Vocal cord dysfunction

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Vocal Cord Dysfunction
Other namesParadoxical Vocal Fold Motion (PVFM) or Paradoxical Vocal Cord Movement (PVCM)
Specialty Otorhinolaryngology

Vocal cord dysfunction (VCD) is a pathology affecting the vocal folds (commonly referred to as the vocal cords) [1] characterized by full or partial vocal fold closure causing difficulty and distress during respiration, especially during inhalation. [1]

Contents

Due to the similarity in symptoms, VCD attack are often mistaken for asthma attacks or laryngospasms. Symptoms of VCD are not always present. [2] Rather, they often occur episodically, often defined as "attacks," where the patient will be symptomatic for a short period of time. [1] Although several contributing factors have been identified, the exact cause of VCD is unknown. [3]

Diagnosis of VCD may include a series of evaluations including pulmonary function tests, medical imaging, and the evaluation or visualization of the vocal folds during an episode through the use of videolaryngoscopy. [3] Such evaluations can also help to rule out other conditions that can affect the upper and lower airway. [3] Treatment of VCD often combines behavioural, medical and psychological approaches, most often including an otolaryngologist, a psychologist, and a speech-language pathologist. [1] Although information on the incidence and prevalence of VCD is limited, it is known to occur most frequently in young women. [4]

Signs and symptoms

Many of the symptoms are not limited to the disorder, as they may resemble a number of conditions that affect the upper and lower airway. Such conditions include asthma, angioedema, vocal cord tumors, and vocal cord paralysis. [5] [6] [7] [8]

People with vocal cord dysfunction often complain of "difficulty in breathing in" or "fighting for breath", [6] which can lead to subjective respiratory distress, [5] and in severe cases, loss of consciousness. [4] They may report tightness in the throat or chest, choking, stridor on inhalation and wheezing, which can resemble the symptoms of asthma. [5] [6] [7] These episodes of dyspnea can be recurrent and symptoms can range from mild to severe and prolonged in some cases. [5] Agitation and a sense of panic are not uncommon and can result in hospitalization. [6]

Different subtypes of vocal cord dysfunction are characterized by additional symptoms. For instance, momentary aphonia can be caused by laryngospasm, an involuntary spasm of the vocal cords [5] and a strained or hoarse voice may be perceived when the vocal cord dysfunction occurs during speech. [5]

Many of the symptoms are not specific to vocal cord dysfunction and can resemble a number of conditions that affect the upper and lower airway.

Presentation

Open vocal cords as seen during normal inhalation PSM V64 D268 Vocal cords during inspiration.png
Open vocal cords as seen during normal inhalation
Closed vocal cords as seen during a VCD episode (or when speaking) PSM V64 D268 Vocal cords in position for speaking or singing.png
Closed vocal cords as seen during a VCD episode (or when speaking)

VCD can mimic asthma, anaphylaxis, collapsed lungs, pulmonary embolism, or fat embolism, which can lead to an inaccurate diagnosis and inappropriate, potentially harmful, treatment. [9] Some incidences[ spelling? ] of VCD are misdiagnosed as asthma, but are unresponsive to asthma therapy, including bronchodilators and steroids.[ citation needed ] Among adult patients, women tend to be diagnosed more often. [10] Among children and teenage patients, VCD has been linked with high participation in competitive sports and family orientation towards high achievement.[ citation needed ]

Vocal cord dysfunction co-occurs with asthma approximately 40% of the time. [11] This frequently results in a misdiagnosis of asthma alone. Even young children can tell the difference between an asthma attack (primarily difficulty exhaling) and a VCD attack (primarily difficulty inhaling).[ citation needed ] Knowing the difference between the two will help those who have both know when to use the rescue inhaler prescribed or when to use the breathing recovery exercises trained by a speech-language pathologist.[ citation needed ]

