Paradoxical vocal fold motion
- Jo Shapiro, MD
Jo Shapiro, MD
- Associate Professor of Otology and Laryngology
- Harvard Medical School
- Jayme Dowdall, MD
Jayme Dowdall, MD
- Instructor, Department of Otology and Laryngology
- Harvard Medical School
- Chandler Thompson, DMA, MS, CCC-SLP
Chandler Thompson, DMA, MS, CCC-SLP
- Speech-Language Pathologist/Professional Voice, Department of Otolaryngology
- Weill Cornell Medicine, The Sean Parker Institute for the Voice
Paradoxical vocal fold motion (PVFM) describes inappropriate motion of the true vocal folds. PVFM refers to a clinical phenomenon rather than to one specific or strictly defined clinical diagnosis. PVFM is most commonly observed as episodic unintentional adduction of the vocal folds on inspiration . Patients most often present to the emergency department with wheezing, stridor, and apparent upper airway obstruction. Delay in diagnosis is common, and unnecessary treatments such as intubation and tracheostomy are not uncommon. Patients are commonly frequent users of the health-care system, often over prolonged periods .
While clinical observations of this phenomenon were described in the 1800s, they began to appear with increasing frequency in the 1970s and 1980s with the greater availability of laryngoscopy . PVFM has unintentionally become a catch-all term for functional laryngeal disorders . However, it is important to explicitly define this functional disorder as “impaired function”, emphasizing that this is not synonymous with a psychogenic disorder.
This topic will review the presentation and treatment of PVFM, also called laryngeal dyskinesia, vocal cord dysfunction (VCD), inspiratory adduction, periodic occurrence of laryngeal obstruction (POLO), Munchausen’s stridor, episodic paroxysmal laryngospasm, psychogenic stridor, functional stridor, hysterical croup, emotional laryngeal wheezing, factitious asthma, pseudoasthma, and irritable larynx syndrome [3-6]. Features of wheezing illnesses other than PVFM are discussed separately. (See "Evaluation of wheezing illnesses other than asthma in adults" and "Diagnosis of asthma in adolescents and adults".)
In the normal larynx, the true vocal folds abduct (open) during inspiration and partially adduct (close) during expiration (figure 1). In addition to inspiration, abduction can also be induced by sniffing and panting. Normal adduction of the true vocal folds occurs with phonation, coughing, throat clearing, swallowing, and during a Valsalva maneuver. Around 10 to 40 percent adduction is normal during expiration. Normal cough mechanics involve vocal fold adduction for 0.2 seconds following the end of the inspiratory phase .
Paradoxical vocal fold motion (PVFM) can be seen during inspiration, expiration, or both (figure 1) [3,8,9]. The false vocal folds and supraglottic tissue may also dynamically constrict the airway. It is imperative to visualize full abduction during laryngoscopy to rule out other causes of laryngeal obstruction.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Hoyte FC. Vocal cord dysfunction. Immunol Allergy Clin North Am 2013; 33:1.
- Lawrence SG. Laryngeal dyskinesia: an under-recognized condition. Emerg Med Australas 2007; 19:96.
- Christopher KL, Wood RP 2nd, Eckert RC, et al. Vocal-cord dysfunction presenting as asthma. N Engl J Med 1983; 308:1566.
- Morris MJ, Christopher KL. Diagnostic criteria for the classification of vocal cord dysfunction. Chest 2010; 138:1213.
- Patterson R, Schatz M, Horton M. Munchausen's stridor: non-organic laryngeal obstruction. Clin Allergy 1974; 4:307.
- Skinner DW, Bradley PJ. Psychogenic stridor. J Laryngol Otol 1989; 103:383.
- McCool FD. Global physiology and pathophysiology of cough: ACCP evidence-based clinical practice guidelines. Chest 2006; 129:48S.
- Perkner JJ, Fennelly KP, Balkissoon R, et al. Irritant-associated vocal cord dysfunction. J Occup Environ Med 1998; 40:136.
- Newman KB, Mason UG 3rd, Schmaling KB. Clinical features of vocal cord dysfunction. Am J Respir Crit Care Med 1995; 152:1382.
- Goldman J, Muers M. Vocal cord dysfunction and wheezing. Thorax 1991; 46:401.
- Forrest LA, Husein T, Husein O. Paradoxical vocal cord motion: classification and treatment. Laryngoscope 2012; 122:844.
- Yelken K, Yilmaz A, Guven M, et al. Paradoxical vocal fold motion dysfunction in asthma patients. Respirology 2009; 14:729.
- Matrka L. Paradoxic vocal fold movement disorder. Otolaryngol Clin North Am 2014; 47:135.
