Multidimensional voice program analysis (MDVP) and the diagnosis of pediatric vocal cord dysfunction

doi:10.1016/S1081-1206(10)61892-3

Annals of Allergy, Asthma & Immunology

Volume 88, Issue 6, June 2002, Pages 601-608

https://doi.org/10.1016/S1081-1206(10)61892-3 Get rights and content

Background

Vocal cord dysfunction (VCD) can present with signs and symptoms that mimic asthma. This may lead to unnecessary pharmacologic treatment or more invasive measures including intubation. Presently, the diagnosis of VCD can only be confirmed when a patient is symptomatic, via pulmonary function testing (PFT) or visualization of adduction of the vocal cords during inspiration by direct laryngoscopy.

Objective

Multidimensional Voice Program (MDVP) analysis, a computer program which analyzes various aspects of voice, can detect abnormal voice patterns of patients with upper airway pathology. We determined whether MDVP analysis was useful in the diagnosis of VCD.

Methods

We conducted chart reviews of patients referred to our department from 1995 to 1998 with the presumed diagnosis of VCD who had undergone MDVP analysis. The diagnosis of VCD was based on the presenting history, PFT results, laryngoscopy results, as well as voice evaluation conducted by a speech-language pathologist. We analyzed six consecutive patients referred for this investigation. We delineated common trends in the variables measured on MDVP analysis in VCD patients, and compared these with controls and other vocal cord pathology.

Results

Five cases of possible VCD had abnormalities in the MDVP variable of soft phonation index (SPI). All five also had abnormalities in the variation in fundamental frequency (vFo). In one case, MDVP analysis was conducted pre- and posttreatment for VCD, and SPI and vFo both normalized. In a sixth case of possible VCD, the diagnosis was not confirmed as the patient had normal PFTs and laryngoscopy. MDVP analysis was normal in this individual. The pattern of abnormal SPI and vFo was not seen in a group of normal controls or in patients with vocal cord nodules.

Conclusions

MDVP analysis may be a useful tool when diagnosingVCD, as well as in evaluating response to treatment.

REFERENCES (19)

RP Wood et al.
Vocal cord dysfunction
J Allergy Clin Immunol
(1996)
JC Selner et al.
Vocal cord dysfunction: the importance of psychologic factors and provocation challenge testing
J Allergy Clin Immunol
(1987)
GK Fritz et al.
Somatoform disorders in children and adolescents: a review of the past 10 years
J Am Acad Child Adolesc Psychiatry
(1997)
ER McFadden
Glottic function and dysfunction
J Allergy Clin Immunol
(1987)
S Kayani et al.
Vocal cord dysfunction associated with exercise in adolescent girls
Chest
(1998)
KL Christopher et al.
Vocal-cord dysfunction presenting as asthma
N Engl J Med
(1983)
KB Newman et al.
Clinical features of vocal cord dysfunction
Am J Respir Crit Care Med
(1995)
DM Murray et al.
All that wheezes is not asthma. Paradoxical vo-4. cal cord movement presenting as severe acute asthma requiring ventilatory support
Anaesthesia
(1998)
RJ Martin
Managing the patient with intractable asthma
Hosp Pract (Off Ed)
(1996)

There are more references available in the full text version of this article.

Cited by (27)

