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Communications to the Editor |

Paradoxical Vocal Cord Movement Paradoxical Vocal Cord Movement FREE TO VIEW

Gregory J. Gallivan, MD, FCCP
Author and Funding Information

Affiliations: University of Massachusetts Medical School Worcester, MA,  Lausanne, Switzerland

Correspondence to: Gregory J. Gallivan, MD, FCCP, Associate Professor of Clinical Surgery, 299 Carew St, Suite 404, Springfield, MA 01104-2361; e-mail: singingsurgeon@mediaone.net



Chest. 2001;119(5):1619-1620. doi:10.1378/chest.119.5.1619
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Maillard and coworkers (September 2000)1 are to be commended for bringing to the readership of CHEST the concepts of paradoxical vocal cord movement (PVCM) and intralaryngeal injection of botulinum toxin type A in the intensive care setting. Their statements that identification remains difficult, and that use of inhaled corticosteroids, IV injected sedatives, and speech therapy or psychotherapy cannot be used efficiently during the acute presentation prompt other viewpoints.

The terms vocal folds and vocal cords are synonymous, as are the terms paradoxical vocal fold movement (PVFM) and episodic paroxysmal laryngospasm (EPL). The choking, stridor, and wheezing in this condition occur primarily on inhalation, rather than on exhalation, differentiating it from the asthma it often mimics. While the problem sometimes involves the entire respiratory cycle, the patient will often point to the larynx as the site of difficulty. Auscultatory differentiation of inspiratory from expiratory stridor is useful as are chest and soft-tissue neck radiographs.2

The two pathognomonic diagnostic criteria that need to be assessed during an acute presentation are strobovideolaryngoscopy and pulmonary function testing. There is a classic pattern of inspiratory adduction of the anterior two thirds of the vocal folds, with a posterior diamond-shaped glottic chink or gap and attenuation of the inspiratory portion of the flow-volume loops.2Panting, sniffing, and encouraging breath holding may release laryngospasm and be effective emergency measures.3

Sedating such patients may cloud the sensorium and precipitate acute respiratory acidosis. Inhaled corticosteroids are often irritative to the larynx and should be withheld. Should syncope occur in patients not subjected to invasive interventions, it will automatically result in an open airway. Once there has been misdiagnosis and mistreatment with endotracheal intubation and tracheostomy, acute and chronic glottic changes exacerbating upper airway obstruction occur.4,5

Most of these patients have a tremendous emotional, psychological, and stress burden, while a small subgroup may have laryngeal and respiratory true dystonias. It is essential to acutely empower the patient with breathing techniques and to intervene with specific speech/language pathology therapy and noninsight psychotherapy.23 The presence of other dystonias and a clinical response to empiric botulinum toxin therapy may distinguish those PVCM/PVFM/EPL patients who primarily have a dystonic rather than a psychogenic etiology.3

Recognition of this entity is critical to appropriate medical and behavioral management of these syndromes, avoiding unnecessary polypharmacotherapy, emergency department and inpatient hospitalizations, endotracheal intubations, tracheostomies, and the creation of unnecessary comorbidities.3

Maillard, I, Schweizer, V, Broccard, A, et al (2000) Use of botulinum toxin type A to avoid tracheal intubation or tracheostomy in severe paradoxical vocal cord movement.Chest118,874-876. [CrossRef] [PubMed]
 
Gallivan, GJ, Hoffman, L, Gallivan, KH Episodic paroxysmal laryngospasm: voice and pulmonary function assessment and management.J Voice1996;10,93-105. [CrossRef] [PubMed]
 
Gallivan GJ, Andrianopoulos, MV. Dysphonia due to paradoxical vocal fold movement/episodic paroxysmal laryngospasm: medical/pharmacologic/behavioral perspective. In: Sapienza, Casper J, eds. For clinicians by clinicians: vocal rehabilitation in medical speech-language pathology. Austin, TX: Pro-Ed, 2001 (in press).
 
Gallivan, GJ, Dawson, JA, Robbins, LD Critical care perspective: videolaryngoscopy after endotracheal intubation; implications for voice.J Voice1989;3,76-80. [CrossRef]
 
Gallivan, GJ, Dawson, JA, Opfell, AP Videolaryngoscopy after endotracheal intubation: Part II. A critical care perspective of lesions affecting voice.J Voice1990;4,159-164. [CrossRef]
 
To the Editor:

We have read with interest the comments by Dr. Gallivan about our article in the September 2000 issue of CHEST. We essentially agree with his statements. However, we wish to emphasize the extremely variable severity of clinical presentation in patients with paradoxical vocal cord movement (PVCM). In the patient described in our case report, well-established techniques of speech therapy and psychotherapy could not be used efficiently during the acute presentation as they are in other patients. In this case, acute respiratory acidosis was present since the arrival of the patient to the hospital before the administration of IV sedatives. We believe that the acute effects of hypercapnia as well as the extreme anxiety of the patient did not allow the implementation of these therapeutic approaches. Only a small subset of patients with PVCM displays such a severe clinical presentation. It is precisely in this group of patients that unnecessary endotracheal intubations or tracheostomies are likely to be performed. We think that intralaryngeal injection of botulinum toxin type A in such patients might be a bridge towards increased stability and towards the later use of behavioral and psychological treatments.


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References

Maillard, I, Schweizer, V, Broccard, A, et al (2000) Use of botulinum toxin type A to avoid tracheal intubation or tracheostomy in severe paradoxical vocal cord movement.Chest118,874-876. [CrossRef] [PubMed]
 
Gallivan, GJ, Hoffman, L, Gallivan, KH Episodic paroxysmal laryngospasm: voice and pulmonary function assessment and management.J Voice1996;10,93-105. [CrossRef] [PubMed]
 
Gallivan GJ, Andrianopoulos, MV. Dysphonia due to paradoxical vocal fold movement/episodic paroxysmal laryngospasm: medical/pharmacologic/behavioral perspective. In: Sapienza, Casper J, eds. For clinicians by clinicians: vocal rehabilitation in medical speech-language pathology. Austin, TX: Pro-Ed, 2001 (in press).
 
Gallivan, GJ, Dawson, JA, Robbins, LD Critical care perspective: videolaryngoscopy after endotracheal intubation; implications for voice.J Voice1989;3,76-80. [CrossRef]
 
Gallivan, GJ, Dawson, JA, Opfell, AP Videolaryngoscopy after endotracheal intubation: Part II. A critical care perspective of lesions affecting voice.J Voice1990;4,159-164. [CrossRef]
 
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