Exercise-induced laryngochalasia: an imitator of exercise-induced bronchospasm

doi:10.1016/S1081-1206(10)62552-5

Annals of Allergy, Asthma & Immunology

Volume 85, Issue 5, November 2000, Pages 387-391

https://doi.org/10.1016/S1081-1206(10)62552-5 Get rights and content

Background

Patients with exercise-induced laryngochalasia present with dyspnea and stridor during exercise. Symptoms are due to a subtotal occlusion of the larynx resulting from mucosal edema from the aryepiglottic folds being drawn into the endolarynx.

Methods

We report on three patients with exercise-induced bronchospasm, refractory to standard therapy.

Results

Spirometry with flow-volume loops revealed truncation of the inspiratory limb. Abnormal movement of the arytenoid region was visualized on laryngoscopy. A diagnosis of exercise-induced laryngochalasia was made.

Conclusions

Evaluation of laryngeal motion in patients with refractory exercise-induced bronchospasm is important. Surgical correction with laser laryngoplasty is effective in carefully selected cases.

REFERENCES (12)

RC Lakin et al.
Upper airway obstruction presenting as exercise-induced asthma
Chest
(1984)
DB Bittleman et al.
Abnormal movement of the arytenoid region during exercise presenting as exercise-induced asthma in an adolescent athelete
Chest
(1994)
L Landwehr et al.
Vocal cord dysfunction presenting as exercise-induced bronchospasm in adolescents
Pediatrics
(1997)
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)
RJH Smith et al.
Exercise-induced laryngomalacia
Ann Otol Rhinol Laryngol
(1996)

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

Cited by (32)

