Lafayette Otolaryngology Associates, Inc.

Lafayette Otolaryngology Associates, Inc. ** LAFAYETTE ENT ** 2320 Concord Road, Lafayette, IN 47909 (765) 477-7436 EAR, NOSE AND THROAT HEAD AND NECK SURGERY FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY VOCAL CORD DYSFUNCTION FACT SHEET DESCRIPTION Vocal Cord Dysfunction (VCD) can present with some voicing complaints but more commonly presents with upper airway obstructive complaints. It is commonly referred to as paradoxical vocal cord movement or paradoxical vocal fold dysfunction. VCD involves intermittent attacks of breathing difficulties whereby the vocal cords close prematurely during inhalation. This partial upper airway obstruction can be mild to severe, sometimes even rarely, resulting in a hospital visit. VCD may co-exist with asthma and is frequently misdiagnosed as asthma. VCD will not improve with typical asthma medications. CAUSES There is not one specific cause for VCD. However, some causes or triggers may include any one or combination of the following: exercise, acid reflux, nasal congestion, postnasal drainage, coughing, anxiety, stress, extreme temperatures, respiratory illness, environmental irritants or pollutants, or inhaled chemicals, such as paints, fumes or perfumes. Symptoms usually consist of tightness in throat or upper chest, stridor or noisy breathing, shortness of breath, lump in the throat, feeling of inability to get air into the lungs, and/or hoarseness. DIAGNOSIS The gold standard to diagnose vocal fold dysfunction is made by flexible laryngoscopy. Vocal fold partial closure during inhalation is the key finding. There may also be signs of inflammation caused by laryngopharyngeal reflux. It can be suspected with symptoms of tightness in the chest or upper throat, noisy breathing (especially during inhalation), lump in the throat sensation, hoarseness, or even passing out. TREATMENT The treatment of VCD usually is multi-factorial. This commonly will require an otolaryngologist to perform flexible laryngoscopy to confirm the diagnosis. Medical therapy by the physician may include acid reflux medications; possibly even anxiety medications. The speech-language pathologist is important for laryngeal control therapy. A psychiatrist or psychologist may be needed to help manage anxiety, as well. In most cases, this comprehensive approach leads to complete resolution of the behavior in a short period of time. For additional information and/or an appointment please contact: Lafayette Otolaryngology Assoc. (Drs. Hillsamer, Berner, and Duberstein) 2320 Concord Road, Lafayette 765-477-7436 Barbara Solomon, Speech-Language Pathologist, Clinical Professor, bsolomon@purdue.edu 765-494-3820 Alice Wilcoxson, Ph.D., PT, ATC, Clinical Associate Professor, wilcoxso@purdue.edu AM Telephone: 765-494-3172 PM Telephone: 765-494-0571 Peter J. Hillsamer, MD, FACS Daniel R Berner, MD, FACS Aaron Duberstein, MD

A TEAM COLLABORATION APPROACH FOR THE VOCAL CORD DYSFUNCTION (VCD) IN ATHLETES: Recognition, Evaluation, Diagnosis, and Treatment 2015 GLATA Annual Meeting and Symposium ALICE WILCOXSON, PHD, PT ATC, CLINICAL ASSOCIATE PROFESSOR PURDUE UNIVERSITY BARBARA SOLOMON, CLINICAL PROFESSOR PURDUE UNIVERSITY Consultation with PETER HILLSAMER, M.D., OTOLARYNGOLOGIST LAFAYETTE OTOLARYNGOLOGY ASSOCIATES 1 1

Athletes we treat 13 year old female Track Stridor while inhaling Throat clearing Begins to feel anxiety 19 year old female Tennis Shortness of breath (breathlessness) occurs during vigorous exercise Begins to breathe heavily through her mouth Throat tightness 15 year old female Basketball Panting for air Coughs Feeling exhausted after playing for 15-20 minutes 15 year old female Swimmer Shortness of breath while swimming Tired and weak episodes while swimming 2

Diagnosis of Vocal Cord Dysfunction This is a laryngeal disorder that affects breathing. When there is inappropriate closure of the true vocal folds during inhalation and respiratory obstruction occurs. 3 3

Symptoms Shortness of breath (Dyspnea)/airway obstruction Stridor on inhalation Cough/Throat clearing Panic/Anxiety disorder Uses INHALER AND DOES NOT HELP Original Diagnosis EIA Throat tightness Chest tightness Refluxing LPR-GERD Asthma can co-exist Hoarseness can co-exist 4 4

