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Exertional Stridor: Differential Diagnosis, Investigation, and Treatment Based on Serial Exercise Tests With Flexible Transnasal Flexible Laryngoscopy FREE TO VIEW

Diana Orbelo, PhD; Shelagh Cofer, MD; Paolo Pianosi, MD
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Mayo Clinic, Rochester, MN

Chest. 2014;145(3_MeetingAbstracts):566A. doi:10.1378/chest.1810600
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SESSION TITLE: Symptoms of Respiratory Disease Posters

SESSION TYPE: Poster Presentations

PRESENTED ON: Saturday, March 22, 2014 at 01:15 PM - 02:15 PM

PURPOSE: To illustrate the value of serial ventilatory and glottic responses to incremental exercise until voluntary exhaustion in an adolescent with exertional dyspnea and stridor before and after supraglottoplasty.

METHODS: Review of serial ventilatory and glottic responses during incremental exercise to voluntary exhaustion in an adolescent with exertional dyspnea and stridor before and after staged supraglottoplasty. Glottic movement was visualized during exercise with transnasal flexible fibreoptic laryngoscopy with subsequent video review.

RESULTS: We shall present a series of 3 exercise tests in a single patient with measurements of tidal flow-volume loops during exercise, accompanied by videolaryngoscopy clips depicting movement of supra-glottic structures and vocal folds: baseline, following R-sided supraglottoplasty, then following L-sided supraglottoplasty, done sequentially because of persistent symptoms. The patient continued to experience exertional stridor following these procedures, but with altered vocal fold behavior and breathing pattern during the final exercise test. Review of the exercise laryngoscopy showed that there was no longer any supraglottic tissue obstructing the airway. However, she still developed stridor at peak exercise with new-found paradoxical vocal fold movement. She did not return for counseling aimed at "un-learning" her conditioned breathing response to exercise.

CONCLUSIONS: This patient still developed stridor with strained vocal cord mobility at peak exercise despite having undergone bilateral supraglottoplasty. She demonstrated a conditioned response to exercise manifested by new onset paradoxical vocal fold movement.

CLINICAL IMPLICATIONS: Transnasal, flexible laryngoscopy allows one to localize the source or cause of stridor during exercise, and devise appropriate management strategy(s). Unfortunately this case illustrates that planning appropriate management does not follow de facto. Clinical implications will be discussed and debated.

DISCLOSURE: The following authors have nothing to disclose: Diana Orbelo, Shelagh Cofer, Paolo Pianosi

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