Paradoxical Vocal Cord Dysfunction


Exercise Induced

Paradoxical Vocal Cord Dysfunction


Dale R. Gregore


Speech Language Pathologist

Clinical Rehabilitation Specialist - Voice

NORMAL Respiration 101

On inhalation, the vocal cords (folds)

ABduct allowing air to flow into the trachea, bronchial tubes, lungs

On exhalation, the vocal folds may close slightly, however should and do remain ABducted

Normal Larynx

Vocal fold

ABDUCTION occurs during respiration

Vocal fold ADDUCTION

Occurs during swallowing, coughing, etc…

Strobe exam

Paradoxical Vocal Fold Movement


The cord function is

reversed in that the vocal folds ADDuct on inspiration versus


Leads to tightness or spasm in the larynx

Inspiratory wheeze evident

Definition of EI-VCD

“Inappropriate closure of the vocal folds upon inspiration resulting in stridor, dyspnea and shortness of breath (SOB) during strenuous activity”

– Matthers-Schmidt, 2001;

Sandage et al, 2004


Vocal Cord Dysfunction (VCD)

– Most common term

Munchausen’s Stridor

Emotional Laryngeal Wheezing


Fictitious Asthma

Episodic Laryngeal Dyskinesia

Patient description of VCD episodes

– “in the top of my throat I see a

McDonalds straw surrounded by darkness. The straw ends in a pool of thick, sticky liquid that is encased by a wall of rubber bands and outside of the rubber bands is air that I can’t access”.

– “The top part of my throat is complete darkness, at the back part of the darkness there are cotton balls. These are holding my fear”.

PVFM Visualized

Anterior portion of the vocal folds are


Only a small area of opening at the

Posterior aspect of the vocal folds

Diamond shaped


May be evident on both inhalation and exhalation

Essential Features

Vocal fold adduct (close) during respiration instead of abducting


Laryngeal instability while patient is asymptomatic

– Treole,K. et. al. 1999

Episodic respiratory distress



Difficulty with inspiratory phase

Throat tightening > bronchial/ chest

Dysphonia during/following an attack

Abrupt onset and resolution

Little or NO response to medical treatment (inhalers, bronchodilators)

Various Etiologies

Laryngo-Pharyngeal Reflux (LPR)

– Food/ liquid/ acid refluxes from the stomach up the esophagus into the pharynx (throat)

– Can spill over and into the larynx

– causes coughing, choking, breathing and voice changes, swelling, irritation,

– Can be SILENT or sensed when it happens


LPR, continued

Clinical characteristics can be observed using videolaryngoscopic or stroboscopic visualization of the larynx

Ideally, diagnosed by a 24hour pH. Probe or EGD

LPR and Athletes

Well documented occurrence in weight lifting

Can be aggravated by bending, pushing/ resisting (tackling, etc…), tight clothing, even drinking water during a game/ meet/ match

Timing of meals before exercise is important

Type of foods/ liquids should be monitored

Laryngopharyngeal Reflux:

Clinical Signs

Interarytenoid Edema

Lx Erythema

Vocal Fold Edema

Other potential causes of

Paradoxical Vocal Cord


Allergic rhinitis or reaction

Conversion disorder


Respiratory-type or druginduced laryngeal dystonia

Etiologies (cont.)

Asthma-associated laryngeal dysfunction

Brainstem dysfunction

CVA or injury

Chronic laryngeal instability, sensitivity & tension

Athlete Profile for EI-VCD

Onset between 11-18

Females have a greater incidence

(generally 3:1)

High achieving

“Type A” personalities

High personal standards and/or social pressures

Intolerant to personal failure

Athlete Profile, cont…


Self demanding

Perceives family pressure to achieve a high level of success

“Choke” under pressure

May have recently graduated to higher level of competition within their sport (JV to Varsity: Rep to Travel team; college level sports, etc)

EI-VCD versus Asthma

Recalcitrant to asthma medications i.e. does not respond to

Individuals with “asthma” after long term steroid use might not truly have asthma, but VCD

Individuals with significant anxiety: is it LIVE OR MEMOREX? Which causes which?

Differential Diagnosis of EI-VCD

Includes a detailed Case History

Pulmonary function Studies

Lab Test

ENT/ Pulmonary/ Allergy evaluations

Flexible Laryngoscopy/ videostroboscopy

Speech-language pathology evaluation

Supplemental as needed: Psychological evaluation

Differential Diagnosis of VCD

Team Must Rule Out:

– Mass Obstruction

– Bilateral vocal fold paralysis

– Anaphylactic laryngeal edema

– Extrinsic airway compression

– Foreign body aspiration

– Infectious croup

– Laryngomalacia

– Exercise Induced Asthma/


Diagnosis of EI-VCD

Often mistaken for asthma

Diagnosis of EI-PVCD is by

exclusion = when patient fails to respond to asthma or allergy medication, then

VCD is finally considered

EI-VCD and Asthma

Can exist independently

Can also coexist

– Patient may experience LPR which causes Asthma flare-up and then laryngospasm (VCD) from coughing

