Opinion Statement
Vocal cord dysfunction (VCD) is a functional disorder of the vocal cords characterized by exaggerated adduction of vocal cords during inspiration and/or expiration causing respiratory and laryngeal symptoms. VCD can exist in isolation and coexist with asthma, or it can mimic asthma. The missteps during the VCD and asthma diagnostic process and subsequent faulty clinical conclusions can lead to mistreatment and increased health care utilization that can last for years. Therefore, diagnostic precision in conjunction with optimal therapeutics is a prerequisite for the best patient outcomes in this patient population. An integrated approach is frequently required using multiple diagnostic modalities to make a correct diagnosis. The treatment options, usually applied in a step-wise progression, depend on the severity of presentation and the underlying type of VCD. Future studies should address the better identification of specific phenotypes of VCD and their corresponding treatments.
Similar content being viewed by others
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Christopher KL, Wood RP 2nd, Eckert RC, Blager FB, Raney RA, Souhrada JF. Vocal-cord dysfunction presenting as asthma. N Engl J Med. 1983;308(26):1566–70. doi:10.1056/NEJM198306303082605.
Dunglison RD. The practice of medicine. Philadelphia, PA. Lea and Blanchard; 1842: 257–258.
MacKenzie M. Use of laryngoscopy in diseases of the throat. Philadelphia, PA: Lindsey and Blackeston; 1869. p. 246–50.
•• Morris MJ, Christopher KL. Diagnostic criteria for the classification of vocal cord dysfunction. Chest. 2010;138(5):1213–23. doi:10.1378/chest.09-2944. This is an excellent review of VCD literature and proposed diagnostic criteria
Christensen PM, Heimdal JH, Christopher KL, Bucca C, Cantarella G, Friedrich G, et al. ERS/ELS/ACCP 2013 international consensus conference nomenclature on inducible laryngeal obstructions. Eur Respir Rev. 2015;24(137):445–50. doi:10.1183/16000617.00006513.
Bucca C, Rolla G, Brussino L, De Rose V, Bugiani M. Are asthma-like symptoms due to bronchial or extrathoracic airway dysfunction? Lancet. 1995;346(8978):791–5.
Ayres JG, Gabbott PLA. Vocal cord dysfunction and laryngeal hyperresponsiveness: a function of altered autonomic balance? Thorax. 2002;57:284–5.
• Traister RS, Fajt ML, Whitman-Purves E, Anderson WC, Petrov AA. A retrospective analysis comparing subjects with isolated and coexistent vocal cord dysfunction and asthma. Allergy Asthma Proc. 2013;34(4):349–55. doi:10.2500/aap.2013.34.3673. This is the largest retrospective study to date examining the relationship between VCD and asthma
Gurevich-Uvena J, Parker JM, Fitzpatrick TM, Makashay MJ, Perello MM, Blair EA, et al. Medical comorbidities for paradoxical vocal fold motion (vocal cord dysfunction) in the military population. J Voice. 2010 Nov;24(6):728–31. doi:10.1016/j.jvoice.2009.03.007.
Morris MJ, Allan PF, Perkins PJ. Vocal cord dysfunction: etiologies and treatment. Clin Pulm Med. 2006;13:73–86.
Christopher KL, Morris MJ. Vocal cord dysfunction, paradoxic vocal fold motion, or laryngomalacia? Our understanding requires an interdisciplinary approach. Otolaryngol Clin N Am. 2010;43(1):43–66. doi:10.1016/j.otc.2009.12.002.
Doshi DR, Weinberger MM. Long-term outcome of vocal cord dysfunction. Ann Allergy Asthma Immunol. 2006;96(6):794–9. doi:10.1016/S1081-1206(10)61341-5.
Forrest LA, Husein T, Husein O. Paradoxical vocal cord motion: classification and treatment. Laryngoscope. 2012;122(4):844–53. doi:10.1002/lary.23176.
• Hull JH, Backer V, Gibson PG, Fowler SJ. Laryngeal dysfunction: assessment and management for the clinician. Am J Respir Crit Care Med. 2016;194(9):1062–72. doi:10.1164/rccm.201606-1249CI. This is an excellent review article of laryngeal dysfunction
Traister RS, Fajt ML, Petrov AA. The morbidity and cost of vocal cord dysfunction misdiagnosed as asthma. Allergy Asthma Proc. 2016;37(2):25–31. doi:10.2500/aap.2016.37.3936.
•• Newman KB, Mason UG 3rd, Schmaling KB. Clinical features of vocal cord dysfunction. Am J Respir Crit Care Med. 1995;152(4 Pt 1):1382–6. doi:10.1164/ajrccm.152.4.7551399. This is one of the first studies to compare the relationship between VCD and asthma
Yelken K, Yilmaz A, Guven M, Eyibilen A, Aladag I. Paradoxical vocal fold motion dysfunction in asthma patients. Respirology. 2009;14(5):729–33. doi:10.1111/j.1440-1843.2009.01568.x.