Episodes can be triggered suddenly or develop gradually and triggers are numerous. Primary causes are believed to be gastroesophageal reflux disease (GERD), extra-esophageal reflux (EERD), exposure to inhaled allergens, post-nasal drip, exercise, or neurological conditions that can cause difficulty inhaling only during waking. [11] Published studies emphasize anxiety or stress as a primary cause while more recent literature indicates a likely physical etiology.[ citation needed ] This disorder has been observed from infancy through old age, with the observation of its occurrence in infants leading some to believe that a physiological cause such as reflux or allergy is likely. Certain medications, such as antihistamines for allergies, cause drying of the mucous membranes, which can cause further irritation or hypersensitivity of the vocal cords.[ citation needed ]

Potential comorbidities

VCD has long been strongly associated with a variety of psychological or psychogenic factors, including  conversion disorder,  major depression,  obsessive-compulsive disorder,  anxiety  (especially in adolescents), stress (particularly stress relating to competitive sports), physical and sexual abuse,  post-traumatic stress disorder,  panic attacks,  factitious disorder  and  adjustment disorder. [10] [5] [6] [4]  It is important to note that anxiety and depression may occur in certain patients as a result of having VCD, rather than being the cause of it. [10] [5]  Psychological factors are important precipitating factors for many patients with VCD; although exercise is also a major trigger for episodes of VCD, some patients experience VCD co-occurring with anxiety regardless of whether or not they are physically active at the time of the VCD/anxiety episode. [4]  Experiencing or witnessing a traumatic event related to breathing (such as a near-drowning or life-threatening asthma attack, for example), has also been identified as a risk factor for VCD. [10]

VCD has also been associated with certain  neurologic  diseases including  Arnold-Chiari malformation, cerebral aqueduct  stenosis, cortical or  upper motor neuron  injury (such as that resulting from  stroke),  amyotrophic lateral sclerosis  (ALS),  parkinsonism  syndromes and other movement disorders. [10] [4] However, this association occurs only rarely. [4] In addition, it has been associated with Ehlers-Danlos Syndromes, a group of connective tissue disorders. [12]

Causes

The exact cause of VCD is not known, and it is unlikely that a single underlying cause exists. [5] [6]  Several contributing factors have been identified, which vary widely among VCD patients with different medical histories. [10]  Physical exercise (including, but not limited to, competitive athletics) is one of the major triggers for VCD episodes, leading to its frequent misdiagnosis as exercise-induced asthma. [10] [5] [6]  Other triggers include airborne pollutants and irritants such as smoke, dust, gases, soldering fumes, cleaning chemicals such as ammonia, perfumes, and other odours. [5] [4] Gastroesophageal reflux disease  (GERD) and  rhinosinusitis  (inflammation of the  paranasal sinuses  and  nasal cavity) may also play a role in inflaming the  airway  and leading to symptoms of VCD as discussed below. [5] [4]

Laryngeal hyperresponsiveness is considered the most likely physiologic cause of VCD, brought on by a range of different triggers that cause inflammation and/or irritation of the  larynx  (voice box). [10] [6] The glottic closure  reflex  (or laryngeal adductor reflex) serves to protect the airway, and it is possible that this reflex becomes hyperactive in some individuals, resulting in the paradoxical vocal fold closure seen in VCD. [10] [4]  Two major causes of laryngeal inflammation and hyperresponsiveness are gastroesophageal reflux disease (GERD) and  postnasal drip  (associated with  rhinosinusitis, allergic or nonallergic  rhinitis, or a viral  upper respiratory tract infection  (URI)). [10] [5] [6] [4]  Rhinosinusitis is very common among patients with VCD and for many patients, VCD symptoms are ameliorated when the rhinosinusitis is treated. [5]  GERD is also common among VCD patients, but only some experience an improvement in VCD symptoms when GERD is treated. [5] [6]  Other causes of laryngeal hyperresponsiveness include inhalation of toxins and irritants, cold and dry air, episodic  croup  and  laryngopharyngeal reflux  (LPR). [6]

Risk factors

The following increase an individual's chances for acquiring VCD: [13]

