Exercise-induced laryngeal obstruction

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Exercise-induced laryngeal obstruction (EILO) is a transient, reversible narrowing of the larynx that occurs during high intensity exercise. This acts to impair airflow and cause shortness of breath, stridor and often discomfort in the throat and upper chest. EILO is a very common cause of breathing difficulties in young athletic individuals but is often misdiagnosed as asthma or exercise-induced bronchoconstriction. [1] [2]

Contents

Causes

EILO may arise because of a relative mechanical 'insufficiency' of the laryngeal structures that should act to maintain glottic patency. It has been proposed that a narrowing at the laryngeal inlet during the state of high airflow (e.g. when running fast), can act to cause a pressure drop across the larynx which then acts to 'pull' the laryngeal structures together. The Bernoulli principle states that increasing airflow through a tube creates increasing negative pressures within that tube. [3] Complex neuromuscular functioning is required to maintain laryngeal opening and to allow the larynx to achieve a great number of tasks (i.e. speaking, airway protection, swallowing). [4] It is thus also possible that EILO may arise as form a degree of neuromuscular failure.

A small heredity study indicated that an autosomal dominant model of inheritance with variable expressivity and reduced penetrance in males may be relevant; because in ten families studied, there was at least one affected person in every generation in which both parents were examined. [5]

Further work is needed to determine if structural deficiencies in the laryngeal tissue of individuals with EILO are present.[ citation needed ]

Mechanism

EILO is typically caused by a narrowing of the supra-glottic structures of the larynx. In severe cases, these structures, also called arytenoids, can close over to almost completely close the laryngeal inlet.[ citation needed ]

In fewer cases, the glottic (i.e. vocal cord) structures close together and this is typically what happens during exercise-induced vocal-cord dysfunction.[ citation needed ]

EILO develops during intense exercise and closure develops as exercise becomes more intense. [6]

Closure of the voice box during exercise causes increased 'loading' on the breathing system and the respiratory muscles have to work much harder. [7]

Epidemiology

The prevalence of EILO in adolescents and young adults appears to be in the range of 5–7% in northern Europe, with some indication that EILO may be more prevalent in highly trained athletes. [8] [9] [10]

Some, but not all studies report a higher female prevalence. Thus, in a study of 94 patients diagnosed using the CLE test, average age was ~15 years, and 68% were female. [11]

In athletic individuals EILO appears to be a highly prevalent cause of cough and wheeze and can co-exist with EIB. In one study, of almost 90 athletes, with unexplained respiratory symptoms, EILO was found to be present in approximately 30% of athletes, whilst EILO and EIB co-existed in one in ten. [12]

This condition can co-exist with other conditions, including severe asthma. [13]

Clinical features

Diagnosis

The current gold-standard means for diagnosing EILO is the continuous laryngoscopy during exercise test (CLE-test). This test involves the placement of a flexible laryngoscope via nostril, which is then secured in place and held with headgear. It allows continuous visualization of the laryngeal aperture during exercise. The CLE test can be used during indoor treadmill or cycle-ergometer exercise but also whilst rowing or swimming [15] or exercising outdoors. [16]

The examiner visually evaluates the relative change of the laryngeal inlet in the patient throughout the CLE-test. One common grading system uses 4 steps (0-3) on glottic and supraglottic level respectively. Grades 0-1 are considered normal, whereas grades 2-3 on either or both levels are consistent with EILO. [17] There is a need to identify other less-invasive means of making a secure diagnosis.

Treatment

The current mainstay of treatment is therapy-based. Specialist breathing techniques, most commonly termed biphasic breathing techniques or EILOBI are recommended to reduce turbulent inspiratory airflow and thus reduce chance of laryngeal closure. [18]

Direct laryngeal visualisation during exercise to deliver biofeedback has been employed with success.[ citation needed ]

The place of inspiratory muscle training (IMT) is yet to be defined in EILO therapy.[ citation needed ]

Surgical treatment with supraglottopasty has also been utilised with success. [19]

Avoiding unnecessary treatment with asthma inhalers is important.[ citation needed ]

Related Research Articles

<span class="mw-page-title-main">Larynx</span> Voice box, an organ in the neck of amphibians, reptiles, and mammals

The larynx, commonly called the voice box, is an organ in the top of the neck involved in breathing, producing sound and protecting the trachea against food aspiration. The opening of larynx into pharynx known as the laryngeal inlet is about 4–5 centimeters in diameter. The larynx houses the vocal cords, and manipulates pitch and volume, which is essential for phonation. It is situated just below where the tract of the pharynx splits into the trachea and the esophagus. The word 'larynx' comes from the Ancient Greek word lárunx ʻlarynx, gullet, throat.ʼ

<span class="mw-page-title-main">Tracheal intubation</span> Placement of a tube into the trachea

Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. It is frequently performed in critically injured, ill, or anesthetized patients to facilitate ventilation of the lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway obstruction.

