Division of Otolaryngology

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Voice and Swallow Clinics, Division of
Otolaryngology Head and Neck Surgery
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Paradoxical Vocal Fold Motion

• The Role of the Speech Pathologist
• ASHA 2008
• Chicago, IL
• Sherri K. Zelazny, MA CCC-SLP
• University of Wisconsin-Madison

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Our Role

• Behavioral Specialist
• Be smart
• Evaluate
• Treat
• Inform and Refer
• Educate

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When Do We Shine?

• Symptoms
• PCP
• Allergy/Asthma
• Pulmonary/Chest x-ray
• Cardiology
• Continued symptoms
• SLP
• ENT if needed /if you do not visualize
• Behavioral diagnosis and treatment
• Resolution done
• Continued symptoms
• More behavioral treatment with SLP
• Back to PCP

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Behavioral Specialist

• PVFM is scary
• Biggest benefit of seeing SLP
• Knowledge/Skill/TIME
• Listen
• Support
• Assure
• Be Confident

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Knowledge

• PVFM is a complex problem
• Not necessarily cut and dry
• General similarities
• Wide variety of differences
• Good treatment comes from a confident,
  knowledgeable SLP

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Knowledge

• Peer reviewed articles
• Continuing education
• Professional resources
• Experience

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Irritable Larynx Syndrome

• Neural plastic change to central brainstem nuclei
  may lead to a form of hyperkinetic laryngeal
  dysfunction.
• Controlling laryngeal neurons are held in a
  "spasm-ready" state and symptoms may be triggered
  by various stimuli.

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Irritable larynx

• Three primary criteria
• Symptoms attributable to laryngeal tension
• dysphonia and/or laryngospasm
• with or without globus and/or chronic cough
• Visible and palpable evidence of tension
• Laryngoscopic lateral and AP contraction
• palpation SH, TH, CT, pharynx
• Presence of a sensory trigger
• airborne substance, esophageal irritant, odor

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Irritable Larynx Syndrome

• Continuum of the following
• Chronic throat clearing
• Chronic cough
• Paradoxical vocal fold motion (PVFM)
• Laryngospasm
• A laryngeal defense/reflex mechanism

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Clinical Presentation

• More frequently female
• Has likely been treated unsuccessfully for asthma
• May have passed out from a PVFM event
• May have been treated in ER multiple times
• LPR has generally not been identified or treated
  prior to SLP assessment
• Skeptical that the SLP can help

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Referral Language

• Hx of GERD, cough, frequent throat clearing
• Hx of asthma, feels like cannot get breath in
• Episodes while playing soccer, inspiratory
  stridor
• Asthma unresponsive to inhalers
• Short of breath with swimming, truncated
  inspiratory loop

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Evaluation

• 90 minute evaluation
• History intake
• Visualization
• Behavioral management

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Intake

• PVFM history can be confusing
• Goals
• Symptom information
• Patient information
• Organize information tell the story
• Identify other contributing factors
• Get a picture
• Guide for report writing

• Questions related to
• Nature of attack
• Triggers
• Reflux
• Behavioral patterns
• Other medical problems
• Stress
• Daily schedule
• Patient awareness

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Intake

• Try to get as much information from the
  individual experiencing the problem as
  possiblevs.
• Getting it from the parents (no matter what age)
• Getting it from whomever comes with them

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Intake

• Describe the nature of the problem in their words
• Try not to ask leading questions
• Give choices if patient cannot give information

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Intake

• How involved is the patient in their care?
• Who referred you to this clinic?
• Why are you here today?

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Intake

• Describe the nature of your breathing difficulty.
• When did the problems begin?
• How long has the individual been dealing with it?
• Any inciting event
• Physical
• Emotional

• I have the most trouble with
• Inhaling
• Exhaling
• Both
• Do you have tightness in your
• Throat
• Chest
• Both
• Other

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Intake

• Wheeze a continuous, coarse, whistling, often
  on exhale
• Asthma
• Chronic obstructive pulmonary disease
• Pulmonary edema
• Tracheobronchitis
• Anaphylaxis
• PVFM

• Stridor high pitch/turbulent
• foreign bodies
• tumor formation,
• infections
• subglottic stenosis
• airway edema Laryngomalacia,
• subglottic hemangioma Congenital anomalies
• PVFM

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Intake

• How often does it happen?
• every day
• every week
• every month
• When was your last event?
• How long is a typical event?
• describe in minutes
• Responses
• 5 minutes
• 20-30 minutes
• All day

• Triggers?
• Exercise
• Nighttime
• While sitting
• Stress
• Coughing
• Other (describe)
• Does it come on slowly or suddenly?

