Vocal cord dysfunction masquerading as bronchial asthma

Vocal cord dysfunction (VCD) is a relatively rare condition that may mimic asthma or upper airway obstruction. In contrast to initial reports, recent work emphasizes that patients with VCD often may have both asthma and VCD concurrently. VCD presents a formidable diagnostic challenge. Spirometry often gives variable results. The diagnosis is confirmed at direct laryngoscopy by observing abnormal vocal cord movements without other pathologic processes. Therapy of VCD involves removal of unnecessary medications, efforts to minimize vocal cord irritation, and aggressive speech therapy. In selected cases, anxiolytic medications and psychiatric consultation may be beneficial.     

Sinus computed tomography scan and markers of inflammation in vocal cord dysfunction and asthma.

BACKGROUND: The inappropriate closure of the vocal cords is characteristic of vocal cord dysfunction (VCD). These patients present with wheezing and frequently receive a misdiagnosis of asthma. OBJECTIVE: To demonstrate the ability of computed tomography (CT) scored for the presence and extent of sinus disease and markers of inflammation to distinguish patients with VCD from patients with asthma. METHODS: Comparisons of 13 patients with VCD were made to 77 patients presenting to the emergency room with acute asthma, 31 non-acute asthmatic patients, and 65 nonasthmatic controls. Evaluation consisted of exhaled nitric oxide gas (eNO), circulating eosinophils, and total serum immunoglobulin (Ig)E, as well as the sinus CT scan. RESULTS: Extensive sinus CT changes were present in 23 of 74 acute asthmatic patients, 5 of 29 non-acute asthmatic patients, and 2 of 59 nonasthmatic controls. In addition, absolute eosinophil counts, eNO, and total IgE were significantly elevated among the asthmatic patients. Sinus symptoms reported by questionnaire did not predict sinus CT findings. Among the patients with VCD, none had extensive sinus disease. They also had normal eNO, low IgE, and normal eosinophil count. Five of the patients presenting to the emergency room who were identified as acute asthmatic were identified with VCD by laryngoscopy and were all characterized by the absence of significant inflammation on their sinus CT scan, low IgE, and normal eosinophil count. CONCLUSIONS: Among patients presenting with intermittent or reversible airway obstruction, patients with VCD can be distinguished from asthma by minimum or absence of inflammation in their sinuses as shown by CT scan. Clinical symptom scores are not predictive of presence or extent of sinus disease in most cases.     

Comorbidities in Severe Asthma: Frequency of Rhinitis, Nasal Polyposis, Gastroesophageal Reflux Disease, Vocal Cord Dysfunction and Bronchiectasis

OBJECTIVES

Severe asthma is found in approximately 10% of patients with asthma. Some factors associated with worse asthma control include rhinitis, gastroesophageal reflux disease, vocal cord dysfunction (VCD), nasal polyposis and bronchiectasis. Therefore, we evaluated the prevalence of these illnesses in patients with severe asthma.

METHODS

We conducted a retrospective analysis of data obtained from electronic medical records of patients with severe asthma between January 2006 and June 2008. Symptoms of rhinitis and gastroesophageal reflux disease were evaluated as well as intolerance to nonsteroidal anti-inflammatory drugs. We evaluated the results of esophagogastroduodenoscopy, videolaryngoscopy and CT scans of the chest in order to confirm gastroesophageal reflux disease, nasal polyposis, vocal cord dysfunction and bronchiectasis.

RESULTS

We evaluated 245 patients. Rhinitis symptoms were present in 224 patients (91.4%); 18 (7.3%) had intolerance to nonsteroidal anti-inflammatory drugs, and 8 (3.3%) had nasal polyposis. Symptoms of gastroesophageal reflux disease were reported for 173 (70.6%) patients, although the diagnosis of gastroesophageal reflux disease was confirmed based on esophagogastroduodenoscopy or laryngoscopy findings in just 58 (33.6%) patients. Vocal cord dysfunction was suspected in 16 (6.5%) and confirmed through laryngoscopy in 4 (1.6%). The patient records provided CT scans of the chest for 105 patients, and 26 (24.8%) showed bronchiectasis.

