Katie is a 16-year-old high school student who is a very good soccer player. She is currently playing on her high school team and a traveling squad of All-Stars. In the last 6 months, Katie has begun having excessive shortness of breath with wheezing while playing soccer. Symptoms are worse when she is playing a match but she also notes similar symptoms during practice. She has had one recent episode which was sufficiently severe and caused her to faint. Katie has seen her family physician and he has suggested that she may have exercise – induced bronchospasm (EIB). She has tried treating with inhaler prior to exercise however this medication has been ineffective and the symptoms continue.
She is referred for allergy and asthma evaluation. Initial lung function studies show excellent airflows in both large and small airways. An exercise challenge is performed and during this challenge, she develops inspiratory wheezing (wheezing during your breath in) that is most notable when listening to her neck area, as well as, shortness of breath, requiring her to stop the exercise challenge. Direct visualization of her larynx with scope shows vocal cord spasm causing this inspiratory wheezing and shortness of breath. She is diagnosed with vocal cord dysfunction (VCD).
Vocal cord dysfunction is a condition characterized by abnormal closure of the vocal cords during inspiration. This can cause change in vocal quality, wheezing, stridor (high-pitched, wheezing sound caused by disrupted airflow), shortness of breath with activities, and even brief loss of consciousness. VCD is frequently misdiagnosed as exercise-induced asthma or EIB. Adolescents who participate in very competitive, aerobic athletics, particularly female athletes, are at high risk for this condition.
Vocal cord dysfunction or paradoxical vocal fold motion is a complex disorder of the vocal cords that is frequently mistaken for asthma. Definitive treatment requires behavioral intervention with a trained speech-language pathologist for complete resolution of symptoms. In addition to shortness of breath, symptoms which might suggest vocal cord dysfunction would include throat tightness, inspiratory wheezing or stridor, change in quality of voice, and absence of wheezing during shortness of breath. The primary symptom for most individuals is shortness of breath. Vocal cord dysfunction does not respond to typical asthma meds, such as, bronchodilators or corticosteroids. Exercise and emotional stress are the primary triggers for symptoms, although extremes of temperature, gastroesophageal reflux, and strong odors can be additional triggers.
Just to make things more complicated, vocal cord dysfunction can masquerade as asthma, but can also coexist in individuals with confirmed asthma. Misdiagnosis of vocal cord dysfunction as asthma can lead to inappropriate use of medications – leading to adverse side effects, frequent emergency room visits, hospitalizations, and sometimes although rare, intubation and tracheostomy.
Diagnosis of VCD is suggested by specific symptoms noted above, and most commonly, failure to respond to exercise pretreatment with albuterol. Diagnosis of VCD can be suggested by appearance of the flow volume curve (flattened inspiratory portion) with baseline spirometry but needs to be confirmed by directly viewing vocal cords during acute symptoms.