Vocal Cord Dysfunction: Rapid Evidence Review

 

Am Fam Physician. 2021 Nov ;104(5):471-475.

  Patient information: See related handout on vocal cord dysfunction.

Author disclosure: No relevant financial affiliations.

Vocal cord dysfunction (i.e., vocal cords closing when they should be opening, particularly during inspiration) should be suspected in patients presenting with inspiratory stridor or wheezing; sudden, severe dyspnea (without hypoxia, tachypnea, or increased work of breathing); throat or chest tightness; and anxiety, particularly in females. Common triggers include exercise, asthma, gastroesophageal reflux disease, postnasal drip, upper or lower respiratory tract infection, and irritants. Nasolaryngoscopy and pulmonary function testing, with provocative exercise and methacholine, can help diagnose vocal cord dysfunction and are helpful to evaluate for other etiologies. Conditions that can trigger vocal cord dysfunction should be optimally treated, particularly asthma, gastroesophageal reflux disease, and postnasal drip, while avoiding potential irritants. Therapeutic breathing maneuvers and vocal cord relaxation techniques are first-line therapy for dyspnea that occurs with vocal cord dysfunction. A subset of vocal cord dysfunction leads to dysphonia, as opposed to dyspnea, secondary to abnormal laryngeal muscle spasms (vocal cord closure is less severe). OnabotulinumtoxinA injections may be helpful for spasmodic dysphonia and for treating dyspnea in certain cases, although evidence is limited.

Vocal cord dysfunction is a condition in which the vocal cords close when they should be opening, particularly during inspiration. This can be more severe and impair breathing or, more commonly, less severe and impact the patient's voice. This article is a brief summary and review of the best available evidence for the presentation, diagnosis, and management of vocal cord dysfunction.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Vocal cord dysfunction should be considered in patients with poor response to optimal medical management of asthma or in those who have sudden, severe dyspnea without hypoxia, tachypnea, or increased work of breathing.1,47,1113

C

Data from small and retrospective studies; expert opinion

The diagnostic workup for vocal cord dysfunction should include nasolaryngoscopy and pulmonary function testing (with provocative exercise and possibly methacholine).47,1620

C

Data from small studies; expert opinion

Therapeutic breathing maneuvers and vocal cord relaxation techniques are effective first-line treatments for dyspnea that occurs with vocal cord dysfunction.13,17,21,22,24

C

Data from a large number of small studies; guidelines; expert opinion

Speech therapy can improve voice in patients with functional dysphonia.26

B

Cochrane review of six small, mostly poor-quality randomized controlled trials

Triggers of vocal cord dysfunction, including asthma, gastroesophageal reflux disease, postnasal drip, and possibly anxiety and depression, should be treated if present.1,47,27

C

Data from small studies; expert opinion


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Vocal cord dysfunction should be considered in patients with poor response to optimal medical management of asthma or in those who have sudden, severe dyspnea without hypoxia, tachypnea, or increased work of breathing.1,47,1113

C

Data from small and retrospective studies; expert opinion

The diagnostic workup for vocal cord dysfunction should include nasolaryngoscopy and pulmonary function testing (with provocative exercise and possibly methacholine).47,1620

C

Data from small studies; expert opinion

Therapeutic breathing maneuvers and vocal cord relaxation techniques are effective first-line treatments for dyspnea that occurs with vocal cord dysfunction.13,17,21,22,24

C

Data from a large number of small studies; guidelines; expert opinion

Speech therapy can improve voice in patients with functional dysphonia.26

B

Cochrane review of six small, mostly poor-quality randomized controlled trials

Triggers of vocal cord dysfunction, including asthma, gastroesophageal reflux disease, postnasal drip, and possibly anxiety and depression, should be treated if present.1,47,27

C

Data from small studies; expert opinion


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Epidemiology

  • Vocal cord dysfunction

The Authors

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JOHN MALATY, MD, FAAFP, is an associate professor in the Department of Community Health and Family Medicine at the University of Florida, Gainesville, where he is medical director of the Main Street Clinic, associate program director of the Family Medicine Residency Program, and director of the Resident as Teacher Program....

VELYN WU, MD, FAAFP, CAQSM, is an assistant clinical professor in the Department of Community Health and Family Medicine at the University of Florida, where she is associate program director of the Family Medicine Residency Program.

Author disclosure: No relevant financial affiliations.

Address correspondence to John Malaty, MD, FAAFP, University of Florida, 1707 N. Main St., Gainesville, FL 32609 (email: malaty@ufl.edu). Reprints are not available from the authors.

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