DISCUSSION

Rhinitis and gastroesophageal reflux disease were the most common comorbidities observed, in addition to bronchiectasis. Therefore, in patients with severe asthma, associated diseases should be investigated as the cause of respiratory symptoms and uncontrolled asthma.     

Nocturnal stridor in olivopontocerebellar atrophy

We describe a patient with olivopontocerebellar atrophy (OPCA) who was referred for alleged "snoring." Polysomnogram with video and audio monitoring revealed that the patient actually had nocturnal stridor causing repetitive oxygen desaturations. Direct laryngoscopy while awake showed a unilateral vocal cord paralysis. The nocturnal stridor persisted after unilateral vocal cord pinning, suggesting that the patient had probably been experiencing bilateral vocal cord paresis while asleep. We conclude that state-dependent vocal cord dysfunction may be severe in OPCA and related multiple system atrophy. Nocturnal stridor has many causes and may mimic snoring and obstructive sleep apnea syndrome. Polysomnography with audio and video recordings are necessary to make the diagnosis.     

Vocal cord dysfunction treated with long-term tracheostomy: 2 case studies.

BACKGROUND: Vocal cord dysfunction (VCD) is an increasingly recognized condition that affects the upper airway, which can be difficult to discriminate from asthma. Speech therapy and psychological cognitive therapy are the mainstays of treatment, but other modalities have been used when response is unsatisfactory. OBJECTIVE: To present 2 case studies in which VCD has been treated with long-term tracheostomy. METHODS: In the first patient, VCD was diagnosed by nasoendoscopic demonstration of paradoxical movement of the vocal cords. The patient was transferred to a regional unit, where nasoendoscopy was performed, which revealed immobile and adducted vocal cords. The decision to perform emergency surgical tracheostomy was made. In the second patient, a possible additional diagnosis of VCD was suggested during a hospital stay, and nasoendoscopy was performed. RESULTS: Both patients report considerable subjective benefits. Objective improvement was seen in only one patient. CONCLUSIONS: Tracheostomy is an invasive procedure that carries risk of potential morbidity and should only be considered as a final option in carefully selected cases.     

Psychophysiologic treatment of vocal cord dysfunction.

BACKGROUND: Vocal cord dysfunction (VCD) is an obstructive upper airway syndrome that frequently mimics asthma and for which there is no empirical treatment of choice. OBJECTIVE: To describe two military service members experiencing VCD who were treated with psychophysiologic self-regulation training. METHODS: Both cases were active-duty military members with VCD confirmed by laryngoscopy They each received biofeedback self-regulation training to decrease tension in the extrinsic laryngeal musculature. RESULTS: Both patients responded to the treatment, denied the presence of dsypnea, and had resumed military physical training. CONCLUSIONS: Psychophysiologic self-regulation strategies both with and without concurrent speech therapy positively impacted VCD symptoms.     

Vocal cord dysfunction in a child

Vocal cord dysfunction (VCD) involves paradoxical adduction of the vocal cord during the respiratory cycle. This usually occurs during inspiration, but can also be seen in expiration. Vocal cord appositioning produces airflow obstruction sufficient to cause wheezing, shortness of breath, chest tightness, and coughing. These symptoms often imitate the respiratory alterations of asthma, thus leading to inappropriate treatment; intubation or tracheotomy may prove necessary. An 11-year-old girl was admitted with intractable dyspnea. She had been diagnosed with atopic asthma, although she failed to respond to an increase in antiasthma medication, including high-dose oral steroids. Flow-volume loops were abnormal, with evidence of variable extrathoracic airway obstruction, manifested as a flat inspiratory loop. No structural abnormalities were seen with either computed tomography (CT) or magnetic resonance imaging (MRI). Fibroscopy revealed paradoxical adduction of the vocal cords during the respiratory cycle, no obstructive disorder being observed. After the diagnosis of VCD, the clinical manifestations resolved with psychiatric treatment. Adduction was not demonstrable at repeat fibroscopy after treatment. VCD may simulate bronchial asthma; it may also be associated with that disorder, thus masking the diagnosis. It should be suspected in patients with recurrent wheezing who fail to respond to usual asthma treatment. An early diagnosis avoids unnecessary aggressive management. Treatment should consist of respiratory and phonatory exercises; psychotherapy may be useful.     

