Gorman Reitz Kegyes LeBorgne Kelchner PDF

Diagnosis and Treatment of
The Blaine Block Institute for Voice Analysis & Rehabilitation

Adolescent VCD
Stephen Gorman, Ph.D, CCC-SLP

Jennifer Reitz, M.S., CCC-SLP
Jennifer Kegyes M.A.,CCC-SLP
Wendy D. LeBorgne, Ph.D., CCC-SLP
Lisa N. Kelchner, Ph.D., CCC-SLP
Adolescent VCD
Prevalence, demographics,
etiology
Vocal Cord Dysfunction defined
Defined: Non-organic disorder of the upper
airway with both true and false vocal folds
showing paradoxical function of closure
upon inspiration, expiration or in a
combination of both, during the respiratory
cycle, and which may involve constriction
of supraglottic structures (Blager, 2006).
Broken down:
Functional disorder (impairs normal function
of a bodily process, mechanism not fully
understood).
Non-organic (no detectable structural or
physiological change to the larynx).
Involves more than just the vocal folds.
Descriptions may vary between medical
professionals
Umbrella term
Chronic cough
Chronic throat clearing
Laryngospasms
Paradoxical vocal fold motion (PVFM)
Early descriptions (Blager, 2006)
Laryngeal asthma, psychogenic stridor, factitious
asthma, emotional laryngeal wheezing, episodic
laryngeal dyskinesias
Prevalence
Cause of between 2.5% and 22% of cases
of intensive emergency care for dyspnea.
Prospective study of pulmonary
rehabilitation cases: VCD as reason for
treatment failure in 30 percent of cases.
Prevalence of VCD in children and
adolescents admitted to hospital for
bronchial asthma may be as high as 14 %.
5% of Olympic athletes.
Dtsch Arztebl Int 2008;
105(41):699-704
Demographics
Age:
Can be seen in infants through elderly
In children, often emerges at age 14 or 15.
In adults, most often seen in ages 20-40.
Gender:
In children under 18, 85% diagnosed with
VCD are girls.
(Encyclopedia of children's
health)
Vocal Cord Dysfunction
Is becoming increasingly recognized

by medical subspecialties (otolaryngology,
pulmonology, allergy).
by athletic coaches, trainers.
May see a patient for the first time during any stage of the
diagnostic process.
Increased awareness of VCD more referrals to the
speech-language pathologist for diagnosis and treatment.
SLPs are uniquely prepared to handle this population
Critical for speech-language pathologists in all settings to
understand the diagnostic process and be familiar with the
treatment protocol.
Etiology
There is no one pathophysiological cause;
rather, a number of contributing factors:
3 Major categories:
1. Psychological conditions
2. Upper airway sensitivity
3. Neurologic causes
(Mathers-Schmidt, 2001)
Contributing psychological factors

in young athletes
History of clinical depression.
History of abuse.
High achievers with perceptions of
extreme external pressure to perform
Very involved parents.
(Newsham et al, 2002)

Etiology
Psychological conditions
Evidence of a temporal link between stress
and VCD symptoms
Anxiety disorder, panic disorder, depression
Causes or consequences?
Psychological factors play some sort of role
Etiology
Upper airway sensitivity
Primary function of larynx is airway
protection.
Chemoreceptors in laryngeal mucosa,
particularly interarytenoid space trigger
protective reflex.
LPR (silent reflux).
Chronic rhinosinusitis noted in 91% of VCD
cases.
Environmental irritants.
Mathers-Schmidt, 2001
Etiology
Neurologic causes
Exacerbation of underlying laryngeal dystonia
Subtle signs of laryngeal movement disorder
Muscle instability noted during
respiration/phonation.
In theory demands on the respiratory
system exceed what the system is capable of.
Pathophysiology
During normal breathing:
During inhalation, vocal
folds abduct (open).
During expiration, brief
adduction (closing) of 2
mm from the fully abducted
position (to generate
physiological autoPEEP).
(Varney, et. al)
Supraglottic structures are
not actively engaged.
*PEEP- positive end
expiratory pressure to
prevent early airway
closure.
Pathophysiology
During VCD episode
Adduction of vocal folds.
Narrowing or complete
closure of glottis/airway.
Results in SOB typically
accompanied by
complaints of tightness in
the throat, difficulty getting
air in, noisy sounds from
the throat/stridor (typically
upon inhalation).
Stridor vs. wheezing.
Constriction of supraglottic
structures (tongue base,
pharyngeal wall).
Normal
Normal vs VCD
VCD

