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One Hundred Case Series of Vocal Cord Dysfunction in a Military Treatment Facility

Clifford Nolt, MD; Michael Ott, MD; Ryann Ennis, MA, CCC-SLP; and Jose Roman, MD

The authors’ evaluation of vocal cord dysfunction cases reveals that prevalence may be higher than previously reported in the literature.

ocal cord dysfunction (VCD), conditions such as brain stem com- seemed to be affected at a higher also known as paradoxi- pression or movement disorders. ratio than were males, 2 to 3 females cal vocal cord movement, is Essentially, all movement disorders per 1 male diagnosis.7 V described as paroxysms of of vocal cords must be considered, In the military population, certain glottis obstruction due to true vocal and organic causes of this movement risk factors were noted in returning cord adduction.1 Since VCD pres- disorder can be evaluated by visual- deployed members, including anxi- ents as a constellation of symptoms ization of the vocal cords. Triggers ety/high stress, exercise, and acute associated with dyspnea, it often is for VCD include exercise, airborne respiratory illnesses.8 In that particu- misdiagnosed as .2 Vocal cord irritants, gastroesophageal reflux lar cohort, 72% positive predictive dysfunction often manifests as epi- disease (GERD), allergic rhinitis, value was noted for VCD if flattened sodic dyspnea and wheezing, may , and psychological inspiratory flow loops with negative occur with exercise, and may be min- conditions.5 Additionally, VCD can methacholine challenge were present. imally responsive to initial . coexist with asthma, further com- Diagnostic criteria are challenging, Flattened inspiratory curves may be plicating accurate diagnoses.6 as symptoms such as dyspnea may be noted on pulmonary function tests Therapies are reported in case present acutely, last < 2 minutes, be (PFTs), but direct laryngoscopy is studies, but no large randomized self-limiting, and completely resolve the gold standard for diagnosis.3 A controlled trials exist to evaluate cur- outside of acute events. Stridor may cohort of proven patients with VCD rent options. Primary treat- be noted, primarily above the vocal with a plateau in the inspiratory ments of asthma therapy were largely cords, and less audible on aus- curve of PFTs also had a plateau on ineffective, and ideal therapy in- cultation.6 A goal of therapy, in addi- expiratory phase in 81% of cases.4 cludes a multidisciplinary approach, tion to dedicated speech pathologist The differential diagnosis of pa- including speech therapy to optimize input, is optimizing comedical condi- tients presenting with upper air- laryngeal control and treatment of all tions, including GERD, allergic rhi- way symptoms is broad. It must identified laryngeal irritants.6 nitis, concomitant asthma, and any include VCD, asthma, angioedema, The prevalence of VCD is un- psychological diagnoses.9 laryngomalacia, vocal cord polyps, known, with no prospective co- Athletes are a particular subset of vocal cord tumors, and neurologic hort studies completed to date and patients with VCD who are crucial conflicting diagnostic criteria used to appropriately diagnose, including Dr. Nolt is a family at Joint Base Lang- in many case studies.7 A prevalence a detailed history and physical, PFTs, ley-Eustis in Virginia. Ms. Ennis is a speech lan- guage pathologist, and Dr. Ott and Dr. Roman of 2.8% was noted in one particular and proceeding to direct laryngos- are pulmonologists, all at Eglin Air Force Base in cohort of 1,028 patients admitted to copy to confirm diagnoses.10 Behav- Florida. Dr. Ott is an assistant professor of medi- a rehabilitation center in a calendar ioral management includes rescue cine at F. Edward Herbert School of at the Uniformed Services University of the Health year with the primary pulmonary breathing techniques, and speech Sciences. diagnosis on admission.6 Females therapy programs focus on

