Laryngospasm and Other Forms of Vocal Cord Dysfunction

Vocal cord dysfunction (aka, paradoxical vocal cord motion, VCD, non-organic wheezing, etc) is a general term used to describe a situation when the vocal cords come together (or ADduct) when taking a breath in when normally they should go apart (or ABduct). The key thing to remember is that everything from the nose down into the lungs generally appears totally normal anatomically speaking; however, the voicebox is functionally abnormal. Normal vocal cord ABduction allows air to easily pass into the trachea (or windpipe). However, when the vocal cords ADduct, air must squeeze through what small opening may be present between the closed vocal cords. In this scenario, a noisy inhalation may occur. The sound that is produced is called stridor. YouTube actually has several examples of what stridor sounds like, at least in an infant due to an anatomical obstruction (NOT laryngospasm or VCD): Example #1 - Example #2 - Example #3

Laryngospasm is the most severe form of vocal cord dysfunction as there is barely if any opening for the air to pass through at all. Often, patients believe they are about to pass out (and sometimes they do), at which point, normal breathing resumes. Literally, their own body is choking itself during laryngospasm and it is a truly frightening experience when it occurs. Watch a video lecture on this topic.

Vocal cord dysfunction is a less severe form of laryngospasm in which the person is still able to breath, but does produce a loud stridor.

Triggers for these episodes are numerous... stress, allergies, anxiety, asthma exacerbation, reflux, exercise, cold air, etc and even idiopathic. Obviously, if such triggeres are known, they should be treated. Also of note, normal breathing immediately resumes after a person passes out (if they pass out) and these episodes never occur while sleeping unless a triggering event occurs (ie, reflux). A typical workup for VCD/laryngospasm include:

The key to treatment is correct diagnosis. I personally have found that vocal cord dysfunction is over-diagnosed erroneously. Examples found in the "Noisy Breathing" section have been initially (and incorrectly) diagnosed as vocal cord dysfunction (except for Example 2 which is a true laryngospasm episode).

Diagnosis

At least for me, when a patient presents with complaints of noisy breathing thought to be due to vocal cord dysfunction, I do a complete fiberoptic exam to look for anatomic abnormalities since 9 times out of 10, I do find something abnormal thereby eliminating vocal cord dysfunction as the problem. If everything indeed looks normal, the next step is to actually to try trigger an episode. For most people in my patient population, it seems to be exercise... SO, I have them run around my office building until they have an episode and I immediately repeat the fiberoptic exam. Another trigger that may work is the rapid counting test. I have the patient count to 50 as fast as they can in one breath, and than have them inhale with their mouth. Endoscopy is performed during the rapid counting test. While symptommatic, if I see vocal cord ADduction with inspiration, the diagnosis of vocal cord dysfunction is real. If not, it most definitely is NOT vocal cord dysfunction. Without this last finding, one must keep looking for some other reason for the noisy breathing attacks.

So, assuming one has vocal cord dysfunction, what is a patient supposed to do if they have an attack and not near a healthcare provider? Other than calling 911 as the attack may not be due to vocal cord dysfunction, I instruct patients on 2 methods which may help abort or reduce the severity of an attack quite often. THESE METHODS APPLY ONLY IF YOU TRULY HAVE VOCAL CORD DYSFUNCTION OR LARYNGOSPASM!

METHOD 1: Breathing Technique

There are 3 steps to this particular method.

As soon as one feels an attack coming, SLOWLY breath in through the NOSE. DO NOT BREATH IN THROUGH THE MOUTH!
More quickly exhale out the mouth with pursed lips.
Continue slow nasal inhalation, and quick mouth exhalation with pursed lips until the episode passes.

Why does this work? For some reason, nasal breathing reinforces the brain to keep the vocal cords apart when inhaling. Quick inhalation through the mouth seems to do the opposite and encourage the vocal cords to close which exacerbates the problem. Also, quick inhalation reinforces the Bernoulli Principle that as a fluid (air in this case) passes through a pipe that suddenly narrows (the vocal cords), the pressure actually decreases which encourages further narrowing (or vocal cord closure). Therefore, SLOW breathing helps keep the vocal cords apart! You can test this principle yourself by sucking air on a narrow short straw slowly and than quickly. You will find that the straw will tend to collapse when sucking in quickly.

METHOD 2: Pressure Point

Another manuever that may work is firm pressure in the "laryngospasm notch." Basically, with an attack, quickly with your (or somebody else's) index fingers, press very firmly just behind both your earlobes where there is a notch between the bone of your mastoid process and ear. Press deep and forward towards the nose. It should hurt. If it doesn't hurt, you are not pressing hard enough. The attack should resolve within 10 seconds. Here is an article describing this method.

Other Treatments

Oftentimes, the above strategies help enough that a patient finds these attacks occur less frequently with decreasing severity over time until they altogether stop. Rarely, a benzodiazepine medication will be prescribed for these attacks to help with the anxiety aspect until the strategy is internalized. Working with speech pathology has also been found to be helpful. In certain situations, laryngeal sensory neuropathy (LSN) may be contributing to VCD and treatment geared towards LSN improves VCD. Of course, treatment of the trigger whether it be allergy, asthma, or reflux is important. A typical workup for VCD/laryngospasm include:

GI
- EGD
- Barium swallow
- 24-Hour Multichannel Intraluminal Impedance (MII) and pH monitoring
- Response after maximum reflux medication treatment for 3 months
  - Proton pump inhibitor twice a day (30 minutes before breakfast and dinner) AND
  - Zantac 300 mg at bedtime AND
  - Reglan 10 mg 4X per day
Allergy
- Allergy testing
- If positive, allergy injection response report
Pulmonary
- Pulmonary function test with methacholine challenge
- Bronchoscopy with lavage cultures
- CT chest
- Response to asthma medications

Find a Local Physician

To find a physician local to where you live who MIGHT be familiar with this disorder, click here.

In rare cases, I will consider injecting BOTOX into the vocal cords which will physically prevent the vocal cords from coming together and as such, prevent the difficulty in breathing should an attack occur. In some people, it decreases not only the severity, but also the frequency of attacks. The way BOTOX is injected into the vocal cords is shown here. Please note that the vast majority of patients upon whom I perform vocal cord BOTOX injections are those suffering from spasmodic dysphonia.

Please contact our office for an appointment with Dr. Chang if vocal cord dysfunction or noisy breathing is a concern.

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