<span class="mw-page-title-main">Laryngoscopy</span> Endoscopy of the larynx

Laryngoscopy is endoscopy of the larynx, a part of the throat. It is a medical procedure that is used to obtain a view, for example, of the vocal folds and the glottis. Laryngoscopy may be performed to facilitate tracheal intubation during general anaesthesia or cardiopulmonary resuscitation or for surgical procedures on the larynx or other parts of the upper tracheobronchial tree.

<span class="mw-page-title-main">Epiglottis</span> Leaf-shaped flap in the throat that prevents food from entering the windpipe and the lungs

The epiglottis is a leaf-shaped flap in the throat that prevents food and water from entering the trachea and the lungs. It stays open during breathing, allowing air into the larynx. During swallowing, it closes to prevent aspiration of food into the lungs, forcing the swallowed liquids or food to go along the esophagus toward the stomach instead. It is thus the valve that diverts passage to either the trachea or the esophagus.

<span class="mw-page-title-main">Laryngitis</span> Medical condition

Laryngitis is inflammation of the larynx. Symptoms often include a hoarse voice and may include fever, cough, pain in the front of the neck, and trouble swallowing. Typically, these last under two weeks.

<span class="mw-page-title-main">Respiratory arrest</span> Medical condition

Respiratory arrest is a serious medical condition caused by apnea or respiratory dysfunction severe enough that it will not sustain the body. Prolonged apnea refers to a patient who has stopped breathing for a long period of time. If the heart muscle contraction is intact, the condition is known as respiratory arrest. An abrupt stop of pulmonary gas exchange lasting for more than five minutes may permanently damage vital organs, especially the brain. Lack of oxygen to the brain causes loss of consciousness. Brain injury is likely if respiratory arrest goes untreated for more than three minutes, and death is almost certain if more than five minutes.

<span class="mw-page-title-main">Laryngectomy</span> Surgical procedure

Laryngectomy is the removal of the larynx and separation of the airway from the mouth, nose and esophagus. In a total laryngectomy, the entire larynx is removed. In a partial laryngectomy, only a portion of the larynx is removed. Following the procedure, the person breathes through an opening in the neck known as a stoma. This procedure is usually performed by an ENT surgeon in cases of laryngeal cancer. Many cases of laryngeal cancer are treated with more conservative methods. A laryngectomy is performed when these treatments fail to conserve the larynx or when the cancer has progressed such that normal functioning would be prevented. Laryngectomies are also performed on individuals with other types of head and neck cancer. Less invasive partial laryngectomies, including tracheal shaves and feminization laryngoplasty may also be performed on transgender women and other female or non-binary identified individuals to feminize the larynx and/or voice. Post-laryngectomy rehabilitation includes voice restoration, oral feeding and more recently, smell and taste rehabilitation. An individual's quality of life can be affected post-surgery.

<span class="mw-page-title-main">Posterior cricoarytenoid muscle</span> Muscle of the larynx

The posterior cricoarytenoid muscle is a intrinsic muscle of the larynx. It arises from the cricoid cartilage; it inserts onto the arytenoid cartilage of the same side. It is innervated by the recurrent laryngeal nerve. Each acts to open the vocal folds by pulling the vocal fold of the same side laterally. It participates in the production of sounds.

