Visual-perceptive assessment of glottic characteristics of vocal nodules by means of high-speed videoendoscopy

Abstract Objective Visual-perceptive assessment of glottic characteristics of vocal nodules by means of high-speed videoendoscopy. Methods Descriptive observational research with convenience sampling of five laryngeal videos of women with an average age of 25 years. The diagnosis of vocal nodules was defined by two otolaryngologists, with 100% intra-rater agreement and 53.40% inter-rater agreement and five otolaryngologists as judge assessed the laryngeal videos based on an adapted protocol. The statistical analysis calculated measures of central tendency and dispersion, as well as percentage. The AC1 coefficient was used for agreement analysis. Results In high-speed videoendoscopy imaging, vocal nodules are characterized by amplitude of the mucosal wave and muco-undulatory movement with magnitude between 50% and 60%. Non-vibrating segments of vocal folds are scarce, and the glottal cycle does not show a predominant phase, it is symmetric and periodic. Glottal closure is characterized by the presence of a mid-posterior triangular chink (double chink or isolated mid-posterior triangular chink), without movement of supraglottic laryngeal structures, with irregular contour of the free edge of vocal folds, which are vertically on-plane. Conclusion Vocal nodules present mid-posterior triangular chink and irregular free edge contour. Amplitude and mucosal wave were partially reduced. Level of evidence: Level 4 (Case-series).

Obstrucción laríngea inducible (OLI): una revisión actualizada de la literatura

La obstrucción laríngea inducible se ha descrito como un trastorno de la respiración que se presenta, habitualmente, como dificultad respiratoria aguda por aducción anormal de los pliegues vocales, típicamente, durante la inspiración. Es más frecuente en mujeres y adultos, que en adolescentes. Es difícil estimar la incidencia exacta dada la heterogeneidad de los criterios diagnósticos y nomenclatura, asociado al frecuente subdiagnóstico de esta entidad. Por ello, en la literatura se ha reportado la prevalencia de acuerdo con las subpoblaciones de pacientes, describiendo que alrededor de un 2,8% de los pacientes que consultan en el servicio de urgencia por disnea podría corresponder a esta patología. El diagnóstico es eminentemente clínico, con confirmación mediante laringoscopia flexible. Se apoya en exámenes de función respiratoria, especialmente para descartar otras patologías pulmonares que expliquen el cuadro. El tratamiento es sencillo y, suele ser exitoso, tanto en situaciones agudas como crónicas. Sin embargo, se ha descrito, frecuentemente, un retraso en el diagnóstico, debido a desconocimiento de esta patología.

Induced laryngeal obstruction has been described as a respiratory disorder, usually presenting as an acute respiratory distress due to abnormal adduction of the vocal folds, typically during inspiration. It is more frequent in women and adults, than adolescents. It is difficult to estimate its exact incidence given the heterogeneity of the diagnostic criteria and nomenclature, together with its common underdiagnosis. Hence, studies have reported its prevalence according to the subpopulations within this entity, with a prevalence of 2.8% in patients who consult in the emergency room for dyspnea. The diagnosis is based upon clinical presentation, confirmed by flexible laryngoscopy, and supported by respiratory function exams to rule out other pulmonary diseases with similar symptoms. Its treatment is simple and usually successful, in both acute and chronic situations. However, a delay in the diagnosis has been frequently described, due to unawareness of this disorder.

Neuropatía laríngea y movimiento paradojal de cuerdas vocales en la edad pediátrica: reporte de un caso / Laryngeal neuropathy and paradoxical vocal fold motion in the pediatric age: case report

Resumen La neuropatía laríngea es una condición de hipersensibilidad, hiperreactividad e hiper-función laríngea secundaria a un desequilibrio entre las aferencias y eferencias laríngeas. La respuesta individual y exagerada frente a diversos gatillantes específicos puede generar síntomas como tos crónica, parestesia laríngea, carraspera, disfonía, estridor, sensación de globus faríngeo, movimiento paradojal de las cuerdas vocales (también conocido como disfunción cordal) y/o laringoespasmo. Existe abundante literatura sobre neuropatía laríngea en adultos, sin embargo, en niños es limitada. El objetivo de este artículo es dar a conocer un caso de neuropatía laríngea en la edad pediátrica y la importancia de su consideración en el enfrentamiento de estos pacientes. Se presenta caso clínico de un paciente de 13 años, con antecedente de cirugía cardiaca reciente, evoluciona con disfonía severa evidenciándose aparente inmovilidad cordal bilateral con resultados discordantes entre nasofibrolaringoscopía y electromiografía laríngea. Posteriormente presenta mejorías en su voz, sin embargo, se agregan otros síntomas laringológicos como carraspera, globus faríngeo y estridor no explicados por causas anatómicas. Se expone la evaluación y abordaje otorrinolaringológico-fonoaudiológico para el caso. Se concluye que el diagnóstico de neuropatía laríngea requiere un alto índice de sospecha clínica ante signos laringológicos sugerentes, debiendo descartarse causas orgánicas y estructurales. El abordaje otorrinolaringológico-fonoaudiológico constituye el pilar terapéutico asociado al uso de neuromoduladores en casos seleccionados.

