Paradoxical Vocal Fold Motion (Vocal Cord Dysfunction)

Case: 44 year-old female gets wheeled into the critical care area in respiratory distress. Through gasping breaths of inspiratory stridor, she says this started one hour ago while at home, mentioning she was getting “aggravated” with her husband. Her husband endorses that this has happened before in similar situations. She denies any toxic inhalations or drug use, foreign body aspiration or choking, recent infectious symptoms, or allergies.

Vital signs: HR 90, BP 140/88, T 98.6, RR 34, SpO₂98%

Exam is notable for apparent respiratory distress: tachypnea with an audible inspiratory noise and accessory muscle use. Her lungs sounds are otherwise clear, and there are no wheezing or expiratory noises. Her neck and oral exam are normal. Although she seems distressed, she can answer in full sentences.

What is Paradoxical Vocal Fold (VC) Motion?

Abnormal adduction of VC during inspiration
- VC should be open (abducted) during inspiration and closed with phonation, swallowing, etc.
Commonly associated with psychogenic /conversion disorder
However, it is now gaining evidence as a functional disorder of glottic closure
Can appear like anaphylaxis or severe asthma and is often not diagnosed on first visit → can lead to intubations, ICU admissions, surgical airways

Presentation

Abrupt onset of inspiratory stridor; often related to stress, scents, exercising
Difficulty more with inspiration than expiration
MUST rule out life-threatening causes first!
- Consider foreign body, anaphylaxis, infection, asthma, etc.

Exam

Stridor, respiratory distress, accessory muscle use
NO swelling, NO drooling, NO ‘hot potato voice’ (but may have slightly strained voice)
Normal O₂ saturation; no cyanosis
Normal level of consciousness

Evaluation

Laryngoscopy should be done to exclude other pathology and confirm diagnosis
Call ENT / visualize VC adduction during inspiration
Should hear stridor when VC are adducted; if not, there may be pathology in trachea below vocal cords (such as tracheal stenosis)
Consider imaging (neck xray or CT) to rule out other dangerous causes of stridor

Management

1st line: Breathing techniques to interrupt the irregular respiratory pattern or spasm and allow familiar neurologic signals to reengage
- Nasal inspiration with pursed lip expiration
- Breathing through ET tube (cut if off at 13cm) or large straw
- Panting ‘like a dog’: chin forward, tongue out, pant through mouth
- 2 quick sniffs and one slow sniff through nose, exhale through mouth
2nd line: Heliox inhalation (if available) and non-invasive ventilation
If above techniques fail, try sedation
- Benzodiazepines (beware of respiratory depression)
- Ketamine at dissociative dosing (beware of laryngospasm at higher doses)

Disposition

If condition resolves and other serious causes are ruled out, can discharge home
If stridor continues despite above techniques, will likely need ICU admission
All patients should have referral to ENT and speech pathology

Click here to watch the video on the Annals of EM website for a live view vocal cord dysfunction.

Reference

Denipah N, Dominguez CM, Kraai EP, Kraai EL, Leos P, Braude D. Acute Management of Paradoxical Vocal Fold Motion (Vocal Cord Dysfunction). Annals of Emergency Medicine. 2017; 69(1): 18-23.