– May experience chest (asthma) and/or laryngeal (VCD) tightness

EI-PVCD versus

Exercise Induced Asthma


Female Preponderance

Chest Tightness

Throat Tightness


Usual onset of symptoms after beginning exercise (min)

Recovery period (min)

Refractory period

Late-phase response

Response to beta-agonist





















Typical Spirometry Findings for



– Flow-volume loops are normal


– Blunted inspiratory curve

– Inspiratory curves highly varied

– Expiratory portion may be blunted

– Ratio of forced expiratory to inspiratory flow at 50% VC can be greater than 1.0

Inspiratory cut-off, flattening of the inspiratory limb (curve)


Case History Questions

– Do you have more trouble breathing in than out?

– Do you experience throat tightness?

– Do you have a sensation of choking or suffocation?

– Do you have hoarseness?

– Do you make a breathing-in noise

(stridor) when you are having symptoms?

Questions (cont.)

– How soon after exercise starts do your symptoms begin?

– How quickly do symptoms subside?

– Do symptoms recur to the same degree when you resume exercise?

– Do inhaled bronchodilators prevent or abort attacks?

– Do you experience numbness and/or tingling in your hands or feet or around your mouth with attacks

Questions (cont.)

– Do symptoms ever occur during sleep?

– Do you routinely experience nasal symptoms (postnasal drip, nasal congestion, runny nose, sneezing)?

– Do you experience reflux symptoms?

Videostroboscopic Examination


– Flexible fiberoptic laryngeal endoscope with stroboscopic capability


– Movement of arytenoids during respiration at rest: Complete closure; Posterior diamond

– Signs of laryngopharyngeal reflux disorder


– Degree of laryngeal instability

Laryngeal Supraglottic


arytenoid compression ventricular compression

Limited airway for phonation

VCD appearance on direct examination




Abnormal ventricular compression during speech

Laryngeal Supraglottic


Sphincteric contraction of the supraglottis during speech production

PVCM Visualized

Posterior ‘chink’

Rounded arytenoids, but normal abduction

Diagnostic Features PVFM Asthma

Flow-volume loop Inspiratory cut-off, Reduced expiratory perhaps some expiratory limb only

limb reduction *

Bronchial provocation Negative test


Laryngoscopic Inspiratory adduction observations

Vocal folds may adduct during of anterior 2/3 of vocal exhalation folds; posterior diamondshaped chink; perhaps medialization of ventricular folds; inspiratory adduction may carry over to expiration

Diagnostic Features PVFM Asthma

Precipitators (triggers) Exercise, extreme Exercise, extreme temperatures, airway temperatures, irritants, emotional airway irritants, stressors emotional stressors, allergens

Number of triggers Usually one Usually multiple

Breathing obstruction Laryngeal area Chest area location

Timing of breathing Stridor on noises inspiration

Wheezing on exhalation

Pattern of dyspneic Sudden onset and More gradual onset event relatively rapid cessation longer recovery period

Almost always Nocturnal awakening Rarely with symptoms

Response to bronchodilators and/or systemic corticosteroids

No response Good response

Acute Management of EI-VCD in the field

Approach to the patient is important

It is generally agreed that patients do not consciously manipulate or control their upper airway obstruction

Acute Management of EI-VCD

During an episode, they usually feel helpless and terrified

Implying that it is “in their head” is incorrect and counterproductive to their recovery

Coach them through, help them out

Be positive

Acute Management of Attacks

– Offer reassurance and empathy

– Eliminate activity and people from environment


– Elicit controlled ‘Panting’

Relaxed jaw

Tongue on floor of mouth behind bottom teeth

Acute Management in the Game


6 lane highway with no roadblocks

Air goes in and circles around, goes out

Shoulders relaxed

Standing w/ open chest, hands on hips, or bent over/ hands on knees….which position works best?

Quick Sniff Technique

– Sniff then Blow….talk the athlete through this

– Sniff in with focal emphasis at the tip of the nose

Sniff = ABduction

– Then exhale with pursed lips on





= Back pressure respiration

ACUTE treatment, cont…

– Breathing against pressure (hand on abdomen)

Resistance and focus on pressure against / in another body part

– Heliox

Administered by Paramedics or ER MDs

– Sedatives and psychotropic medications

Last resort

Calming effect

Eliminates tension/ constriction

Treatment: Speech Therapy

Patient counseling, education

Respiratory retraining

Focal and whole body relaxation

Phonatory retraining

Monitor reflux Sx or anxiety

Develop / outline a ‘Game Plan’ = practice when asymptomatic; implement at the onset of sx

Therapeutic goals and methods


– Ability to overcome fear and helplessness

– Reduced tension in- extrinsic laryngeal muscles

– Diversion of attention from larynx


– Mastery of breathing techniques

– Open throat breathing; resonant voice technique

– Diaphragmatic breathing and active exhalation

Therapeutic goals and methods


– Reduced tension in neck, shoulders and chest

– Ability to use techniques to reduce severity and frequency of attacks


– Movement, stretching, progressive relaxation

– Increase awareness of early warning symptoms;

