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Abstract
BACKGROUND: Vocal cord dysfunction is an upper-airway disorder characterized by exaggerated and transient glottic constriction causing respiratory and laryngeal symptoms. Common presentation is with inspiratory stridor often in the context of emotional stress and anxiety. Other symptoms include wheezing (which may be on inspiration), frequent cough, choking sensation, or throat and chest tightness. This is seen commonly in teenagers, particularly in adolescent females. The COVID-19 pandemic has been a trigger for anxiety and stress with an increase in psychosomatic illness. Our objective was to find out if the incidence of vocal cord dysfunction increased during COVID-19 pandemic.
METHODS: We performed a retrospective chart review of all the subjects with a new diagnosis of vocal cord dysfunction who were seen at the out-patient pulmonary practice at our children’s hospital between January 2019–December 2020.
RESULTS: The incidence of vocal cord dysfunction in 2019 was found to be 5.2%, (41/786 subjects seen) compared to 10.3% (47/457 subjects seen) in 2020, which is a nearly 100% increase in incidence (P < .001).
CONCLUSIONS: It is important to recognize that vocal cord dysfunction has increased during the COVID-19 pandemic. In particular, physicians treating pediatric patients, as well as respiratory therapists, should be aware of this diagnosis. It is imperative to avoid unnecessary intubations and treatments with bronchodilators and corticosteroids as opposed to behavioral and speech training to learn effective voluntary control over the muscles of inspiration and the vocal cords.
Introduction
Dyspnea is a complex sensation that occurs in many pathophysiologic disorders, both functional and cardiopulmonary. Vocal cord dysfunction or paradoxical vocal fold motion disorder is an upper-airway disorder characterized by exaggerated and transient glottic constriction causing respiratory and laryngeal symptoms.1 Common presentation is with dyspnea, often in the context of exertion, emotional stress, and anxiety. This is seen commonly in teenagers, particularly in adolescent females.2 Other symptoms include wheezing, frequent cough, inspiratory stridor, choking sensation, and throat and/or chest tightness.3
In our tertiary out-patient pediatric pulmonary practice, we have observed an increase in the number of patients with symptoms of stridor or dyspnea who were subsequently diagnosed with vocal cord dysfunction by spirometry or laryngoscopy. These patients present with a wide array of specific symptomologies so that the diagnosis of vocal cord dysfunction can mimic several conditions such as asthma, croup, laryngomalacia, angioedema, vocal cord paralysis, and vocal cord tumors or polyps. Many patients with vocal cord dysfunction are incorrectly given the diagnosis of asthma and unnecessarily receive bronchodilators and frequent steroid treatments. Therapy for vocal cord dysfunction often involves teaching the patient (and family members) effective diaphragmatic breathing and not utilizing shoulder or chest muscles to inhale. Respiratory therapists may recognize the spectrum of vocal cord dysfunction symptoms and initiate appropriate breathing exercises.
There are many different possible triggers for vocal cord dysfunction such as exercise, strong emotions and stress, psychological conditions, acid reflux, post-nasal drip, and strong odors or fumes.4 The COVID-19 pandemic has been a trigger for anxiety and stress with an increase in psychosomatic illness.5 We aimed to compare the incidence of vocal cord dysfunction among the patients seen in our practice between 2019 (before pandemic) and 2020 (during the pandemic). We hypothesized that the COVID-19 pandemic, which has been a trigger for anxiety and stress causing many psychosomatic illnesses, elicited an uptick in the incidence of vocal cord dysfunction in 2020.
QUICK LOOK
Current Knowledge
Vocal cord dysfunction is characterized by exaggerated and transient glottic constriction causing respiratory and laryngeal symptoms. Possible triggers include exercise, strong emotions and stress, psychological conditions, acid reflux, post-nasal drip, and strong odors or fumes.
What This Paper Contributes to Our Knowledge
The COVID-19 pandemic, which has been a trigger for anxiety and stress, elicited an uptick in the incidence of vocal cord dysfunction. In most cases, behavioral and speech training, administered by respiratory or speech therapists, helped subjects learn to effectively control the vocal cords and recruit the diaphragm.
