlete to get the asthma diagnosed correctly, but not the vocal cord dysfunction,” said Anna Marcinow, MD, co-author of the study and a senior resident in the otolaryngology program at Ohio State’s College of Medicine. “Nearly a third of our study athletes had been previously prescribed an inhaler for exercise-induced asthma – but many reported that the inhalers weren’t helping. A minimal response to bronchodilators should also point toward a PVFMD diagnosis.”

After FFL review, 45 of the 46 athletes in the study were prescribed laryngeal control therapy (LCT), a method in which athletes learn how to relax the vocal cords and retrain the way they breathe. Thirty-six athletes attended at least one LCT session and 25 (69 percent) reported improvement of symptoms. Patients who attended two or more sessions were more likely to experience symptom improvement.

Biofeedback, practice observed therapy and thyroarytenoid muscle botulinum toxin injection were utilized in patients that did not respond to LCT.

“Because PVFMD can have both physical and emotional impacts, using tactics that help athletes gain a sense of control over their breathing can be really effective,” said Marcinow. “Athletes may also need additional alternative forms of therapy such as biofeedback or intervention from a sports psychologist.”

The researchers also noted that while PVFMD is first often seen in athletes who have recently intensified activity and training, it can also occur in non-athletes who are adopting a more rigorous exercise program.

Diagnosis of spasmodic dysphonia

It usually takes a long time, sometimes many years, before the right diagnosis is made.
People notice that their voice is off and sounds different. You first think that it is because
you are fatigued. Then you think you have a laryngitis, maybe caught a cold. It doesn’t
go away and you go to see the doctor.

The doctor

The doctor sees no strange things and sends you to a ENT.
The ENT thinks that it is maybe psychological and sends you to a therapist or
psychologist. You start to doubt your sanity and you become depressed.
Hopefully soon in this process you encounter somebody who knows what is going on.
When you end up with some doctor or speech therapist who can recognize spasmodic
dysphonia you are in luck. They will send you to a specialized ENT who can make the
correct diagnosis.

Medical history

They take your medical history, and then they have a look at your vocal chords while
you have to make certain sounds. There are two ways of doing this.

Flexible endoscope

The doctor will stick the flexible piece through your nose and let is glide down to look at
your vocal chords from above. He looks through the eye-piece on the left to evaluate the
closing and opening of the chords.

Rigid endoscope

This is a straight rod which is inserted through the mouth and can provide better image
quality and video recording of the movement of the vocal chords.

Below you see a video where the flexible and the rigid endoscope are demonstrated.

Spasmodic dysphonia diagnosis

Diagnosis of spasmodic dysphonia is often delayed due to lack of recognition of its symptoms by screening physicians. Most patients who are correctly diagnosed are evaluated by a team that usually includes an otolaryngologist, a speech-language pathologist and a neurologist.

The otolaryngologist examines the vocal folds to look for other possible causes for the voice disorder. Fiberoptic laryngoscopy, a method whereby a small lighted flexible tube is passed through the nose and into the throat, is a helpful tool that allows the otolaryngologist to evaluate vocal cord movement during speech.

Additional diagnostic testing may include stroboscopy, which allows the physician to view the vibrations of the vocal cords in slow motion. The speech-language pathologist evaluates the patient’s voice and voice quality.

The neurologist evaluates the patient for signs of other movement disorders.