Diagnosis

The most effective diagnostic strategy is to perform laryngoscopy during an episode, at which time abnormal movement of the cords, if present, can be observed. If the endoscopy is not performed during an episode, it is likely that the vocal folds will be moving normally, a 'false negative' finding.[ citation needed ]

Spirometry may also be useful to establish the diagnosis of VCD when performed during a crisis or after a nasal provocation test. [14] With spirometry, just as the expiratory loop may show flattening or concavity when expiration is affected in asthma, so may the Inspiratory loop show truncation or flattening in VCD. Of course, testing may well be negative when symptoms are absent. [15]

Differential diagnosis

The symptoms of VCD are often inaccurately attributed to asthma, [5] which in turn results in the unnecessary and futile intake of corticosteroids, bronchodilators and leukotriene modifiers, [7] although there are instances of comorbidity of asthma and VCD. [16]

The differential diagnosis for vocal cord dysfunction includes vocal fold swelling from allergy, asthma, or some obstruction of the vocal folds or throat. Anyone suspected of this condition should be evaluated and the vocal folds (voice box) visualized.
In individuals who experience a persistent difficulty with inhaling, consideration should be given to a neurological cause such as brain stem compression, cerebral palsy, etc. [17]

The main difference between VCD and asthma is the audible stridor or wheezing that occurs at different stages of the breath cycle: VCD usually causes stridor on the inhalation, while asthma results in wheezing during exhalation. [5] [6] [7] Patients with asthma usually respond to the usual medication and see their symptoms resolve. [6] [7] Clinical measures that can be done to differentiate VCD from asthma include: [6]

Treatments

Once a diagnosis of VCD has been confirmed by a medical professional, a specific treatment plan can be implemented. If vocal cord dysfunction is secondary to an underlying condition, such as asthma, gastroesophageal reflux disease (GERD), or postnasal drip, it is important to treat the primary condition as this will help control VCD symptoms. [4] Conventional treatments for VCD are often multidisciplinary and include speech-language pathology, psychotherapy, behavioral therapy, use of anti-anxiety and anti-depressant medications, medical interventions, and hypnotherapy. [4] [18] [19] There is no uniform approach. [19] The information from randomized, blinded studies is limited. [18]

Behavioral approaches

Speech-language pathologists provide behavioral treatment of VCD. Speech therapy usually involves educating the client on the nature of the problem, what happens when symptoms are present, and then comparing this to what happens during normal breathing and phonation. [1] Intervention goals target teaching a client breathing and relaxation exercises so that they can control their throat muscles and keep the airway open, allowing air to flow in and out. [4]

Breathing techniques can be taught to reduce tension in the throat, neck, and upper body and bring attention to the flow of air during respiration. [20] Diaphragm support during breathing decreases muscle tension in the larynx. [20] These techniques are meant to move awareness away from the act of breathing in and focus on the auditory feedback provided by the air moving in and out. [4]

Other techniques can involve breathing through a straw and panting, which widens the opening of the throat by activating the Posterior cricoarytenoid (PCA) muscle. [4] [19] Endoscopic feedback can also be used to show a patient what is happening when they are doing simple tasks such as taking a deep breath or speaking on an inspiration. [1] This provides the client with visual information so that they can actually see what behaviours help to open the throat and what behaviors constrict the throat. [1] Respiratory muscle strength training, a form of increased resistance training using a hand-held breathing device has also been reported to alleviate symptoms. [1]

Speech therapy has been found to eliminate up to 90% of ER visits in patients with VCD. [19]

Medical approaches

Medical often works in conjunction with behavioral approaches. A pulmonary or ENT (otolaryngologist) specialist will screen for and address any potential underlying pathology that may be associated with VCD. Managing GERD has also been found to relieve laryngospasm, a spasm of the vocal cords that makes breathing and speaking difficult. [21]

Non-invasive positive pressure ventilation can be used if a patient's vocal cords adduct (close) during exhalation. [4] Mild sedatives have also been employed to reduce anxiety as well as reduce acute symptoms of VCD. [4] [19] Benzodiazepines are an example of one such treatment, though they have been linked to a risk of suppression of the respiratory drive. [19] While Ketamine, a dissociative anesthetic, does not suppress respiratory drive, it has been thought to be associated with laryngospasms. [19]