28 • FEDERAL PRACTITIONER • MARCH 2017 www.fedprac.com relaxation of the larynx and dia- cases. Patients eligible for care at phragmatic breathing techniques, Eglin AFB included active-duty and Table. Pulmonary with the goal of establishing sense of Reserve military members plus de- Function Testing Data control during acute events.10 Mili- pendents and retirees. tary service members are expected to The majority of patients diag- Data Median Range operate at a high-intensity level simi- nosed in this cohort were seen and FEV 3.66 1.23-6.04 lar to that of athletes, and treatments diagnosed by Speech Therapy. Video 1 considered for athletes are applicable stroboscopy is based on the principle FVC 4.46 1.67-7.14 to military service members as well. that a movement of an object higher Military strength and cardiovascular than a certain flicker rate appears to FEV /FVC 0.82 0.54-1.20 standards are measured by a combi- stand still to direct visualization, but 1 nation of push-ups, sit-ups, and a run with a rate of light exposure and im- PIF 5.06 0.91-9.29 test, in addition to waist measure- aging above the flicker rate by video, ments. Some of the cohort were iden- the true movement of the object can PEF 8.21 2.96-15.05 tified during physical fitness standard be identified.¹¹ Video stroboscopy is failures, usually in the run test, and considered highly sensitive for organic PIF/PEF 0.61 0-1.04 ultimately received a pulmonology disorders of vocal cords, but it is not MVV 118.50 34-203.00 referral for wheezing or dyspnea with specific for either organic or dysfunc- exertion. The objective of this retro- tional disorders.¹¹ It is still the gold stan- MVV/FEV1 32.00 14.4-48.70 spective cohort study was to evaluate dard above direct visualization, as it can 100 consecutively diagnosed cases of detect abnormal movement of vocal FEF 25%-75% 3.31 0.73-6.38 VCD in a military treatment facility. cords above the critical rate that the human eye would perceive as not mov- Abbreviations: FEF 25%-75%, forced expiratory flow from 25%-75% of FVC; FEV1, METHODS ing due to the frequency of movement forced expiratory volume at 1 second; FVC, The authors conducted a retrospec- (Figures 1 & 2).¹¹ forced vital capacity; PIF, peak inspiratory flow; PEF, peak expiratory flow; MVV, maximum tive chart review of DoD military In an older study, voluntary ventilation. medical records of outpatient diag- was able to diagnose 100% of pa- noses in 100 consecutive diagnoses tients with symptomatic para- of VCD from January 2011 to Febru- doxical vocal cord movement and causes. Pulmonology worked closely ary 2014. Institutional review board additional 60% asymptomatic pa- with Speech Therapy and referred approval was obtained under Proj- tients with a constellation of symp- VCD cases for speech evaluation, ect RSM20130001E by the Exempt toms consistent with paradoxical including video stroboscopy. Nota- Determination Official at Eglin Air vocal cord movement.¹² bly, of the patients in this cohort, al- Force Base (AFB), Florida. Speech Therapy; Ear, Nose, and though some were suspected to have All cases were identified at time Throat (ENT); and Pulmonology asthma, those patients were ruled of VCD visualization and were di- may not perform direct visualiza- out during part of the pulmonology agnosed with video stroboscopy by tion in these patients at initial pre- evaluation, both with PFT testing and speech therapy or by visual laryn- sentation due to other suspected methacholine challenges. An asthma goscopy by the otolaryngology or diagnoses. A more common test diagnosis is important in a military pulmonology departments via direct is the PFT, especially if asthma or treatment facility, as asthma is often visualization. other airway tract diseases are sus- grounds for discharge. Cases were collected chronologi- pected (Figure 3). Patients ranged in age from 13 to cally, and all diagnosed cases at Eglin 68 years, with a median age at 31 years AFB were included. Follow- PATIENT DESCRIPTIONS diagnosis. Thirty-nine females and up was scheduled with all patients di- Study patients were referred for a va- 61 males comprised the total case se- agnosed in Speech Therapy, and most riety of reasons, often from primary ries. Speech Therapy diagnosed 97 pa- patients were concurrently treated by care for concerns for asthma, tients, 96 were diagnosed at Eglin AFB Pulmonology or /Immunol- episodic dyspnea, wheezing, or de- hospital via stroboscopy. One patient ogy. Pulmonary function tests were creased exercise tolerance thought was diagnosed off-base by Speech obtained in 98 of the 100 diagnosed to be related to pulmonary or allergy Therapy via direct visualization,

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dent on follow-up care and patient Figure 1. Normal Vocal Figure 2. Paradoxical reporting for improvement. No pre- Cord Function During Adduction of Vocal Cords defined number of follow-ups was Inspiration During Inspiration determined; patients were followed monthly until they declined further care, fully improved, moved out of the military treatment system, or were lost to follow-up. Treatment included structured Speech Therapy sessions. Response to treatment was subjectively quali- fied by patient report. Fifteen pa- tients reported complete resolution of symptoms, 57 reported partial improvement, 24 reported poor im- Vocal cords showing the loss of available airflow capability; this motion can vary in severity. provement, and 4 patients were lost to follow-up.