Assessment
Speech-Language Pathology:
Detailed case history
Videostroboscopic examination
Other Medical:
Chest X-ray
Pulmonary function testing
Methacholine challenge
Allergy testing
Doctors Meeting 2/10
Interview
Describe your breathing problem
Are there specific patterns?
Are there specific triggers?
How long does an attack last?
How long does it take to recover?
Do inhalers help?
Do you have trouble breathing during sleep?
Where do you feel tightness?
Is it harder to inhale/exhale/both?
Do you experience Sx of reflux?
How long after exercise do Sx begin?
Common Issues Faced by

Adolescents
Puberty, changing hormones
School/social life balance
Grades
Rebellion
Peer Pressure
Strong emotions
Drugs/alcohol
Psychological identity
Risk-taking behavior
Learning to drive
Developing independence
Laryngeal Assessment
Imitation of event if patient is able
Does SLP have to see an actual event to
make an accurate diagnosis?
Visual biofeedback of perception of

laryngeal closure vs. opening during
sniffing
May be single most powerful tool for engaging
patient confidence in therapy
Pulmonary Function Tests
Up to 40% of patients with VCD also have

asthma (Mathers-Schmidt, 2001)
If asthma is not present:
Spirometry may be normal
Methacholine challenge test may be normal
Meeting 2/10
Pulmonary Function Tests

Flow-volume loop demonstrates flattened inspiratory loop when symptomatic.
Perkner et al, 1998

Symptom Comparison

Differential Diagnosis
Must rule out:
Asthma
Subglottic stenosis
Bilateral vocal fold paralysis
Laryngomalacia
Infectious (croup, epiglottitis)
Laryngeal lesion (laryngocele, polyp, granuloma, etc.)
Case Study #1
17 yr old female basketball player, team captain
C/O difficult inhalation, shortness of breath, decreased stamina X
several yrs
Chest pain X 2 months
Medications: ProAir, Optivar, Nasonex
Denied Sx of reflux
Frequent yelling
Negative ECHO, EKG and stress test
PFTs revealed FVC of 3600mL
Negative methacholine challenge
Treatment
Diaphragmic breathing exercises
Laryngeal control exercises
Review of videostroboscopic examination
Vocal hygiene counseling
Challenged breathing: Treadmill, sprints, stairs
Reflux counseling
Tx period: Three sessions across four weeks