For more severe VCD cases, physicians may inject botulinum toxin into the vocal (thyroarytenoid) muscles to weaken or decrease muscle tension. [4] [1] Nebulized Lignocaine can also been used in acute cases and helium-oxygen inhalation given by face mask has been used in cases of respiratory distress. [4] [21] [22]

Psychological approaches

Psychological interventions including psychotherapy, cognitive behavioural therapy (CBT), Biofeedback, and teaching self-hypnosis are also suggested to treat VCD. [18] Intervention is generally targeted at making the client aware of stressors that may trigger VCD symptoms, to implement strategies to reduce stress and anxiety, and to teach techniques for coping with their symptoms. [18] [1]

CBT can focus on bringing awareness to negative thought patterns and help reframe them by focusing on problem solving strategies. [18] Psychologists may also use relaxation to reduce distress when a patient is experiencing symptoms. [4] [1] Biofeedback can be a helpful addition to psychotherapy. The aim of Biofeedback is to educate the client on what happens to the vocal cords during breathing and to help them learn to control their symptoms. [4]

Choosing an intervention strategy needs to be assessed by a multidisciplinary team and individualized therapy planned carefully, keeping the characteristics of each patient in mind. [18]

Prognosis

The natural prognosis of VCD in both children and adults is not well described in the literature. [7] Additionally, there is currently no research that has studied whether the underlying cause of VCD makes a difference in the resolution of symptoms or in the long-term prognosis of the impairment. [23]

Information on the prognosis of VCD after acute therapies is also limited. Minimal response has been documented with the continued treatment of asthma in people with VCD using inhaled bronchodilators, corticosteroids and other asthma medications. [23] While using Botox in VCD has limited reports, those that are available report successful resolution of exercise-induced VCD symptoms for up to 2 months. [23]

Outcomes of chronic VCD treatment are similarly limited. When pediatric patients undergoing hypnosis therapy were studied, more than half saw either a reduction or resolution of VCD. [23] Even though it is widely used, no long-term studies have been done to study the prognosis of VCD after psychotherapy. [23]

Speech therapy is the main course of treatment for long-term management of VCD and includes a variety of techniques such as relaxed-throat breathing, respiratory retraining therapy, and vocal hygiene counselling. [5] Most studies agree that symptoms of VCD improve in patients and few continue to require asthma medications six months post speech therapy intervention. [7] [23] Significant improvements were reported for respiratory retraining therapy, including fewer episodes of dyspnea per month and decreased respiratory stress severity. [24]

For those adolescent patients who recovered from VCD, the average time before the symptoms were resolved was 4–5 months. [7] However, some adolescents had VCD symptoms even 5 years post VCD onset, regardless of intervention. [7] It has been noted that some patients do not respond to standard VCD therapies and continue to express recurrent symptoms. [23]

Epidemiology

There is currently a limited amount of information available on the incidence and  prevalence  of VCD, and the various rates reported in the literature are most likely an underestimate. [4] [25]  Although VCD is thought to be rare overall, its prevalence among the population at large is not known. [6]

However, numerous studies have been conducted on its incidence and prevalence among patients presenting with asthma and  exertional dyspnea. A VCD incidence rate of 2% has been reported among patients whose primary complaint was either asthma or dyspnea; the same incidence rate has also been reported among patients with acute asthma exacerbation. [6] [25]  Meanwhile, much higher VCD incidence rates have also been reported in asthmatic populations, ranging from 14% in children with refractory asthma to 40% in adults with the same complaint. [25]  It has also been reported that the VCD incidence rate is as high as 27% in non-asthmatic teenagers and young adults. [25]