Abstract Laryngeal neuropathy is a condition of hypersensitivity, hyperresponsiveness and laryngeal hyperfunction secondary to an imbalance between laryngeal afferent and efferent information. The individual and exaggerated response to diverse specific triggers can lead to symptoms such as chronic cough, laryngeal paresthesia, throat clearing, dysphonia, stridor, globus pharyngeus, vocal cord dysfunction, and/or laryngospasm. There is plentiful literature on laryngeal neuropathy in adults, however, in children, it is limited. Here, we present a case report of laryngeal neuropathy in the pediatric age and discuss the importance of its consideration in the approach of these patients. A case of a 13-year-old patient, recently intervened with cardiac surgery that evolves with severe dysphonia is presented. Nasofibrolaryngoscopy shows apparent bilateral vocal fold immobility with discordant results in laryngeal electromyography. Later, his voice improves but other laryngological symptoms appeared, such as throat clearing, globus pharyngeus and stridor, not explained by anatomical causes. The otolaryngological-speech therapy evaluation and approach for the case is exposed. We conclude that for the diagnosis of laryngeal neuropathy, a high index of clinical suspicion is required in the presence of suggestive laryngological symptoms, and organic and structural causes must be previously ruled out. The otorhinolaryngological-logopedic approach constitutes the mainstay of treatment associated with the use of neuromodulators in selected cases.

Vocal cord dysfunction: analysis of 27 cases and updated review of pathophysiology & management

Introduction: Vocal cord dysfunction is characterized by unintentional paradoxical vocal cord movement resulting in abnormal inappropriate adduction, especially during inspiration; this predominantly manifests as unresponsive asthma or unexplained stridor. It is prudent to be well informed about the condition, since the primary presentation may mask other airway disorders. Objective: This descriptive study was intended to analyze presentations of vocal cord dysfunction in a tertiary care referral hospital. The current understanding regarding the pathophysiology and management of the condition were also explored. Methods: A total of 27 patients diagnosed with vocal cord dysfunction were analyzed based on demographic characteristics, presentations, associations and examination findings. The mechanism of causation, etiological factors implicated, diagnostic considerations and treatment options were evaluated by analysis of the current literature. Results: There was a strong female predilection noted among the study population ( n = 27), which had a mean age of 31. The most common presentations were stridor (44%) and refractory asthma (41%). Laryngopharyngeal reflux disease was the most common association in the majority (66%) of the patients, with a strong overlay of anxiety, demonstrable in 48% of the patients. Conclusion: Being aware of the condition is key to avoid misdiagnosis in vocal cord dysfunction. Fiberoptic laryngoscopy is the diagnostic gold standard to demonstrate paradoxical vocal cord adduction during an attack. A multidisciplinary approach should be adapted for the management, which should be specific and tailored for individual patients (AU)

Correlations between Aspiration and Pharyngeal Residue Scale Scores for Fiberoptic Endoscopic Evaluation and Videofluoroscopy

PURPOSE: To examine correlations among rating scales and findings suggestive of tracheal aspiration and pharyngeal residue between fiberoptic endoscopic evaluation of swallowing (FEES) and videofluoroscopic swallowing study (VFSS) in dysphagia patients. MATERIALS AND METHODS: We studied patients referred to our hospital for dysphagia assessment. Three raters judged the residue severity and laryngeal penetration or tracheal aspiration of FEES and VFSS. The raters applied the Penetration-Aspiration Scale (PAS) for tracheal aspiration and pixel-based circumscribed area ratio and Yale Pharyngeal Residue Severity for post-swallow residue in VFSS and FEES, respectively. Anatomy-physiologic findings during FEES associated with tracheal aspiration were also analyzed. RESULTS: A total of 178 participants were enrolled in our study. In correlation analysis, PAS (r=0.74), vallecula retention (r=0.76), and pyriform sinus retention (r=0.78) showed strong positive correlations between FEES and VFSS. Intra-rater agreement between VFSS and FEES was good for PAS (κ=0.65) and vallecula (κ=0.65) and pyriform sinus retention (κ=0.69). Among 72 patients who showed subglottic shelf residue, a suspected finding of aspiration, in FEES, 68 had concomitant tracheal aspiration during VFSS. Both vocal fold hypomobility and glottic gap during phonation were significantly associated with findings suggestive of tracheal aspiration during FEES (p<0.05). CONCLUSION: Quantitative and reliable aspiration and post swallow residue rating scales showed strong positive correlations and good agreement between VFSS and FEES.