1 patient was diagnosed by Pulm- (FEV1); forced vital capacity (FVC), RESULTS onology on-base via direct visualiza- FEV1/FVC ratio; peak inspiratory Risk factors for the diagnosis of tion, and 2 patients were diagnosed flow (PIF) and peak expiratory flow VCD included possible associa- by ENT on-base via direct visualiza- (PEF)—available in 97 studies; forced tions with GERD, allergic rhini- tion. These patients had direct la- expiratory flow (FEF) at 25% to 75% tis, smoking, prior smoking, BMI, ryngoscopy completed, often to rule of FVC (FEF 25%-75%)—available in and mental health diagnoses. Body out other organic causes for upper 96 studies; and maximum voluntary mass index ranged from 17 to 36 in airway disease processes, and were ventilation (MVV) and MVV/FEV1 the case series, with median BMI of found to have visual paradoxical ratio—available in 60 of 98 PFTs. 27. Mental health diagnoses were vocal cord movement. Ninety-eight present in 35 patients and included patients completed PFTs. Several pa- INTERVENTIONS diagnoses of anxiety, depression, tients were lost to follow-up, as can All patients diagnosed by Speech and adjustment disorders. Gastro- be common in a military population Therapy on-base were provided with esophageal reflux disease diagnosis with frequent moves or members laryngeal relaxation techniques, di- was present in 59 of the case series leaving service. aphragmatic breathing techniques, patients, 80 had the diagnosis of On record review, patient symptoms and controlled inhale/exhale tech- allergic rhinitis, 63 were diagnosed were present in the range of 2 months niques at time of diagnosis, with with postnasal drip. Sixteen case to 20 years, with a median duration frequent follow-up scheduled with series patients were current smok- of symptomatic reports lasting 2 years Speech Therapy and Pulmonology. ers. An additional 26 were previous prior to diagnosis. Common diagnoses All diagnoses potentially contributing smokers (at least 100 cigarettes in prior to visual VCD diagnosis included to laryngeal irritation were treated, lifetime) for a total of 42 patients asthma, exercise-induced asthma, including GERD, allergic rhinitis, that were current or prior smokers. anxiety, and episodic wheezing. Risk smoking cessation, weight loss, and The chart review was completed factors that were evaluated in this case exercise recommendations as needed to evaluate for the presence of these series included age, sex, body mass Patients reported improvement on diagnoses, which included previous index (BMI), GERD, allergic rhinitis, follow-up appointments with Speech treatments; for example, proton pump postnasal drip, active smoker, previous Therapy in overall control of symp- inhibitors for GERD, smoker, and mental health diagnoses toms, subjectively categorized as for depression, or intranasal steroids (Figure 4). poor improvement, partial improve- for allergic rhinitis. The diagnosis was Pulmonary function test results ment, and complete improvement. counted as present if the patient was were analyzed on 98 patients, including This was a subjective measurement currently being treated for the partic- forced expiratory volume in 1 second of improvement and fully depen- ular diagnosis in question.