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Intake

• Have you ever passed out?
• Have you ever been treated in the Emergency Room
  for this breathing difficulty?
• If yes, how many times and when was the last
  time?
• Have you ever been hospitalized for this
  breathing difficulty?
• If yes, how often
• When was the last time?

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Intake

• Does anything help you when you have trouble
  breathing?
• What has the patient figured out on their own?
• What will you be able to build on in treatment?

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Intake

• How quickly can you resume your activity after an
  event?
• When you resume your activity does the breathing
  problem come back?
• Does this condition limit your activity?

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Intake

• Do you have diagnosed reflux disease?
• Do you have diagnosed asthma?
• Do you have diagnosed allergies?
• Do you have an associated cough/throat clearing?

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Intake

• Are current breathing attacks the same as asthma?
• If no, how is it different?
• Important place to start treatment.

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Intake

• Have you experienced hoarseness?
• Does the quality of your voice change when you
  have on of these events?
• Did your voice change begin when you started
  having this breathing difficulty?
• Have you had any voice changes with use of
  inhalers?

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Lifestyle

• Smoking history
• Water intake daily
• Caffeine intake
• Carbonated beverages
• Alcohol intake weekly
• Eat late at night

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Intake

• Other medical conditions
• Surgeries
• Medications

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Young Kids

• Do you like school?
• Do you have friends?
• What is your favorite part of school?
• What is the hardest?
• Do you play
• Sports
• Instrument
• What else do you like to do?

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Young Kids

• Do you get a tummy ache after you eat?
• Do you ever have a yucky taste in your mouth?
• Do you ever have to swallow your lunch/dinner
  twice? (MTUs)

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Young Kids

• Can ask parents
• Any changes at home?
• How does child handle emotions?
• Good eater?
• Good sleeper?
• Reflux related foods?

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Athletes

• Have your workouts changed intensity?
• Have you had this problem during this sport
  before?
• Are you losing time in your events?
• Are you in competition for a spot on the team?
• Does it occur with every practice?

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Athletes

• Do you like your sport?
• I hate running, I do it because I am good.
• Are you a good student?
• Do you put a lot of pressure on yourself to
  succeed?
• In what other activities do you participate?

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Instrumental Evaluation

• At UW-Madison
• PVFM evaluations are performed by experienced
  speech language pathologists.
• Referral to ENT if needed.
• Medical needs and additional referrals are
  addressed by the referring physician.
• Speech language pathologist performs instrumental
  evaluation.
• Flexible fiberoptic nasendoscopy only if MD in
  clinic. (adult and peds)

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Instrumental Evaluation

• Laryngeal visualization
• Fiberoptic nasopharyngoscopy
• Patient can talk, breath, swallow
• Rarely need for nasal anesthetic in older kids
  and adults
• Rigid videostroboscopy
• Suspected lesion or evaluation of phonatory
  parameters
• Rarely need topical anesthetic

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Visualization tasks

• Observation of structure
• Resting breathing
• Sniff inhalation
• Pitch glide
• Cough
• Connected speech
• Reproduction of breathing attack
• Introduce ab-duction recovery exercise
• Visual feedback of recovery exercise may
• be the most important part of your
  evaluation/treatment

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Observation of Structure

• Edema
• Swelling around arytenoid complex
• Swelling in interarytenoid space
• Erythema
• Arytenoid complex
• Vocal folds

• Pseudosulcus
• Infraglottic edema
• Granuloma
• Vascularization
• Ectasias

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Resting Breathing

• Resting vs. essential tremor
• Extraneous movement of the arytenoid complex
• Percent adduction on resting exhale
• Stridor
• Margins of the vocal folds

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Sniff inhalation

• What
• Sufficiency of airway patency
• Bilateral movement of the vocal folds
• Laryngeal web or other obstruction lesion

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Pitch Glide

• Superior laryngeal nerve
• Cricothyroid muscle
• Laryngeal tilt
• Symmetry

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Cough

• Recurrent laryngeal nerve
• Lateral cricoarytenoid
• Interarytenoid
• Aspiration risk
• Airway protection Mucus versus lesion
• Functional dysphonia
• Mutational falsetto

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Connected speech

• Muscle tension dysphonia
• Primary or secondary tension involvement

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Reproduction of breathing attack

• Motion of the vocal folds
• Airway
• Noise

• Introduction of nasal abduction breathing
  exercises for visual biofeedback and training.

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Rigid videostroboscopy

• Voice concerns
• Lesion seen on flex

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PVFM Differential Diagnosis

• All ruled out or well managed
• Cardiac
• Pulmonary
• Asthma
• Allergy

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PVFM Differential Diagnosis

• Intake information
• Visualization
• Extraneous movement of the vocal folds
• Laryngeal edema
• Laryngeal erythema
• Reproduction of breathing attack
• Success of behavioral management

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Evaluation

• Evaluation and introduction to behavioral
  management.

