Vocal cord dysfunction (VCD) is a condition affecting the vocal cords. It is characterized by abnormal closure of the vocal folds, which can result in significant difficulties and distress during breathing, particularly during inhalation. Due to the similarity in symptoms, VCD attacks are often mistaken for asthma attacks or laryngospasms. Symptoms of VCD are not always present. Rather, they often occur as episodic "attacks," where the patient will be symptomatic for a short period. Although several contributing factors have been identified, the exact cause of VCD is unknown. Diagnosis of VCD may include a series of evaluations, including pulmonary function tests, medical imaging, and the evaluation or visualization of the vocal folds during an episode through the use of videolaryngoscopy. Such evaluations can also help to rule out other conditions that can affect the upper and lower airways. Treatment of VCD often combines behavioral, medical, and psychological approaches, most often including an otolaryngologist, a psychologist, and a speech-language pathologist. Although information on the incidence and prevalence of VCD is limited, it is known to occur most frequently in young women.
Signs and symptoms Many of the symptoms are not limited to the disorder, as they may resemble a number of conditions that affect the upper and lower airways. Such conditions include asthma, angioedema, vocal cord tumors, and vocal cord paralysis. People with vocal cord dysfunction often complain of "difficulty in breathing in" or "fighting for breath", which can lead to subjective respiratory distress, and in severe cases, loss of consciousness. They may report tightness in the throat or chest, choking, stridor on inhalation and wheezing, which can resemble the symptoms of asthma. These episodes of dyspnea can be recurrent and symptoms can range from mild to severe and prolonged in some cases. Agitation and a sense of panic are not uncommon and can result in hospitalization. Different subtypes of vocal cord dysfunction are characterized by additional symptoms. For instance, momentary aphonia can be caused by laryngospasm, an involuntary spasm of the vocal cords and a strained or hoarse voice may be perceived when the vocal cord dysfunction occurs during speech. Many of the symptoms are not specific to vocal cord dysfunction and can resemble a number of conditions that affect the upper and lower airways.
Presentation
VCD can mimic asthma, anaphylaxis, collapsed lungs, pulmonary embolism, or fat embolism, which can lead to an inaccurate diagnosis and inappropriate, potentially harmful, treatment. Some cases of VCD are misdiagnosed as asthma, but are unresponsive to asthma therapy, including bronchodilators and steroids. Among adult patients, women tend to be diagnosed more often. Among children and teenage patients, VCD has been linked with high participation in competitive sports and family orientation towards high achievement. Vocal cord dysfunction co-occurs with asthma approximately 40% of the time. This frequently results in a misdiagnosis of asthma alone. Even young children can tell the difference between an asthma attack (primarily difficulty exhaling) and a VCD attack (primarily difficulty inhaling). Knowing the difference between the two will help those who have both know when to use the rescue inhaler prescribed or when to use the breathing recovery exercises trained by a speech-language pathologist. Episodes can be triggered suddenly or develop gradually and triggers are numerous. Primary causes are believed to be gastroesophageal reflux disease (GERD), extra-esophageal reflux (EERD), exposure to inhaled allergens, post-nasal drip, exercise, or neurological conditions that can cause difficulty inhaling only during waking. Published studies emphasize anxiety or stress as a primary cause while more recent literature indicates a likely physical etiology. This disorder has been observed from infancy through old age, with the observation of its occurrence in infants leading some to believe that a physiological cause such as reflux or allergy is likely. Certain medications, such as antihistamines for allergies, cause drying of the mucous membranes, which can cause further irritation or hypersensitivity of the vocal cords.
Potential comorbidities VCD has long been strongly associated with a variety of psychological or psychogenic factors, including conversion disorder, major depression, obsessive-compulsive disorder, anxiety (especially in adolescents), stress (particularly stress relating to competitive sports), physical and sexual abuse, post-traumatic stress disorder, panic attacks, factitious disorder and adjustment disorder. Anxiety and depression may occur in certain patients as a result of having VCD, rather than being the cause of it. Psychological factors are important precipitating factors for many patients with VCD; although exercise is also a major trigger for episodes of VCD, some patients experience VCD co-occurring with anxiety regardless of whether or not they are physically active at the time of the VCD/anxiety episode. Experiencing or witnessing a traumatic event related to breathing (such as a near-drowning or life-threatening asthma attack, for example), has also been identified as a risk factor for VCD. VCD has also been associated with certain neurologic diseases including Arnold-Chiari malformation, cerebral aqueduct stenosis, cortical or upper motor neuron injury (such as that resulting from stroke), amyotrophic lateral sclerosis (ALS), parkinsonism syndromes and other movement disorders. However, this association occurs only rarely. In addition, it has been associated with Ehlers-Danlos Syndromes, a group of connective tissue disorders.
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