Separating the Symptoms Allergy & Asthma Today, Volume 6, Issue 1, Updated 2/09 Vocal cord dysfunction (VCD) is often mistaken for asthma, especially exercise-induced asthma (EIA). Timing of symptoms VCD less than 5 minutes after beginning exercise EIA 5-10 minutes or more after beginning exercise Tightness in throat middle or lower chest Wheezing or high-pitched sound when breathing in; hoarse voice when breathing out Recurrence symptoms can recur immediately and more severely when exercise resumes symptoms tend to be less severe when exercise resumes (after bronchodilator use) Recovery time may take less than 10 minutes usually takes up to an hour without medication Medications bronchodilator won t help bronchodilator will help 5

COMMON characteristics of athlete with VCD Young women (female 18:1) High achiever/ perfectionist Anxiety / stress perception Intense physical activity Outdoor sports Incidence 3-5% of ALL athletes 6 6

Respiration-Breathing VCD Video 7 7

TRIGGERS URI Stress Exercise - Children and Adults who are high achievers and usually participate in competitive sports Extreme temperatures Irritants: environmental pollutants, dust, smoke, chemicals, paints, perfume-cologne, mist, mold, and fumes 8 8

ENT PATIENT PLAN 9 9

DIAGNOSIS History MOST IMPORTANT, therefore need to educate coaches, athletic trainers, etc. Physical Examination/Flexible laryngoscopy to rule in and rule out other dx - GOLD STANDARD Ideally when symptoms are present with or without exercise Greater than 50% ADDuction inhalation Count to ten and/or count until end volume and watch for incomplete ABDuction Ask to mimic episode 10 10

LESS COMMON characteristics of athlete with VCD Allergy/asthma coexisting Sinonasal pathology (CRS, polyps, septal deviation) LPR Irritants (tobacco, odors, dryness, cool air) Glottic lesion (ulcer, polyp, edema) Psychosocial disorder (PTSD, etc) 11 11

WARNING if you are a hammer everything looks like a nail -Think before treat -Wrong dx..bad results - Proper dx. Outcomes are very good! 12 12

TREATMENT Reassure SLP Laryngeal Support Therapy (LST) Laryngeal Control Therapy (LCT). RX LPR- PPI and GERD instructions* RX ASTHMA (bronchodilator inhalers, steroids)* RX Nasal disease (meds or surgery)* Psychotherapy Hypnosis Biofeedback to decrease sympathetics Botox Thyroarytenoid muscle Heliox (30:70 Oxygen: Helium) 13 13

SLP PATIENT PLAN 14 14

VCD Fact Sheet - Handout DESCRIPTION CAUSES DIAGNOSIS TREATMENT CONTACT INFORMATION 15

Evaluation with VCD Case History Breathing Respiration Testing (IMST-EMST) GERD RSI Stress-emotional factors Triggers Laryngeal Visualization Dyspnea Index Laryngeal Visualization Swallowing Eat -10 (if needed) 16 Voice testing (if needed) 16

IMST/EMST 17 17

Treatment Body Awareness Physiological Awareness Reassurance (not life-threatening) Nancy Swigert VCD Fact Sheet Training of Breathing Exercises Relaxed Breathing Three Step Breathing PowerBreathe LPR-GERD Consultation and Follow-up with AT Stress Management Collaborative Team Approach with other Health Professionals: Pulmonologist, Allergist, Psychology, etc. 18 18

Breathing Techniques POWERbreathe 19 19

Treatment - Inspiratory/Expiratory Muscle Strength Training Set to 70% of the patient s maximum expiratory pressure or the highest level the patient can tolerate Patient completes: 5 breaths through the device, 5 times per day 5 days per week For 4-5 weeks Device setting is increased as the patient improves ATHLETIC TRAINER COLLABORATION 20 20

Weekly Home Practice Log Day Set 1 Set 2 Set 3 Set 4 Set 5 21 21

MANAGING LARYNGEAL REFLUX - (LPR) Drink Water Avoid eating for at least 2-3 hours before going to bed or Eat Friendly Refluxing foods Reduce/Eliminate stress/tension, Elevate the head of the bed 6-10 inches. Place cinder blocks, bricks, wood under the legs at the head of the bed. REFLUX FRIENDLY FOODS REFLUX UNFRIENDLY FOODS Medication We recommend that you consult with your physician regarding the above suggestions. 22 22

TEAM APPROACH Otolaryngologist Pulmonologist Team physician SLP Athletic Trainer/Coaches Sports Psychologist Sports Nutritionist 23 23

What is the role of the AT in a team collaborative approach to the effective assessment and treatment of the athlete with VCD? How do they contribute? Knowledge of VCD Recognition of S/S which might indicate VCD Referral to appropriate ENT / SLP AT attends voice therapy session(s) Oversee administration of daily plan of care Encourage / require follow-up SLP and AT attend athlete s practice/events 24 24