Data on the prevalence of VCD is also limited. An overall prevalence of 2.5% has been reported in patients presenting with asthma. [19]  Among adults with asthma considered "difficult to control", 10% were found to have VCD while 30% were found to have both VCD and asthma. [6]  Among children with severe asthma, a VCD prevalence rate of 14% has been reported. [6]  However, higher rates have also been reported; among one group of schoolchildren thought to have exercise-induced asthma, it was found that 26.9% actually had VCD and not asthma. [4]  Among intercollegiate athletes with exercise-induced asthma, the VCD rate has been estimated at 3%. [4]

In patients presenting with symptoms of dyspnea, prevalence rates ranging from 2.8% to 22% have been reported in various studies. [6] [4] [19]  It has been reported that two to three times more females than males have VCD. [6] [4] [25]  VCD is especially common in females who have psychological conditions. [4]  There is an increased risk associated with being young and female. [4]  Among patients with VCD, 71% are over the age of 18. [6]  In addition, 73% of those with VCD have a previous psychiatric diagnosis. [6]  VCD has also been reported in newborns with gastroesophageal reflux disorder (GERD). [4]

See also

Related Research Articles

<span class="mw-page-title-main">Asthma</span> Long-term inflammatory disease of the airways of the lungs

Asthma is a long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, coughing, chest tightness, and shortness of breath. These may occur a few times a day or a few times per week. Depending on the person, asthma symptoms may become worse at night or with exercise.

A bronchodilator or broncholytic is a substance that dilates the bronchi and bronchioles, decreasing resistance in the respiratory airway and increasing airflow to the lungs. Bronchodilators may be originating naturally within the body, or they may be medications administered for the treatment of breathing difficulties, usually in the form of inhalers. They are most useful in obstructive lung diseases, of which asthma and chronic obstructive pulmonary disease are the most common conditions. Although this remains somewhat controversial, they might be useful in bronchiolitis and bronchiectasis. They are often prescribed but of unproven significance in restrictive lung diseases.

<span class="mw-page-title-main">Reinke's edema</span> Medical condition

Reinke's edema is the swelling of the vocal cords due to fluid (edema) collected within the Reinke's space. First identified by the German anatomist Friedrich B. Reinke in 1895, the Reinke's space is a gelatinous layer of the vocal cord located underneath the outer cells of the vocal cord. When a person speaks, the Reinke's space vibrates to allow for sound to be produced (phonation). The Reinke's space is sometimes referred to as the superficial lamina propria.

<span class="mw-page-title-main">Cough</span> Sudden expulsion of air from the lungs as a reflex to clear irritants

A cough is a sudden expulsion of air through the large breathing passages which can help clear them of fluids, irritants, foreign particles and microbes. As a protective reflex, coughing can be repetitive with the cough reflex following three phases: an inhalation, a forced exhalation against a closed glottis, and a violent release of air from the lungs following opening of the glottis, usually accompanied by a distinctive sound.

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

Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is one of the upper gastrointestinal chronic diseases in which stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/or complications. Symptoms include dental corrosion, dysphagia, heartburn, odynophagia, regurgitation, non-cardiac chest pain, extraesophageal symptoms such as chronic cough, hoarseness, reflux-induced laryngitis, or asthma. In the long term, and when not treated, complications such as esophagitis, esophageal stricture, and Barrett's esophagus may arise.

<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">Post-nasal drip</span> Medical condition

Post-nasal drip (PND), also known as upper airway cough syndrome (UACS), occurs when excessive mucus is produced by the nasal mucosa. The excess mucus accumulates in the back of the nose, and eventually in the throat once it drips down the back of the throat. It can be caused by rhinitis, sinusitis, gastroesophageal reflux disease (GERD), or by a disorder of swallowing. Other causes can be allergy, cold, flu, and side effects from medications.

Aerophagia is a condition of excessive air swallowing, which goes to the stomach instead of the lungs. Aerophagia may also refer to an unusual condition where the primary symptom is excessive flatus (farting), belching (burping) is not present, and the actual mechanism by which air enters the gut is obscure or unknown. Aerophagia in psychiatry is sometimes attributed to nervousness or anxiety.

