What are the symptoms and treatment options for vocal cord dysfunction?

Vocal Cord Dysfunction: Symptoms and Treatment

Primary Symptoms

Vocal cord dysfunction presents with intermittent inspiratory stridor, throat tightness, and dyspnea that peaks during exercise and resolves within 5 minutes of stopping activity—not 5-20 minutes after like asthma. 1

Respiratory Manifestations

• Sudden, severe dyspnea without hypoxia, tachypnea, or increased work of breathing distinguishes VCD from true respiratory emergencies 2
• Inspiratory stridor with throat tightness during maximal exercise that rapidly resolves with rest 1
• Variable, intermittent shortness of breath triggered by exercise, irritants, or psychological stress 3, 4
• Wheezing that fails to respond to beta-2 agonists or inhaled corticosteroids—a critical red flag suggesting VCD rather than asthma 1

Laryngeal Symptoms

• Throat tightness or choking sensation is the hallmark differentiating feature 1
• Globus sensation (lump in throat) may co-occur as part of laryngeal hypersensitivity syndrome 1
• Chronic cough can manifest as part of the broader laryngeal hypersensitivity spectrum 1
• Voice changes or dysphonia in a subset of patients with abnormal laryngeal muscle spasms 2

Diagnostic Clues on Testing

• Variable flattening of the inspiratory flow loop on spirometry during symptomatic periods (contrasts with expiratory flow limitation in asthma) 1
• Normal physical exam and spirometry between episodes makes diagnosis challenging 3
• Symptoms inconsistent with severity of any structural pathology and complete resolution between episodes 1

Critical Pitfall

• VCD coexists with asthma in 20-40% of cases, requiring high suspicion even in confirmed asthmatics with atypical or refractory symptoms 1

Treatment Approach

Speech therapy with therapeutic breathing maneuvers and vocal cord relaxation techniques is first-line therapy for VCD-related dyspnea. 2

Immediate Management of Acute Episodes

Behavioral Interventions (First-Line)

• Reassurance and breathing instruction to abort acute episodes 5
• Heliox (80% helium/20% oxygen) reduces work of breathing during severe episodes 3, 5
• Topical lidocaine to the larynx can provide rapid relief 3
• Anxiolytics for severe episodes with significant anxiety component 3

Advanced Interventions for Refractory Cases

• Superior laryngeal nerve blocks with botulinum toxin for severe, recurrent episodes 3
• OnabotulinumtoxinA injections may help spasmodic dysphonia and certain dyspnea cases, though evidence is limited 2

Long-Term Management Strategy

Speech Therapy (Cornerstone of Treatment)

Speech therapy with biofeedback teaches techniques to override dysfunctional breathing habits and is essential for long-term control. 3

The 2021 consensus guidelines from the Journal of Neurology, Neurosurgery and Psychiatry provide specific therapeutic techniques organized by domain 6:

Education and Explanation:

• Clear explanation that abnormal vocal cord movements are reversible habitual patterns, not irreversible structural damage 6
• Review laryngoscopy images with patients to demonstrate that "abnormal movements" in reports reflect reversible habits, not permanent abnormalities 6
• Explain excessive muscle tension can prevent normal function but is controllable 6

Symptomatic Voice Techniques:

• Natural reflexive behaviors: coughing with voice present, yawning followed by sighing, grunting, gargling with firm sound 6
• Playful pre-linguistic sounds: blowing raspberries while voicing, phonating with rising/falling scales 6
• Automatic phrases: counting, reciting days of the week, singing familiar songs 6

Physical Maneuvers:

• Circumlaryngeal massage with concurrent vocalization (after explaining and obtaining permission to touch the neck) 6
• Laryngeal repositioning/lowering during phonation 6
• Postural manipulations: phonating while bending over or looking at ceiling 6

Attentional Redirection:

• Bubble blowing into water with vocalization 6
• Large body movements (jumping, shaking) while making sounds 6
• Walking and talking in various environments, including against traffic noise 6
• Electroglottography or electromyography as laryngeal biofeedback 6

Treat Underlying Triggers Aggressively

Gastroesophageal reflux disease, postnasal drip, and chronic rhinosinusitis must be optimally treated as they cause laryngeal hyperresponsiveness. 3, 2

• GERD and laryngopharyngeal reflux should be aggressively managed when present 3, 7
• Postnasal drip and rhinosinusitis require treatment to reduce laryngeal irritation 3, 5
• Avoid airborne irritants and environmental triggers 5
• Discontinue ACE inhibitors if present—can resolve cough within 3-7 days 8

Psychological Support

• Communication counseling addressing predisposing, precipitating, and perpetuating factors 6
• Identify and address avoidance patterns or excessive dependence on communication aids 6
• Cognitive-behavioral therapy referral for long-standing anxiety, comorbid depression, or ongoing medicolegal issues 6
• Outcomes improve when patients understand the relationship between voice problems and psychosocial issues 6

Evidence Quality Note

Moderate-to-good evidence supports direct symptomatic and behavioral voice therapies, either alone or combined with indirect therapies involving education and vocal hygiene. 6

Outcome Expectations

With successful multidisciplinary therapy including speech therapy and treatment of underlying triggers, corticosteroids can often be discontinued entirely. 3