Pediatric Paradoxical Vocal-Fold Motion: Presentation and Natural History

Department of Otology and Laryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA 02114, USA.
PEDIATRICS (Impact Factor: 5.3). 12/2011; 128(6):e1443-9. DOI: 10.1542/peds.2011-1003
Source: PubMed

ABSTRACT To describe (1) a cohort of children with paradoxical vocal-fold motion (PVFM) who were referred to a multidisciplinary airway center and (2) the outcomes of various treatment modalities including speech therapy, gastroesophageal reflux disease treatment, and psychiatric treatment.
This was a case series with chart review of children younger than 18 years with PVFM evaluated at a tertiary care pediatric airway center over a 36-month period.
Fifty-nine children with PVFM were evaluated. The cohort had a mean age of 13.64 years (range: 8-18 years) and a female-to-male ratio of 3:1. Speech therapy as an initial treatment resulted in a 63% (24 of 38) success rate after an average of 3.7 treatment sessions. Speech therapy was a more successful treatment than antireflux therapy (P = .001). Ten percent (6 of 59) of the children presented with a known psychiatric diagnosis, and 30% (18 of 59) of children in the cohort were ultimately diagnosed with a psychiatric condition. Children with inspiratory stridor at rest had a lower initial success rate with speech therapy (56%), a higher rate of underlying psychiatric disorders (75%), and a high rate of success after psychiatric treatment (100%) that required, on average, 3 sessions over a 2-month period.
To our knowledge, this is the largest study to date on pediatric PVFM. The majority of children with PVFM improve with speech therapy. Children with PVFM at rest may be better treated with psychiatric therapy than speech therapy. Furthermore, children who present with symptoms at rest may have a higher likelihood of underlying psychiatric disease.