<span class="mw-page-title-main">Bronchoconstriction</span> Constriction of the terminal airways in the lungs

Bronchoconstriction is the constriction of the airways in the lungs due to the tightening of surrounding smooth muscle, with consequent coughing, wheezing, and shortness of breath.

Acute severe asthma, also known as status asthmaticus, is an acute exacerbation of asthma that does not respond to standard treatments of bronchodilators (inhalers) and corticosteroids. Asthma is caused by multiple genes, some having protective effect, with each gene having its own tendency to be influenced by the environment although a genetic link leading to acute severe asthma is still unknown. Symptoms include chest tightness, rapidly progressive dyspnea, dry cough, use of accessory respiratory muscles, fast and/or labored breathing, and extreme wheezing. It is a life-threatening episode of airway obstruction and is considered a medical emergency. Complications include cardiac and/or respiratory arrest. The increasing prevalence of atopy and asthma remains unexplained but may be due to infection with respiratory viruses.

Exercise-induced asthma (E.I.A.) occurs when the airways narrow as a result of exercise. The preferred term for this condition is exercise-induced bronchoconstriction (EIB). While exercise does not cause asthma, it is frequently an asthma trigger.

<span class="mw-page-title-main">Laryngospasm</span> Involuntary contraction of the vocal folds restricting inhalation

Laryngospasm is an uncontrolled or involuntary muscular contraction (spasm) of the vocal folds. It may be triggered when the vocal cords or the area of the trachea below the vocal folds detects the entry of water, mucus, blood, or other substance. It may be associated with stridor or retractions.

Reactive airway disease (RAD) is an informal label that physicians apply to patients with symptoms similar to those of asthma. An exact definition of the condition does not exist. Individuals who are typically labeled as having RAD generally have a history of wheezing, coughing, dyspnea, and production of sputum that may or may not be caused by asthma. Symptoms may also include, but are not limited to, coughing, shortness of breath, excess mucus in the bronchial tube, swollen mucous membrane in the bronchial tube, and/or hypersensitive bronchial tubes. Physicians most commonly label patients with RAD when they are hesitant about formally diagnosing a patient with asthma, which is most prevalent in the pediatric setting. While some physicians may use RAD and asthma synonymously, there is controversy over this usage.

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

Contact granuloma is a condition that develops due to persistent tissue irritation in the posterior larynx. Benign granulomas, not to be confused with other types of granulomas, occur on the vocal process of the vocal folds, where the vocal ligament attaches. Signs and symptoms may include hoarseness of the voice, or a sensation of having a lump in the throat, but contact granulomas may also be without symptoms. There are two common causes associated with contact granulomas; the first common cause is sustained periods of increased pressure on the vocal folds, and is commonly seen in people who use their voice excessively, such as singers. Treatment typically includes voice therapy and changes to lifestyle factors. The second common cause of granulomas is gastroesophageal reflux and is controlled primarily through the use of anti-reflux medication. Other associated causes are discussed below.

Sinus disease, allergies, and asthma have been shown to be intimately related through recent research. Moreover, gastroesophageal reflux disease (GERD), laryngopharyngeal reflux disease (LPRD) and/or snoring or sleep apnea are often present as well. "Chronic Airway-Digestive Inflammatory Disease" (CAID) is a phrase which has been coined by Dr. Jordan S. Josephson, M.D., F.A.C.S. and Dr. Jens Ponikeau, M.D. to describe this very complex set of problems which are caused by inflammation. This term was first described in a book entitled Sinus Relief Now. CAID directly affects the upper respiratory system, the lower airway and the GI tract and these areas are intimately connected.

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

Laryngopharyngeal reflux (LPR) 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.

<span class="mw-page-title-main">Pathophysiology of asthma</span> Medical condition

Asthma is a common pulmonary condition defined by chronic inflammation of respiratory tubes, tightening of respiratory smooth muscle, and episodes of bronchoconstriction. The Centers for Disease Control and Prevention estimate that 1 in 11 children and 1 in 12 adults have asthma in the United States of America. According to the World Health Organization, asthma affects 235 million people worldwide. There are two major categories of asthma: allergic and non-allergic. The focus of this article will be allergic asthma. In both cases, bronchoconstriction is prominent.

