SPPA 640 Voice Disorders

Paradoxical Vocal Fold Motiona.k.a…. Munchausen’s Stridor Psychogenic Stridor Functional Inspiratory

Stridor Functional upper airway

obstruction Atypical asthma Factitious asthma Emotional laryngeal

wheezing

vocal cord dysfunction Adult spasmodic croup Functional abduction

paresis Emotional

laryngospasm Episodic laryngeal

dyskinesia pseudoasthma

SPPA 640 Voice Disorders

Paradoxical Vocal Fold Motion (PVFM): What is it?

Primarily a breathing impairment upper airway (extrathoracic) obstruction vocal folds adducting (closing) when they should be

abducting (opening) Inspiration, expiration or both occurs in isolation, or with asthma

SPPA 640 Voice Disorders

Paradoxical Vocal Fold Motion Etiology

Unknown psychological factors are implicated but well

controlled studies are lacking

SPPA 640 Voice Disorders

Paradoxical Vocal Fold Motion Commonly induced by

Stress Exercise gastroesophageal reflux (nocturnal) Post-nasal drip Respiratory irritants cold air panic associated with asthma

SPPA 640 Voice Disorders

PVFM: Patient Characteristics

More common in girls/women 3-4/1 female/male ratio

Children, adolescents, adults 20-40 years Diagnosis of uncontrolled asthma Anomalous findings for severe asthma

Brugman & Newman, (1993)Kuppersmith et al. (1993)

SPPA 640 Voice Disorders

PVFM: Some Characteristics

May see Hx of asthma treatment Previous emergency intubation (rare) Hx of tracheotomy (rare) Chronic steroid use Hoarseness and other voice changes

SPPA 640 Voice Disorders

Assessment of PVFM

Team approach including Speech pathology Otolaryngology Pulmonary function Gastroenterology (GERD/LPR) Allergy Psychiatry

SPPA 640 Voice Disorders

PVFM: Signs

Clinical Stridor rapid breathing accelerated pulse rate anxiety/panic Auscultation identifies the larynx as site of

obstruction

SPPA 640 Voice Disorders

PVFM: Signs

Laryngoscopy Adduction of anterior 2/3’s of TVFs during

inspiration small posterior diamond shaped glottic chink Mediolateral compression of ventricular

folds Exam normal when asymptomatic

SPPA 640 Voice Disorders

PVFM: Signs

Laryngoscopic Assessment (SLP & ENT) Tidal breathing (rest) Forced inspiration, forced expiration Panting Sniffing Repeated rapid deep inspirations Exercise challenge

SPPA 640 Voice Disorders

PVFM: SignsPulmonary Function (Spirometry)When symptomatic…PVFM Forced vital capacity: normal Forced expiratory volume in 1 sec: normal Inspiratory flow: reduced Expiratory flow/inspiratory flow ratio: elevated Bronchodilator treatment: limited improvement

Asthma Forced vital capacity: normal Forced expiratory volume in 1 sec: reduced Expiratory flow/inspiratory flow: normal or reduced Bronchodilator treatment: marked improvement

SPPA 640 Voice DisordersTilles (2003)

SPPA 640 Voice Disorders

PVFM: Bronchoprovocation

Methacholine challenge Induces small airway narrowing A negative response will help exclude asthma

SPPA 640 Voice Disorders

PVFM: Provocation

Exercise challenge Helpful for eliciting symptoms in certain clients Does not differentiate asthma and PVCD Allows signs/symptoms to be observed so that a

Dx may be made

SPPA 640 Voice Disorders

PVFM: Psychosocial CharacteristicsReports of Perfectionism Obsessive-compulsive features Anxiety disorders (panic) Somatization disorder Difficulty expressing anger, sadness and fear Conversion reaction (??)

Rate of psychopathology no different from severe asthmatics

Mathers-Schmidt (2001)

SPPA 640 Voice Disorders

Mathers-Schmidt (2001)

SPPA 640 Voice Disorders

PVFM: Management

Education Review normal airway function Review test results Discuss possible precipitants

stress, exercise, GERD, panic etc

SPPA 640 Voice Disorders

PVFM: Management

Quick controls (+/- endoscopic feedback) Sniffing, 3 quick sniff in, slow controlled

exhalation on /s/ or /sh/, lips pursed Manual lowering of larynx Panting: shallow and limited number of times (but

not with asthma)

SPPA 640 Voice Disorders

PVFD: Management Teach relaxed throat breath, awareness of laryngeal

muscle tension Flatten tongue, drop jaw, inhale through nose and exhale on /s/

Abdominal breathing pattern Controlled exhalation General relaxation exercises (audiotapes) Stress management, counseling Antireflux protocol Biofeedback using endoscope