    • "Many of the terms imply a significant psychological component, and this perceived link between psychological dysfunction and DB is one of the reasons physicians often avoid this area. Similarly, the relatively well characterised form of DB known as paradoxical vocal cord dysfunction (pVCD) [32] [33] [34] [35] [36] [37] has been labelled factitious asthma, functional stridor, episodic laryngeal dyskinesia, hysterical croup and psychogenic stridor [33]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Dysfunctional breathing is described as chronic or recurrent changes in breathing pattern causing respiratory and non-respiratory symptoms. It is an umbrella term that encompasses hyperventilation syndrome and vocal cord dysfunction. Dysfunctional breathing affects 10% of the general population. Symptoms include dyspnoea, chest tightness, sighing and chest pain which arise secondary to alterations in respiratory pattern and rate. Little is known about dysfunctional breathing in children. Preliminary data suggest 5.3% or more of children with asthma have dysfunctional breathing and that, unlike in adults, it is associated with poorer asthma control. It is not known what proportion of the general paediatric population is affected. Breathing training is recommended as a first-line treatment for adults with dysfunctional breathing (with or without asthma) but no similar recommendations are available for the management of children. As such, breathing retraining is adapted from adult regimens based on the age and ability of the child. Objectives To determine whether breathing retraining in children with dysfunctional breathing has beneficial effects as measured by quality of life indices. To determine whether there are any adverse effects of breathing retraining in young people with dysfunctional breathing. Search methods We identified trials for consideration using both electronic and manual search strategies. We searched CENTRAL, MEDLINE and EMBASE. We searched the National Research Register (NRR) Archive, Health Services Research Projects in Progress (HSRProj), Current Controlled Trials register (incorporating the metaRegister of Controlled Trials and the International Standard Randomised Controlled Trial Number (ISRCTN) to identify research in progress and unpublished research. The latest search was undertaken in October 2013. Selection criteria We planned to include randomised, quasi-randomised or cluster-randomised controlled trials. We excluded observational studies, case studies and studies utilising a cross-over design. The cross-over design was considered inappropriate due to the purported long-lasting effects of breathing retraining. Children up to the age of 18 years with a clinical diagnosis of dysfunctional breathing were eligible for inclusion. We planned to include children with a primary diagnosis of asthma with the intention of undertaking a subgroup analysis. Children with symptoms secondary to cardiac or metabolic disease were excluded. We considered any type of breathing retraining exercise for inclusion in this review, such as breathing control, diaphragmatic breathing, yoga breathing, Buteyko breathing, biofeedback-guided breathing modification and yawn/sigh suppression. We considered programmes where exercises were either supervised (by parents or a health professional, or both) or unsupervised. We also considered relaxation techniques and acute episode management as long as it was clear that breathing exercises were a component of the intervention. Any intervention without breathing exercises or where breathing exercises were not key to the intervention were excluded. Data collection and analysis We planned that two authors (NJB and MJ) would extract data independently using a standardised form. Any discrepancies would be resolved by consensus. Where agreement could not be reached a third review author (MLE) would have considered the paper. Main results We identified 264 potential trials and reviews from the search. Following removal of duplicates, we screened 224 papers based on title and abstract. We retrieved six full-text papers and further evaluated them but they did not meet the inclusion criteria. There were, therefore, no studies suitable for inclusion in this review. Authors' conclusions The results of this systematic review cannot inform clinical practice as no suitable trials were identified for inclusion. Therefore, it is currently unknown whether these interventions offer any added value in this patient group or whether specific types of breathing exercise demonstrate superiority over others. Given that breathing exercises are frequently used to treat dysfunctional breathing/hyperventilation syndrome, there is an urgent need for well-designed clinical trials in this area. Future trials should conform to the CONSORT statement for standards of reporting and use validated outcome measures. Trial reports should also ensure full disclosure of data for all important clinical outcomes.
    Cochrane database of systematic reviews (Online) 12/2013; 18(Issue 2):Art. No.: CD010376. DOI:10.1002/14651858.CD010376 · 5.94 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: rsak ebesvaer obstruksjonen en adduksjon av stemmebåndene alene (glottisk EILO eller VCD). Ofte finner man en kombinasjon av supraglottisk og glottisk EILO, men da er det vanligst at adduksjonen starter supraglottisk (7–9). Forekomsten av EIA har blitt anslått til 8–10 % i en uselektert barnepopulasjon og til ca 35 % blant barn med astma (10). Forekomsten av EILO var 7,5 % i en uselektert kohort av ungdommer i København (11). Diagnostikk av eILO Tre hovedkriterier har blitt foreslått som sentrale for å stille diagnosen EILO (3). Det skal foreligge: 1) kliniske symptomer på EIIS 2) bekreftende lungefunksjonsfunn og 3) verifisert laryngoskopisk EILO. Kliniske symptomer EILO er en viktig differensialdiagnose til EIA og mange pasienter med EILO har blitt behandlet for EIA i flere år, ofte uten saerlig effekt. I et materiale fra Bergen (9) hadde 10 % av kontroll-pasientene og hele 85 % av pasienter med EIIS fått behandling for astma i årene før de ble diagnostisert med EILO. Hele 64 % av pasientene med EIIS rapporterte at medisineringen ikke hadde hatt effekt på symptomer relatert til anstrengelse. Dette viser at man skal ha en aktiv holdning til sykehistorien og til utredningen ved anstrengelsesutløste symptomer, og at de riktige spørsmålene må stilles. EIA har sin karakteristiske symptomprofil preget av ekspirato-riske symptomer som kommer som respons på anstrengelsesutløst hyperventilasjon. EIA har dessuten et karakteristisk spirometrisk mønster med spesifikke endringer i lunge-funksjon (FEV 1) fra før til bestemte tidsintervaller etter en standardisert anstrengelse (12). Det er viktig at man ikke glemmer at det finnes pasienter som både har EIA og EILO. En test for anstrengelsesutløst astma kan også benyttes til å reprodusere sympto-mene som beskrives av pasienter med EIIS. Da er det viktig at testleder observerer og noterer hva som skjer mens testen pågår, og ikke kun rapporterer endringer i FEV 1 etter avsluttet test. Man må lytte til pasientens respirasjon og notere grad av besvaer, respirasjonslyder (for eksempel stridor), respirasjons-mønster (forlenget inspirium), hyper-ventilasjon og panikkreaksjoner. En grundig beskrivelse kan gi indi-kasjon på om symptomene har sitt utspring fra perifere bronkier (astma) eller sentrale luftrør. EIIS er ikke noe entydig definert symptom, men heller en relativt vag
  • Source
    Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology 10/2012; 109(4):233-6. DOI:10.1016/j.anai.2012.07.006 · 2.75 Impact Factor
Show more