Gasping for a Diagnosis: Pediatric Vocal Cord Dysfunction
2019, Journal of Pediatric Health Care
Citation Excerpt :
The recognition of VCD as a diagnosis may also be impeded by lack of consensus surrounding typical clinical presentation and lack of diagnostic criteria. The misdiagnosis of VCD has resulted in patients requiring emergency department visits and/or hospitalization with inappropriate treatment of high-dose corticosteroids, intubation, or tracheostomy (Zelcer, Henri, Twefik, & Mazer, 2002). VCD can present independently or coexist with other pulmonary conditions.
Vocal cord dysfunction is an obstruction of the upper airway, primarily on inspiration, due to the paradoxical adduction of the vocal cords. Vocal cord dysfunction continues to be underdiagnosed as its own entity. The lack of diagnosis can be attributed to the overlap of symptoms between asthma and exercise-induced bronchospasm. It is possible for patients diagnosed with asthma and/or exercise-induced bronchospasm to have underlying vocal cord dysfunction, which needs to be considered when prescribing asthma medications. This article will review the history of vocal cord dysfunction, the differential diagnosis, diagnostic testing, and the role of the nurse practitioner in caring for these patients.
Differential diagnosis in paradoxical vocal fold movement (PVFM): An interdisciplinary task
2014, International Journal of Pediatric Otorhinolaryngology
Citation Excerpt :
Although laryngoscopic methods are well established as fundamental in PVFM diagnosis, attempts to pinpoint voice quality impairments associated with the disorder have been pursued, using perceptual and objective methods [25,26]. Evidence of abnormalities associated with PVFM include reduced maximum phonation time (MPT), phonation range, and maximum phonation time (MPTs) as well as elevated perturbation measures (i.e., jitter and shimmer) in comparison with healthy controls [26–28]. Deterioration in voice quality in association with PVFM can be detected even between acute episodes [25,29].
The objective of this study was to contribute to the discussion of differential diagnosis in paradoxical vocal fold movement (PVFM), a disorder frequently associated with episodes of breathing difficulty and stridor. Because of analogous respiratory symptoms, PVFM is often misdiagnosed as asthma. Additional evidence suggests the association of factors such as respiratory struggle during physical exertion, digestive reflux, and respiratory allergies with PVFM, particularly in athletes and young females. Interdisciplinary attention is warranted to avoid unnecessary utilization of medical resources and potential delay in the application of proper treatment.
A description of critical points in PVFM differential diagnosis is proposed, featuring the assessment of a seven-year-old female with a history of behaviors considered to exacerbate voice fatigue symptoms. Noticeably, the child has consistently demonstrated tiredness and respiratory difficulties during physical education classes. Past use of oral steroids to reduce respiratory problems was applied with no improvement; short-acting beta 2-agonists have been also tried with mild improvement. Indications of instability and effort associated with respiratory–phonatory functions were demonstrated.
Furthermore, there was evidence of GERD and seasonal allergies.
The literature suggests an association of factors such as respiratory struggle during physical exertion, unwanted vocal effort, GERD, and respiratory allergies in individuals with PVFM, particularly in young females. A diagnosis of PVFM was suggested, in association with paradoxical vocal folds motion caused by respiratory difficulties verified by laryngeal examination.
In PVFM, the vocal folds adduct during inhalation, thereby restricting the airway opening. Inconsistent vocal folds movement during phonation may also lead to PVFM symptoms. Acute bronchospasm/asthma-like symptoms, as well as additional morbidity may impact accuracy of diagnosis, leading to unnecessary use of asthma medications and office/emergency room consultations.
Impairment of voice quality in paradoxical vocal fold motion dysfunction
2010, Journal of Voice
Citation Excerpt :
Zelcer et al demonstrated increase in soft phonation index and in the variation of fundamental frequency variables in five cases with possible diagnosis of PVFMD by using Multidimensional Voice Program.5 They related the increased soft phonation index with inadequate adduction of the vocal cords, and high variation of fundamental frequency scores with the poor control in regulating vocal cord movements.5 A study of acoustic and electroglottography (EGG) examinations also confirmed significant abnormalities in voice features in PVFMD patients as reduced HNR and increased jitter was determined in participants with PVFMD in comparison with healthy controls.7
To compare subjective and objective voice-quality parameters between asymptomatic paradoxical vocal fold motion dysfunction (PVFMD) patients and healthy individuals.
Prospective.