Vocal cord abnormalities in Williams syndrome: a further manifestation of elastin deficiency

Williams syndrome (WS) is due to a deletion in the WS critical region at 7q11.23 which includes the elastin gene (ELN). One of the most characteristic features of this disorder is a harsh, brassy, or hoarse voice but the etiology of the vocal characteristics are unknown. We report two patients with WS who had bilateral vocal cord abnormalities, bringing to four the number of children with WS in whom such defects have been documented. We suggest that vocal cord abnormalities may be a far more common feature of WS than has been previously suspected, and that mild vocal cord dysfunction caused by abnormal vocal cord elastin may be the cause of the hoarse voice in this condition.     

Measurement of upper airway movement by acoustic reflection

The acoustie reflection method provides a noninvasive way to determine the airway geometry. Based on a discrete upper airway model, an inverse scheme is developed to infer the upper airway area as a function of distance. We incorporate this scheme into a system that can generate multiple acoustic pulses to sample the upper airway geometry at a maximum frequency of 30 Hz, making possible determination of the airway area-distance relation as a function of time. Therefore, we can monitor the dynamic behavior of the upper airway during breathing. To validate the approach, we visualized vocal cord movements in three normal subjects via laryngoscopy; simultaneously acoustic measurements were made at 10 Hz. Video images of vocal cord movement were recorded and digitized. We compared the laryngeal area from analysis of the video images with the acoustic assessment at the level of the glottis. Linear regression analysis shows that the correlation coefficients are between 0.85 and 0.9 for all three subjects. We conclude that the acoustic reflection method is a useful tool for measuring vocal cord movement without the use of laryngoscopy, and the approach promises to be a useful one to measure the movement of the whole upper airway. This paper also discusses the limitations inherent in the algorithm and some useful procedures to ensure accurate and reliable area computation during implemention.     

Eucalyptus as a specific irritant causing vocal cord dysfunction.

BACKGROUND: Vocal cord dysfunction (VCD) is a well-recognized clinical entity that frequently mimics asthma and is characterized by inappropriate adduction of the vocal cords during inspiration. The pathogenesis of VCD has not yet been defined. The only previous report suggested that respiratory irritants may trigger paradoxical motion of the vocal cords. OBJECTIVE: To report the case of a 46-year-old woman with VCD precipitated by eucalyptus exposure. METHODS: A masked flexible fiberoptic nasolaryngoscopy was performed to confirm whether VCD occurred with eucalyptus and not with other known respiratory irritants. The patient underwent inhalation challenges consisting of water, ammonia, pine oil, and a combination of eucalyptus (dried leaves) and ammonia. Two independent observers before patient challenge could not identify eucalyptus. RESULTS: Vocal cord dysfunction occurred within minutes of exposure to eucalyptus. This is the first report to prospectively document that a specific irritant, eucalyptus, can precipitate VCD. Negative skin prick test results, total IgE level, and negative IgE eucalyptus-specific antibodies support a nonimmunologic mechanism. CONCLUSIONS: A new pathogenic mechanism for this clinical entity is supported by our observations. Furthermore, a nonimmunologic mechanism in which respiratory irritants may induce VCD is suspected. Future studies to elucidate this mechanism need to be performed in individuals with irritant-specific VCD.     

Long-term outcome of vocal cord dysfunction.