Methods
We performed a retrospective chart review of all the patients > 8 y old with a diagnosis of vocal cord dysfunction who were seen at the out-patient pulmonary practice at our children’s hospital between January 2019–December 2020. The data analytics team at our hospital helped us to retrieve the list of all the patients with diagnosis of vocal cord dysfunction seen at the pulmonary office using the ICD-10 Clinical Modification diagnosis code for vocal cord dysfunction. Only subjects with a new diagnosis of vocal cord dysfunction were included; patients who had history of vocal cord dysfunction were excluded. Medical records were reviewed and data collected that included demographics and presenting symptoms such as stridor, dyspnea, hoarseness of voice, choking sensation, wheezing, chest tightness, and throat tightness. Triggers for vocal cord dysfunction such as depression, anxiety, family or school stressors, allergies to medications or food, asthma, acid reflux, and post-nasal drip were evaluated. We also examined how the diagnosis of vocal cord dysfunction was made whether by clinical exam or by abnormality on spirometry testing (truncation of inspiratory limb) or by direct visualization of vocal cords during laryngoscopy (paradoxical movement). The various types of treatments (such as speech therapy, psychotherapy, relaxation techniques or abdominal breathing, biofeedback), treatment of underlying risk factors (asthma or post-nasal drip or acid reflux), or a combination of both speech therapy and relaxation techniques in these subjects were also collected. Finally, outcomes for each subject such as whether the symptoms were well controlled with the above recommended therapies or if there were frequent exacerbations with emergency department visits despite therapy leading to in-patient hospitalizations were also evaluated. The study was approved by Albany Medical Center Institutional Review Board (IRB#6255).
Results
A total of 98 patients were diagnosed with vocal cord dysfunction between 2019–2020 of which 50 patients were diagnosed in 2019 and 48 patients in 2020. Among the 50 patients who were diagnosed in 2019, 82% (41/50) had a new diagnosis of vocal cord dysfunction, and the other 18% (9/50) were follow-up from previous years. In 2020, 98% of patients (47/48) had a new diagnosis of vocal cord dysfunction. Thus, a total of 88 subjects were included in our study analysis, and 10 patients were excluded as we aimed to study only subjects who were newly diagnosed during the study period. The incidence of vocal cord dysfunction in 2019 was found to be 5.2%, (41/786 patients seen) compared to 10.3% (47/457 patients seen) in 2020, which is a nearly 100% increase in incidence (P < .001). The incidence of vocal cord dysfunction was calculated using the 2 × 2 contingency table with one-tailed t test with P value < .05 considered statistically significant.
Discussion
Vocal cord dysfunction is an upper-respiratory condition characterized by paradoxical adduction of the vocal cords during inspiration that can manifest in a wide variety of symptoms.6 The clinical presentation of vocal cord dysfunction can range from no symptoms to mild shortness of breath to acute onset of respiratory distress. The most common symptoms seen in vocal cord dysfunction are inspiratory dyspnea, wheezing or stridor, throat tightness, and dysphonia.7 In our sample, 53% (47/88) of the subjects presented with the sole symptom of dyspnea; and 17% (15/88) had multiple symptoms of dyspnea, cough, or wheezing. Other symptoms included throat tightness (10%), chest tightness (10%), stridor (5%), choking sensation (2%), and hoarseness of voice (2%) (Table 1).
The symptoms in our study are comparable to a large review study of 1,020 subjects with vocal cord dysfunction where they found that 73% of their subjects had dyspnea, 36% had wheezing, 28% had stridor, and 25% had cough.8
Vocal cord dysfunction can appear at any age and appears to be more common in females, with a 2:1 to 3:1 predominance.9 Review of the literature by Morris10 described that 71% of subjects with vocal cord dysfunction were adults, and the remaining 29% of subjects were < 18 y. The average age of diagnosis in subjects < 18 y had been reported to be 14.5 y. In our group, 72% (64/88) of the subjects were female, and the average age was 14.1 y.
The diagnosis of vocal cord dysfunction is challenging due to its wide symptomatology and overlap with common diseases like asthma, laryngomalacia, and other diseases of upper-airway obstruction. Also, the transient nature of this disease makes it easier to misdiagnose because it can coexist with other diagnoses.11 The diagnosis of vocal cord dysfunction is based on clinical history, physical examination, and pulmonary function testing. The accepted standard is the finding of paradoxical narrowing of vocal cords by laryngoscopy during inspiration when the patient is symptomatic.12 The most frequent pattern on spirometry in patients with vocal cord dysfunction is the truncation or plateau in the inspiratory limb (Fig. 1). Some individuals can also have a plateau in the expiratory limb (Santiago et al13) that makes it difficult to diagnose. Spirometry testing in our subjects showed flattened inspiratory loop in 64% (56/88); the rest had normal loops. As mentioned above, if the patient is not symptomatic at the time of laryngoscopy, there may not be any observed paradoxical motion. In our group, laryngoscopy was able to be performed in only 39% (34/88) of the subjects due to COVID precautions and protocols. Laryngoscopy showed paradoxical movement in only 59% (20/34) of these subjects. Most of the subjects 81% (71/88) had signs of excessive shoulder and neck muscle use during inspiration (maladaptive breathing) with symptoms consistent with vocal cord dysfunction (see Table 1).
