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

Patient information: See related handout on vocal cord dysfunction.

This clinical content conforms to AAFP criteria for CME.

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.


  • Vocal cord dysfunction predominantly occurs in females (prevalence is two to three times greater in females than in males).1,2

  • It occurs at any age but is more commonly diagnosed in patients 30 to 40 years of age.1

  • It may coexist with asthma (25% to 30%),3,4 gastroesophageal reflux disease, or anxiety disorders.1,47

  • Vocal cord dysfunction is categorized as inducible laryngeal obstruction and is known by many other names,2,810 which are listed in Table 1.8

Emotional laryngeal asthma
Episodic laryngeal dyskinesia
Exercise-induced dyspnea
Factitious asthma
Functional dysphonia
Inducible laryngeal obstruction
Irritable larynx syndrome
Munchausen stridor
Paradoxical vocal cord dysfunction
Paradoxical vocal fold motion
Psychosomatic stridor
Spasmodic dysphonia


  • 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

  • The differential diagnosis includes poorly controlled asthma, anatomic defects, laryngeal edema, nerve injury, and neurologic disorders11 (Table 2).

  • A suggested approach to the diagnosis of vocal cord dysfunction includes obtaining a clinical history focusing on triggers (Table 3) and symptoms, physical examination focusing on location and timing of stridor or wheezing, pulmonary function testing, and direct nasolaryngoscopy performed during an episode.1,47

Amyotrophic lateral sclerosis
Anatomic defects (laryngomalacia, subglottic stenosis, tracheal masses, vocal cord polyps)
Foreign body
Laryngeal edema (croup, epiglottitis)
Poorly controlled asthma
Vagus or recurrent laryngeal nerve injury
Inflammatory states
 Episodic croup
 Gastroesophageal reflux disease
 Postnasal drip
 Recent upper or lower respiratory tract infection
 Dry, cold air
 Toxin inhalation
 Workplace chemicals
Postoperative injury (with vocal cord paresis)
Psychiatric conditions
 Generalized anxiety disorder
 Major depression
 Obsessive-compulsive disorder
 Performance stress/anxiety


  • Many symptoms are a result of difficulty with breathing in air due to inappropriate closure of the vocal cords during inspiration. These symptoms include:

    Inspiratory stridor11

    Wheezing, predominantly over the upper airway11

    Severe, sudden dyspnea without oxygen desaturation, tachypnea, or increased work of breathing; often associated with anxiety1113

    Chest or throat tightness12

    Chronic cough may be an associated condition, although it typically does not occur during symptoms related to vocal cord dysfunction14

    Onset with exposure to known triggers (Table 3)

  • When the vocal cord closure is less severe (from abnormal laryngeal muscle spasm), it impacts the voice, but not breathing, causing dysphonia or aphonia.15


  • The diagnostic standard is direct visualization of vocal cord adduction during inspiration using nasolaryngoscopy.7 Diagnostic yield of nasolaryngoscopy is improved when the patient is experiencing symptoms and with provocation, such as exercise or use of methacholine.35,1115 Based on expert opinion, nasolaryngoscopy should be performed when signs and symptoms suggest vocal cord dysfunction.

  • In patients with vocal cord dysfunction, pulmonary function testing may show a flattened inspiratory flow loop or FEF50/FIF50 (ratio of expiratory flow to inspiratory flow at 50% of forced vital capacity) of 1 or greater.6,7,11 Yield is higher when the patient is experiencing symptoms.6 Use of methacholine during pulmonary function testing helps evaluate for asthma as an alternative diagnosis.7,1620

  • Pulmonary function testing should be performed when signs and symptoms suggest vocal cord dysfunction or when asthma is considered as a possible etiology.

  • If asthma is being considered, initial pulmonary function testing should be ordered before flexible nasolaryngoscopy. However, if asthma is unlikely, flexible nasolaryngoscopy should be used for the initial evaluation based on expert opinion.

  • Chest radiography may be considered to evaluate for other etiologies, such as a compressive mass, although vocal cord dysfunction tends to cause more intermittent symptoms.

  • Reviewing a patient-generated video of an acute, symptomatic episode can be helpful to assess signs and symptoms.

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