Rehearse action plan

Speech Therapy

Patient Counseling & Education

– Description of laryngeal events

– Viewing of laryngoscopy tape

– Relate parallels to other stress induced disorders: migraine, irritable colon, muscle tension dysphonia, GEReflux

– Flexible endoscopic biofeedback

– Sensory biofeedback (sEMG)

Speech Therapy

Respiratory training

– Low “diaphragmatic” breathing versus

“high” clavicular thoracic

– Rhythmic respiratory cycles

– Use resistance exhale (draw attention away from larynx and extend exhale)

– Prevention and coping strategies during episodes = Action Plan

Back Pressure Breathing

Nasal Sniff = OPEN cords

Prolonged exhalation /w/, /f/, /sh/,


Shoulders relaxed

Throat open

Implement when laying, sitting, standing, walking, jogging, running, playing sports, etc

Relaxation Training


– Teach the patient to relax focal areas then the entire body during an episode of respiratory distress


– Use progressive relaxation with guided imagery

– Explore the patient’s visual concept of their disorder and alter

ST Duration: The CCHS Approach

2-8 sessions

Average 4 sessions

Followed by clinical observation during sport/ game

Followup phone / email contact: tell me how it is going?

Re-evaluation as necessary, if symptoms reoccur (rarely)


14 year old female

Sports: field hockey, soccer

Travel soccer U-17 team/ midfiled

Initial symptoms: ‘throat closes’ ~5 minutes in to game; hand on throat; signals coach; pulled from game; 20 minute recovery: lying on sideline

Therapy Focus and Outcome

5 sessions

Breathing 101

Training from static to active movement/ running

Full coaching then observation of strategy implemetation in therapy and during game

Outcome: (-) sx during mile run; cool down routine implemented; 20-30 minute game play/ no EI-VCD w/ ‘game plan’

Case Discussion #2

14 year old female

Sports: cross country; basketball

Initial Symptoms: ‘throat closed’ during CC trials; had to ‘drop out’

Secondary Symptoms: inspiratory stridor when wearing mouth guard/ basketball; felt ‘faint’

Therapy Focus and Outcome

5 sessions

Goals: establish ‘low’ AD breathing/ eliminate shoulder elevation and CT respiration pattern; train in back pressure breathing w/ and w/out mouthguard during activities of progressive effort including walk; jog; stairs, treadmill; suicide drills;

BB drills; sprints, etc


Successful resolution of PVFM during

20 minute runs and when playing BB

Increased awareness of AD versus

CT respiration

Habituated alternate use of sniff/ pant – blow, etc.

Increased perceived ‘control’ over breathing and performance

Spring Sport pending: soccer


Brugman, S. M., & Newman, K. (1993). Vocal cord dysfunction. Medical/Scientific Update. 11. 5. 1-5.

Christopher, K. L., WoodII, R. P., Eckert, R. C., Blager,

F. B., Raney, R. A., & Souhrada, J. F. (1983). Vocalcord dysfunction presenting as asthma. The New England

Journal of Medicine. 308. 1556-1570.

Gavin, L. A., Wamboldt, M., Brugman, S., Roesler, T.

A., & Wamboldt, F. (1998). Psychological and family characteristics of adolescents with vocal cord dysfunction.

Journal of Asthma. 35. 409-417.

Martin, R. J., Blager, F. B., Gay, M. L., & WoodII, R. P.

(1987). Paradoxic vocal cord motion in presumed asthmatics. Seminars in Respiratory Medicine. 8. 332-337.

Matthers-Schmidt B.A Paradoxical Vocal Fold Motion: A

Tutorial on a Complex Disorder and the Speech Language

Pathologist’s Role. American Journal of Speech-Language

Pathology 2001; 10:111-25.

Sandage et. al. Paradoxical vocal fold motion in children and adolescents. Lang. Speech Hear. Serv. Sch. 2004: 35

(4) 353-62

Vlahakis NE, Patel AM, Maragos NE, Beck KC.

Diagnosis of Vocal Cord Dysfunction: The Utility of

Spirometry and Plethysmography. Chest 2002; 122: 2246-


Nastasi, K. J., Howard, D. A., Raby, R. B., Lew, D. B.,

& Blaiss, M. S. (1997). Airway fluoroscopic diagnosis of vocal cord dysfunction syndrome. Annals of Allergy,

Asthma, Immunology. 78. 586-588.

Powell DM, Karanfilov BI, Beechler KB, Treole K,

Trudeau MD, Forrest L. Paradoxical vocal cord dysfunction in Juveniles.Arch. Otolaryngol Head Neck Surg.

2000 Jan; 126 (1): 29-34

Morris MJ, Deal LE, Bean DR, Grbach VX, Morgan JA.

Vocal Cord Dysfunction in Patients with Exertional Dyspnea.

Chest 1999; 116: 1676-1682.