What is the diagnosis and treatment for vocal cord dysfunction (VCD)?

From the Guidelines

Vocal cord dysfunction (VCD) should be managed with speech therapy techniques to control breathing patterns, and patients should work with a speech-language pathologist to learn exercises like pursed-lip breathing and relaxed throat breathing, as recommended by the most recent evidence 1.

Key Points

• VCD is a condition where the vocal cords close inappropriately during breathing, causing symptoms like shortness of breath, throat tightness, and wheezing that can mimic asthma.
• Treatment primarily involves speech therapy techniques to control breathing patterns, particularly learning to focus on abdominal breathing and techniques to relax the throat muscles during episodes.
• Patients should work with a speech-language pathologist who can teach specific exercises like pursed-lip breathing and relaxed throat breathing.
• During an acute episode, patients should try slow breathing through the nose, focus on exhaling, and use relaxation techniques.
• Certain medications may help in specific cases, such as inhaled ipratropium for some patients or very short-term benzodiazepines like lorazepam 0.5-1mg for severe episodes, though these should be used cautiously.
• Avoiding triggers is important - common ones include exercise, strong odors, reflux, post-nasal drip, and stress.
• VCD occurs because the vocal cords paradoxically adduct (close) during inhalation instead of abducting (opening), often due to laryngeal hypersensitivity or as a learned response to irritants or stress.
• Understanding that this is not dangerous, though uncomfortable, can help reduce anxiety that often worsens symptoms.

Management Strategies

• Education and explanatory approaches to help patients understand the nature of the disorder and the rationale for the diagnosis.
• Symptomatic approaches, such as natural, reflexive, or instinctive behaviors, to help patients manage their symptoms.
• Psychological approaches, such as communication counseling and cognitive-behavioral therapy, to address underlying issues that may be contributing to the voice symptoms.
• Redirection of attentional focus, such as bubble blowing or large body movements, to help patients redirect their attention away from their voice symptoms.

Importance of Speech Therapy

• Speech therapy is a crucial component of VCD management, as it can help patients learn to control their breathing patterns and relax their throat muscles during episodes.
• Speech-language pathologists can teach patients specific exercises and techniques to help manage their symptoms and improve their quality of life.
• The goal of speech therapy is to help patients develop strategies to manage their VCD symptoms and improve their overall communication abilities.

From the Research

Definition and Characteristics of Vocal Cord Dysfunction

• Vocal cord dysfunction (VCD) is characterized by intermittent paradoxical adduction of the vocal cords, mainly during inspiration, leading to airflow obstruction and dyspnea 2.
• VCD can mimic or coexist with asthma, leading to overtreatment with corticosteroids and consequent morbidity 2, 3.
• Patients with VCD may have repetitive emergency room visits due to acute dyspnea, which can be mistaken for exacerbations of asthma 2.

Diagnosis of Vocal Cord Dysfunction

• The diagnosis of VCD can be difficult because physical exams and spirometry may be normal between episodes 2.
• During symptomatic episodes, spirometry typically reveals variable extrathoracic airway obstruction (truncated inspiratory flow volume loop) 2.
• The gold standard for identifying VCD is flexible fiberoptic rhinolaryngoscopy 2.
• Other diagnostic tests, such as nasolaryngoscopy and pulmonary function testing with provocative exercise and methacholine, can also be helpful 4.

Triggers and Risk Factors for Vocal Cord Dysfunction

• Common triggers for VCD include exercise, asthma, gastroesophageal reflux disease, postnasal drip, upper or lower respiratory tract infection, and irritants 4, 5.
• Certain groups are at increased risk for developing VCD, including young women, elite athletes, military recruits, and individuals exposed to irritants 2.
• Chronic postnasal drip, laryngopharyngeal reflux (LPR), and gastroesophageal reflux (GER) may lead to laryngeal hyperresponsiveness and contribute to VCD 2.

Management and Treatment of Vocal Cord Dysfunction

• Management of VCD includes identification and treatment of underlying disorders, such as chronic postnasal drip, LPR, GER, anxiety, and depression 2.
• A multidisciplinary approach, including speech therapy and biofeedback, is critical in teaching techniques to override dysfunctional breathing habits 2, 3.
• Therapeutic breathing maneuvers and vocal cord relaxation techniques are first-line therapy for dyspnea that occurs with VCD 4.
• In some cases, onabotulinumtoxinA injections may be helpful for treating dyspnea or spasmodic dysphonia associated with VCD 4.