A total number of 12 patients with PVFMD and 12 healthy control subjects had voice evaluations by means of laryngostroboscopy, acoustic analysis (jitter, shimmer, and harmonics-to-noise ratio [HNR]), aerodynamic measurements (maximum phonation time [MPT], s/z ratio), and perceptual analysis (Grade, Roughness, Breathiness, Asthenicity, and Strain Scale [GRBAS] and Voice Handicap Index-10 [VHI-10] scales). Evaluations were conducted when all the patients were asymptomatic.
False vocal cord adduction, anteroposterior constriction of the supraglottic larynx, decreased amplitude, and decreased mucosal wave were observed in the great majority of the PVFMD patients during laryngostroboscopy. Mean jitter and shimmer rates were significantly high in PVFMD patients and there was no significant difference in mean HNR between groups (P < 0.05). Mean MPT was significantly long in control subjects (P < 0.05) and mean s/z ratio was nearly equal between patients and control subjects. There was a statistically significant difference between groups about GRBAS and VHI-10 scales (P < 0.05).
Based on the subjective and objective voice parameters, voice quality is significantly impaired in asymptomatic PVFMD patients when compared with the healthy control subjects.
Vocal acoustic characteristics in pre-school aged children
2008, Brazilian Journal of Otorhinolaryngology
Citation Excerpt :
Acoustic analysis is a non-invasive evaluation method that makes it possible to separate normal and pathological voice. Its results, however, cannot yet be generalized due to the lack of reference measurements.18,20,22–27 Following a review of studies on acoustic measurements in children, researchers27 have found that many papers do not differentiate normal and dysphonic voice sufficiently; this finding underlines a need for further investigation to increase measurement standardization and provide reference values.
Evaluation is the first step for any treatment. Therefore, normal parameters are the bases for proper evaluation.
Verify measures and vocal acoustic characteristics of 23 pre-school aged children of both genders, aged four to six years and eight months.
The sampling process comprised a questionnaire -that was sent to parents, auditory screening and vocal-perception auditory assessment, based on the R.A.S.A.T. scale. Acoustic analysis was carried out through the Multi Dimensional Voice Program.
Prospective and cross-sectional.
The noise-harmonic ratio (NHR) and frequency variation (vf0) of the total sample was higher than what was found for five and six-year-olds. As age increased, NHR values decreased. As the total mean of amplitude perturbation quotient (APQ) increased, vf0, variation of amplitude (vAm) soft phonation index (SPI) and NHR also increased; the same occurred between mean total NHR and vf0. As the total means of pitch perturbation quotient (PPQ) and voice turbulence index (VTI) increased, SPI mean value decreased.
The results of the acoustic parameters at the age of four years seem to show an immaturity of the structures and lack of neuro-muscular control at that age and the maturation process onset happens near five and six years old.
The Relationship Between Chronic Cough and Paradoxical Vocal Fold Movement: A Review of the Literature
2006, Journal of Voice
Chronic cough (CC) and paradoxical vocal fold movement (PVFM) are debilitating conditions. PVFM has been given many labels,¹ including vocal cord dysfunction,² Munchausen's stridor, functional inspiratory stridor, nonorganic functional or psychogenic upper airway obstruction, factitious asthma, psychogenic stridor, emotional laryngeal wheezing, and episodic laryngeal dyskinesia.³ Although CC and PVFM have been considered separate entities in many reports, there is preliminary support for the notion that there may be an underlying link between these two conditions. Speech pathologists have become increasingly involved in the treatment of these patients and therefore need to understand the theoretical background of these disorders, the pathophysiological links between the two, and the impact of voice disorders on these populations. The aim of this article is to review the current literature on CC and PVFM from a speech pathology perspective to provide a model for defining and conceptualizing the disorders and to provide a framework for management and future research.
The Association between Paradoxical Vocal Fold Motion and Dysphonia in Adolescents
2020, Folia Phoniatrica et Logopaedica

View all citing articles on Scopus

: Supported by the J.T. Costello Memorial Research Fund and Le Fonds de la recherche en santé de Québec (FRSQ). Dr. Mazer is a recipient of a Chercheur-Boursier Clinicien award from FRSQ.

View full text

ORIGINAL ARTICLESMultidimensional voice program analysis (MDVP) and the diagnosis of pediatric vocal cord dysfunction

Background

Objective

Methods

Results

Conclusions

J Allergy Clin Immunol

J Allergy Clin Immunol

J Am Acad Child Adolesc Psychiatry

J Allergy Clin Immunol

Chest

Vocal-cord dysfunction presenting as asthma

N Engl J Med

Clinical features of vocal cord dysfunction

Am J Respir Crit Care Med

All that wheezes is not asthma. Paradoxical vo-4. cal cord movement presenting as severe acute asthma requiring ventilatory support

Anaesthesia

Managing the patient with intractable asthma

Hosp Pract (Off Ed)

ORIGINAL ARTICLES
Multidimensional voice program analysis (MDVP) and the diagnosis of pediatric vocal cord dysfunction