<span class="mw-page-title-main">Laryngeal papillomatosis</span> Medical condition

Laryngeal papillomatosis, also known as recurrent respiratory papillomatosis (RRP) or glottal papillomatosis, is a rare medical condition in which benign tumors (papilloma) form along the aerodigestive tract. There are two variants based on the age of onset: juvenile and adult laryngeal papillomatosis. The tumors are caused by human papillomavirus (HPV) infection of the throat. The tumors may lead to narrowing of the airway, which may cause vocal changes or airway obstruction. Laryngeal papillomatosis is initially diagnosed through indirect laryngoscopy upon observation of growths on the larynx and can be confirmed through a biopsy. Treatment for laryngeal papillomatosis aims to remove the papillomas and limit their recurrence. Due to the recurrent nature of the virus, repeated treatments usually are needed. Laryngeal papillomatosis is primarily treated surgically, though supplemental nonsurgical and/or medical treatments may be considered in some cases. The evolution of laryngeal papillomatosis is highly variable. Though total recovery may be observed, it is often persistent despite treatment. The number of new cases of laryngeal papillomatosis cases is approximately 4.3 cases per 100,000 children and 1.8 cases per 100,000 adults annually.

<span class="mw-page-title-main">Arytenoid cartilage</span> Part of the larynx, to which the vocal folds (vocal cords) are attached

The arytenoid cartilages are a pair of small three-sided pyramids which form part of the larynx. They are the site of attachment of the vocal cords. Each is pyramidal or ladle-shaped and has three surfaces, a base, and an apex. The arytenoid cartilages allow for movement of the vocal cords by articulating with the cricoid cartilage. They may be affected by arthritis, dislocations, or sclerosis.

Exercise-induced bronchoconstriction (EIB) occurs when the airways narrow as a result of exercise. This condition has been referred to as exercise-induced asthma (EIA), however this term is no longer preferred. While exercise does not cause asthma, it is frequently an asthma trigger.

<span class="mw-page-title-main">Laryngomalacia</span> Medical condition

Laryngomalacia is the most common cause of chronic stridor in infancy, in which the soft, immature cartilage of the upper larynx collapses inward during inhalation, causing airway obstruction. It can also be seen in older patients, especially those with neuromuscular conditions resulting in weakness of the muscles of the throat. However, the infantile form is much more common. Laryngomalacia is one of the most common laryngeal congenital disease in infancy and public education about the signs and symptoms of the disease is lacking.

Vocal cord paresis, also known as recurrent laryngeal nerve paralysis or vocal fold paralysis, is an injury to one or both recurrent laryngeal nerves (RLNs), which control all intrinsic muscles of the larynx except for the cricothyroid muscle. The RLN is important for speaking, breathing and swallowing.

<span class="mw-page-title-main">Laryngopharyngeal reflux</span> Medical condition

Laryngopharyngeal reflux (LPR) or laryngopharyngeal reflux disease (LPRD) is the retrograde flow of gastric contents into the larynx, oropharynx and/or the nasopharynx. LPR causes respiratory symptoms such as cough and wheezing and is often associated with head and neck complaints such as dysphonia, globus pharyngis, and dysphagia. LPR may play a role in other diseases, such as sinusitis, otitis media, and rhinitis, and can be a comorbidity of asthma. While LPR is commonly used interchangeably with gastroesophageal reflux disease (GERD), it presents with a different pathophysiology.

Vocal cord dysfunction (VCD) is a pathology affecting the vocal folds characterized by full or partial vocal fold closure causing difficulty and distress during respiration, especially during inhalation.

<span class="mw-page-title-main">Laryngeal saccules</span> Extensions of the laryngeal ventricles

The laryngeal saccules are soft tissue masses that are extensions of the laryngeal ventricles in the larynx. Their function is not well understood, but they may lubricate the vocal cords, and increase the resonance of vocalisation. They may be involved in airway disease and airway obstruction. They may be surgically removed using a laryngeal sacculectomy.

<span class="mw-page-title-main">Advanced airway management</span>

Advanced airway management is the subset of airway management that involves advanced training, skill, and invasiveness. It encompasses various techniques performed to create an open or patent airway – a clear path between a patient's lungs and the outside world.

Laryngeal cysts are cysts involving the larynx or more frequently supraglottic locations, such as epiglottis and vallecula. Usually they do not extend to the thyroid cartilage. They may be present congenitally or may develop eventually due to degenerative cause. They often interfere with phonation.

Muscle tension dysphonia (MTD) was originally coined in 1983 by Morrison and describes a dysphonia caused by increased muscle tension of the muscles surrounding the voice box: the laryngeal and paralaryngeal muscles. MTD is a unifying diagnosis for a previously poorly categorized disease process. It allows for the diagnosis of dysphonia caused by many different etiologies and can be confirmed by history, physical exam, laryngoscopy and videostroboscopy, a technique that allows for the direct visualization of the larynx, vocal cords, and vocal cord motion.