Role of the AT: Knowledge of VCD AT has a responsibility to: Develop a knowledge base related to VCD Not a familiar diagnosis Not addressed in AT educational competencies Not commonly reported on PPEs Share this information with team physicians, coaches, strength and conditioning staff 25 25

Role of the AT: Recognition of S/S which might indicate VCD The Athletic Trainer Sees the athlete in a variety of situations Sees how often and in what situations the athlete has respiratory distress Sees how often and in what manner the athlete uses a rescue inhaler. 26 26

Role of the AT: and Recognition of situations which might stimulate VCD 27 27

Role of the AT: Referral to appropriate ENT / SLP Work with team physician to identify appropriate ENT(s) / SLP(s) for diagnosis and treatment of athletes with VCD Establish a referral protocol Attend Voice Therapy session(s) with athlete Similar to identification of other specialists for other diagnosis or conditions 28 28

Role of the AT: Oversee administration of daily plan of care AT typically interacts with athlete every day before, during and after activity Answer questions / concerns of athlete Accountability for athlete to perform HEP Remind athlete of breathing exercises / techniques during stimulus situations Assist with appropriate progression of HEP Encourage / require follow-up with ENT / SLP 29 29

Role of the AT: Facilitate SLP attendance at athlete s practice and/or event Opportunity to experience / understand athlete s activity and environment Allows insight and potential improvement of established plan of care 30 30

CASE SCENARIO 31 31

FUTURE OF VCD TREATMENT COLLABORATION FOLLOW-THROUGH SLP TRAINING IN VCD ENT TRAINING IN VCD ATHLETIC TRAINER TRAINING IN VCD ELEMENTARY-H.S.-UNIVERSITY-COLLEGE PE TRAINING IN VCD AD TRAINING IN VCD COACH TRAINING IN VCD TEAM MD TRAINING IN VCD 32 32

Resources/References Marcinow, Thompson, Chiang, Forest, and desilva. Paradoxical Vocal Fold Motion Disorder in the Elite Athlete: Experience at a Large Division I University. The Laryngoscope 2013; Chiang, Marcinow, desilva, Ence, Lindsey, and Forrest. Exercise-induced paradoxical vocal fold motion: diagnosis and management. The Laryngoscope 2013; (3) 727-731. Wilson, Cooke, and Edwards. Predicted normal values for maximal respiratory pressures in Caucasian adults and children. Thorax 1984; (39) 535-538. Wilson JJ, and Wilson. Practical management: Vocal cord dysfunction in athletes. Clin J Sport Med. 2006; Jul;16 (4): 357-60 Weir M, Vocal cord dysfunction mimics asthma and may respond to Heliox. Clin Pediatr (Phila). 2002 Jan-Feb; 41 (1): 37-41. Newsham KR, Klaben BK, Miller VJ, and Saunders JE. Paradoxical vocal-cord dysfunction: management in athletes. J. Athl. Train. 2002; Sep; 37 (3): 325-328. Rundell KW, Spiering BA. Inspiratory Stridor in elite athletes. Chest 2003; Feb; 123 (2): 468-74. 33 33

Inspiratory Muscle Training in Exercise Induced VCD Mathers-Schmidt and Brilla Journal of Voice 2005 Does inspiratory muscle training (IMT) result in increased inspiratory muscle strength, reduced perception of exertional dyspnea, and improved measures of maximal exercise effort in an athlete with exercise-induced VCD? At end of the study, the participant reported experiencing no VCD symptoms when playing soccer. The findings suggest that IMT may be a promising treatment approach for athletes with exerciseinduced VCD. The participant was a nonsmoking 18-year-old woman with a 2-year history of acute dyspnea triggered by high intensity exertion during soccer workouts and games. She had been treated for exercise-induced asthma, with a bronchodilator inhaler, with no improvement. The participant trained 5 days per week for 5 weeks, with a custom-made inspiratory muscle strengthening device. 34 34

Inspiratory muscle strength training with behavioral therapy in a case of a rower with presumed exercise-induced VCD International Bari Hoffman Ruddy, et. al. Journal of Pediatric Otorhinolaryngology 2004 VCD with high effort exercise can result in disruptions to ventilation, dyspnea, inspiratory stridor, elevated heart rate, and syncope. This single subject study experimentally tested an inspiratory muscle strength training (IMST) program with behavioral therapy on a 15-year-old male crew member. Following 5 weeks of IMST, MIP increased by 93% from baseline function while dyspnea ratings substantially decreased. Outcome included successful competition with his high-school crew team, a task he was previously unable to complete. Discussion focuses on IMST combined with traditional approaches of voice therapy for treating PVFD. As per the subject s anecdotal report, this combined treatment, in his opinion, was most effective. 35 35

DISCUSSION 36 36