- Chiang T, Marcinow AM, deSilva BW, et al. Exercise-induced paradoxical vocal fold motion disorder: diagnosis and management. Laryngoscope 2013; 123:727.
- Sullivan MD, Heywood BM, Beukelman DR. A treatment for vocal cord dysfunction in female athletes: an outcome study. Laryngoscope 2001; 111:1751.
- Rundell KW, Spiering BA. Inspiratory stridor in elite athletes. Chest 2003; 123:468.
- Morris MJ, Deal LE, Bean DR, et al. Vocal cord dysfunction in patients with exertional dyspnea. Chest 1999; 116:1676.
- Marcinow AM, Thompson J, Chiang T, et al. Paradoxical vocal fold motion disorder in the elite athlete: experience at a large division I university. Laryngoscope 2014; 124:1425.
- Arndt GA, Voth BR. Paradoxical vocal cord motion in the recovery room: a masquerader of pulmonary dysfunction. Can J Anaesth 1996; 43:1249.
- Hammer G, Schwinn D, Wollman H. Postoperative complications due to paradoxical vocal cord motion. Anesthesiology 1987; 66:686.
- Harbison J, Dodd J, McNicholas WT. Paradoxical vocal cord motion causing stridor after thyroidectomy. Thorax 2000; 55:533.
- Larsen B, Caruso LJ, Villariet DB. Paradoxical vocal cord motion: an often misdiagnosed cause of postoperative stridor. J Clin Anesth 2004; 16:230.
- Powell DM, Karanfilov BI, Beechler KB, et al. Paradoxical vocal cord dysfunction in juveniles. Arch Otolaryngol Head Neck Surg 2000; 126:29.
- Branski RC, Bhattacharyya N, Shapiro J. The reliability of the assessment of endoscopic laryngeal findings associated with laryngopharyngeal reflux disease. Laryngoscope 2002; 112:1019.
- Woo P, Mangaro M. Aberrant recurrent laryngeal nerve reinnervation as a cause of stridor and laryngospasm. Ann Otol Rhinol Laryngol 2004; 113:805.
- Husein OF, Husein TN, Gardner R, et al. Formal psychological testing in patients with paradoxical vocal fold dysfunction. Laryngoscope 2008; 118:740.
- Morris MJ, Oleszewski RT, Sterner JB, Allan PF. Vocal cord dysfunction related to combat deployment. Mil Med 2013; 178:1208.
- Martin RJ, Blager FB, Gay ML. Paradoxical vocal cord motion in presumed asthmatics. Semin Respir Med 1987; 8:322.
- Freedman MR, Rosenberg SJ, Schmaling KB. Childhood sexual abuse in patients with paradoxical vocal cord dysfunction. J Nerv Ment Dis 1991; 179:295.
- Maricle R. Vocal-cord dysfunction presenting as asthma. N Engl J Med 1983; 309:1190.
- Powell SA, Nguyen CT, Gaziano J, et al. Mass psychogenic illness presenting as acute stridor in an adolescent female cohort. Ann Otol Rhinol Laryngol 2007; 116:525.
- Gavin LA, Wamboldt M, Brugman S, et al. Psychological and family characteristics of adolescents with vocal cord dysfunction. J Asthma 1998; 35:409.
- Maturo S, Hill C, Bunting G, et al. Pediatric paradoxical vocal-fold motion: presentation and natural history. Pediatrics 2011; 128:e1443.
- Thomas PS, Geddes DM, Barnes PJ. Pseudo-steroid resistant asthma. Thorax 1999; 54:352.
- Koufman JA, Block C. Differential diagnosis of paradoxical vocal fold movement. Am J Speech Lang Pathol 2008; 17:327.
- Mobeireek A, Alhamad A, Al-Subaei A, Alzeer A. Psychogenic vocal cord dysfunction simulating bronchial asthma. Eur Respir J 1995; 8:1978.
- Perkins PJ, Morris MJ. Vocal cord dysfunction induced by methacholine challenge testing. Chest 2002; 122:1988.
- Guss J, Mirza N. Methacholine challenge testing in the diagnosis of paradoxical vocal fold motion. Laryngoscope 2006; 116:1558.
- Sokol W. Vocal cord dysfunction presenting as asthma. West J Med 1993; 158:614.
- Tervonen H, Niskanen MM, Sovijärvi AR, et al. Fiberoptic videolaryngoscopy during bicycle ergometry: a diagnostic tool for exercise-induced vocal cord dysfunction. Laryngoscope 2009; 119:1776.
- Heimdal JH, Roksund OD, Halvorsen T, et al. Continuous laryngoscopy exercise test: a method for visualizing laryngeal dysfunction during exercise. Laryngoscope 2006; 116:52.
