What is the appropriate management and treatment 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 patient education that the abnormal vocal cord movements are reversible habitual patterns, not structural damage. 1

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis through:

• Laryngoscopy during symptomatic episodes showing paradoxical vocal cord adduction during inspiration 1, 2, 3
• Spirometry with flow-volume loops demonstrating variable flattening of the inspiratory limb during symptomatic periods (this may be normal between episodes) 1, 2
• Provocative exercise testing in athletes to reproduce symptoms and confirm abnormal vocal cord motion laryngoscopically 4, 5

The key distinguishing features from asthma include: inspiratory stridor with throat tightness that peaks during exercise and resolves within 5 minutes of stopping activity, and wheezing that fails to respond to beta-2 agonists or inhaled corticosteroids 1, 2.

Primary Treatment Algorithm

1. Patient Education (Essential First Step)

• Explain that abnormal vocal cord movements are reversible habitual patterns, not irreversible structural damage—patients often misunderstand medical reports describing "abnormal movements" 1
• 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

2. Speech Therapy with Biofeedback (First-Line Treatment)

Speech therapy delivered by certified speech-language pathologists should include 1, 2, 5:

Direct Symptomatic Techniques:

• Breathing retraining to teach techniques that override dysfunctional breathing habits 1, 2
• Vocal cord relaxation techniques during symptomatic episodes 1, 5
• Natural reflexive behaviors and playful pre-linguistic sounds 1
• Circumlaryngeal massage with concurrent vocalization and laryngeal repositioning/lowering during phonation 1
• Attentional redirection techniques such as bubble blowing into water with vocalization and large body movements while making sounds 1

Acute Episode Management:

• Reassurance and breathing instruction during acute respiratory distress 5
• Helium-oxygen mixture (heliox) for severe acute episodes 5

3. Treat Underlying Triggers

Optimize management of conditions that commonly trigger VCD 2, 3, 5:

• Gastroesophageal reflux disease and laryngopharyngeal reflux 2, 3
• Postnasal drip and rhinosinusitis 2, 5
• Coexisting asthma (present in 20-40% of VCD cases) 1, 4
• Discontinue ACE inhibitors if present, as cough can resolve within 3-7 days 1
• Avoid airborne irritants and environmental triggers 3, 5

4. Psychological Support When Indicated

• Cognitive-behavioral therapy referral for long-standing anxiety, comorbid depression, or ongoing medicolegal issues 1
• Address psychological conditions that may contribute to VCD, though these are not considered causative 4, 3

Evidence Quality

Moderate-to-good evidence supports direct symptomatic and behavioral voice therapies, either alone or combined with indirect therapies involving education and vocal hygiene 1. The multidisciplinary approach combining speech therapy with treatment of underlying triggers results in optimal outcomes 6, 4.

Critical Clinical 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
• Do not rely solely on spirometry between episodes—VCD may show normal flow-volume loops when asymptomatic 1
• Suspect VCD in elite athletes with exercise-related breathlessness unresponsive to asthma medication 1
• Maintain high suspicion even in confirmed asthmatics with atypical or refractory symptoms, as VCD coexists with asthma in 20-40% of cases 1

Special Populations

Adolescent athletes often require free running exercise challenge to reproduce symptoms and confirm abnormal vocal cord motion laryngoscopically, and most may resume activities without significant limitation after treatment 4. Female patients are disproportionately affected by VCD 6, 2.