Functional airway obstruction presenting as stridor: A case report and literature review

doi:10.1016/0736-4679(90)90007-I

The Journal of Emergency Medicine

Volume 8, Issue 3, May–June 1990, Pages 285-289

https://doi.org/10.1016/0736-4679(90)90007-I Get rights and content

Abstract

We report the case of a young man who presented to 3 emergency departments with apparent upper airway obstruction and was intubated each time before being diagnosed with paradoxical vocal cord motion. His previous discharge diagnoses were laryngeal edema secondary to anaphylaxis, even though he had no other objective findings of IgE-mediated disease. Flexible fiberoptic laryngoscopy demonstrated tight apposition of the vocal cords during inspiration while symptomatic, but normal movement when asymptomatic. Psychiatric evaluation revealed severe posttraumatic stress disorder. Of the approximately 41 reported cases of functional airway obstruction in the medical literature, only two have been adult males and none have been associated with posttraumatic stress disorder. The current literature is reviewed, and an approach to evaluation and management of such patients is provided.

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Cited by (26)

Drug-Induced Paradoxical Vocal Fold Motion
2018, Journal of Allergy and Clinical Immunology: In Practice
Citation Excerpt :
The purpose of the breathing techniques is to disrupt the irregular respiratory pattern or spasm and relax the vocal folds.8,18,22,27 Benzodiazepines have been shown to be effective in relaxing patients and terminating acute symptoms of PVFM but have a risk of oversedating the patient and suppressing respiratory drive.13,27,30,31 Another effective treatment is the use of heliox, a mixture of helium and oxygen that is less dense than air and reduces turbulence on inhalation, and thus requires less effort to breathe.
Vocal cord dysfunction, also known as paradoxical vocal fold motion (PVFM), is a disorder characterized by abnormal vocal cord adduction during inspiration. PVFM is commonly misdiagnosed as asthma because of the similarity of symptoms: cough, wheezing, chest pain, and dyspnea. We present the clinical vignette of a 36-year-old woman with juvenile rheumatoid arthritis and multiple adverse drug reactions who presented with recurrent episodes of unrecognized PVFM during skin testing for drug allergy, omalizumab treatment, and tocilizumab desensitization. Before the diagnosis of PVFM, these episodes were treated as anaphylaxis, including the administration of epinephrine. Once diagnosed and treated for PVFM, the patient did not present any further events and continued treatment for drug allergy. PVFM may be underreported in hypersensitivity reactions because of the similarity to Type 1-mediated respiratory symptoms and comorbid asthma.
Acute Management of Paradoxical Vocal Fold Motion (Vocal Cord Dysfunction)
2017, Annals of Emergency Medicine
Citation Excerpt :
In persistently symptomatic patients, mild sedatives may facilitate paradoxical vocal fold motion management.26 Benzodiazepines have been shown to be effective, but there is a potential risk of suppressing respiratory drive.11,16,22,39,40 In our experience, dissociative dosing of ketamine has been particularly effective and is attractive because it does not suppress respiratory drive or airway reflexes.
Paradoxical vocal fold motion disorder, also commonly termed vocal cord dysfunction, is a poorly understood cause of acute upper airway obstruction. Patients with paradoxical vocal fold motion frequently present to the emergency department (ED) with acute respiratory distress and stridor. Lack of familiarity with this disorder may lead to delayed diagnosis or misdiagnosis and unnecessary intubations or surgical airway procedures. Although long-term management of paradoxical vocal fold motion is well described, there is a paucity of information about acute evaluation and management. This article aims to summarize the ED presentation and management of paradoxical vocal fold motion.
Vocal cord dysfunction: An uncommon cause of stridor
2005, Journal of Emergency Medicine
Paradoxical vocal cord motion: An often misdiagnosed cause of postoperative stridor
2004, Journal of Clinical Anesthesia
This conference reports a case of acute functional airway obstruction occurring in the postoperative anesthesia care unit, which was diagnosed by fiberoptic laryngoscopy and successfully treated with intravenous midazolam after other more common causes of stridor were ruled out. The presentation, etiology, diagnosis, and treatment of paradoxical vocal cord motion as it relates to the care of the postoperative patient are discussed.
Inspiratory stridor in elite athletes
2003, Chest
Citation Excerpt :
When wheeze or IS was detected by investigators, auscultation of the larynx and chest was performed to determine the origin of the sound. The audible IS during exercise that quickly resolves within 5 min of exercise cessation is a defining feature of VCD; the asthma or EIB wheeze is typically on exhalation and becomes more severe 5 to 20 min after exercise.234569111518 Actual competition, simulated competition, or a 7- to 8-min free run was used as the exercise challenge for EIB provocation.
