Vocal Cord Dysfunction

Today we discussed a case of a middle aged woman who presented with difficulty taking a deep breath with rest or exertion in the last week associated with a seemingly pan-positive review of systems, but an extensive workup without findings until she was found to have vocal cord dysfunction on flexible laryngoscopy by ENT. Some learning points:

1) Normally the vocal cords ABduct in mid-inspiration, but with vocal cord dysfunction (VCD), there is paradoxical ADDuction at this point (this can be partial or "chinking" as pictured above, or complete as in most cases).

2) Vocal cord dysfunction is often mis-diagnosed as asthma but this can be co-morbid. Other associated conditions are: GERD (laryngopharyngeal reflux), neurologic injury (such as after thyroid or cervical spine surgery), and psychosocial disorders, depression, PTSD, sexual abuse, and generalized anxiety.

3)  The clinical manifestations of VCD are: classically inspiratory stridor with respiratory distress, often associated with throat tightness, choking sensation, dysphonia, and cough--and episodes can last hours to days (compared with laryngospasm lasting seconds to minutes).

4) The gold standard for diagnosis is laryngoscopy, but PFTs can also be suggestive with a truncated or flat area on the inspiratory loop.