Vocal cord dysfunction (VCD) is a disorder that occurs when the vocal
cords move toward each other when a person breathes, narrowing the airway
and causing wheezing and difficulty breathing. VCD is also called
paradoxical vocal cord motion (PVCM).
Normally when an individual breathes in (inhales) or out (exhales) the
vocal cords are drawn apart by the muscles of the larynx (voice box) to
make a wider opening for air to move into or out of the lungs. In an
individual with vocal cord dysfunction, instead of being drawn apart, the
vocal cords move together, narrowing and partially blocking the airway.
This is called adduction of the vocal cords. Adduction of the vocal cords
happens most commonly during inhalation, although it can also happen
during exhalation. As a result of the narrowed airways, the individual may
, wheeze, feel short of breath, or make a high-pitched, harsh sound
) with each breath.
VCD is often misdiagnosed as either
or exercise-induced bronchospasm. As a result, many individuals with VCD
are treated with inhalers and steroids for asthma, which do not help
control VCD and which have potentially harmful side effects.
The number of people with VCD in the general U.S. population is unknown.
The disorder often occurs in conjunction with asthma and is frequently a
missed diagnosis. Several small studies have found that about 40 percent
of individuals who have VCD also have asthma and that about 10 to 15
percent of individuals whose asthma does not respond to aggressive
treatment (refractory asthma) actually have VCD.
VCD has been found in individuals as young as three and as old as 82.
However, in adults it most often occurs between the ages of 20 and 40. In
children it appears most often about age 14 or 15. VCD is much more common
in females than in males. In children under 18, about 85 percent of
individuals diagnosed with VCD are girls. In children, the disorder has a
strong association with competitive
orientation toward high achievement. In adults it has a strong
and stress. This association with stress is present, but less frequent in
Causes and symptoms
VCD was first recognized in 1842, when it was thought that hysteria, a
common designation at that time for several psychological conditions,
brought about spasm of the muscles of the larynx. By 1900, it was
generally accepted that VCD was the physical expression of stress or other
psychological conditions. It was not until the 1980s that physicians began
to revisit the assumptions about the disorder and examine more closely its
physical causes. As of 2004, the causes of VCD was not completely clear.
In the early 2000s, it is thought that the disorder may have multiple
causes and that some of the triggers may be different in children and
adults. VCD appears to be associated with the following:
VCD usually comes on suddenly. Between attacks, the individual can breathe
normally. The symptoms of a VCD attack are varied, but most strongly
imitate those of asthma. Its similarity to asthma, along with the fact
that some people with VCD actually also have asthma, complicates
diagnosis. Common signs and symptoms include the following:
Immediate emergency medical assistance is essential whenever there are any
signs of breathing difficulty.
Diagnosis of VCD is quite difficult. VCD can mimic the symptoms of severe
asthma, allergic reactions (
), spasm of the larynx (laryngospasm), or a foreign object lodged in the
throat. VCD is often a diagnosis of exclusion, which means that other
possibilities are considered first, and when these are eliminated, VCD is
considered. This may require a lot of testing.
The best way to determine if an individual has VCD is by doing a
laryngoscopy. In a laryngoscopy, a slender, flexible tube containing a
fiber optic camera is inserted through the nose and down the throat to the
larynx. This examination allows the doctor to see the vocal cords and
watch how and when they move.
Since between attacks the vocal cords appear to move normally, it is
necessary to trigger an attack. Individuals cannot voluntarily produce
symptoms of VCD, so they are usually exposed to an irritant or undergo an
exercise stress test in order to bring on a VCD attack. The doctor then
watches the vocal cords move. A classic finding is that the vocal cords
move toward each other when the individual inhales, leaving a small
triangular hole or chink at the back of the larynx. Individuals with
asthma do not show this triangular chink.
Most people go through a series of other tests and often get other
diagnoses, most commonly refractory (unresponsive) asthma, before they
have a laryngoscopy and receive a definite diagnosis of VCD. Other tests
that are frequently done to pinpoint or eliminate certain respiratory
disorders include arterial blood gas values (to measure oxygen in the
pulmonary function tests
(to measure lung capacity), with flow-volume loops (to measure the rate
of air flow at different points in the breathing process). A methacholine
provocation test, which stimulates a response in asthmatics, but not in
persons with VCD, also helps narrow the diagnosis.
—A congenital malformation of the base of the brain.
—A disease in which the air passages of the lungs become inflamed
and narrowed, causing wheezing, coughing, and shortness of breath.
—A sudden contraction in the lower airway that causes breathing
problems and is brought about by heavy exercise.
Gastroesophageal reflux disease (GERD)
—A disorder of the lower end of the esophagus in which the lower
esophageal sphincter does not open and close normally. As a result the
acidic contents of the stomach can flow backward into the esophagus and
irritate the tissues.
—An endoscope that is used to examine the interior of the larynx.
—A term used to describe noisy breathing in general and to refer
specifically to a high-pitched crowing sound associated with croup,
respiratory infection, and airway obstruction.
In an experimental procedure, botulinum toxin (Botox) may be injected into
the larynx. The drug paralyzes the muscle, making it impossible for the
vocal cords to move across the airway. This technique appears
to be successful but may require repeated injections as the toxin wears
off. Another experimental device is a facemask that provides resistance
when the individual inhales but not during exhalation. The resistance
forces the person to breathe in more slowly and reduces stridor.
Some individuals have found biofeedback very helpful in controlling or
moderating VCD attacks. Others have benefited from relaxation and mind
The long-term outcome for VCD is not known and probably varies among
individuals depends on the underlying cause of the disorder. Only a
handful of people with VCD have been followed for 10 or more years, and
all of them continued to have symptoms of the disorder. However, speech
therapy and psychotherapy are often successful in reducing the number of
Although the physical conditions that cause VCD cannot be prevented,
individuals can be educated not to panic and to use certain breathing
techniques when they begin to feel symptoms of VCD. In addition, airborne
pollutants should be eliminated from the individual's environment.
These steps can be somewhat successful in minimizing attacks.
Parents have obvious reason to be concerned when their child has sudden
breathing problems. Many children with VDC make multiple trips to the
emergency room before the condition is correctly diagnosed. Many medical
professionals are only marginally familiar with VCD, because this problem
is much less common than asthma. Parents may want to suggest additional
testing for VCD if their child is being treated for asthma without
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