BACKGROUND: Vocal cord dysfunction (VCD) is an involuntary functional disorder commonly misdiagnosed as asthma. Previous reports describe the disorder and treatment but not the long-term outcome. OBJECTIVE: To determine the long-term outcome of VCD. METHODS: A retrospective medical record review identified 49 patients, ages 8 to 25 years, diagnosed as having VCD from 1989 to 2002. Telephone contact was attempted in all. RESULTS: Of the 49 patients, 41 had previously been treated for asthma; that diagnosis was confirmed by us as a comorbidity in only 12 patients. Two distinct phenotypes of VCD were observed. Symptoms were limited to exercise-induced VCD (EIVCD) in 29 and spontaneously occurring VCD (SVCD) in 20, only 4 of whom additionally had EIVCD. Twenty-eight of the 49 were successfully contacted by telephone. Eight of the 11 contacted patients with SVCD followed the recommendation to see our speech therapist, all of whom learned to control symptoms. However, 2 who also had EIVCD continued with that problem. Pretreatment with an anticholinergic inhaler prevented EIVCD in 6 patients in whom this was tried. Complete absence of symptoms, at times ranging from 1 week to 5 years (median, 5 months), was reported in 26 of the 28 contacted patients. CONCLUSIONS: VCD continues to be frequently misdiagnosed as asthma. Two phenotypes of VCD are apparent: EIVCD and SVCD. Speech therapy provides relief of symptoms for SVCD. Prevention of EIVCD with an anticholinergic inhaler in 6 patients suggests that a controlled clinical trial is warranted. Regardless of treatment, eventual spontaneous resolution was common.     

一种喉部疾病口语声诊断新方法

本文提出了声带的三质量块模型,并应用这种模型模拟病嗓产生的嘶哑语声。这些嘶声包括有声带闭合不全、声带小结、声带麻痹、喉炎、声带淀粉样变和声门癌等十六种典型情况。采用快速傅里叶变换、线性预测、倒谱技术和离散余弦变换等方法,分析各类喉病引起的嘶哑语声,实验结果表明声带模型分析法是喉病诊断的一种有效方法。     

Pathological assessment of patients’ speech signals using nonlinear dynamical analysis

Acoustic analysis of voice features can complete the invasive observation-based methods for the diagnosis of vocal fold pathologies. Selection of an appropriate feature extraction method from the voice can significantly improve the diagnostic results for patients with vocal disorders. In this paper, the performance of nonlinear dynamics and acoustical perturbation features is evaluated in order to distinguish patients with vocal fold disorder and other normal cases. As a matter of fact, vocal fold pathology is one of the major causes of voice quality reduction or feature variation in patients with dysphonic voices. Due to the devastating impact of vocal folds dysfunction on the complex dynamical structure of the speech signals, spectral analysis methods are not suitable for characterizing such changes in disordered voices. Therefore, the using measures that can reflect the nonlinear nature of such changes in the acoustical signals is an efficient alternative for the conventional methods. In order to compare and contrast the effectiveness of such approaches, we exploit features such as correlation dimension, the largest Lyapunov exponent, approximate entropy, fractal dimension and Ziv-Lempel complexity, and we also evaluate their performance with respect to some conventional features like jitter and shimmer, in the voice diagnosis task. Using the support vector machine classifier, our simulation results show that correlation dimension and the largest Lyapunov exponent features with the highest recognition rates of 94.44% and 88.89% can be used as a highly reliable method for the clinical diagnosis of vocal folds pathologies and other relevant applications.     

Prevalence of Laryngeal Disease in South Korea: Data from the Korea National Health and Nutrition Examination Survey from 2008 to 2011

Purpose

The aim of this study was to evaluate the prevalence of Benign Vocal Fold Lesion (polyp, cysts, nodules) and Leukoplakia in Korea.

Materials and Methods

The data from the 2008 to 2011 Korea National Health and Nutrition Examination Surveys, which were cross-sectional survey of the civilian noninstitutionalized population of South Korea. A survey team that included an otolaryngology residents, nurses, and interviewers moved with a mobile examination unit and performed laryngologic interviews and examinations of vocal folds using rigid telescopic laryngoscopy on survey participants over 19 years old (n=19636).

