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Irritative Vocal Cord Dysfunction
It is a well known medical adage that "all that Table 1. Differential Diagnosis of Laryngeal Movement
wheezes is not asthma". Vocal cord dysfunction Disorders
(VCD) is one of the entities that needs to be Associated Conditions considered in the differential diagnosis when evaluating a patient with possible work-related Psychogenic VCD Somatoform disorder asthma after irritant exposure. Conversion disorder Psychiatric illness Two review articles in 2010 summarize the
multiple causes, diagnosis and treatment of
Other components (anxiety disorder, vocal cord dysfunction1,2. See Table 1.
stress, depression) Case reports and a case control study of work- related irritative VCD have reported that VCD and work-related asthma, particularly Reactive Chemical irritants Airways Dysfunction Syndrome (RADS) may Olfactory stimuli have similar presentations3-5. For example, a 44 year old railroad worker was Rhinitis/postnasal drip exposed to anhydrous ammonia after a rail car leaked3. He immediately developed a cough, hoarseness, Supraglottic disorders Laryngomalacia burning eyes, tearing, rhinitis and felt "his lungs and Exercise-induced supraglottic closure stomach to be on fire". He was treated with inhaled Laryngospasm Intubation bronchodilators and corticosteroids. His hoarseness Airway manipulation persisted. Five months later he was found to have an abnormal inspiratory loop on spirometry, a negative methacholine challenge test and paradoxical adduction Nocturnal aspiration of his vocal cord on laryngoscopy. A second example, Vocal cord paresis Prolonged intubation with a less immediate onset of symptoms was a 45 Vocal cord paralysis Head and neck malignancy year old nurse who developed dyspnea and cough one week after transferring to a gastroenterology unit4. She was in charge of cleaning endoscopy instruments, with 40-50 washes per day using various disinfectants. Pre/ Neurogenic Brainstem post bronchodilator testing was negative. She had a Upper motor neuron injury 22% decrease in FEV1 to saline and no methacholine Lower motor neuron injury was administered. No eosinophilia was found in induced sputum. On laryngoscopy she had adduction Movement disorders of her vocal cords during inspiration with posterior Adductor laryngeal breathing dystonia (From reference 1) The case-control study from Denver compared 11 patients with irritant-exposed vocal cord dysfunc-tion to 33 patients with vocal cord dysfunction caused by non irritative etiologies3. They found no dif-ference in gender, cigarette smoking, symptoms or pulmonary function results but did report that a higher percentage of the individuals with irritative vocal cord dysfunction were Hispanic (27% vs. 3%, p = 0.02) and had chest pain or chest tightness (100% vs. 57%, p = 0.04). Among the 11 patients with irritative vocal cord dysfunction: two had the sudden onset of dyspnea and upper airway irritation after spills of ammonia; two were electronic assemblers who had throat tightness, dry cough and dry heaves after the inappropriate mixing of flux and solder; one was a registered nurse in an emergency depart-ment who had wheezing and dyspnea after scrubbing a bed; one was a bus driver who developed cough and dyspnea 24 hours after being exposed to an aerosolized carburetor cleaning solution; one was a machine operator who developed dyspnea and chest tightness two hours after exposure to metal work-ing fluid; one was a restaurant worker who developed dyspnea and sore throat 24 hours after an offen-sive odor while cooking "Cajun salmon"; one was an office worker with immediate cough and hoarse-ness after exposure to construction dust; and two were individuals who developed symptoms including chest burning and nausea after exposure to smoke from fires3. The diagnostic criteria for irritative vo-cal cord dysfunction used in the case-control study are shown in Table 2. Table 2.Clinical Criteria for Vocal Cord Dysfunction
Other authors have also described foods, perfume and chlorine as causes of irritative vocal cord dysfunction6-9. Irritant VCD
All authors have emphasized the contri- 1. Documented absence of preceding vocal cord dys- bution of psychosocial issues. function or laryngeal disease 2. Onset of symptoms after a single specific exposure Differentiating whether the etiology of symptoms is due to asthma or VCD may be difficult. First, patients with vocal 3. Exposure to an irritating gas, smoke, fume, vapor, cord dysfunction may also have asthma. Second, a methacholine challenge may 4. Onset of symptoms within 24 hours after exposure precipitate vocal cord dysfunction10, 11. 