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PFT Data Data from PFTs were avail- Figure 3. Flow-Volume Loops able for 98 of 100 cases PEF Normal PEF Variable diagnosed. Review of data 10 10 Extrathoracic across all 98 patients is Normal Obstruction noted for median FEV of 7.5 MEF 7.5 1 50% FVC 3.6, a median FVC of 4.5, Expiration Expiration MEF with ratio of 0.80. The me- 5.0 5.0 50% FVC dian PIF was 5.1, and me- 2.5 2.5 dian PEF was 8.2, with a PIF/PEF ratio of 0.62. Mid- 0 0 flow volumes also were TLC RV TLC RV analyzed, and FEF 25% to Flow (L/sec) 2.5 Flow (L/sec) 2.5 MIF 75% median was 3.3. For MIF 5.0 50% FVC Inspiration 50% FVC the 60 patients that had 5.0 minute ventilator volumes 7.5 Inspiration 7.5 calculated, the median MVV was 118.5 L/min and 6 5 4 3 2 1 0 median MVV/FEV1 was 6 5 4 3 2 1 0 32.0 (Table). Volume (L) Volume (L) Since PFT values vary according to age, sex, A normal flow-volume loop compared with a variable extrathoracic obstruction as seen with VCD. Expiration and ethnicity, PFTs were essentially remains normal, while a flattened inspiratory peak often can be seen in the VCD patient. Abbreviations: FVC, forced vital capacity; MEF, mid-expiratory flow; MIF, maximum inspiratory flow; PEF, peak expiratory analyzed for percent pre- flow; RV, residual volume; TLC, total capacity; VCD, vocal cord dysfunction. dicted values based on Source: Parker R, ed. MSD Manual Professional Version (Known as the Merck Manual in the U.S. and Canada). age, gender, and race. http://www.msdmanuals.com/professional. Updated 2016. Accessed February 6, 2017. Notably, median val- ues for FEV1, FVC, and PEF were trated in a Chest review article, the diagnosis with other diseases such as all close to 100% of the predicted diagnosis of VCD on history, physi- asthma was common. Also, referral value. The MVV percent predicted cal examination, or PFTs remains to Pulmonology and Speech Therapy was available in 60 cases and was ellusive.1 The PFT evaluation con- was usually completed after failed out- 93% of predicted values. The most tains some subjectivity regarding the patient primary care management for significant difference from expected flattening of inspiratory flow-volume the alternative diagnoses. values was FEF 25% to 75%, at 84% loops and is not routinely reported Improvement with therapy of expected results. in PFT results. In patients diagnosed was mixed, and during the time of Flow-volume loop evaluations with VCD, a clear consensus of treat- documented follow-up, 72 patients on the 97 PFTs available were com- ment modalities remains lacking. reported complete or partial improve- pleted, and 58 of the 97 were noted Modification of risk factors (allergic ment. Most active-duty patients in for variable extrathoracic airway ob- rhinitis, GERD, smoking cessation, the partial improvement category struction consistent with inspiratory weight loss) assisted in self-reported based this subjective reporting on inhibition in the patient population. patient improvement, as did focused their ability to meet military physical This is 60% of the available PFTs in speech therapy. fitness standards. this cohort study. The median age of 31 years, likely Previous data suggested a reflected the younger military popula- female predominance, but this DISCUSSION tion served at Eglin AFB. Seventy-five study population was 61% male. This retrospective chart review of of these patients were currently on ac- Military populations are about 80% 100 consecutive VCD diagnoses in a tive duty, 6 were retired from active to 85% male, so an increase in male military treatment facility reinforces duty (veterans), and 19 were depen- diagnosis is expected. many of the findings currently dents. The median time of symptoms Many patients in the pa- available in the literature. As illus- to diagnosis was 2 years. Prior mis- tient cohort arrived as a result of

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nel, 6 veterans, and 19 dependents Figure 4. Associated Comorbidities by Gender of varying ages. This case series is 1.00 retrospective and tabulates suspected ■ Female ■ Male risk factors; stronger and more in- .82 formative studies could certainly be .80 .77 completed in prospective studies (al- .72 though likely difficult with low prev- alence) or in treatment comparison .59 .59 .60 studies at the time of diagnosis. Since the cohort had varied and lengthy time to diagnosis from onset

Prevalence .38 .40 .36 of related symptoms, the treatment .33 patients received prior to diagnosis .26 .26 differed extensively. Diagnosis was .21 completed by numerous primary .20 care managers or other .08 prior to arrival to Pulmonology and Speech Therapy at Eglin AFB. Once .00 Mental Allergic Postnasal Esophageal Smoker Previous diagnosed in Speech Therapy, consis- Health Rhinitis Drip Reflex Smoker tent treatment options were provided Diagnosis to patients in accordance with stan- dard of care. Pulmonology referrals with a pre- to 75%, with 84% of expected val- It is the authors’ suspicion that sumptive diagnoses of asthma but ues. The FEV1, FVC, and PEF all fell VCD may have a higher prevalence were determined not to have asthma within predicted values of normal, than previously reported in the lit- through PFT results inconsistent despite wide ranges in age, sex, and erature. Military service members with asthma, no improvement with ethnicity among the subjects. Inspi- are tested annually or biannually on β-agonist therapies, and negative ratory flattening consistent with ex- physical fitness standards and are methacholine challenges (if per- trathoracic obstruction was present evaluated for medical reasons for formed). These results prompted in 58 of the 97 PFTs available for re- recurrent fitness standard failures. evaluations for other conditions view at Eglin AFB. This selection of patients is more and eventually a VCD diagnosis. likely to have a VCD evaluation as As noted, exclusion of asthma is of Limitations part of a comprehensive evaluation particular importance in a military Limitations to this retrospective case than is a healthy adult in a civilian population, as medical discharges series are illustrated here. Cases were population. A prospective study in often are pursued in service mem- found only when VCD was diagnosed military service members would be bers with asthma whether con- and coded; and it is the authors’ sus- more fruitful and possibly yield a trolled or uncontrolled. Lag time to picion that many have been misdiag- higher prevalence postdeployment. referral also is possible in failures of nosed or improperly treated for asthma military physical, which prompted or other pulmonary/oropharynx con- CONCLUSION medical evaluation once several ditions. If providers are not familiar Vocal cord dysfunction remains a failures had occurred over a 1- to with VCD or if PFT readings do not difficult diagnosis to treat, be- 2-year time frame. comment on inspiratory findings, diag- cause multiple comorbidities likely The PFT data evaluation was in- nosis is less likely. Some of the authors’ contribute to the diagnosis. This conclusive for statistically significant colleagues already have determined retrospective case series attempted changes when compared with age- that postdeployment prevalence of to compile common themes and matched normal PFT values. This VCD seems to be elevated.8 noted that most of the patients had also was noted in previous studies This cohort was completed on 2 or more risk factors of smoking, of VCD cases. Most notable was per- all patients in a military treatment allergic rhinitis, GERD, or mental cent predicted values of FEF 25% facility, with 75 active-duty person- health diagnoses. A prospective trial