Remaining Complaint: All Sx had resolved with the exception of chest pain
Rehabilitation
Analysis&&Rehabilitation
Treatment
Blager, Florence B. Vocal Cord Dysfunction. Perspectives on Voice and Voice Disorders. March 2006.
Mathers-Schmidt, Barbara A. Paradoxical Vocal Fold Motion (PVFM): A Tutorial on a Complex Disorder and the Speech-Language
Pathologist's Role. American Journal of Speech-Language Pathology, 2001; 10: 1111-125.
Mascheka, D.A., Bauman, N.M., McCray, P.B., Hoffman, H.T., Karnell, M.P., Smith, J.H. A Classification Scheme for Paradoxical Vocal
Cord Motion. Laryngoscope. 1997; 107:1429-1435
Powell, D.M., Karanfilov, B.I., Beechler, K.B., Treole, K., Trudeau, M.D., Arick, F.L. Paradoxical Vocal Cord Dysfunction in Juveniles. Arch
Analysis
Otolaryngol Head Neck Surg. 2000; 126:29-34.
Perkner JJ, Fennelly KP, Balkissoon R, et al. Irritant-associated vocal cord dysfunction. J Occup Environ Med. Feb 1998;40(2):136-43.
Vertigan, A., Theodoros, D., Gibson, P., Winkworth, A. The Relationship Between Chronic Cough and Paradoxical Vocal Fold Movement: A
Review of the Literature. Journal of Voice. 2006; 20: 466-480.
TheBlaine
The BlockInstitute
BlaineBlock Voice
forVoice
Institutefor
Adolescent VCD
Principles of Treatment
The
The Blaine
Blaine Block
Block Institute
Institute for
for Voice
Voice Analysis
Analysis &
& Rehabilitation
Rehabilitation
Goals of Treatment
Role of the SLP
Patient education
Control the laryngeal area and maintain an
open airway
Supportive counseling
Appropriate referrals
Treatment
Education
Starts with the evaluation
Recognition of an open, patent airway for both
inhalation and exhalation
Recognition of normalcy of the patients
laryngeal and respiratory control
Recognition of the problem, but that there is
also a solution
Treatment
Control the laryngeal area and maintain an
open airway
Relaxed throat breathing: Inhalation
Breathe in through the nose, tongue resting on the
floor of the mouth, lips gently touching
Expansion of lower rib cage, abdominal area
Place hand inferior to sternum, or hands on either side of
rib cage, thumbs pointing back
Treatment
Relaxed throat breathing: Exhalation
Let the breath out with a hissing sound, or a gently,
prolonged s
Focus on exhalation, lessening patient tendency to
hold breath
Count silently while exhaling, counting to resting
exhalatory level
Establishes pressure-volume relationships
conducive to optimal respiratory patterns
Treatment
Hierarchy of training
Master first in comfortable, quiet clinic setting
in the absence of symptoms
Feeling whats happening with abdomen, rib
cage expansion
Focuses on an adaptive response rather than
maladaptive struggle behavior
Treatment
Hierarchy of training
Back and forth from relaxed throat breathing
in non-challenging situations
Introduce trigger situations: odor exposure,
exercise, etc.
With odors, hierarchy of noxious odors: smelly
stuff that does not induce symptoms, then
practice with those that do.
Treatment
In exercise, most sports involve running:
Start on a treadmill, walking, pace slightly faster
than normal for individuals
Increase speed incrementally, trying to push the
threshold of onset of symptoms
If sport is anaerobic in nature (soccer, basketball,
skill positions in football, sprinting, etc.) intervals
of fast to slow, in order to simulate actual game
activity
Treatment
Exercise (cont.)
If distance sport (distance events in track, cross
country), start running at an easy pace, slower
than race pace
Incrementally increase pace, pushing the threshold
of onset until they can control breathing
Treatment
Swimmers
Start out on treadmill, to establish exercise
breathing
Have to try nasal inhale while in the pool, at less
than race pace (warm-up pace) to get confidence
in it
May have to use sips of breath through slightly
parted lips if the patient cant get comfortable with
sniffs in the water.
Out of water practice: practice strokes and
breathing while on exercise ball
Treatment
Adjunct treatment
Medicinal and behavioral management of
LPR if indicated during the evaluation
Pulmonologist input if asthma and VCD co-
occur
Referral to Psychologist/Sports Psychologist if
stress/anxiety/performance anxiety are issues
Work with coaches and athletic trainers to
educate and provide support
Treatment
Alternative treatments:
Low dose amitriptyline (antidepressant)
62 patients, ages 18-90 (17 male, 45 female)
10 mg, 2-3 hours before bed, increased until
adequate sleep was induced
94% males, 82% females with cessation of VCD
100% improved insomnia; 90% male, 96% female
with improved anxiety
Avg. dose 20 mg; treatment period, 3-6 months
Varney, et al; 2009