5. Symptoms of wheezing, stridor, dyspnea, cough, Normal spirometry with an inspiratory or throat tightness flow volume loop may be useful in the diagnosis by showing changes of extra 6. Abnormal direct laryngoscopy for vocal cord dys- function either in the asymptomatic state, during thoracic obstruction. However, in differ- symptoms, or with a provocative study ent case series this positive finding has varied from as low as 20% to 79% of pa- 7. Exclusion of other types of significant vocal cord tients with VCD 1. (From reference 3) Flexible laryngoscopy is the gold standard for diagnosis. Findings diagnostic of vocal cord dysfunc-tion are 1) inspiritory vocal cord adduction of the anterior two-thirds of the vocal cords with a poste-rior diamond shaped chunk; or 2) adduction on both inspiration and expiration; or 3) adduction of the false vocal cords. Greater than 50% inspiratory closure of the vocal cords is sufficient for diagnosis but since vocal cord motion may only be abnormal during an acute episode, a negative vocal cord study may not rule out the condition where the diagnosis is highly suspected. In exercise induced vocal cord dysfunction, laryngoscopy is recommended before and after exercise. Since the typical asthma medications are ineffective in treating vocal cord dysfunction, differentiating VCD from asthma is important. Many times individuals with vocal cord dysfunction have been treated for long periods as difficult-to-treat asthmatics with significantly greater use of health care resources than the average asthmatic. Recommendations to remove the patient from the irritative exposure have been included in treatment modalities although the most effective recommended treatment options have been speech therapy with psychotherapy or psychological counseling (Table 3)1, 2, 10. There are no controlled studies to show addi-tional improvement in outcome if the patient is removed from the irritative exposure. Table 3. Short- and Long-term Management of Vocal Cord Dysfunction
Reassure patient. Instruct patient in breathing behaviors, including panting, diaphragmatic breathing, breathing through the nose or a straw, pursed-lip breathing, and exhaling with a hissing sound. Consider a trial of helium and oxygen (heliox) in patients with persistent or severe vocal cord dys-function. Long-term
Avoid known triggers, such as smoke, airborne irritants, or certain medications. Treat underlying conditions, including anxiety, depression, gastroesophageal reflux disease, and rhi-nosinusitis. Consider a trial of inhaled ipratropium (Atrovent) in patients with exercise induced symptoms. Referral for speech therapy is indicated in patients with unresolved symptoms. Long-term tracheostomy may be appropriate in severe, resistant cases. (From reference 2) References
1) Morris MJ, Christopher KL. Diagnostic criteria for the classification of vocal cord dysfunction. Chest 2010; 2) Deckert J, Deckert L. Vocal cord dysfunction. American Family Physician 2010; 81:156-159. 3) Perkner JJ, Fennelly KP, Balkisson R, Bartelson BB, Ruttenber AJ, Wood RP, Newman LS. Irritant-associated vocal cord dysfunction. J Occup Environ Med 1998; 40:136-43. 4) Tonini S, Dellabianca A, Costa C, Lanfranco A, Scafa F, Candura SM. Irritant vocal cord dysfunction and occu- pational bronchial asthma: differential diagnosis in a health care worker. Int J Occup Med Environ Health 2009; 22:401-6. 5) Galdi E, Perfetti L, Pagella F, Bertino G, Ferrari M, Moscato G. Irritant vocal cord dysfunction at first misdiag- nosed as reactive airway dysfunction syndrome. Scand J Work Environ Health. 2005; 31:224-6. 6) Morrison M, Rammage L, Emmami AJ. The irritable larynx syndrome. J Voice 1999; 13:447-455. 7) Andrianopoulos MV, Gallivan GJ, Gallivan KH. PVCM, PVCD, EPL, and irritable larynx syndrome: what are we talking about and how do we treat it? J Voice 2000; 14:607-618. 8) Allan PF, Abouchahine S, Harvis L, Morris MJ. Progressive vocal cord dysfunction subsequent to a chlorine gas exposure. J Voice 2006; 20:291-296. 9) Bhargava S, Panitch HB, Allen JL. Chlorine induced paradoxical vocal cord dysfunction. Chest 2000; 118 (suppl):295S-296S. 10) Christopher KL, Morris MJ. Vocal cord dysfunction, paradoxical vocal fold motion or layrngomalacia? Our un- derstanding requires an interdisciplinary approach. Otolaryngology Clinics of North America 2010; 43:43-66. 11) Perkins PJ, Morris MJ. Vocal cord dysfunction induced by methacholine challenge testing. Chest 2002; 122:1988 12) Mikita J, Parker J. High levels of medical utilization by ambulatory patients with vocal cord dysfunction as com- pared to age-and gender-matched asthmatics. Chest 2006; 129:905-908. We are interested in receiving reports of patients with either work-related
asthma or irritative vocal cord dysfunction, please call 1-800-446-7805.
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ASCO SPECIAL ARTICLE Recommendations for the Use of Antiemetics: Evidence-Based, Clinical Practice Guidelines By Richard J. Gralla, David Osoba, Mark G. Kris, Peter Kirkbride, Paul J. Hesketh, Lawrence W. Chinnery, Rebecca Clark-Snow, David P. Gill, Susan Groshen, Steven Grunberg, James M. Koeller, Gary R. Morrow, Edith A. Perez, Jeffrey H. Silber, and David G. Pfister for the American Society of Clinical Oncology
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