Results

Laryngoscopic examination revealed normal results in 19251 (98.04%) of those included in the survey. Abnormal laryngoscopic findings were observed in 1.96% of the population examined, and vocal cord nodules were the most common abnormal finding. The prevalence of vocal cord nodules was 0.99-1.72%, the prevalence of vocal cord polyps was 0.31-0.55%, the prevalence of vocal cysts was 0.04-0.17%, and the prevalence of vocal cord leukoplakia was 0.07-0.21%. There was no significant correlation of linear trend of prevalence by year, and there were no significant differences in prevalence between males and females.

Conclusion

This is the first nationwide epidemiologic study to assess the prevalence of Benign Vocal Fold Lesion (polyp, cysts, nodules) and Leukoplakia by both the Korean Otolaryngologic Society and the Ministry of Health and Welfare. The results of this large epidemiologic study provide valuable information regarding the prevalence of voice disorders and the management of laryngologic diseases.     

Actinomycosis of the vocal cord: a case report

A 30-year-old Chinese lady was admitted for hoarseness of voice of one month's duration. Clinical examination revealed a granuloma of the left vocal cord while chest X-ray showed an opacity in the lower lobe of the right lung. The provisional clinical diagnosis was tuberculous laryngitis. A biopsy of the vocal cord lesion revealed inflamed tissue with actinomycotic colonies. Cultures and sputum smears did not reveal any tuberculous bacilli. The patient responded to a 6-week course of intravenous C-penicillin, regaining her voice on day 5 of commencement of antibiotics. A subsequent CT scan of the neck and thorax revealed multiple non-cavitating nodular lesions in both lung fields, felt to be indicative of resolving actinomycosis. She was discharged well after completion of treatment. It was felt that this is a case of primary actinomycosis of the vocal cord with probably secondary pulmonary actinomycosis.     

Angioimmunoblastic T-cell lymphoma with dual genotype of TCR and IgH genes

A 70-year-old man complained of fever and sore throat accompanied by hoarseness of voice. On physical examination, there was no systemic abnormality but a mild lymphadenopathy of cervical lymph nodes. With laryngoscopy, there was a marked outgrowth of the bilateral palatine tonsils proximal to the vocal cord. The histology of the resected tumor was compatible with angioimmunoblastic T cell lymphoma (AITL), revealing the effacement of normal tonsillar architecture and small to medium-sized neoplastic cell proliferation around marked vascular proliferation and atrophic lymphoid follicles. Tumor cells were positive for conventional T-cell antigens as well as for the follicular helper T-cell marker, PD-1, and CXCL13. Large hodgkinoid cells, but no tumor cells, were positive for latent membrane protein-1 and Epstein-Barr virus-encoded small RNA (EBER)-1 (in situ hybridization). Non-neoplastic, double positive cells for EBER-1 and CD20 were also scattered. Southern blot analysis revealed dual TCR-Cβ1 and IGH-JH gene rearrangements. Although the swelling of bilateral inguinal and perigastric lymph nodes developed later, the radical resection of tumor and chemotherapy appeared to be effective for the treatment of AITL with clinical stage IIIa. We here report a rare case of AITL involving palatine tonsil as primary site and give a review of the literature.     

Clinical experiences of fiberoptic bronchoscopy in patients with respiratory failure in the intensive care unit