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Citation Excerpt :
Bent and colleagues14 published a combined report that included the patient in the Smith report, as well as a second patient, and concluded a positive outcome in response to carbon dioxide laser supraglottoplasty featuring removal of the corniculate cartilages, as this second patient was significantly improved. In 2000, Björnsdóttir and colleagues described treatment with surgical removal of superfluous mucosa at the rim of the aryepiglottic folds and superfluous mucosa on the tuberculum corniculatum and tuberculum cuneiforme in 2 patients with EILO-supraglottic type.15 A positive outcome was concluded based on unspecified resolution of symptoms that persisted for 3 years.
Exercise-induced bronchoconstriction update—2016
2016, Journal of Allergy and Clinical Immunology
The first practice parameter on exercise-induced bronchoconstriction (EIB) was published in 2010. This updated practice parameter was prepared 5 years later. In the ensuing years, there has been increased understanding of the pathogenesis of EIB and improved diagnosis of this disorder by using objective testing. At the time of this publication, observations included the following: dry powder mannitol for inhalation as a bronchial provocation test is FDA approved however not currently available in the United States; if baseline pulmonary function test results are normal to near normal (before and after bronchodilator) in a person with suspected EIB, then further testing should be performed by using standardized exercise challenge or eucapnic voluntary hyperpnea (EVH); and the efficacy of nonpharmaceutical interventions (omega-3 fatty acids) has been challenged. The workgroup preparing this practice parameter updated contemporary practice guidelines based on a current systematic literature review. The group obtained supplementary literature and consensus expert opinions when the published literature was insufficient. A search of the medical literature on PubMed was conducted, and search terms included pathogenesis, diagnosis, differential diagnosis, and therapy (both pharmaceutical and nonpharmaceutical) of exercise-induced bronchoconstriction or exercise-induced asthma (which is no longer a preferred term); asthma; and exercise and asthma. References assessed as relevant to the topic were evaluated to search for additional relevant references. Published clinical studies were appraised by category of evidence and used to document the strength of the recommendation. The parameter was then evaluated by Joint Task Force reviewers and then by reviewers assigned by the parent organizations, as well as the general membership. Based on this process, the parameter can be characterized as an evidence- and consensus-based document.
Pathogenesis, prevalence, diagnosis, and management of exercise-induced bronchoconstriction: A practice parameter
2010, Annals of Allergy, Asthma and Immunology
Citation Excerpt :
Since the initial description of VCD as a functional disorder that mimicked attacks of asthma,297 VCD and glottic structural abnormalities elicited seen with exercise have been increasingly recognized. These functional and structural disorders can be grouped as EILD, including (1) paradoxical VCD, (2) exercise-induced laryngeal prolapse,298 (3) exercise-induced laryngomalacia,299 and (4) variants, including arytenoid collapse while the vocal cords move normally.300 Exercise-induced laryngeal dysfunction occurs in all age groups, especially among young adult female elite athletes.250
Diagnostic criteria for the classification of vocal cord dysfunction
2010, Chest
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Several studies using exercise laryngoscopy diagnosed patients with either VCD or “exercise-related laryngomalacia” with supraglottic and glottic closure during maximal exercise.86,87 Several case reports describe either arytenoid or aryepiglottic fold closure with exercise.57,88,89 Findings of arytenoid closure have likewise been reported that were unrelated to exercise.90–92
Vocal cord dysfunction (VCD) is a syndrome characterized by paroxysms of glottic obstruction due to true vocal cord adduction resulting in symptoms such as dyspnea and noisy breathing. Since first described as a distinct clinical entity in 1983, VCD has inadvertently become a collective term for a variety of clinical presentations due to glottic disorders. Despite an increased understanding of laryngeal function over the past 25 years, VCD remains a poorly understood and characterized entity. Disparities in the literature regarding etiology, pathophysiology, and management may be due to the historic approach to this patient population. Additionally, disorders clearly not due to paroxysms of true vocal cord adduction, such as laryngomalacia, vocal cord paresis, and CNS causes, need to be differentiated from VCD. Although a psychologic origin for VCD has been established, gastroesophageal reflux disease (GERD), nonspecific airway irritants, and exercise have also been associated with intermittent laryngeal obstruction with dyspnea and noisy breathing. VCD has been repeatedly misdiagnosed as asthma; however, the relationship between asthma and VCD is elusive. There are numerous case reports on VCD, but there is a paucity of prospective studies. Following an in-depth review of the medical literature, this article examines the available retrospective and prospective evidence to present an approach for evaluation of VCD including: (1) evaluation of factors associated with VCD, (2) differential diagnosis of movement disorders of the upper airway, and (3) clinical, spirometric, and endoscopic criteria for the diagnosis.
Vocal Cord Dysfunction, Paradoxic Vocal Fold Motion, or Laryngomalacia? Our Understanding Requires an Interdisciplinary Approach
2010, Otolaryngologic Clinics of North America
Exercise induced dyspnea in the young. Larynx as the bottleneck of the airways
2009, Respiratory Medicine
Citation Excerpt :
The larynx (Fig. 1) accounts for a significant fraction of total airway resistance at rest, and becomes even more important during exercise.6,7 Patients without symptoms or findings at rest may therefore exhibit inspiratory airflow obstruction at the laryngeal level during high intensity exercise.2,4,8–19 Current understanding of airflow obstruction in the upper airways during exercise has been hampered by lack of diagnostic tools.
Exercise induced asthma may symptomatically be difficult to differentiate from exercise related obstruction in the upper airways, sometimes leading to diagnostic confusion and inappropriate treatment. Larynx accounts for a significant fraction of total airway resistance, but its role as a limiting factor for airflow during exercise has been hampered by lack of diagnostic tools. We aimed to study laryngeal function in exercising humans by transnasal laryngoscopy.
Continuous video recording of the larynx was performed in parallel with continuous film recording of the upper part of the body and recording of breath sounds in subjects running to respiratory distress or exhaustion on a treadmill.
A successful examination was obtained in 20 asymptomatic volunteers and 151 (91%) of 166 young patients with a history of inspiratory distress or stridor during exercise. At rest, six patients had abnormal laryngeal findings. During exercise, a moderate or severe adduction of laryngeal structures was observed in parallel with increasing inspiratory distress in 113 (75%) patients. In 109 of these, adduction started within supraglottic structures, followed by adduction of the vocal cords in 88. In four patients, laryngeal adduction started in the vocal cords, involving supraglottic structures secondarily in three.
Larynx can safely be studied throughout a maximum intensity exercise treadmill test. A characteristic laryngeal response pattern to exercise was visualised in a large proportion of patients with suspected upper airway obstruction. Laryngoscopy during ongoing symptoms is recommended for proper assessment of these patients.

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ORIGINAL ARTICLESExercise-induced laryngochalasia: an imitator of exercise-induced bronchospasm

Background

Methods

Results

Conclusions

Chest

Chest

Vocal cord dysfunction presenting as exercise-induced bronchospasm in adolescents

Pediatrics

Vocal cord dysfunction presenting as asthma

N Engl J Med

Clinical features of vocal cord dysfunction

Am J Respir Crit Care Med

Exercise-induced laryngomalacia

Ann Otol Rhinol Laryngol

ORIGINAL ARTICLES
Exercise-induced laryngochalasia: an imitator of exercise-induced bronchospasm