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Vocal Cord Dysfunction
Daniel A. Cieslak, MD
Emily M. Culliney, MD, FAAFP
image BASICS
  • Vocal cord dysfunction (VCD): a breathing disorder in which vocal cords adduct inappropriately primarily on inspiration, producing airflow obstruction that may result in dyspnea, wheezing, and stridor
  • Synonym(s): paradoxical vocal fold motion (PVFM)
Not well defined
  • Unknown; likely uncommon in the general population
  • Most frequently diagnosed in patients evaluated for asthma and exercise-induced dyspnea
  • Female predominance, 2:1 (1)
  • 71% of patients are adults and 29% of patients <18 years of age. Also has been diagnosed in young children/infants (1)
  • Suspect occurrence in approximately 3% of intercollegiate athletes with exercise-induced asthma (2).
  • Exact etiology is unclear—both organic and nonorganic causes have been identified.
  • Possible laryngeal hyperresponsiveness to irritants, such as smoke, dust, postnasal drip, gastroesophageal reflux disease (GERD), URI, or other irritants (3)
  • Noncompetitive and competitive exercises—unknown mechanism (4)
  • Psychological factors such as anxiety, severe social stresses (e.g., competitive sports), history of sexual abuse (2)
None defined
See “Commonly Associated Conditions.”
  • Asthma
  • GERD
  • Rhinosinusitis
  • Psychological conditions such as posttraumatic stress disorder, anxiety, depression, and panic disorder
  • Inspiratory stridor
  • Cough
  • Wheezing (especially if unresponsive to bronchodilators)
  • Mild respiratory distress
  • Asthma: primary differential diagnosis because wheezing is a big component—although VCD can coexist with asthma (1,2). The key differences between the two are the following:
    • Asthma typically has wheeze on expiration, VCD on inspiration.
    • Asthma symptoms associated with nocturnal awakenings, uncommon in VCD
    • Asthma is not typically associated with a sensation of choking.
    • Asthma symptoms usually improve with albuterol use (3).
    • VCD causes more difficulty with inspiration rather than expiration.
    • VCD is not responsive to asthma treatment (unless coexisting) (2).
  • Anaphylaxis
  • Foreign body
  • Laryngeal angioedema
  • Chronic obstructive pulmonary disease
  • Epiglottitis
  • Vocal cord polyps/tumor
  • Vocal cord paralysis
  • Croup
  • Tracheal stenosis or masses
  • Laryngomalacia (1)
  • Neurologic cause: vagus or recurrent laryngeal nerve injury, amyotrophic lateral sclerosis (3)
Initial Tests (lab, imaging)
  • Flexible laryngoscopy—gold standard (2)[C]
    • Allows for direct visualization of abnormal adduction of the vocal cords
    • May allow for diagnosis in more than half of asymptomatic patients; however, provocation tests such as methacholine (5), exercise (4), and histamine may be needed for diagnosis (4,5)[C].
  • P.1129

  • Pulmonary function testing with flow volume loop
    • Most commonly used test
    • Positive findings consist of normal expiratory volume loop with a flattened inspiratory volume loop. This is consistent with extrathoracic upper airway obstruction (6)[C].
    • May require exercise testing for patients in whom exercise is the trigger
    • Useful for distinguishing from asthma, which may show a scooped expiratory loop
  • Imaging
    • Chest radiographs to rule out other causes of dyspnea (2)
    • High-resolution CT of upper airways to evaluate for stenosis, masses (if not able to visualize trachea during laryngoscopy) (7)
  • Arterial blood gases
    • Useful to rule out other causes of severe respiratory distress
  • Short term
    • Asthma control/treatment with appropriate meds, if coexisting (3)[C]
    • Reassurance and relaxation techniques:
      • Pursing lips
      • Panting (rapid, shallow breathing)
      • Diaphragmatic breathing
      • Breathing through the nose or a straw
      • Exhaling with a hissing sound
    • Continuous positive airway pressure (CPAP)
    • Intermittent CPAP with heliox (helium-oxygen) mixture may reduce airway resistance in some patients (1,2)[C].
    • Anxiolytics if associated with anxiety attack (must confirm normal oxygen saturation prior to administration)
    • Intubation with severe symptoms (3)[C]
  • Long term
    • Avoid triggers.
    • Behavioral speech/voice therapy (8)[B]
    • Treat underlying conditions.
First Line
No medications are specifically helpful. Exerciseinduced VCD may respond to anticholinergics in addition to speech therapy; thus, consider a trial of ipratropium if symptoms are exercise-induced (9)[C].
  • Diagnosis and treatment may require assistance of pulmonologist, otolaryngologist, allergist, psychiatrist, and/or psychologist.
  • Speech therapy is the mainstay of long-term treatment for patients with ongoing symptoms. It helps reduce recurrence.
Spontaneous resolution is common.
1. Morris MJ, Allan PF, Perking PJ. Vocal cord dysfunction: etiologies and treatment. Clin Pulm Med. 2006;13(2):73-86.
2. Ibrahim WH, Gheriani HA, Almohamed AA, et al. Paradoxical vocal cord motion disorder: past, present and future. Postgrad Med J. 2007;83(977): 164-172.
3. Gimenez LM, Zafra H. Vocal cord dysfunction: an update. Ann Allergy Asthma Immunol. 2011;106(4): 267-274.
4. Chiang T, Marcinow AM, deSilva BW, et al. Exercise-induced paradoxical vocal fold motion disorder: diagnosis and management. Laryngoscope. 2013;123(3):727-731.
5. Perkins PJ, Morris MJ. Vocal cord dysfunction induced by methacholine challenge testing. Chest. 2002;122(6):1988-1993.
6. Mobeireek A, Alhamad A, Al-Subaei A, et al. Psychogenic vocal cord dysfunction simulating bronchial asthma. Eur Respir J. 1995;8(11):1978-1981.
7. Lee KS, Boiselle PM. Update on multidetector computed tomography imaging of the airways. J Thorac Imaging. 2010;25(2):112-124.
8. Sullivan MD, Heywood BM, Beukelman DR. A treatment for vocal cord dysfunction in female athletes: an outcome study. Laryngoscope. 2001;111(10):1751-1755.
9. Doshi DR, Weinberger MM. Long-term outcome of vocal cord dysfunction. Ann Allergy Asthma Immunol. 2006;96(6):794-799.
Additional Reading
  • Deckert J, Deckert L. Vocal cord dysfunction. Am Fam Physician. 2010;81(2):156-159.
  • Jain S, Bandi V, Zimmerman J, et al. Incidence of vocal cord dysfunction in patients presenting to emergency room with acute asthma exacerbation. Chest. 1997;116(Suppl 2):243S.
  • Newsham KR, Klaben BK, Miller VJ, et al. Paradoxical vocal-cord dysfunction: management in athletes. J Athl Train. 2002;37(3):325-328.
  • Pargeter NJ, Mansur AH. The effectiveness of speech and language therapy in vocal cord dysfunction. Thorax. 2006;61(Suppl 2):ii126.
  • Weir M. Vocal cord dysfunction mimics asthma and may respond to heliox. Clin Pediatr (Phila). 2002;41(1):37-41.
  • J38.3 Other diseases of vocal cords
  • J38.00 Paralysis of vocal cords and larynx, unspecified
  • J38.1 Polyp of vocal cord and larynx
Clinical Pearls
  • Always consider VCD in poorly controlled asthmatics.
  • A multidisciplinary approach may be required for diagnosis and treatment.
  • Speech therapy is the mainstay of long-term treatment.