Seventy-nine fiberoptic bronchoscopies were performed in 46 Patients during 2 years in the Intensive Care Unit of Severance Hospital, Yonsei Medical Center. Bronchoscopies were done more than twice in 13 patients. Forty-three bronchoscopies were done through the orotracheal tube in 27 patients, and narcotics and sedatives such as morphine sulfate, diazepam and lorazepam were added with pancuronium bromide during 52 bronchoscopy procedures in 21 patients. Ventilatory support was accomplished by control mode ventilation for 63 bronchoscopies in 37 patients. Twenty-four patients were from the surgical department, and 37 bronchoscopies were performed in 18 patients in a post-thoracotomy state. Twenty-two patients were nonsurgical patients. We performed 48 bronchoscopies in 26 patients to treat lung haziness, 14 bronchoscopies in 3 patients to confirm the operative anastomosis after pneumonectomy or tracheoplasty, and 11 bronchoscopies to confirm the airway patency and vocal cord movement. We obtained good results from 41 bronchoscopies performed for therapeutic purposes and 28 bronchoscopies done for diagnostic purposes. But in 4 patients with pleural effusion and pneumonia, we could not get any improvement in chest X-ray taken after bronchoscopy. We suggested other procedures in 6 patients for diagnosis or treatment, such as suspension laryngoscopy, thoracentesis, ultrasonogram and laser surgery.     

Diagnosis of histoplasmosis in urine cytology: reactive urothelial changes, a diagnostic pitfall. Case report and literature review of urinary tract infections

Histoplasmosis not uncommonly causes systemic infection, particularly in immunocompromised patients. In systemic infection, the urinary tract is often involved, although the diagnosis of histoplasmosis in urine cytologic specimens has never been reported. Urinary tract histoplasmosis may present with gross hematuria, raising clinical suspicion for malignancy. The index case presented with intermittent gross hematuria, suprapubic pain, significant weight loss, hoarse voice, and a painful tongue ulcer. Examination of the patient revealed an ulcerated tongue lesion, an anal ulcer, a polypoid lesion on the vocal cord, and cystoscopic examination of the urinary bladder revealed erythematous patchy areas. Surgical biopsy sections from the vocal cord and tongue lesion were diagnostic of histoplasma infection. Urine cytologic examination showed atypical urothelial cells suspicious for malignancy. However, fungal stains performed on the urine specimen showed histoplasma organisms. We conclude that with a high index of suspicion, and the use of special stains, histoplasma organisms can be identified in urine.     

Exercise-induced dyspnea in children and adolescents: if not asthma then what?

BACKGROUND: Exercise-induced dyspnea (EID) in children and adolescents is a common manifestation of asthma and is therefore commonly attributed to exercise-induced asthma (EIA) when present in otherwise healthy children. OBJECTIVE: To report the outcome of evaluations for EID when other symptoms and signs of asthma were absent or if there was no response to previous use of an inhaled beta2-agonist. METHODS: We reviewed the results of all exercise tests performed in otherwise healthy patients with EID during 1996 to 2003. Physiologic measures included preexercise and postexercise spirometry with the addition of oxygen uptake, carbon dioxide production, continuous oximetry, and electrocardiogram monitoring during most tests. EIA was diagnosed if symptoms were reproduced in association with a 15% or greater decrease in forced expiratory volume in 1 second from baseline. Endoscopy was performed if stridor and/or decreased maximal inspiratory flow were present. Criteria were established for restrictive abnormalities, physical conditioning, exercise-induced hyperventilation, and normal physiologic limitation. RESULTS: A total of 142 patients met our criteria for inclusion. EID had been present in these patients for a mean duration of 30.2 months (range, <1 to 192 months) before evaluation and had been previously attributed to asthma by the referring physician in 98 of them. Symptoms of EID were reproduced during exercise testing in 117 patients. EIA was identified as the cause of EID in only 11 of those 117. Seventy-four demonstrated only normal physiologic exercise limitation; 48 of these 74 had normal to high cardiovascular conditioning, and 26 had poor conditioning. Other diagnoses associated with reproduced EID included restrictive abnormalities in 15, vocal cord dysfunction in 13, laryngomalacia in 2 (1 of whom had unilateral vocal cord paralysis), primary hyperventilation in 1, and supraventricular tachycardia in 1. CONCLUSION: The diagnosis of EIA should be questioned as the etiology of EID in children and adolescents who have no other clinical manifestations of asthma and who do not respond to pretreatment with a beta2-agonist. Exercise testing that reproduces symptoms while monitoring cardiac and respiratory physiology is then indicated to identify causes of EID other than EIA.