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

Tracheobronchomalacia (TBM) is a condition characterized by flaccidity of the tracheal support cartilage which leads to tracheal collapse. This condition can also affect the bronchi. There are two forms of this condition: primary TBM and secondary TBM. Primary TBM is congenital and starts as early as birth. It is mainly linked to genetic causes. Secondary TBM is acquired and starts in adulthood. It is mainly developed after an accident or chronic inflammation.

Medical gas therapy is a treatment involving the administration of various gases. It has been used in medicine since the use of oxygen therapy. Many other gases, collectively known as factitious airs, were explored for medicinal value in the late eighteenth century.

Chronic cough is long-term coughing, sometimes defined as more than several weeks or months. Generally a cough lasting for more than eight weeks for an adult would meet the clinical definition of a chronic cough; and for children this threshold is lower. The term can be used to describe the different causes related to coughing, the three main ones being upper airway cough syndrome, asthma and gastroesophageal reflux disease. It occurs in the upper airway of the respiratory system. Generally, a cough lasts around one to two weeks; however, chronic cough can persist for an extended period of time defined as six weeks or longer. People with chronic cough often experience more than one cause present. Due to the nature of the syndrome, the treatments used are similar; however, there are a subsequent number of treatments available, and the clinical management of the patients remains a challenge.

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  18. 1 2 3 4 5 6 Guglani L, Atkinson S, Hosanagar A, Guglani L (8 August 2014). "A systematic review of psychological interventions for adult and pediatric patients with vocal cord dysfunction". Frontiers in Pediatrics. 2: 82. doi: 10.3389/fped.2014.00082 . PMC   4126208 . PMID   25152871.
  19. 1 2 3 4 5 6 7 8 9 Denipah N, Dominguez CM, Kraai EP, Kraai TL, Leos P, Braude D (January 2017). "Acute Management of Paradoxical Vocal Fold Motion (Vocal Cord Dysfunction)". Annals of Emergency Medicine. 69 (1): 18–23. doi:10.1016/j.annemergmed.2016.06.045. PMID   27522309. S2CID   29171884.
  20. 1 2 Schwartz SK (2004). The source for voice disorders : adolescent & adult. East Moline, IL: LinguiSystems. ISBN   978-0-7606-0504-2.
  21. 1 2 Kendall KA, Louie S (December 2003). "Severe obstructive airway disorders and diseases: vocal fold dysfunction". Clinical Reviews in Allergy & Immunology. 25 (3): 221–31. doi:10.1385/CRIAI:25:3:221. PMID   14716068. S2CID   12175841.
  22. ↑ Tilles SA (November 2003). "Vocal cord dysfunction in children and adolescents". Current Allergy and Asthma Reports. 3 (6): 467–72. doi:10.1007/s11882-003-0056-z. PMID   14531966. S2CID   25328704.
  23. 1 2 3 4 5 6 7 Morris MJ, Allan PF, Perkins PJ (2006). "Vocal cord dysfunction: etiologies and treatment". Clinical Pulmonary Medicine. 13 (2): 73–86. doi:10.1097/01.cpm.0000203745.50250.3b. S2CID   18108490.
  24. ↑ Patel RR, Venediktov R, Schooling T, Wang B (August 2015). "Evidence-Based Systematic Review: Effects of Speech-Language Pathology Treatment for Individuals With Paradoxical Vocal Fold Motion". American Journal of Speech-Language Pathology. 24 (3): 566–84. doi:10.1044/2015_AJSLP-14-0120. PMID   25836980.
  25. 1 2 3 4 5 Katial RK, Hoyte FC (2014). Mackay IM, Rose NR (eds.). Diseases in DDx of Asthma: Vocal Cord Dysfunction. Encyclopedia of medical immunology: Volume 3. Berlin: Springer. pp. 245–251.
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