Paradoxical vocal fold motion

Background

• Also known as "vocal cord dysfunction"
• Occurs from abnormal adduction of the vocal cords during inspiration
• Lack of familiarity may lead to delayed diagnosis and unnecessary intubation or surgical airway procedures

Clinical Features

• Stridor

Differential Diagnosis

Stridor

Trauma

• Larynx fracture
• Tracheobronchial tear/injury
• Thyroid gland injury/trauma
• Tracheal injury
• Electromagnetic or radiation exposure
• Burns, inhalation injury

Infectious Disorders

• Bacterial tracheitis
• Diphtheria
• Tetanus
• Tracheobronchial tuberculosis
• Poliomyelitis, paralytic, bulbar, or acute
• Fungal laryngitis

Abscesses

• Retropharyngeal abscess
• Epiglottitis, acute
• Peritonsillar abscess
• Laryngotracheobronchitis (croup)
• Retropharyngeal abscess

Neoplastic Disorders

• Neoplasms/tumors

Allergic and Auto-Immune Disorders

• Spasmodic/tracheobronchitis
• Angioedema/Angioneurotic edema

Metabolic, Storage Disorders

• Cerebral Gaucher's of infants (acute)
• Tracheobronchial amyloidosis

Biochemical Disorders

• Tetany

Congenital, Developmental Disorders

• Angioedema/Angioneurotic edema, hereditary

Psychiatric Disorders

• Somatization disorder

Anatomical or Mechanical

• Foreign body aspiration
• Acute gastric acid/aspiration syndrome
• Airway obstruction
• Neck compartment hemorrhage/hematoma
• Paradoxical vocal fold motion

Vegetative, Autonomic, Endocrine Disorders

• Esophageal free reflux/GERD syndrome
• Laryngospasm, acute
  • Bilateral vocal cord paralysis
• Hypoparathyroidism

Poisoning

• Smoke inhalation
• Chemical burn/esophagus

Chronic Pediatric Conditions

• Laryngotracheomalacia
• Subglottic stenosis or prior intubation
• Vascular ring (double aortic arch)
• Vocal cord dysfunction/paroxysmal vocal fold movement

Evaluation

Diagnosis

• Gold standard is laryngoscopy (ideally with flexible fiberoptics)

Management

• Reassurance and breathing techniques to resolve stridor:
  • Jaw thrust while breathing
  • Pursed lip breathing through straw or endotracheal tube
  • Inhale through nose for 3 seconds and exhale through pursed lips for 3 seconds
  • "Pant like a dog" - rhythmic breathing with mouth open and tongue protruding forward
  • 3 sniffs - take 2 quick then 1 slow inhalational sniffs through the nose, exhale slowly through mouth
• Mild sedatives (eg benzodiazepines) may be effective in cases refractory to breathing techniques