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would be ideal to evaluate VCD Inc., the U.S. Government, or any of its cord dysfunction [in Spanish]. An Pediatr (Barc). 2013;78(3):173-177. further. A focused trial in the par- agencies. This article may discuss un- 5. Deckert J, Deckert L. Vocal cord dysfunction. Am ticular communities of athletes or labeled or investigational use of certain Fam Physician. 2010;81(2):156-159. 6. Benninger C, Parsons JP, Mastronarde JG. Vocal of military service members may be drugs. Please review the complete pre- cord dysfunction and asthma. Curr Opin Pulm Med. of increased benefit to better define scribing information for specific drugs 2011;17(1):45-49. 7. Campainha S, Ribeiro C, Guimar M, Lima R. Vocal VCD. It is notable that 100 cases or drug combinations—including indi- cord dysfunction: a frequently forgotten entity. Case were found in a relatively short pe- cations, contraindications, warnings, Rep Pulmonol. 2012;2012:525493. 8. Morris MJ, Oleszewski RT, Sterner JB, Allan PF. riod for a community hospital, and and adverse effects—before administer- Vocal cord dysfunction related to combat deploy- prevalence may be higher than pre- ing pharmacologic therapy to patients. ment. Mil Med. 2013;178(11):1208-1212. 9. Al-Alwan A, Kaminsky D. Vocal cord dysfunction viously reported. ˜ in athletes: clinical presentation and review of the literature. Phys Sportsmed. 2012;40(2):22-27. REFERENCES 10. Kenn K, Schmitz M. Prevalence of vocal cord Author disclosures 1. Morris MJ, Christopher KL. Diagnostic criteria for dysfunction in patients with dyspnea. First pro- The authors report no actual or poten- the classification of vocal cord dysfunction. Chest. spective clinical study. Am J Respir Crit Care Med. 2010;138(5):1213-1223. 1997;155:A965. tial conflicts of interest with regard to 2. National , Lung, and Institute. 11. Wendler, J, Nawka, T, Verges, D. Instructional this article. Expert panel report 3: guidelines for the di- course: videolaryngo-stroboscopy and phonetogra- agnoses and management of asthma. Full phy—basic tools for diagnostics and documenta- report 2007. https://www.nhlbi.nih.gov/files/docs tion in the voice . Poster presented at: 15th Disclaimer /guidelines/asthgdln .pdf. Published 2007. European Congress of Oto-Rhino-Laryngology, Accessed February 1, 2017. Head and Neck ; September 11-16, 2004; The opinions expressed herein are those 3.  Newman KB, Mason UG III, Schmaling KB. Clinical Rodos-Kos, Greece. of the authors and do not necessarily features of vocal cord dysfunction. Am J Respir Crit 12. Ibrahim WH, Gheriani HA, Almohamed AA, Care Med. 1995;152(4, pt 1):1382-1386. Raza T. Paradoxical vocal cord motion disor- reflect those of Federal Practitioner, 4. Sanz Santiago V, López Neyra A, Almería Gil E, der: past, present and future. Postgrad Med J. Frontline Medical Communications Villa Asensi JR. patterns in vocal 2007;83(977):164-172.