Related Problems

 

Vocal Fold Dysfunction/Paradoxical Vocal Fold Motion/Laryngospasm

Irritable Larynx Syndrome/Chronic Cough

Laryngopharyngeal Reflux Disorder (LPRD)


 

Paradoxical Vocal Fold Motion (PVFM)

Other names

  • vocal cord dysfunction (VCD)
  • stridor
  • laryngospasm
  • paradoxical vocal cord motion (PVCM)
  • laryngeal dyskinesia

PVFM is commonly seen in young athletes who develop symptoms during athletic exertion. These athletes may be incorrectly diagnosed with exercise-induced asthma.

The disorder is also common in adults. Symptoms often cause awakening in the middle of the night, but they may occur at any time. These symptoms may be triggered by eating or drinking, especially something sour or very sweet.

Symptoms

Some of the common symptoms of PVFM are:

  • sudden inability to inhale
  • a sensation of shortness of breath, choking, strangling
  • gasping sound when inhaling

Cause

When symptoms occur during the night, the cause is nearly always related to reflux.  In this case, acid from the stomach refluxes back up the esophagus and spills over onto the larynx, irritating the vocal folds and surrounding laryngeal mucosa.  The irritation can cause the vocal folds to twinge or spasm, in much the same way that the eye will shut forcefully if irritated by a sudden foreign object or substance. This feels like a choking sensation, or like the airway is suddenly shut off.  When the individual attempts to inhale forcefully, the vocal folds are actually sucked together, preventing inhalation. This causes more forceful inhalation and creates a vicious cycle that can be very frightening to the individual. The vicious cycle is such that the vocal folds may relax slightly during exhalation, but come together during inhalation. Thus, the disorder is called Paradoxical Vocal Fold Motion because of this backwards movement of the vocal folds. The gasping sound on inhalation is known as inhalatory stridor.

The scenario is similar for an athlete. The individual begins panting and gasping for air, trying to inhale more forcefully, and the vocal folds are sucked together. The same frightening cycle ensues. It may also happen when the athlete chokes slightly on his or her own saliva, especially when the throat becomes very dry from panting.

In some cases, an individual with PVFM is able to gain control of his or her own breathing, and the episode ends. In other cases, he or she needs to be seen in an emergency room. In either case, the experience can be so alarming that if the conditions present themselves again, the same set of responses is triggered by the anxiety. Moreover, it is generally not helpful to suggest to an individual who cannot breathe that they should "just relax."

Treatment

Treatment for reflux is an important component of treating most cases of PVFM. This usually involves prescribing anti-reflux medications to reduce the irritation. Also, you may be counseled about dietary precautions to alleviate reflux. Relief may occur in days, or may take a month more.

In the Lions Voice Clinic, we provide breathing training is given so you know how to reverse the paradoxical motion of the vocal folds and breathe easily again. Most often, the breathing training includes flexible endoscopy. This enables you to observe the motion of the vocal folds while doing the various maneuvers learned in training. Watching yourself control your own breathing is generally very reassuring, and even if the laryngospasms continue for a time, the full-blown paradoxical episodes usually end within a few weeks.

In the case of an athlete, particularly a young athlete, care is taken to differentiate between a pulmonary (lung) problem such as asthma, and PVFM. Evaluation is done jointly with the Department of Pulmonology or Pediatric Pulmonology. Often, we use a treadmill to simulate athletic exertion, and then, an endoscopic exam is done immediately after to confirm the occurrence of PVFM during exertion. Interestingly, we see many athletes with breathing problems who do not actually demonstrate true paradoxical motion of the vocal folds.  Often, the arytenoid cartilages rock forward during the forced inhalation.  Even though this does not occlude the airway, it diverts the air and causes a sensation of inability to inhale.  It is also quite common that the airway remains completely open, but air is not moving adequately to support the level of exertion, because the diaphragm is not contracting fully enough to fill the lungs adequately.  If the abdominal musculature is held too tightly, the diaphragm cannot descent for inhalation.  In all these cases, breathing training is done as previously described, and may include work on the treadmill to train special breathing techniques for athletic exertion. Because of the anxiety associated with this disorder, the young athlete and his or her parents are counseled carefully and sensitively.


 

Irritable Larynx Syndrome (ILS)

ILS is a cluster of symptoms connected with no specific disease process.  These symptoms include:

  • globus (sensation of a lump or presence in the throat)

  • throat irritation

  • throat burning

  • throat tightness

  • chronic cough

  • paradoxical vocal fold motion (PVFM) aka Vocal Cord Dysfunction (VCD)

  • laryngospasm

What do all of these have in common?  They are responses to laryngeal irritation!

