What is the management approach for vocal cord dysfunction?

Management of Vocal Cord Dysfunction

Speech therapy with breathing retraining and vocal cord relaxation techniques is the primary treatment for vocal cord dysfunction, combined with clear patient education that the abnormal vocal cord movements are reversible habitual patterns, not structural damage. 1, 2

Diagnostic Confirmation Before Treatment

• Distinguish VCD from asthma by recognizing inspiratory stridor with throat tightness during exercise that resolves within 5 minutes of rest, versus persistent expiratory symptoms in asthma 2
• Variable flattening of the inspiratory flow loop on spirometry during symptomatic periods is the key pulmonary function finding 1, 2
• Wheezing unresponsive to beta-2 agonists or inhaled corticosteroids is a critical red flag suggesting VCD rather than asthma 2
• Direct laryngoscopic visualization of paradoxical vocal cord adduction during symptoms is the diagnostic gold standard 3, 4, 5
• Exercise provocation testing may be necessary in athletes to reproduce symptoms and confirm diagnosis 4, 6
• VCD coexists with asthma in 20-40% of cases, so maintain high suspicion even in confirmed asthmatics with atypical symptoms 2

Primary Treatment Algorithm

Step 1: Education and Explanation (Essential Foundation)

• Explain that abnormal vocal cord movements are reversible habitual patterns, not irreversible structural abnormality, as patients often misunderstand medical reports describing "abnormal movements" 1, 2
• Review laryngoscopy images together with the patient to demonstrate the functional nature of the disorder 1
• Emphasize that excessive muscle tension can prevent normal breathing but represents a controllable abnormality that can be brought under their control 1
• Provide written materials and acknowledge the problem seriously 7

Step 2: Speech Therapy with Breathing Techniques (First-Line Treatment)

Natural reflexive behaviors to restore normal vocal cord function 1:

• Cough and throat clearing while allowing voice to be present 1
• Yawn followed by a sigh as if with genuine relief 1
• Gargling with firm sound, first with water then simulated without water 1
• Phonation on inhalation while maintaining a very relaxed body 1

Playful pre-linguistic vocal sounds 1:

• Blow raspberries while voicing 1
• Phonate with rising and falling scale blowing the lips like a horse 1
• Siren quietly down the scale using nasal sounds such as /m/, /n/, or /ng/ 1
• Produce low-pitched glottal fry at the very bottom of the vocal range 1

Physical and postural maneuvers 1:

• Circumlaryngeal massage with concurrent vocalization (explain and obtain consent before touching the neck) 1, 2
• Laryngeal repositioning/lowering during phonation on open vowels like /ah/ or nasal sounds like /mm/ 1, 2
• Postural manipulations such as phonating while bending over or looking at the ceiling 1

Attentional redirection techniques 1:

• Bubble blowing into water with vocalization 1, 2
• Large body movements such as jumping while making "shivering noises" 1, 2
• Walking and talking inside or outside the clinical setting, against background noise 1

Step 3: Treat Underlying Triggers

• Optimize asthma control if coexisting, as VCD frequently occurs with asthma 3, 4, 8
• Treat gastroesophageal reflux disease aggressively, as GERD is strongly associated with VCD 3, 4, 8, 5
• Manage postnasal drip and rhinosinusitis which can trigger laryngeal hyperresponsiveness 3, 8, 5
• Discontinue ACE inhibitors if present, as they can resolve cough within 3-7 days 2
• Avoid airborne irritants that may trigger episodes 8, 5

Step 4: Address Psychological Comorbidities

• Screen for anxiety, depression, and PTSD, as these significantly worsen outcomes and prevent maintenance of treatment gains 2, 7
• Refer for cognitive-behavioral therapy if long-standing anxiety, comorbid depression, or ongoing medicolegal/workers' compensation issues are present 1, 2, 7
• Treat comorbid depression concurrently with SSRIs or low-dose amitriptyline before or alongside speech therapy 7
• Address avoidance behaviors and hypervigilance related to breathing symptoms 7

Acute Episode Management

• Provide reassurance and calm the patient 8
• Instruct in relaxed-throat breathing patterns using techniques learned in speech therapy 8, 5
• Consider heliox (helium-oxygen mixture) for severe acute episodes 8
• Avoid excessive use of asthma medications, as VCD does not respond to beta-2 agonists or corticosteroids 2, 3

Special Considerations

Athletes with Exercise-Induced VCD

• Free running exercise challenge is often required to reproduce symptoms and confirm diagnosis laryngoscopically 4
• Most athletes can resume activities without significant limitation after speech therapy 4
• VCD should be suspected in elite athletes with exercise-related breathlessness unresponsive to asthma medication 1

Spasmodic Dysphonia Variant

• OnabotulinumtoxinA injections may be helpful for the subset of VCD presenting with dysphonia rather than dyspnea, though evidence is limited 3

Common Pitfalls to Avoid

• Do not misdiagnose VCD as refractory asthma and escalate asthma therapy unnecessarily—look for inspiratory symptoms and lack of response to bronchodilators 1, 2, 3
• Do not ignore psychological comorbidities—treating VCD symptoms alone without addressing anxiety or depression leads to treatment failure and relapse 2, 7
• Do not provide communication aids that perpetuate avoidance patterns in functional disorders 7
• Do not assume absence of psychological trauma excludes a functional component, but avoid injudicious probing 7
• Do not rely solely on spirometry between episodes—VCD may show normal flow-volume loops when asymptomatic 1, 2