- Nastasi KJ, Howard DA, Raby RB, et al. Airway fluoroscopic diagnosis of vocal cord dysfunction syndrome. Ann Allergy Asthma Immunol 1997; 78:586.
- Ooi LL. Re: Vocal cord dysfunction: two case reports. Ann Acad Med Singapore 1997; 26:875.
- Corren J, Newman KB. Vocal cord dysfunction mimicking bronchial asthma. Postgrad Med 1992; 92:153.
- Maceri DR, Zim S. Laryngospasm: an atypical manifestation of severe gastroesophageal reflux disease (GERD). Laryngoscope 2001; 111:1976.
- Randolph C, Lapey A, Shannon DC. Bilateral abductor paresis masquerading as asthma. J Allergy Clin Immunol 1988; 81:1122.
- Tilles SA, Ayars AG, Picciano JF, Altman K. Exercise-induced vocal cord dysfunction and exercise-induced laryngomalacia in children and adolescents: the same clinical syndrome? Ann Allergy Asthma Immunol 2013; 111:342.
- Pitchenik AE. Functional laryngeal obstruction relieved by panting. Chest 1991; 100:1465.
- Heiser JM, Kahn ML, Schmidt TA. Functional airway obstruction presenting as stridor: a case report and literature review. J Emerg Med 1990; 8:285.
- Weir M. Vocal cord dysfunction mimics asthma and may respond to heliox. Clin Pediatr (Phila) 2002; 41:37.
- Christopher KL, Morris MJ. Vocal cord dysfunction, paradoxic vocal fold motion, or laryngomalacia? Our understanding requires an interdisciplinary approach. Otolaryngol Clin North Am 2010; 43:43.
- Kivity S, Bibi H, Schwarz Y, et al. Variable vocal cord dysfunction presenting as wheezing and exercise-induced asthma. J Asthma 1986; 23:241.
- Rogers JH, Stell PM. Paradoxical movement of the vocal cords as a cause of stridor. J Laryngol Otol 1978; 92:157.
- Logvinoff MM, Lau KY, Weinstein DB, Chandra P. Episodic stridor in a child secondary to vocal cord dysfunction. Pediatr Pulmonol 1990; 9:46.
- Cormier YF, Camus P, Desmeules MJ. Non-organic acute upper airway obstruction: description and a diagnostic approach. Am Rev Respir Dis 1980; 121:147.
- Alpert SE, Dearborn DG, Kercsmar CM. On vocal cord dysfunction in wheezy children. Pediatr Pulmonol 1991; 10:142.
- Pinho SM, Tsuji DH, Sennes L, Menezes M. Paradoxical vocal fold movement: a case report. J Voice 1997; 11:368.
- McCabe D, Altman KW. Laryngeal hypersensitivity in the World Trade Center-exposed population: the role for respiratory retraining. Am J Respir Crit Care Med 2012; 186:402.
- Murry T, Tabaee A, Aviv JE. Respiratory retraining of refractory cough and laryngopharyngeal reflux in patients with paradoxical vocal fold movement disorder. Laryngoscope 2004; 114:1341.
- Fowler SJ, Thurston A, Chesworth B, et al. The VCDQ--a Questionnaire for symptom monitoring in vocal cord dysfunction. Clin Exp Allergy 2015; 45:1406.
- Doshi DR, Weinberger MM. Long-term outcome of vocal cord dysfunction. Ann Allergy Asthma Immunol 2006; 96:794.
- Ruddy BH, Davenport P, Baylor J, et al. Inspiratory muscle strength training with behavioral therapy in a case of a rower with presumed exercise-induced paradoxical vocal-fold dysfunction. Int J Pediatr Otorhinolaryngol 2004; 68:1327.
- Mathers-Schmidt BA, Brilla LR. Inspiratory muscle training in exercise-induced paradoxical vocal fold motion. J Voice 2005; 19:635.
- Murry T, Sapienza C. The role of voice therapy in the management of paradoxical vocal fold motion, chronic cough, and laryngospasm. Otolaryngol Clin North Am 2010; 43:73.
- ANATOMIC FINDINGS
- Laryngopharyngeal reflux
- Neurologic injury
- Psychosocial disorders and stress
- CLINICAL PRESENTATION
- EVALUATION AND DIAGNOSIS
- Pulmonary function tests
- Provocation with exercise challenge
- Arterial blood gases
- DIFFERENTIAL DIAGNOSIS
- Acute management
- Long-term prevention
- Communicating the diagnosis
- Behavioral speech/voice therapy
- ADDITIONAL RESOURCES
- SUMMARY AND RECOMMENDATIONS