Evaluación de la disnea asociada al ejercicio / Exercise-induced dyspnea evaluation

Exercise-induced dyspnea is a common pediatric question but difficult to address since usually symptoms are described ambiguously by the child or parents. Most of times dyspnea is secondary to poor training but sometimes may be due to an underlying condition like exercise-induced bronchoconstriction or vocal cord dysfunction. To provide clinicians with a practical approach about exercise-induced dyspnea we have review pathogenesis and clinical characteristics of respiratory diseases and proposed an algorithm for study.

Frecuentemente nos vemos enfrentados a evaluar un niño con síntomas vagos asociados al ejercicio que el mismo paciente o sus padres describen como ahogo o sensación de pecho apretado. La mayoría de las veces se trata de cansancio atribuible al ejercicio normal que solo refleja pobre condicionamiento físico del individuo; sin embargo, este cansancio puede ser desproporcionado al esfuerzo, lo que obliga a considerar enfermedades comunes como asma o poco comunes como disfunción de cuerdas vocales. El objetivo de esta revisión es actualizar el conocimiento aquellas enfermedades respiratorias que forman parte del diagnóstico diferencial de la disnea asociada al ejercicio y proponer un algoritmo de estudio que permita un acercamiento práctico según causas de origen.

Estridor y dificultad respiratoria: aproximación neurológica: caso clínico / Stridor and dyspnea caused by a conversion disorder: a case report

Paradoxical vocal cord motion or vocal cord dysfunction is a descriptive term for an inappropriate adduction of the vocal cords during respiration, which can cause respiratory obstruction and stridor. It is associated with psychiatric conditions in the great majority of cases. We report a 23 year-old high performance female athlete, referred for a recurrent bilateral paralysis of the vocal cords, with a history of four intensive care unit admissions for severe dyspnea and stridor, which were treated several times with intubation and with tracheostomy on two occasions. Myasthenia gravis was suspected and she was treated with pyridostigmine and prednisone. She was discharged but despite the treatment, she presented new episodes of stridor and was readmitted six months later. This time the pharmacological treatment was suspended. The neurological study disclosed a normal brain magnetic resonance, normal cerebrospinal fluid analysis and a normal electromyography. A conversion disorder was suspected and the patient was successfully treated with psychotherapy.

Munchausen Stridor-A Strong False Alarm of Anaphylaxis

The diagnosis of anaphylaxis is often based on reported symptoms which may not be accurate and lead to major psychosocial and financial impacts. We describe two adult patients who were diagnosed as having recurrent anaphylaxis witnessed by multiple physicians based on recurrent laryngeal symptoms. The claimed cause was foods in one and drugs in the other. We questioned the diagnosis because of absent documentation of objective findings to support anaphylaxis, and the symptoms occurred during skin testing though the test sites were not reactive. Our initial skin testing with placebos reproduced the symptoms without objective findings. Subsequent skin tests with the suspected allergens were negative yet reproduced the symptoms without objective findings. Disclosing the test results markedly displeased one patient but reassured the other who subsequently tolerated the suspected allergen. In conclusion, these 2 patients' symptoms and evaluation were not supportive of their initial diagnosis of recurrent anaphylaxis. The compatible diagnosis was Munchausen stridor which requires psychiatric evaluation and behavior modification, but often rejected by patients.

Inspiratory and Expiratory Resistances During Exercise.