Treatment
Inspiratory muscle training
18 yo female with 2 year history of SOB w exertion
(soccer)
Single subject design, 5 week training and
withdrawal phases
5 sets of 12 breaths at 75% max inspiratory
pressure (MIP) per session
At end of study, subject reported no SOB when
performing measurement tasks or playing soccer
Mathers-Schmidt, Brilla; 2005

Treatment
If just VCD, then the patient has re-
established an airway unobstructed by the
vocal folds
If VCD+Asthma, then the delivery of
inhaled medications will be more effective
as the vocal folds no longer block the
medication from reaching the lungs
Case Study #1
C/O difficult inhalation, shortness of breath, decreased stamina
Denied Sx of reflux
Frequent yelling
Case Study #1
C/O difficult inhalation, shortness of breath, decreased stamina X
several yrs
Denied Sx of reflux
Frequent yelling
Treatment
Diaphragmic breathing exercises
Laryngeal control exercises
Review of videostroboscopic examination
Vocal hygiene counseling
Challenged breathing: Treadmill, sprints, stairs
Reflux counseling
Tx period: Three sessions across four weeks

Remaining Complaint: All Sx had resolved with the exception of chest pain
Case Study
14 yo female competitive swimmer
2-3 week history of SOB while competing,
practicing hard, sometimes not able to
complete her event
Persistence of symptoms for 5-10 minutes
after stopping activity
Lungs clear
Has noticed reflux symptoms: scratchy throat,
infrequent regurgitation of small amounts
History of asthma, uses Symbicort
Case Study
Examination of VFs showed signs of LPR with
pachydermia, erythema of arytenoid and
posterior arytenoid area, bilateral contact
ulcers, already being treated with Prevacid
Slight adduction of the vocal folds during
inhalation after exercise period (patient stated
not quite the same level of exercise as in
swimming)
Case Study
Began with diaphragmatic/abdominal
breathing w/ relaxed throat breathing
Exercise breathing on the treadmill w/
relaxed throat breathing
To accommodate swimming breathing,
inhale with slightly parted lips, exhale
through pursed lips
Case Study
Dry land swim practice:
Mimic strokes (free, back) while standing w/
relaxed throat breathing
Mimic strokes on exercise ball w/ relaxed
throat breathing
Practice in the pool
Treatment

Treatment

Treatment

Case Study
Problems
Sucking in water on the inhale!
Had to adjust lip position to accommodate
Diet issues w/ reflux
Guzzles sports drinks! Citric acid content
Less sports drinks, more water
Some nausea/vomitting during workouts,
meets (?)
Case Study
Most important thing for swimmers?
Faster times!
Her event times started getting faster, but still
with some issues of nausea/vomiting
preventing her from completing some events
Referral made to GI specialist via PCP
Delayed gastric emptying!
Started on Erythromycin therapy
New swim season just beginning.

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Diagnosis and Treatment of

The Blaine Block Institute for Voice Analysis & Rehabilitation

Stephen Gorman, Ph.D, CCC-SLP

Is becoming increasingly recognized

The Blaine Block Institute for Voice Analysis & Rehabilitation

(Newsham et al, 2002)

The Blaine Block Institute for Voice Analysis & Rehabilitation

The Blaine Block Institute for Voice Analysis & Rehabilitation

Visual biofeedback of perception of

Up to 40% of patients with VCD also have

The Blaine Block Institute for Voice Analysis & Rehabilitation

Perkner et al, 1998

The Blaine Block Institute for Voice Analysis & Rehabilitation

Tx period: Three sessions across four weeks

Varney, et al; 2009

Mathers-Schmidt, Brilla; 2005

Tx period: Three sessions across four weeks

The Blaine Block Institute for Voice Analysis & Rehabilitation

The Blaine Block Institute for Voice Analysis & Rehabilitation

The Blaine Block Institute for Voice Analysis & Rehabilitation

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