<span class="mw-page-title-main">Intubation granuloma</span> Medical condition

Intubation granuloma is a benign growth of granulation tissue in the larynx or trachea, which arises from tissue trauma due to endotracheal intubation. This medical condition is described as a common late complication of tracheal intubation, specifically caused by irritation to the mucosal tissue of the airway during insertion or removal of the patient's intubation tube.

References

  1. ↑ Hall, Andrew; Thomas, Mike; Sandhu, Guri; Hull, James H (September 2016). "Exercise-induced laryngeal obstruction: a common and overlooked cause of exertional breathlessness". British Journal of General Practice. 66 (650): e683–e685. doi:10.3399/bjgp16X687001. PMC   5198683 . PMID   27563141.
  2. ↑ Halvorsen, Thomas; Walsted, Emil Schwarz; Bucca, Caterina; Bush, Andrew; Cantarella, Giovanna; Friedrich, Gerhard; Herth, Felix J.F.; Hull, James H.; Jung, Harald; Maat, Robert; Nordang, Leif; Remacle, Marc; Rasmussen, Niels; Wilson, Janet A.; Heimdal, John-Helge (September 2017). "Inducible laryngeal obstruction: an official joint European Respiratory Society and European Laryngological Society statement". European Respiratory Journal. 50 (3): 1602221. doi: 10.1183/13993003.02221-2016 . hdl: 10044/1/54549 . PMID   28889105.
  3. ↑ Røksund, Ola Drange; Heimdal, John-Helge; Olofsson, Jan; Maat, Robert Christiaan; Halvorsen, Thomas (September 2015). "Larynx during exercise: the unexplored bottleneck of the airways". European Archives of Oto-Rhino-Laryngology. 272 (9): 2101–2109. doi:10.1007/s00405-014-3159-3. PMC   4526593 . PMID   25033930.
  4. ↑ Hull, James H.; Backer, Vibeke; Gibson, Peter G.; Fowler, Stephen J. (1 November 2016). "Laryngeal Dysfunction: Assessment and Management for the Clinician". American Journal of Respiratory and Critical Care Medicine. 194 (9): 1062–1072. doi:10.1164/rccm.201606-1249CI. PMID   27575803.
  5. ↑ Walsted, Emil Schwarz; Hvedstrup, Jeppe; Eiberg, Hans; Backer, Vibeke (August 2017). "Heredity of supraglottic exercise-induced laryngeal obstruction". European Respiratory Journal. 50 (2): 1700423. doi: 10.1183/13993003.00423-2017 . PMID   28818875.
  6. ↑ Olin, J. Tod; Clary, Matthew S.; Fan, Elizabeth M.; Johnston, Kristina L.; State, Claire M.; Strand, Matthew; Christopher, Kent L. (October 2016). "Continuous laryngoscopy quantitates laryngeal behaviour in exercise and recovery". European Respiratory Journal. 48 (4): 1192–1200. doi: 10.1183/13993003.00160-2016 . PMID   27418554.
  7. ↑ Walsted, Emil S.; Faisal, Azmy; Jolley, Caroline J.; Swanton, Laura L.; Pavitt, Matthew J.; Luo, Yuan-Ming; Backer, Vibeke; Polkey, Michael I.; Hull, James H. (1 February 2018). "Increased respiratory neural drive and work of breathing in exercise-induced laryngeal obstruction". Journal of Applied Physiology. 124 (2): 356–363. doi:10.1152/japplphysiol.00691.2017. PMC   5867370 . PMID   29097629.
  8. ↑ Johansson, Henrik; Norlander, Katarina; Berglund, Lars; Janson, Christer; Malinovschi, Andrei; Nordvall, Lennart; Nordang, Leif; Emtner, Margareta (January 2015). "Prevalence of exercise-induced bronchoconstriction and exercise-induced laryngeal obstruction in a general adolescent population". Thorax. 70 (1): 57–63. doi: 10.1136/thoraxjnl-2014-205738 . PMID   25380758.
  9. ↑ Christensen, Pernille M.; Thomsen, S. F.; Rasmussen, N.; Backer, V. (September 2011). "Exercise-induced laryngeal obstructions: prevalence and symptoms in the general public". European Archives of Oto-Rhino-Laryngology. 268 (9): 1313–1319. doi:10.1007/s00405-011-1612-0. PMID   21528411. S2CID   23253671.