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Treatment and Referral

• Treatment
• Medical treatment of co-morbidities by referring
  MD or ENT
• Behavioral treatment of breathing difficulty
• Behavioral management of reflux.

• Referrals
• Any medical concern not previously addressed
• Asthma
• GI
• Pulmonary
• Cardiac
• Psychology
• Complimentary medicine

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Behavioral Treatment

• Attention to physical stress in body tightening
  relaxing exercises.
• Abdominal breathing
• Abduction breathing and recovery exercise
• Activity based breathing
• Odor de-sensitivity
• 3-4 sessions

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What else could it be?
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What else could it be?

• Competitive Speed Skater

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What else could it be?

• Post intubation phonatory insufficiency

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What else could it be?

• Sarcoidosis
• Chronic cough

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What else could it be?

• 2 year old child

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What if you do not visualize?

• Establish a relationship with your referral
  sources and team.
• Provide education to your referral sources and
  team.
• Train your ENT in the PVFM diagnostic protocol.

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The next best thing is being there

• Be present for the ENT evaluation!
• Speech language pathologists and ENTs look at the
  larynx differently
• MD Medical evaluation
• SLP Behavioral evaluation

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What if you do not visualize?

• Make sure you have all the diagnostic
  information you need.
• Advocate for your role in diagnostics.
• Know your resources local and national.

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Schools

• Referral checklist
• If a child presents with one or any combination
  of the following symptoms that result in apparent
  airway obstruction and/or inability to continue
  activity, refer child to PCP for initiation of
  medical management to rule out PVCM. It is
  recommended that you communicate with the PCP as
  to the reason for referral and include this
  checklist for documentation purposes.
• Student
• Date
• Time of event
• Treatment given
• Treatment provided by

• Provide inservice education to
• Teachers
• Physical education staff
• Nursing
• Caregivers

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Referral Checklist for School Staff

• Asthma symptoms that do not follow their usual
  pattern
• Breathing status not restored with prescribed
  inhalers
• Intermittent shortness of breath
• Shortness of breath with neck tightness
• Shortness of breath during and/or following
  physical activity
• Shortness of breath during and/or following
  eating
• Voice changes during activity
• Choking sensation
• Intermittent wheezing or stridor

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Billing

• ICD-9
• 478.79
• Other disease of the larynx
• CPT
• 92506 Medical Speech Language Evaluation
• 31575 - Flexible only
• 31579 Flexible or Rigid Stroboscopy

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Marketing

• Identify your team members and referral sources
• Introduce yourself
• Sell yourself
• Phone call

• Follow-up with referral source after evaluation
• Provide treatment updates
• Relay results
• Phone call
• Fax
• Email

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Marketing

• Provide education
• Grand Rounds
• You to them
• Them to you
• Letter with peer reviewed articles
• How to refer
• When to refer
• Contact information

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Resources

• Sherri K. Zelazny, MA CCC-SLP
• University of Wisconsin Madison
• 608.263.4448
• zelazny_at_surgery.wisc.edu

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References

• American Speech-Language-Hearing Association.
  (2004). Knowledge and skills for speech-language
  pathologists with respect to vocal tract
  visualization and imaging. ASHA Supplement,24.
• Andrianopoulos, M. V., Gallivan, G. J.,
  Gallivan H. (2000).PVCD, PVCM, EPL, and irritable
  larynx syndrome What are we talking about and
  how do we treat it? Journal of Voice, 14,607618.
• Balkissoon, R. C., Blager, F. B. (2002). Vocal
  cord dysfunction Often misdiagnosed and treated
  inappropriately. Medical Scientific Update,
  19(1), 17.
• Brugman, S. M., Simons, S. M. (1998). Vocal
  cord dysfunction Dont mistake it for asthma.
  The Physician and Sports Medicine, 26(5), 6374.
• Ford, C N. (2005) Evaluation and Management of
  Laryngopharyngeal RefluxJAMA 294(12)1534-1540.
  
• Mathers-Schmidt, B. A. (2001). Paradoxical vocal
  fold motion A tutorial on a complex disorder and
  the speech-language pathologists role. American
  Journal of Speech-Language Pathology, 10,
  111125.
• Morrison, M. ,Rammage,L., Emami, A.J., (1999)
  Paradoxical vocal fold motion presentation and
  treatment options. Journal of Voice, 13, 447-455.
• Sandage, M. J., Zelazny, S. K. , Paradoxical
  Vocal Fold Motion in Children and Adolescents,
  (2004) Language, Speech and Hearing Services in
  the Schools, 35, 353362.