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Assessment and Treatment of Paradoxical Vocal Fold Movement (PVFM)
Terms in this set (22)
What do you know?
-people have become more aware of it and learning more about it
History of PVFM
-First described in the literature in 1802
-In 1842 it was described as "hysteric croup"
-Unfortunately, it is often STILL misdiagnosed
-Can present as a confusing entity
-we are educating people more as a professio
Many Names/Terms to Describe
There are over 70 different names for the disorder
-Paradoxical vocal fold movement or adduction
-Vocal cord dysfunction
-Irritable larynx syndrome
-Episodic laryngeal dyskinesia
-Functional laryngeal obstruction
-Psychogenic stridor or wheeze
-Hysterical croup or stridor
You can see by some of the names that a psychogenic etiology has long be thought to be the cause
So, what is PVFM?
-A laryngeal disorder characterized by paradoxical vocal cord movement on inspiration.
-Finding during laryngoscopy is adduction of the anterior vocal folds during inhalation.
-Severity is highly variable
-may range from intractable respiratory distress with desaturation and eventual intubation to....
-dyspnea in conditioned athletes only at high levels of exercise (McFadden E.R. & Zawadski, D.K., 1996).
-closing on inhalation
-attacks brought on by smells and exercise
Visualization of PVFM
-Most patients are between the ages of 10 and 40 years of age.
-Can be diagnosed in children as young as neonates.
-Occurs more often in adults than children (71% vs 29%)
-More common in females than males at a ratios of 2 or 3:1 WHY?
-important to watch them when this happens
-we really don't know why
-females: internalization of stress, seek more medical tx,
Higher Female to Male ratio
No one knows why though some speculate that
-Female sex hormones make the upper airway more sensitive
-The cough reflex in women is much more sensitive than in men possibly due to estrogen and/or progesterone
-More females pursue therapy and are more likely to pursue medical treatment than males
-Coaches of male athletes simply tell them to "work through it and keep going!"
-May have to do with the size and shape of the female larynx
-female: constriction happens faster because it is smaller
Who are PVFM Patients/Clients? Personality Traits
-Type A: wound-tight
-Feel as if they carry the weight of the team
-Ask patients and parents to rate the client's competitiveness on a scale of 1-10 (often high ratings)
PVFM Symptoms: PVFM vs. Asthma
-Upper airway obstruction
-Stridor (often called "wheezing" by patients)
-Shortness of breath
-Exertional Dyspnea (shortness of breath w/activity)
-Occasional expiratory wheezing
-Chronic throat clearing
These similarities in symptoms can:
-make diagnosis difficult without the proper diagnostic skills
-result in the prescription of unnecessary medications and invasive tests
Why PVFM? Triggers
Two main categories
1. Laryngeal Hyper-responsiveness (sensitivities)
Laryngeal Hyper responsiveness (triggers also often associated with asthma) -reacting to something more than it needs too
-Fumes (perfume, smoke, cooking smells, chlorine)
-Weather conditions (hot/humid, cold/dry)
-Can also occur at rest or without an obvious trigger
-Associations with other conditions
2. Chronic nasal and /or sinus congestion
-May lead to chronic irritation of the throat causing the vocal folds to become hypersensitive to irritant stimuli (National Jewish website); however there has not been research to support this.
2. Social stressors (in athletics as well)
Diagnosis: Not Easy
These individuals may have been seen by many professionals and may have undergone many tests, WHY?
-not a lot of information on this disorder
-Primary Care Physician
-Cardiologist for chest pain/tightness
-Allergist for coughing and the fact that allergens are at times identified by the patient as a trigger
-Pulmonologist for breathing issues
-Some patients have had inpatient admissions and numerous trips to the ER
-can pass out and not get air in
-better after passing out (relaxing)
If misdiagnosed, may result in
Introduction of many aggressive asthma therapies that are not effective
-inhaled and oral corticosteroids
Invasive testing including
Each of which has significant side effects!
-more money, more copays, etc.
Disorders that mimic PVFM in children
(Similarities: cough, wheeze, dyspnea and stridor)
-Subglottic stenosis (acquired or congenital)
-Vocal cord paresis or paralysis
-Laryngeal or subglottic hemangioma
-Laryngomalacia or tracheomalacia
-Foreign body (larynx, trachea, bronchus, esophagus)
-Extrinsic airway compression
-Asthma/exercise induced bronchospasm
-As many as 50% of PVFM patients can have coexisting asthma
-On instrumental exam, specifically spirometry, the patients with asthma can have expiratory flow obstruction along with the inspiratory flow abnormalities seen in patients with PVFM.
-It is difficult to get reliable instrumentational results because it is difficult to obtain the exam during an episode, timing in really everything.
-About 40% of asymptomatic patients have normal exams (Noise and Kemp, 2007)
-Difficult to get a good history from patients; many cannot tell you if they have more trouble inhaling or exhaling
Medical diagnosis begins with a good history and an understanding of what is and what is not PVFM
Asthma versus PVFM
Primary respiratory phase affected
1. PVFM: inspiratory stridor
-extra thoracic disorder🡪 best heard with a stethoscope over the larynx or trachea
2. Asthma: expiratory stridor
-Intra thoracic airway disorder 🡪 best heard with a stethoscope over the chest wall
PVFM patients will tend to point to their neck when they are asked to show where they feel tight.
Asthma versus PVFM cont.
-abrupt onset (can begin within 5 minutes of playing). Patient has few symptoms between episodes. Rarely occurs at night
-symptoms occur after 5-10 minutes. Symptoms are persistent and can develop over hours or days. Can be present at night as well as during the day.
Asthma versus PVFM part 3
-Upon resuming exercise after the initial episode the patient can have severe and repeated episodes
-Recovery may take less than 10 minutes
-After initial episode symptoms are less severe after resuming exercise. Symptoms may spontaneously resolve in 30 to 60 minutes in EIA or the "refractory period" can last up to 4 hours. Coughing may persist for several hours after the episode.
Asthma versus PVFM pt. 4
Response to asthma medications
-medications do not resolve attacks
-medication is effective
Asthma versus PVFM pt. 5
Performance on Spirometry
-Abnormal inspiratory loop (in some)
-Normal expiratory loop
-Normal inspiratory loop
-Reduced expiratory loop (a normal expiratory loop would be highly unusual)
-flip of each other
-mimic each other in symptoms though
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