Laryngospasm and Other Forms of Vocal Cord Dysfunction
Vocal cord dysfunction (aka, paradoxical vocal cord motion, VCD, non-organic wheezing, etc) is a general term used to describe a situation when the vocal cords come together (or ADduct) when taking a breath in when normally they should go apart (or ABduct). The key thing to remember is that everything from the nose down into the lungs generally appears totally normal anatomically speaking; however, the voicebox is functionally abnormal. Normal vocal cord ABduction allows air to easily pass into the trachea (or windpipe). However, when the vocal cords ADduct, air must squeeze through what small opening may be present between the closed vocal cords. In this scenario, a noisy inhalation may occur. The sound that is produced is called stridor. YouTube actually has several examples of what stridor sounds like.
Laryngospasm is the most severe form of vocal cord dysfunction as there is barely if any opening for the air to pass through at all. Often, patients believe they are about to pass out (and sometimes they do), at which point, normal breathing resumes. Literally, their own body is choking itself during laryngospasm and it is a truly frightening experience when it occurs. Watch a video.
Vocal cord dysfunction is a less severe form of laryngospasm in which the person is still able to breath, but does produce a loud stridor.
Triggers for these episodes are numerous... stress, allergies, anxiety, asthma exacerbation, reflux, exercise, cold air, etc and even idiopathic. Obviously, if such triggeres are known, they should be treated. Also of note, normal breathing immediately resumes after a person passes out (if they pass out) and these episodes never occur while sleeping unless a triggering event occurs (ie, reflux).
The key to treatment is correct diagnosis. I personally have found that vocal cord dysfunction is over-diagnosed erroneously. Examples found in the "Noisy Breathing" section have been initially (and incorrectly) diagnosed as vocal cord dysfunction (except for Example 2 which is a true laryngospasm episode).
At least for me, when a patient presents with complaints of noisy breathing thought to be due to vocal cord dysfunction, I do a complete fiberoptic exam to look for anatomic abnormalities since 9 times out of 10, I do find something abnormal thereby eliminating vocal cord dysfunction as the problem. If everything indeed looks normal, the next step is to actually to try trigger an episode. For most people in my patient population, it seems to be exercise... SO, I have them run around my office building (or obtain a pulmonary stress test) until they have an episode and I immediately repeat the fiberoptic exam. Another trigger that may work is the rapid counting test. I have the patient count to 50 as fast as they can in one breath, and than have them inhale with their mouth. Endoscopy is performed during the rapid counting test. While symptommatic, if I see vocal cord ADduction with inspiration, the diagnosis of vocal cord dysfunction is real. If not, it most definitely is NOT vocal cord dysfunction. Without this last finding, one must keep looking for some other reason for the noisy breathing attacks.
So, assuming one has vocal cord dysfunction, what is a patient supposed to do if they have an attack and not near a healthcare provider? Other than calling 911 as the attack may not be due to vocal cord dysfunction, I instruct patients on a few methods which may help abort or reduce the severity of an attack. THESE METHODS APPLY ONLY IF YOU TRULY HAVE VOCAL CORD DYSFUNCTION OR LARYNGOSPASM!
Bear in mind, once vocal cord dysfunction/laryngospasm is diagnosed, a workup is also pursued to figure out the trigger which, once addressed, should result in cure (more info on this below under "Other Treatments").
METHOD 1: Breathing Technique
There are 3 steps to this particular method.
- As soon as one feels an attack coming, SLOWLY breath in through the NOSE. DO NOT BREATH IN THROUGH THE MOUTH! Sometimes deliberately holding breath for 5 seconds prior to nasal inhalation helps.
- More quickly exhale out the mouth with pursed lips.
- Continue slow nasal inhalation, and quick mouth exhalation with pursed lips until the episode passes.
Why does this work? For some reason, nasal breathing reinforces the brain to keep the vocal cords apart when inhaling. Quick inhalation through the mouth seems to do the opposite and encourage the vocal cords to close which exacerbates the problem. Also, quick inhalation reinforces the Bernoulli Principle that as a fluid (air in this case) passes through a pipe that suddenly narrows (the vocal cords), the pressure actually decreases which encourages further narrowing (or vocal cord closure). Therefore, SLOW breathing helps keep the vocal cords apart! You can test this principle yourself by sucking air on a narrow short straw slowly and than quickly. You will find that the straw will tend to collapse when sucking in quickly.
METHOD 2: Straw Breathing
This method essentially forces a person to decrease the speed of breathing allowing for vocal cord relaxation. In essence, cut a regular drinking straw to half its length. When an attack occurs, place the straw in your mouth and make a tight seal. Breath thru the straw (via mouth) until attack passes.
