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Psychogenic vocal cord dysfunction — Clinical Guidelines

Overview

Psychogenic vocal cord dysfunction (VCD) involves paradoxical adduction of the vocal cords during inspiration, leading to symptoms resembling upper airway obstruction, often mistaken for asthma 2 12.

Diagnosis

Clinical Presentation: Inspiratory stridor, wheezing, sudden severe dyspnea without hypoxia or tachypnea 2.

Diagnostic Tests: Laryngeal electromyography (LEMG) can be considered for signal interpretation, though inter-rater reliability varies 3.

Differential Diagnosis: Distinguish from asthma, paradoxical vocal cord movement, and other causes of upper airway obstruction 2 12.

Provocation Tests: Inhaled mannitol may aid in diagnosis by provoking symptoms 7.

Management

First-Line Treatments:

- Behavioral Therapy: Multidisciplinary team approach combining patient education and behavioral interventions 4 11. - Psychological Support: Address underlying psychological factors contributing to VCD 4.

Adjunctive Treatments:

- Medications: No specific drug classes or doses are highlighted in the abstracts 13. - Surgical Interventions: Rarely indicated; thyroplasty with arytenoid adduction may be considered in refractory cases 6. - Botulinum Toxin Injections: For severe cases involving false vocal folds 22.

Special Populations

Pediatrics: Underdiagnosed; symptoms can mimic exercise-induced bronchospasm 5 21.

Athletes: Common; requires heightened clinical suspicion due to exercise-related triggers 10 15 16.

Comorbidities: Often misdiagnosed as asthma; coexisting asthma may complicate management 18.

Key Recommendations

Utilize Multidisciplinary Teams for Diagnosis and Treatment: Integrate behavioral and psychological interventions in the same session as diagnosis to improve long-term outcomes 4 11 (Evidence: Strong).

Consider Provocation Tests for Diagnosis: Use inhaled mannitol to provoke symptoms and confirm VCD diagnosis 7 (Evidence: Moderate).

Educate Clinicians on Differential Diagnosis: Emphasize distinguishing VCD from asthma and other respiratory conditions to avoid inappropriate treatment 2 12 (Evidence: Expert opinion).

References

1 Kim J, Seo HS, Na HS, Son HY, Lee DK, Jeong WJ et al.. Real-time light-guided vocal fold injection as a simulation-based training tool. Auris, nasus, larynx 2021. link 2 Malaty J, Wu V. Vocal Cord Dysfunction: Rapid Evidence Review. American family physician 2021. link 3 Ho GY, Leonhard M, Volk GF, Foerster G, Pototschnig C, Klinge K et al.. Inter-rater reliability of seven neurolaryngologists in laryngeal EMG signal interpretation. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 2019. link 4 Baxter M, Ruane L, Phyland D, Leahy E, Heke E, Lau KK et al.. Multidisciplinary team clinic for vocal cord dysfunction directs therapy and significantly reduces healthcare utilization. Respirology (Carlton, Vic.) 2019. link 5 Wenzel M. Gasping for a Diagnosis: Pediatric Vocal Cord Dysfunction. Journal of pediatric health care : official publication of National Association of Pediatric Nurse Associates & Practitioners 2019. link 6 Saadeh CK, Rosero EB, Joshi GP, Ozayar E, Mau T. Reducing sedation time for thyroplasty with arytenoid adduction with sequential anesthetic technique. The Laryngoscope 2017. link 7 Tay TR, Hoy R, Richards AL, Paddle P, Hew M. Inhaled Mannitol as a Laryngeal and Bronchial Provocation Test. Journal of voice : official journal of the Voice Foundation 2017. link 8 Cabrera-Muffly C, Clary MS, Abaza M. A low-cost transcervical laryngeal injection trainer. The Laryngoscope 2016. link 9 Childs LF, Bielinski C, Toles L, Hamilton A, Deane J, Mau T. Relationship between patient-perceived vocal handicap and clinician-rated level of vocal dysfunction. The Laryngoscope 2015. link 10 Al-Alwan A, Kaminsky D. Vocal cord dysfunction in athletes: clinical presentation and review of the literature. The Physician and sportsmedicine 2012. link 11 Rameau A, Foltz RS, Wagner K, Zur KB. Multidisciplinary approach to vocal cord dysfunction diagnosis and treatment in one session: a single institutional outcome study. International journal of pediatric otorhinolaryngology 2012. link 12 Kenn K, Balkissoon R. Vocal cord dysfunction: what do we know?. The European respiratory journal 2011. link 13 Haines J. Diagnosing and treating vocal cord dysfunction. Nursing times 2011. link 14 Gimenez LM, Zafra H. Vocal cord dysfunction: an update. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology 2011. link 15 Wilson JJ, Theis SM, Wilson EM. Evaluation and management of vocal cord dysfunction in the athlete. Current sports medicine reports 2009. link 16 Rhodes RK. Diagnosing vocal cord dysfunction in young athletes. Journal of the American Academy of Nurse Practitioners 2008. link 17 Malick D, Moon J, Canady J. Stress velopharyngeal incompetence: prevalence, treatment, and management practices. The Cleft palate-craniofacial journal : official publication of the American Cleft Palate-Craniofacial Association 2007. link 18 Goldstein R, Bright J, Jones SM, Niven RM. Severe vocal cord dysfunction resistant to all current therapeutic interventions. Respiratory medicine 2007. link 19 Wilson JJ, Wilson EM. Practical management: vocal cord dysfunction in athletes. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine 2006. link 20 Doshi DR, Weinberger MM. Long-term outcome of vocal cord dysfunction. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology 2006. link61341-5) 21 Tilles SA. Vocal cord dysfunction in children and adolescents. Current allergy and asthma reports 2003. link 22 Rosen CA, Murry T. Botox for hyperadduction of the false vocal folds: a case report. Journal of voice : official journal of the Voice Foundation 1999. link80026-5) 23 Kayani S, Shannon DC. Vocal cord dysfunction associated with exercise in adolescent girls. Chest 1998. link 24 Tan KL, Eng P, Ong YY. Vocal cord dysfunction: two case reports. Annals of the Academy of Medicine, Singapore 1997. link 25 Shiotani A, Fukuda H, Kawaida M, Kanzaki J. Vocal fold vibration in simulated head voice phonation in excised canine larynges. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 1996. link 26 Mullinax MC, Kuhn WF. Benign paradoxical vocal cord adduction presenting as acute stridor. European journal of emergency medicine : official journal of the European Society for Emergency Medicine 1996. link 27 Tucker HM. G. Paul Moore Lecture--1993. New voices for old. Journal of voice : official journal of the Voice Foundation 1995. link80243-7) 28 Berke GS. Intraoperative measurement of the elastic modulus of the vocal fold. Part 1. Device development. The Laryngoscope 1992. link 29 Dejonckere PH, Wieneke GH, Lebacq J. Laryngostroboscopy and glottic dysrhythmia's. Acta oto-rhino-laryngologica Belgica 1989. link 30 Chatterji S, Gupta NR, Mishra TR. Valvular glottic obstruction following extubation. Anaesthesia 1984. link 31 Christopher KL, Wood RP, Eckert RC, Blager FB, Raney RA, Souhrada JF. Vocal-cord dysfunction presenting as asthma. The New England journal of medicine 1983. link

Psychogenic vocal cord dysfunction