Furthering the challenge to confirm the diagnosis, vocal cord dysfunction is labeled in the medical community by different names such as psychogenic stridor, episodic paroxysmal laryngospasm, emotional laryngeal wheezing, factitious asthma, maladaptive beathing, and paradoxical vocal fold motion. As a result of underdiagnosis or misdiagnosis, the true incidence of vocal cord dysfunction is unknown. In our subjects, we found a nearly 100% increase in the incidence of vocal cord dysfunction from 5.2% in 2019 to 10.3% in 2020, during the pandemic. Among many triggers of vocal cord dysfunction, emotional stress and anxiety or psychosomatic illness are an important precipitant.14 The literature search revealed a high incidence of vocal cord dysfunction in psychiatric conditions. Lacy and McManis15 reviewed 45 cases of vocal cord dysfunction in which psychiatric disorders were reported; 52% had a conversion disorder; 13% had major depression, and 10% had a factitious disorder. Underlying all these diagnoses was the presence of significant emotional stress.
It may be useful to look at vocal cord dysfunction as a spectrum of conditions, not exclusively involving the vocal cords. In several ways the use of the term vocal cord dysfunction is a misnomer. The unifying concept is the constriction or tightening of muscles in the neck and upper chest in response to a stressor. Another unifying concept is the amelioration of symptoms with relaxation techniques, which can be utilized by respiratory therapists, physicians, or psychologists. These draw on a combination of relaxing the neck and shoulder muscles and recruiting the diaphragm and abdominal wall musculature in breathing.
During the COVID-19 pandemic, children and adolescents were greatly impacted by the abrupt withdrawal from school, social life, and outdoor activities.16 The prevalence of anxiety, depressive symptoms, and other psychiatric disorders has heightened during the pandemic as reported by multiple studies.17,18 In our group, we noted that 36% (32/88) of subjects had a history of anxiety or depression or some stressor with other comorbidities such as asthma (19%), food allergies and postnasal drip (11%), and gastroesophageal reflux (7%). Only 11% had no risk factors. We believe that the COVID-19 pandemic is associated with induction of stress and hence triggering the incidence of vocal cord dysfunction in our practice.
The acute management of a patient with vocal cord dysfunction, after establishing the correct diagnosis, is reassurance that the condition is benign and self-limited.10 Most of these patients are often misdiagnosed as asthma or laryngomalacia or anaphylaxis and receive inhaled bronchodilators, corticosteroids, or unnecessary intubation. Speech therapy and behavioral treatment are regarded as the primary therapies for vocal cord dysfunction. Techniques involving controlled breathing exercises focusing on diaphragmatic breathing have been shown to be effective. Respiratory therapists can often assist patients in learning these controlled breathing techniques, whether in the in-patient or out-patient setting. The majority of the subjects (61%) in our study received a combination of speech therapy along with relaxation and breathing techniques, and 32% of subjects received only relaxation techniques due to lack of availability of speech therapist. In our study group, 30% of the subjects were well controlled with above treatment, with a 64% loss to follow-up. Only 6% of the total subjects had frequent exacerbations requiring out-patient visits.
Conclusions
It is important to recognize that vocal cord dysfunction incidence was increased during the COVID-19 pandemic. In particular, respiratory therapists as well as pediatricians, primary care, emergency department, and ICU physicians should be aware of this diagnosis. It is imperative to diagnose vocal cord dysfunction as lack of diagnosis can lead to unnecessary intubations and/or treatments with bronchodilators and corticosteroids. In most cases, behavioral and speech training to learn effective voluntary control over the vocal cords and recruitment of the diaphragm was effective.
Footnotes
- Correspondence: Shashikanth R Ambati MBBS, Department of Pediatrics, Albany Medical Center, 47 New Scotland Avenue, MC 102, Albany, NY 12208. E-mail: ambatis{at}amc.edu
The authors have disclosed no conflicts of interest.
Dr Edge presented a version of this paper at the Society of Critical Care Medicine 2022 Critical Care Congress, held virtually April 18–21, 2022.
- Copyright © 2023 by Daedalus Enterprises
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