What are some causes of irritation to the mucosa of the larynx?

They include, but are not limited to:

  • Irritants:

    • Perfume

    • Hairspray

    • Cigarette smoke

    • Other kinds of smoke

    • Harsh chemicals/cleaners

    • Allergens (ragweed, animal dander….)

  • Strong emotions (anxiety, stress…)

  • Acid Reflux

  • Cold air

  • Post nasal drip

  • Hyperfunction of the muscles of the vocal mechanism during speech

ILS is associated with worsening irritation and sensitivity of the laryngeal area. This irritation and sensitivity are often the precursors to more-severe symptoms such as chronic cough and/or coughing fits, and significant difficulty breathing.

Although not all patients experience all of the symptoms listed above, we find the symptoms tend to become worse in severity and one symptom can lead to others.

What causes ILS?

Those secretions are very important for the health of the mucosa.  In a healthy larynx, the secretions are thin, and are swallowed without being noticed.  (We swallow a quart of secretions every day!)  In an irritated larynx, the secretions can become dry and thick, leading to the desire to cough or throat clear.

 

Laryngo-Pharyngeal Reflux Disorder (LPRD)

Other names

  • reflux
  • Gastro-Esophageal Reflux Disorder (GERD)

Symptoms

  • dry, choking sensation, especially during the night
  • voice quality that is worst in the morning
  • raw, burning sensation in the throat
  • pain in throat, neck, or running from back of chin along neck
  • frequent coughing or desire to clear throat
  • rough, gritty voice quality
  • decline in voice quality or comfort with continued voice use
  • a sour taste in your mouth upon waking up

 

Interestingly, the majority of the patients in the Lions Voice Clinic who have laryngeal symptoms of GERD do not have any stomach discomfort or sensation of heartburn.

Cause

Acid from the stomach refluxes back up through the esophagus and spills over onto the larynx. This irritates the vocal folds (also called vocal cords; see the explanation of this terminology) and creates inflammation, which causes the vocal folds to vibrate unevenly. Coughing and throat clearing from the irritation can make the inflammation worse. The resulting voice disorder is often related to the poor vibratory quality of the inflamed vocal folds and the muscle tension created by effortful attempts at compensation.

Treatment

Anti-reflux medication and dietary precautions are the first line of defense. Functional voice therapy is useful to teach techniques for reducing effortful compensation and instruct the individual in improved vocal hygiene.

At the Lions Voice Clinic, we do not hand out a list of foods and beverages that must be avoided. Rather, we educate about types of foods and beverages known to cause reflux and encourage the individual to systematically investigate which foods stimulate their own reflux. Also, the individual is encouraged to manage reflux under the care of a Gastroenterologist (gastrointestinal specialist).

Interested readers are encouraged to look at the website of the Center for Voice Disorders at Wake Forest University for a more in depth discussion of GERD and the voice (see our Links page).

Lifestyle changes that may help reduce symptoms of GERD/LPRD

  • eat smaller meals more frequently throughout the day, rather than three large meals
  • elevate the head of your bed 2-3 inches (don't just use extra pillows for your head)
  • avoid clothes that fit tightly around the waist
  • avoid lying down within 2-3 hours of eating (don't eat dinner late at night)

Types of foods known to trigger increased stomach acid

  • spicy food (such as chili or jalapeño peppers, Thai or Szechuan spices)
  • acidic foods such as tomato products or citrus products
  • greasy foods
  • caffeine
  • alcohol
  • carbonation
  • roughage, such as popcorn and peanuts, or raw vegetables
  • dairy products
  • strong mint such as peppermint candies
  • chocolate

Reading this list might make you think you can only eat bread and oatmeal for the rest of your life. Fortunately, most individuals are not triggered by everything on this list. For example, for every person who is lactose intolerant and has problems with dairy products, there may be someone else whose digestive system is calmed by milk. Also, in our experience, few persons are triggered by peppermints or chocolate. Therefore, we recommend that you experiment with your own dietary habits, changing one food class at a time. Also, if you have recently started taking anti-reflux medications, you may want to wait for several months, to see how the medication works without any change in your dietary habits.

Home | Who We Are | About The Voice | Voice Problems | Singers etc... | Related Problems | Research | Links | Index | Glossary

Deirdre D. Michael - micha008@umn.edu
To make an appointment, please call us at (612) 676-5717.