Paradoxical Vocal Fold Movement

Paradoxical Vocal Fold Movement (PVFM) is a condition characterized by occasional attacks of breathing difficulty in which one’s vocal folds involuntarily adduct during inhalation and/or exhalation, and therefore restrict the airflow to and from the lungs (Mathers-Schmidt, 2001). It is also referred to as Vocal Cord Dysfunction and although it is not necessarily a voice disorder, voice disorders often co-occur with it. This paper will look to explore factors influencing the differential diagnosis of PVFM, treatment options, and the role of a Speech-Language Pathologist in working with patients with this diagnosis.
PVFM is likely to occur more frequently in adults than children and in females than males at a ratio of 3:1 (Patel, Venediktov,
Schooling, & Wang (2015). Patients with PVFM may report symptoms of shortness of breath, inability to breathe during inspiration, shortness of breath with activity, and episodes of choking. They may also report frequent complaint of tightness localized to the laryngeal area, wheezing, coughing, voice changes, chest tightness, and stridor (Patel, Venediktov, Schooling, & Wang (2015). A differential diagnosis is necessary, as many symptoms are often confused with the diagnosis of asthma.
PVFM is diverse not only in its clinical presentation, but also in its etiology.
There are many different proposed etiologies to the diagnosis of PVFM, but no single cause has yet to be empirically established. PVFM occurs as the result of a threat to the upper respiratory tract (Mathers-Schmidt, 2001). It’s possible etiologies include psychological, upper airway sensitivities from laryngeal irritants, neurological origins, or as the manifestation of an underlying laryngeal dystonia.
Psychological factors play a role in the etiology of PVFM, because patients with emotional problems such as stress, anxiety, or depression may exacerbate the problems associated with PVFM. Conversely, it is also possible that depression and anxiety are consequences of rather than causes of persistent respiratory problems. Literature suggests difficulty drawing firm conclusions regarding the psychological etiologies of PVFM, as only a subgroup of patients with PVFM have revealed emotional conflicts or psychiatric disturbances (Mathers-Schmidt,
2001).
Upper airway sensitivities from laryngeal irritants may have an etiological relationship with PVFM, as issues of gastroesophageal reflux disease, post-nasal drip of the sinuses, and numerous respiratory tract irritants have been linked to the onset of PVFM. Gastroesophageal reflux disease (GERD) may compromise the reflexive adduction of the vocal folds, thus causing the vocal folds to involuntarily adduct. Respiratory irritants include issues of the sinuses which have been linked to both extrathoracic airway hyperresponsiveness and bronchial hyperresponsiveness (Koufman & Block, (2008). Respiratory irritants also include those of smoke, gases, vapors, dusts, pollutants, and odors. Exposure to such irritants may cause vocal fold inflammation, which may serve as a contributing factor in triggering the development of PVFM (Mathers-Schmidt, 2001).
There is also a subgroup of PVFM patients whose diagnosis may stem from the manifestation of an underlying laryngeal dystonia or neuropathy. Brainstem compression, cortical or upper motor neuron injury, nuclear or lower motor neuron injury, and movement disorders have been found to cause PVFM, although cases are rare. Additionally, patients with a neurogenic etiology are expected to have more continuous symptoms than PVFM patients with differing etiologies (Koufman & Block, 2008).
II. Diagnosis:
Assessment of patients with a potential or confirmed diagnosis of PVFM requires the combined efforts of a multidisciplinary team. This team is necessary in order to make a differential diagnosis from other potential conditions; especially asthma. Multidisciplinary team involvement may consist of a pulmonologists, otolaryngologists, gastroenterologists, cardiologists, allergy specialists or immunologists, psychologists, neurologists, and speech-language pathologists (Franca, 2014). The Speech-Language Pathologist should be knowledgeable about any potential medical terminology that may be used by the other professionals.
Although the referring physician often provides information regarding case history, it is important for the Speech-Language Pathologist to gather a thorough and complete case history that includes observations of the patient and assessing the impact of the problem on the patient’s daily life.
Relevant information to obtain includes questioning the patient about the onset of his or her symptoms along with any co-occurring events or illnesses, finding out the duration each episode may last, or any triggers they may experience prior to an episode. The Speech-Language Pathologist may also want to question if the patient feels any tightness or pain and the location of such issues if present, if he or she is noticing a concurrent cough, or lightheadedness. Perceptual symptoms to listen for and question the presence of include hoarseness, aphonia, a sense of effort upon inhalation or exhalation, stridor, wheezing, and stridor (Reitz, Gorman, & Kegyes,
2014).