Holmes PW, Lau KK, Crossett M, Low C, Buchanan D, Hamilton GS, et al. Diagnosis of vocal cord dysfunction in asthma with high resolution dynamic volume computerized tomography of the larynx. Respirology. 2009;14(8):1106–13. doi:10.1111/j.1440-1843.2009.01629.x.
Jain S, Bandi V, Officer T, Wolley M, Guntupalli KK. Role of vocal cord function and dysfunction in patients presenting with symptoms of acute asthma exacerbation. J Asthma. 2006;43(3):207–12. doi:10.1080/02770900600566892.
• Bucca CB, Bugiani M, Culla B, Guida G, Heffler E, Mietta S, et al. Brussino chronic cough and irritable larynx. J Allergy Clin Immunol. 2011;127(2):412–9. doi:10.1016/j.jaci.2010.10.038. This is a very interesting article that explores the concept of laryngeal hypersensitivity in patients with chronic cough
Vertigan AE, Gibson PG, Theodoros DG, Winkworth AL. A review of voice and upper airway function in chronic cough and paradoxical vocal cord movement. Curr Opin Allergy Clin Immunol. 2007 Feb;7(1):37–42. doi:10.1097/ACI.0b013e328012c587.
• Vertigan AE, Bone SL, Gibson PG. Laryngeal sensory dysfunction in laryngeal hypersensitivity syndrome. Respirology. 2013;18(6):948–56. doi:10.1111/resp.12103. This study suggests common pathophysiology for 4 distinct upper airway disorders
Li RC, Singh U, Windom HP, Gorman S, Bernstein JA. Clinical associations in the diagnosis of vocal cord dysfunction. Ann Allergy Asthma Immunol. 2016;117(4):354–8. doi:10.1016/j.anai.2016.08.002.
•• Traister RS, Fajt ML, Landsittel D, Petrov AA. A novel scoring system to distinguish vocal cord dysfunction from asthma. J Allergy Clin Immunol Pract. 2014;2(1):65–9. doi:10.1016/j.jaip.2013.09.002. This is the first and easy to use symptom scoring index with high sensitivity and specificity that discriminates VCD from asthma
Pinto LH, Aun MV, Cukier-Blaj S, Stelmach R, Cukier A, Kalil J, et al. Vocal cord dysfunction diagnosis may be improved by a screening check list. Allergol Int. 2016;65(2):180–5. doi:10.1016/j.alit.2015.11.001.
Parsons JP, Benninger C, Hawley MP, Philips G, Forrest LA, Mastronarde JG. Vocal cord dysfunction: beyond severe asthma. Respir Med. 2010;104(4):504–9. doi:10.1016/j.rmed.2009.11.004.
Gartner-Schmidt JL, Shembel AC, Zullo TG, Rosen CA. Development and validation of the Dyspnea Index (DI): a severity index for upper airway-related dyspnea. J Voice. 2014;28(6):775–82. doi:10.1016/j.jvoice.2013.12.017.
Vertigan AE, Bone SL, Gibson PG. Development and validation of the Newcastle laryngeal hypersensitivity questionnaire. Cough. 2014;10(1):1. doi:10.1186/1745-9974-10-1.
Ye J, Nouraie M, Holguin F, Gillespie AI. The ability of patient-symptom questionnaires to differentiate PVFMD. J Voice. 2016;30(16):30229–6. doi:10.1016/j.jvoice.2016.08.013.
Heimdal JH, Roksund OD, Halvorsen T, Skadberg BT, Olofsson J. Continuous laryngoscopy exercise test: a method for visualizing laryngeal dysfunction during exercise. J Laryngoscope. 2006;116(1):52–7. doi:10.1097/01.mlg.0000184528.16229.ba.
• Olin JT, Clary MS, Fan EM, Johnston KL, State CM, Strand M, et al. Continuous laryngoscopy quantitates laryngeal behaviour in exercise and recovery. Eur Respir J. 2016;48(4):1192–200. doi:10.1183/13993003.00160-2016. This is an elegant study that reviews the use of continuous laryngoscopy for diagnosis of exercise induced laryngeal obstruction
Davis RS, Brugman SM, Larsen GL. Use of videography in the diagnosis of exercise-induced vocal cord dysfunction: a case report with video clips. J Allergy Clin Immunol. 2007;119(6):1329–31. doi:10.1016/j.jaci.2007.04.007.
Treole K, Trudeau MD, Forrest LA. Endoscopic and stroboscopic description of adults with paradoxical vocal fold dysfunction. J Voice. 1999;13(1):143–52.