  10. ↑ Ersson, Karin; Mallmin, Elisabet; Malinovschi, Andrei; Norlander, Katarina; Johansson, Henrik; Nordang, Leif (December 2020). "Prevalence of exercise‐induced bronchoconstriction and laryngeal obstruction in adolescent athletes". Pediatric Pulmonology. 55 (12): 3509–3516. doi: 10.1002/ppul.25104 . ISSN   8755-6863. PMC   7702091 . PMID   33002318.
  11. ↑ Maat, Robert Christiaan; Hilland, Magnus; Røksund, Ola Drange; Halvorsen, Thomas; Olofsson, Jan; Aarstad, Hans Jørgen; Heimdal, John-Helge (October 2011). "Exercise-induced laryngeal obstruction: natural history and effect of surgical treatment". European Archives of Oto-Rhino-Laryngology. 268 (10): 1485–1492. doi:10.1007/s00405-011-1656-1. PMC   3166603 . PMID   21643933.
  12. ↑ Nielsen, Emil Walsted; Hull, James H.; Backer, Vibeke (November 2013). "High Prevalence of Exercise-Induced Laryngeal Obstruction in Athletes". Medicine & Science in Sports & Exercise. 45 (11): 2030–2035. doi: 10.1249/MSS.0b013e318298b19a . PMID   23657163. S2CID   6603638.
  13. ↑ Hull, James H.; Walsted, Emil S.; Pavitt, Matt J.; Menzies-Gow, Andrew; Backer, Vibeke; Sandhu, Guri (15 February 2019). "High Prevalence of Laryngeal Obstruction during Exercise in Severe Asthma". American Journal of Respiratory and Critical Care Medicine. 199 (4): 538–542. doi:10.1164/rccm.201809-1734LE. PMC   6376624 . PMID   30570393.
  14. ↑ Griffin, Steffan Arthur; Walsted, Emil S; Hull, James H (September 2018). "Breathless athlete: exercise-induced laryngeal obstruction". British Journal of Sports Medicine. 52 (18): 1211–1212. doi:10.1136/bjsports-2018-099159. PMID   29669719. S2CID   4930495.
  15. ↑ Walsted, Emil S.; Swanton, Laura L.; van van Someren, Ken; Morris, Tessa E.; Furber, Matthew; Backer, Vibeke; Hull, James H. (October 2017). "Laryngoscopy during swimming: A novel diagnostic technique to characterize swimming-induced laryngeal obstruction: Laryngoscopy During Swimming". The Laryngoscope. 127 (10): 2298–2301. doi:10.1002/lary.26532. PMID   28236311. S2CID   45634351.
  16. ↑ Hull, James H.; Walsted, Emil S.; Orton, Christopher M.; Williams, Parris; Ward, Simon; Pavitt, Mathew J. (February 2019). "Feasibility of portable continuous laryngoscopy during exercise testing". ERJ Open Research. 5 (1). doi:10.1183/23120541.00219-2018. PMC   6360209 . PMID   30740460.
  17. ↑ Røksund, Ola Drange; Maat, Robert Christiaan; Heimdal, John Helge; Olofsson, Jan; Skadberg, Britt Torunn; Halvorsen, Thomas (1 December 2009). "Exercise induced dyspnea in the young. Larynx as the bottleneck of the airways". Respiratory Medicine. 103 (12): 1911–1918. doi:10.1016/j.rmed.2009.05.024. hdl: 1956/5337 . PMID   19782550.
  18. ↑ Johnston, Kristina L.; Bradford, Hannah; Hodges, Heather; Moore, Camille M.; Nauman, Emily; Olin, J. Tod (November 2018). "The Olin EILOBI Breathing Techniques: Description and Initial Case Series of Novel Respiratory Retraining Strategies for Athletes with Exercise-Induced Laryngeal Obstruction". Journal of Voice. 32 (6): 698–704. doi:10.1016/j.jvoice.2017.08.020. PMID   29050661. S2CID   36324540.
  19. ↑ Heimdal, John-Helge; Maat, Robert; Nordang, Leif (May 2018). "Surgical Intervention for Exercise-Induced Laryngeal Obstruction". Immunology and Allergy Clinics of North America. 38 (2): 317–324. doi:10.1016/j.iac.2018.01.005. PMID   29631739.

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