Patients with recurrent laryngospasm attacks typically keep a straw in their pocket/purse to have immediately on hand.
METHOD 3: Pressure Point
Another manuever that may work is firm pressure in the "laryngospasm notch." Basically, with an attack, quickly with your (or somebody else's) index fingers, press very firmly just behind both your earlobes where there is a notch between the bone of your mastoid process and ear. Press deep and forward towards the nose. It should hurt. If it doesn't hurt, you are not pressing hard enough. The attack should resolve within 10 seconds. Here is an article describing this method.
This particular method applies only if laryngospasm attacks occur mainly at night while sleeping. Essentially, one uses a CPAP machine which blows air into your lungs while you sleep. This treatment helps by preventing the body from believing it is "drowning" which would result in vocal cord adduction. By having a persistent positive airflow from the CPAP device, it also reinforces to the brain to keep the vocal cords apart. At worst case, if an attack occurs, the CPAP machine helps push air into your lungs past the vocal cords. Indeed... if you ask any anesthesiologist what they do when a laryngospasm attack occurs during intubation, they'll say apply strong positive pressure by mask (along with other things of course).
Make sure you use heated humidification. Please be aware that the air pressure being applied MAY actually cause laryngospasm due to direct vocal cord irritation of the forced air. Unfortunately, there's no way to predict someone who will respond vs someone who will do worse with this treatment method.
Oftentimes, the above strategies help enough that a patient finds these attacks occur less frequently with decreasing severity over time until they altogether stop. A more formal behavior modificaton program to address laryngospasm can be found here.
Rarely, a benzodiazepine medication will be prescribed for these attacks to help with the anxiety aspect until the strategy is internalized. Working with speech pathology has also been found to be helpful. In certain situations, laryngeal sensory neuropathy (LSN) may be contributing to VCD and treatment geared towards LSN improves VCD. Of course, treatment or avoidance of the trigger whether it be allergy, asthma, medication side effect (ACE Inhbitors) or reflux is important. A typical workup for VCD/laryngospasm include:
- GI Workup
- EGD (Evaluate for esophageal pathology. In rare cases, mucosal ulcers have been found hypothesized to irritate the recurrent laryngeal nerve, found alongside the esophagus, resulting in VCD).
- Barium swallow (Evaluate for esophageal motility problems as well as Zenker's diverticulum)
- 24-Hour Multichannel Intraluminal Impedance (MII) and pH monitoring (Evaluate for acid as well as non-acid reflux)
- Response after maximum reflux medication treatment
for 3 months
- Proton pump inhibitor twice a day (30 minutes before breakfast and dinner) AND
- Zantac 300 mg at bedtime
- CT Sinus scan (Evaluate for subclinical chronic sinusitis)
- Allergy testing (Evaluate for allergies). If positive, allergy injection response report
- Pulmonary Workup
- Pulmonary function test with methacholine challenge (Evaluate for asthma)
- Bronchoscopy with lavage cultures (Evaluate for subclinical pulmonary infections/masses)
- CT Chest scan (Evaluate for lung masses too small to be seen on Chest X-ray)
- Response to asthma medications
In rare cases, I will consider injecting BOTOX into the vocal cords which will physically prevent the vocal cords from coming together and as such, prevent the difficulty in breathing should an attack occur. In some people, it decreases not only the severity, but also the frequency of attacks. The way BOTOX is injected into the vocal cords is shown here. Please note that the vast majority of patients upon whom I perform vocal cord BOTOX injections are those suffering from spasmodic dysphonia.
- An approach to the management of paroxysmal laryngospasm. J Laryngol Otol. 2008 Jan;122(1):57-60. Epub 2007 Feb 26.
- Use of botulinum toxin type A to avoid tracheal intubation or tracheostomy in severe paradoxical vocal cord movement. Chest. 2000 Sep;118(3):874-7.
- Paradoxical vocal fold motion: presentation and treatment options. J Voice. 2000 Mar;14(1):99-103.
- Spasmodic croup in the adult. Am Rev Respir Dis. 1983 Apr;127(4):500-4.
- Primary laryngospasm in a patient with Parkinson's disease: treatment with CPAP via minitracheostomy following intubation. Intensive Care Med. 1995 Oct;21(10):863-4.
- Effects of continuous positive airway pressure on stridor in multiple system atrophy-sleep laryngoscopy. J Clin Sleep Med. 2009 Feb 15;5(1):65-7.
- Sleep-related laryngospasm. Eur Respir J. 1997 Sep;10(9):2084-6.
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- Benign Stridor Often Mistaken for Laryngospasm
- Does Stridor HAVE to be Present for Diagnosis of Vocal Cord Dysfunction?
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