Karen Drake, MA, CCC-SLP, generally treats adolescents and older adults with paradoxical vocal cord dysfunction (VCD). While the condition typically is caused by exercise in adolescents and environmental irritants in adults, the goal of treatment is the same for both populations: to achieve laryngeal relaxation during the breathing cycle.
"I look at preventative things that we can do to try to keep the larynx as relaxed as possible during the day," said Drake, on staff at the Northwest Clinic for Voice and Swallowing at Oregon Health & Science University in Portland. "That involves breathing efficiently at rest and doing some breathing exercises to make sure the larynx is relaxed."
She and medical director Joshua Schindler, MD, a laryngologist, assess the patients, who typically are referred by a pediatrician or allergy specialist. Drake conducts a general patient interview and physical examination and asks questions about vocal and respiratory symptoms. Treatment can begin while the patient undergoes a laryngoscopy.
"We give them feedback regarding what we're seeing with their laryngoscopy," Drake told ADVANCE. "Sometimes we even start biofeedback at that point, depending on what we see."
At the completion of the procedure, Dr. Schindler reviews the results with the patient and, if necessary, addresses any related complications. Ideally, Drake prefers that patients who are symptomatic undergo a second laryngoscopy.
If the suspected VCD is exercise-induced, patients are asked to run or engage in the physical activity that spurred the symptoms. "I have an athletic background, so in our clinic we exercise them," she said. "If a patient is symptomatic running lines, we're going to go out and run lines. I want to see how the patient breathes during the activity."
Such an approach may not be feasible if the athlete requires an intense work-out sequence that cannot be replicated onsite or if the condition is caused by an environmental irritant not readily available in the clinic setting. For those patients Drake uses the baseline laryngoscopy combined with the patient's description and imitation of their symptoms to make a diagnosis.
"Typically, that's enough for us to make a pretty confident diagnosis," she said. "A lot of times they have already seen an asthma/allergy doctor, so we already know if they have asthma in addition to the vocal cord dysfunction."
Other coexisting conditions in patients with VCD are irritable larynx syndrome, reflux, complications from asthma medications, and stress. "There is usually not one specific cause," Drake said.
There are usually several factors contributing to the VCD, she explains to patients. "Sometimes we don't know what caused the VCD, but we can treat it successfully by treating the symptoms."
The condition commonly is confused with asthma, particularly exercise-induced asthma. This can result in misdiagnosis, although more widespread knowledge of VCD has helped stem this problem. A key indicator in patients who are misdiagnosed is the ineffectiveness of asthma medications they have been prescribed.
"People used to go a long time between their first symptoms and actually being diagnosed with VCD because physicians just weren't familiar with it," Drake said. "That's getting better now."
A number of her patients present with both asthma and VCD. During the first clinic visit, she explains the difference in the symptoms of the two conditions before beginning treatment. "Sometimes we'll have them do a few rescue breaths for the VCD and see if the symptoms get better," she explained. "If they don't, at least you've opened up the airway so asthma medication can be inhaled properly.
The duration of VCD treatment usually is short. Drake sees most patients for three to five sessions and some for a single session. "It's really a breathing technique, and they're able to get it under control very quickly once they learn to be aware of what is correct versus incorrect," she said.
Patients with exercise-induced VCD, particularly adolescents, learn to use breathing exercises as a warm-up before competition or a sporting event as a preventative measure. However, Drake provides most patients with "rescue strategies." Patients can use these measures to quell the onset of symptoms during exercise.
"Optimally, it's learning how to breathe efficiently with the focus of the breath more in the front of the mouth versus in the throat and helping the patient get the feel of breathing without tightening the throat muscles," she said.
Patients with irritant-induced VCD gradually are exposed to the irritant that causes their symptoms in order to create the most effective rescue strategies. "Just breathing in through the nose and blowing the air out through the front of the mouth sometimes is all that people need," she noted. "That can get them back on track."
Drake draws on a number of sources to find the most effective strategies, including the VCD research of Florence Blager, PhD, and breathing exercises used in yoga practice.
"I try to keep it as simple as possible so a strategy doesn't call a lot of attention to itself when being used by someone," she said. "If they walk into a waiting room and someone has perfume on, they can do that breathing. It's exaggerated, but it's fairly innocuous."
Some patients require more creative strategies. Drake uses alternate nostril breathing-an abdominal breathing technique drawn from yoga-as a rescue strategy for some patients. Patients press their thumb against one nostril, breathe in deeply through the abdomen, press their middle finger against the other nostril, release the first nostril, and exhale.
"They're breathing in, expanding the abdominal muscles, and breathing out," Drake explained. "It brings the focus of the breath up to the nose and out of the throat, which tends to release the laryngeal muscles."
Some patients have such severe VCD that they need to breathe in and out through a straw in order to bring their focus to the front of the mouth. "Focusing on the exhalation helps to release the muscles," she said, "and patients can gradually take away the straw and still breathe with that focus on the front of their mouth, which allows them to release the laryngeal muscles and get the feel of a more normal breath."
Different rescue strategies are particularly useful to treat the variations in VCD that Drake commonly sees in her clinic. Classic VCD occurs when the vocal cords approximate or begin to approximate during breathing cycle, usually on inhalation.
A common variant occurs when the cartilages pull forward during the breathing cycle, usually during inhalation, even though the vocal cords stay open. "The arytenoids pull forward, and the larynx elevates a little," Drake explained. "You still hear some sound, butit's just not as dramatic as if the cords were coming together." Since the airflow through the larynx is interrupted, the patient experiences shortness of breath.
Another variation occurs when a patient presents with laryngeal elevation. "As the person focuses their breath in the throat, the larynx elevates, and the extrinsic muscles are tight," she said, "but the actual vocal cords stay open a fair amount." The patient experiences shortness of breath, and this variant can cause a negative effect on athletic performance.
Drake's most creative rescue strategy was required for a patient who experienced a tightening in his bronchial area, or a "bronchial collapse."
"We had to figure out what position he could get into where the muscles wouldn't do that," she recalled. Drawing on her knowledge of yoga, she had the patient face the wall, put his hands up high against the wall, and stretch up through his abdomen to prevent an attack. "It doesn't look natural," she conceded, "but turning blue and having to go to the emergency room isn't natural either. We have to get creative in more extreme cases."
General relaxation exercises for related muscle and voice issues also can benefit some patients. Voice relaxation is a common need in adolescents with VCD.
"Kids with VCD are using a lot of laryngeal tension when they're speaking, so those muscles are tight all day long," Drake explained. "Then they go to do sports, and they're still tight. That's the position their larynx is used to being in. When they start exercising and have increased airflow, it sort of sucks the vocal cords right together."
She works with these patients on abdominal breath support, breath coordination and front voice resonance.
Psychological variables such as stress also may impact the adolescent population. "Some of the cases are much more complicated," she said, citing sports anxiety, trying to please parents, trying to live up to a sibling who is doing the same sport, or living up to their past performance in a sport. Patients with these issues may be referred for psychological counseling.
Drake particularly is gratified to work with a patient population in which therapy provides direct results. "Some people haven't been able to walk 20 feet, and you can get them out there and to a point where they can see themselves as healthy people again," she said. "That can be very rewarding."
For More Information:
Karen Drake, e-mail: firstname.lastname@example.org; online: www.ohsu.edu/ent/gen/voice/indexvoice.html
Alyssa Banotai is Senior Associate Editor of ADVANCE. She can be contacted at email@example.com.