IMPORTANT The information provided is of a general nature and should not be used as a substitute for professional advice. If you think you may suffer from an allergic or other disease that requires attention, you should discuss it with your family doctor. The content of the information articles and all illustrations on this website remains the intellectual property of Dr Raymond Mullins and cannot be reproduced without written permission.

Introduction

During normal breathing, the vocal cords open up to allow the passage of air. In Vocal Cord Dysfunction (VCD), the vocal cords clamp together, especially when breathing in. The end result is the onset of throat tightness, choking sensation, noisy breathing (noisy in more than out) and difficulty breathing. Since symptoms can be frightening, VCD can also be accompanied by symptoms of anxiety, fast breathing rates, heart pounding and dizziness and pins and needles around the mouth, fingers and toes.

VCD is not rare

VCD is more common in females than males, and can occur at any age but most commonly in adults aged 20 to 40 years. It is estimated to occur in up to 2% of acute hospital presentations with difficulty breathing and round 2/3 have had a previous diagnosis of asthma.

VCD can be mistaken for asthma

It can be mistaken for asthma but does not respond to asthma treatment and can be associated with side-effects from excessive asthma medicine use. As a rough rule of thumb, VCD results in noisy breathing in, so-called air hunger (hard to get enough air into the chest) and faster breathing. By contrast, asthma usually results with wheeze when breathing out, harder to breath out and slower breathing.

VCD symptoms can resemble laryngospasm

Laryngospasm results from sudden contraction of the muscles of the throat, often occurring in seconds. The vocal cords slam shut when trying to breathe in. Unlike VCD, most episodes of laryngospasm last less than a few minutes.

VCD triggers

Symptoms usually follow throat irritation triggered by spicy food, acid reflux after a large or fatty meal or alcohol. Sometimes symptoms are triggered inhaling strong irritants such as strong smells or perfumes and sometimes with vigorous exercise and can be mistaken for exercise-induced asthma. Anxiety is also a well-described trigger. Postnasal drip from allergy or sinus infection may also trigger episodes.  Oversensitive nerves of the upper airways may be a contributing factor.

Mimicking conditions

Asthma – see above

Angioedema - swelling of the throat or upper airway gradually develops and worsens over many minutes.

Food allergy/anaphylaxis  - does not normally cause isolated sensation of throat swelling without accompanying g itchy theory or other symptoms like itchy skin, rash or stomach upset.

Vocal cord paralysis or tumours

Laryngomalacia – floppy upper airways

Diagnosis

Listen to the throat – most of the noise comes from the throat and not the lungs

Noisy breathing – it is noisier in than out

Have a look at the vocal cords – during an episode, the vocal cords are moving in/clamping together when breathing in rather than moving out/apart (which is normal). Sometimes this can be seen when a person is between episodes.

Lung function testing- this can be abnormal during episodes. The presence of asthma does not exclude VCD as they often occur together in the same person.

Scoring symptoms to differentiate VCD from asthma

The major symptoms indicating VCD over asthma include those of:

•Tight throat

•Husky voice

•Absence of wheezing

•Symptoms triggered by odours

Acute Management

Management of acute attacks involves:

•Trying to avoid coughing or talking;

•Trying to relax and slow breathing down (faster treating makes the situation worse by worsening collapse of the upper airways);

•Panting breathing (shallow and fast) may assist.

•Breathing through the nose if possible (this can trigger a reflex opening of the vocal cords) and out through the mouth slowly; and

•Pointing the chin up and extending the neck while breathing is though to anchor the voice box and make muscle spasm harder to sustain.

•So-called “:straw breathing” techniques as per the videos below.

1. •Heliox (a blend of oxygen and helium) may help oxygenation die to lower airway resistance to gas flow but evidence if helps is conflicting.
   

Investigations

Lung function testing may be needed to help diagnose asthma, ENT surgical review may be needed to examine the upper airways to exclude anatomical problems with the throat and vocal cords. Sometimes xrays might be needed if an anatomical problem with the throat is suspected.

Long term management

Treat and other underlying condition that is present that may make the situation worse. Eg. Acid reflux, asthma or post-nasal drip from allergy or infection or anxiety. Atrovent asthma puffer may help exercise induced VCD. Amitryptilline is an old sleepy anti-depressant but at a lower does of 10-20mg/night may also assist.

Speech therapy is often recommended

Long term though, speech therapy is recommended to learn relaxed breathing techniques to reduce the risk of recurrence. Patients can benefit from reassurance that VCD is non dangerous and triggered by reflex irritability, which can be reversed via behavioral techniques to open up the vocal cords during breathing.

•Pursed lip breathing.

•Blowing against finger held to the lips.

•Nasal only breathing.

•Abdominal breathing.

Weblink’s for more information

AAAAI: https://www.aaaai.org/conditions-and-treatments/related-conditions/vocal-cord-dysfunction

CLEVELAND CLINIC: https://my.clevelandclinic.org/health/diseases/17623-vocal-cord-dysfunction

MAYO CLINIC: https://www.mayoclinic.org/diseases-conditions/asthma/expert-answers/vocal-cord-dysfunction/faq-20058019

Youtube videos

https://www.youtube.com/watch?v=nPtdkqOLLP4

https://www.youtube.com/watch?v=3KV2D5w9hVw

Other references

1: Denipah N, Dominguez CM, Kraai EP, Kraai TL, Leos P, Braude D. Acute Management of Paradoxical Vocal Fold Motion (Vocal Cord Dysfunction). Ann Emerg Med. 2017 Jan;69(1):18-23. doi: 10.1016/j.annemergmed.2016.06.045. 

2: Daley CP, Ruane LE, Leong P, Lau KK, Low K, Hamza K, Finlay P, MacDonald M, Baxter M, Bardin PG. Vocal Cord Dysfunction in Patients Hospitalized with Symptoms of Acute Asthma Exacerbation. Am J Respir Crit Care Med. 2019 Sep 15;200(6):782-785. doi: 10.1164/rccm.201902-0396LE.

3: Idrees M, FitzGerald JM. Vocal cord dysfunction in bronchial asthma. A review article. J Asthma. 2015 May;52(4):327-35. doi: 10.3109/02770903.2014.982288.

4: Pinto LHE, Aun MV, Cukier-Blaj S, Stelmach R, Cukier A, Kalil J, Agondi RC, Giavina-Bianchi P. Vocal cord dysfunction diagnosis may be improved by a screening check list. Allergol Int. 2016 Apr;65(2):180-185. doi: 0.1016/j.alit.2015.11.001.

5: Traister RS, Fajt ML, Landsittel D, Petrov AA. A novel scoring system to distinguish vocal cord dysfunction from asthma. J Allergy Clin Immunol Pract. 2014 Jan-Feb;2(1):65-9. doi: 10.1016/j.jaip.2013.09.002.

Last reviewed 10 June 2020