Aims: Paradoxical vocal fold motion, especially during exercise, causes symptoms of dyspnea in patients experiencing this condition. At present, the standard means to diagnose this condition is invasive using a laryngoscope. The Airflow Perturbation Device (APD) could offer a simpler means of diagnosis and monitoring, but the APD must be validated with laryngoscopy. Both devices require access to the mouth, and so cannot be used simultaneously. The aim of this study was to determine if respiratory resistance of exercising subjects changes immediately after exercise begins and ends. Study Design: The study was conducted as a prospective study. Place and Duration of Study: All tests were conducted in the Human Performance Laboratory, Fischell Department of Bioengineering, University of Maryland, College Park, MD between August 2011 and August 2012. Methodology: Fifteen subjects exercised on a bicycle ergometer at 70% of maximum predicted heart rate while breathing through the APD. Results: Results show that APD measurements made just prior and after the cessation of exercise are comparable. Conclusion: APD measured inspiration and expiration resistances do not change immediately after exercise cessation.

A Case of Vocal Cord Dysfunction / 소아과

Vocal cord dysfunction is a recently described entity in which paradoxical adduction of the vocal cords produces airflow obstruction at the level of the larynx. Recurrent wheezing results, which may imitate asthma. Inspiratory closure of the cords can also cause stridor, commonly misdiagnosed as an upper airway obstruction of undefined cause. The acute presentation is often dramatic and has led to inappropriate treatment, including intubation, tracheotomy, or high doses of steroids. We present the case of a 9 yr old boy with allergic rhinitis who was referred to us for the evaluation of wheezing and dyspnea which did not respond to asthma management. Pulmonary function tests had abnormal inspiratory phases and laryngoscopy revealed typical adduction of the vocal cord during inspiration. Psychological tests suggested anxiety and tension with repressed aggression. There have been no further episodes, possibly due to counseling and education of relaxed throat breathing as well as avoidance of inhaled medication.

A Case of Vocal Cord Dysfunction Masqueraded as Exercised-Induced Asthma / 결핵

Vocal cord dysfunction (VCD) is respiratory disorder characterized by paradoxical closure of the vocal cord during the respiratory cycle leading to obstructive airway symptoms. The clinical presentation of VCD is often dr amatic and its misdiagnosis as asthma of exercise-induced brochospasm(EIB) has led to inappropriate treatment including high dose corticosteroids, intubation, and tracheostomy. Many VCD patients are asympromatic at rest and require exercise challenge to elicit symptoms and vocal cord abnormalities. The "gold standard" for the diagnosis of VCD remains laryngoscopy of bronchoscopy with direct visualization of paradoxical adduction of the vocal cords. We report a case of exercise-induced Vocal cord masqueraded as exercise-induced asthma unresponsive to corticosteroids. And bronchodilator confirmed by typical bronchoscopic findings with paradoxial adduction of the vocal cords.

A Case of Functional Upper Airway Obstruction Due to Vocal Cord Dysfunction in Obstructive Pulmonary Disease / 결핵

A functional upper airway obstruction due to a vocal cord dysfunction(VCD) is characterized by a paradoxical adduction of the vocal cords throughout the respiratory cycle with no obvious organic cause for the obstruction. It commonly occurs paroxysmally and imitates acute asthmatic attacks, often in patients with coexisting asthma. They present with episodes of dyspnea associated with inspiratory wheezing that persists despite conventional asthma treatment and a flattening of the inspiratory limb of the flow-volume curve; an adduction of the vocal cord during inspiration. Failure to recognize concurrent vocal cord dysfunction and asthma has led not only to the excessive use of bronchodilators and corticosteroids, but also to intubation and tracheostomy. Here, we report a case of coexistent obstructive pulmonary disease and functional upper airway obstruction due to a vocal cord dysfunction where a bronchoscopy showed a paradoxical vocal cord motion and typical features of a variable extrathoracic obstruction and a lower airway obstruction on the Flow-volume loop during a symptomatic period.

A Case of Functional Upper Airway Obstruction Due To Vocal Cord Dysfunction / 결핵

Functional upper airway obstruction due to vocal cord dysfunction is being increasingly recognized and has been variously described as "Munchausen's stridor", "Emotional laryngeal wheezing", "Nervous asthma". It's features are symptoms of acute reversible recurrent dyspnea associated with an inspiratory stridor, normal anatomy of the upper airway, demonstration of variable severe exthrathoracic upper airways obstruction with pathologic adduction of the vocal cord at bronchoscopy. The patients with this condition are frequently misdiagnosed as asthma and the diagnosis is often delayed. So they can present a serious medical problem and are exposed to the complication of treatment and investigation. We report a case of functional upper airway obstruction due to vocal cord dysfunction who showed paradoxical vocal cord motion at bronchoscopy and typical features of variable exthrathoracic obstruction on Flow-volume loop during a symptomatic period.