Diagnosis and medical intervention for exercise-induced bronchospasm (EIB) are often based on self-reported symptoms, without spirometric confirmation. Inspiratory stridor (IS), a symptom of vocal cord dysfunction (VCD), is frequently mistaken for EIB wheeze. Athletes with exercise IS that spontaneously resolves on activity cessation are suspect for VCD and may not have EIB. This study estimated IS prevalence in elite athletes and determined its relationship to EIB.
Three hundred seventy athletes (174 female and 196 male subjects) provided a medical history, and underwent spirometry before and after exercise challenge. Exercise challenges were conducted in cold, dry ambient conditions. EIB positive (EIB +) was defined as a ≥ 10% postexercise fall in FEV₁. Athletes were monitored for IS during exercise; 78.4% of the athletes in this study (n = 290) were tested on multiple occasions.
EIB was identified in 30% of 370 athletes tested (58 female and 53 male subjects). IS was observed in 5.1% (18 female and 1 male subjects) during exercise and spontaneously resolved in these subjects within 5 min after exercise cessation. Ten IS-positive (IS +) athletes (52.6%) were EIB +, and 8 of these athletes had a previous EIB diagnosis; however, β₂-agonist treatment resolved IS in only 2 subjects. Eight of nine IS +/EIB-negative (EIB −) athletes had a previous EIB diagnosis; seven subjects received β₂-agonist treatment with no IS resolution. Resting spirometric measurements did not distinguish IS, but postexercise mid-flow (FEF₅₀/FIF₅₀) ratio > 1.5 was more frequent (33%, p < 0.05) among IS + athletes. The FEF₅₀/FIF₅₀ ratio was higher for IS +/EIB + athletes than for IS −/EIB + athletes (1.97 ± 1.69 vs 0.81 ± 0.39, p < 0.05). The postexercise fall in FVC was greater (p < 0.05) for IS +/EIB − athletes (9.2 ± 5.0%) than for IS-negative (IS −) /EIB − athletes (5.3 ± 4.3%). No difference in postexercise FEV₁ was identified between IS + and IS − athletes (within EIB + or EIB − groups).
Five percent of athletes were IS +, with EIB comorbidity observed in 53% of these subjects. Misdiagnosis of IS as EIB is common. The lack of a β₂-agonist response in combination with postexercise serial spirometry can be useful in excluding solitary IS and confirming EIB diagnosis.
Functional respiratory disorders
1997, Annals of Allergy, Asthma and Immunology
Reading this article will enable health care providers to recognize and to diagnose paroxysmal sneezing, sighing dyspnea, habit cough, and vocal cord dysfunction and to reinforce their knowledge of the epidemiology, etiopathology, clinical features, and treatment of these disorders.
The literature was reviewed using a MEDLINE search for information relating to the above-mentioned disorders. Indexing terms used included psychogenic wheezing, vocal cord dysfunction, functional respiratory disorders, sighing dyspnea, paroxysmal sneezing, habit cough, and psychogenic stridor. Review was restricted to English language articles from 1966 onward, with cross-referencing to obtain older references.
All human studies that clearly identified the above-mentioned disorders as being nonorganic on the basis of historic and appropriate laboratory evaluation were reviewed. No studies were rejected on the basis of subject age, although special emphasis was given to articles concerning children and adolescents (<18 years old). Of all initially identified studies, 95% fulfilled the inclusion criteria.
Functional respiratory disorders are common and affect mostly children, adolescents, and young adults, resulting in considerable morbidity and contributing significantly to patient and physician cost and frustration. A history of a psychiatric disorder with temporally related psychogenic stressors is frequently found. Professionals disagree on the technical classification of some of these conditions (ie, psychosomatic versus somatoform), but there is agreement that treatment directed toward underlying stressors should be the cornerstone of therapy.
Functional respiratory disorders must be considered in patients with atypical symptoms, especially those resistant to conventional therapy. Possible psychogenic stressors must be inquired into and, when identified, treated in a multidisciplinary manner. This may involve reassurance regarding the absence of significant organic abnormality, counseling, and occasional recourse to formal psychiatric intervention.

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Clinical communicationFunctional airway obstruction presenting as stridor: A case report and literature review

Abstract

Psychosomatics

J Peds.

Am J Med.

Am J Med.

Ann Emerg Med.

Munchausen's stridor: nonorganic laryngeal obstruction

Clin Allergy.

Pseudoasthma: a new clinical entity?

JACEP.

Paradoxical movement of the vocal cords as a cause of stridor

J Laryngol and Otol.

Functional inspiratory stridor in children