• Milstein CF, Charbel S, Hicks DM, Abelson TI, Richter JE, Vaezi MF. Prevalence of laryngeal irritation signs associated with reflux in asymptomatic volunteers: impact of endoscopic technique (rigid vs. flexible laryngoscope). Laryngoscope. 2005;115(12):2256–61. doi:10.1097/01.mlg.0000184325.44968.b1. This study highlights the poor inter-rater agreement when using laryngoscopy for diagnosis of laryngopharyngeal reflux
J Haines, A Vyas, C Slinger, L Howell, SJ Fowler. M10 The development of a vocal cord dysfunction laryngoscopic appearance scale. Thorax December 2015-Volume 70 - Suppl 3.
Sterner JB, Morris MJ, Sill JM, Hayes JA. Inspiratory flow volume curve evaluation for detecting upper airway disease. Respir Care. 2009;54(4):461–6.
Owens CR, Murphy DM. Spirometric diagnosis of upper airway obstruction. Arch Intern Med. 1983;143:1331–4.
Murry T, Cukier-Blaj S, Kelleher A, Malki KH. Laryngeal and respiratory patterns in patients with paradoxical vocal fold motion. Respir Med. 2011;105(12):1891–5. doi:10.1016/j.rmed.2011.08.023.
Neukirch F, Weitzenblum E, Liard R, Korobaeff M, Henry C, Orvoën-Frija E, et al. Frequency and correlates of the saw-tooth pattern of flow-volume curves in an epidemiological survey. Chest. 1992;101(2):425–31.
Krieger J, Weitzenblum E, Vandevenne A, Stierle JL, Kurtz D. Flow-volume curve abnormalities and obstructive sleep apnea syndrome. Chest. 1985;87(2):163–7.
Perkins PJ, Morris MJ. Vocal cord dysfunction induced by methacholine challenge testing. Chest. 2002;122:1988–93.
Guss J, Mirza N. Methacholine challenge testing in the diagnosis of paradoxical vocal fold motion. Laryngoscope. 2006;116:1558–61. doi:10.1097/01.mlg.0000228007.74561.33.
Peters EJ, Hatley TK, Crater SE, Phillips CD, Platts-Mills TA, Borish L. Sinus computed tomography scan and markers of inflammation in vocal cord dysfunction and asthma. Ann Allergy Asthma Immunol. 2003;90(3):316–22. doi:10.1016/S1081-1206(10)61800-5.
Komarow HD, Young M, Nelson C, Metcalfe DD. Vocal cord dysfunction as demonstrated by impulse oscillometry. J Allergy Clin Immunol Pract. 2013;1(4):387–93. doi:10.1016/j.jaip.2013.05.005.
Gareth Hynes, Hugh Bakere, Claire McAleer, Philip Mitchelmore, Malcom Hilton, David Halpin. The benefits of an integrated vocal cord dysfunction service in treating a subgroup of patients with difficult to control asthma B107. Asthma Management and Health Education. May 1, 2015, A3813-A3813.
Denipah N, Dominguez CM, Kraai EP, Kraai TL, Leos P, Braude D. Acute management of paradoxical vocal fold motion (vocal cord dysfunction). Ann Emerg Med. 2017;69(1):18–23. doi:10.1016/j.annemergmed.2016.06.045.
Ibrahim WH, Gheriani HA, Almohamed AA, Raza T. Paradoxical vocal cord motion disorder: past, present and future. Postgrad Med J. 2007 Mar;83(977):164–72. doi:10.1136/pgmj.2006.052522.
Shin YH, Song KL, Ko DC, Pin JW, Ryu KH, Kim HS. Effectiveness of applying continuous positive airway pressure in a patient with paradoxical vocal fold movement after endotracheal extubation: a case report. Korean J Anesthesiol. 2016;69(1):84–7. doi:10.4097/kjae.2016.69.1.84.
Weir M. Vocal cord dysfunction mimics asthma and may respond to heliox. Clin Pediatr (Phila). 2002;41(1):37–41. doi:10.1177/000992280204100108.
Park DP, Ayres JG, McLeod DT, Mansur AH. Vocal cord dysfunction treated with long-term tracheostomy: 2 case studies. Ann Allergy Asthma Immunol. 2007;98(6):591–4.
Kenn K, Balkissoon R. Vocal cord dysfunction: what do we know? Eur Respir J. 2011;37(1):194–200. doi:10.1183/09031936.00192809.
Tay TR, Radhakrishna N, Hore-Lacy F, Smith C, Hoy R, Dabscheck E, et al. Comorbidities in difficult asthma are independent risk factors for frequent exacerbations, poor control and diminished quality of life. Respirology. 2016;21(8):1384–90. doi:10.1111/resp.12838.
Education NA, Program P. Expert Panel Report 3 (EPR-3): guidelines for the diagnosis and management of asthma—summary report 2007. J Allergy Clin Immunol. 2007;120(5 Suppl):S94–138. doi:10.1016/j.jaci.2007.09.043.
Global Initiative for Asthma. Global strategy for asthma management and prevention, 2017. Available from: www.ginasthma.org
Radhakrishna N, Tay TR, Hore-Lacy F, Stirling R, Hoy R, Dabscheck E, et al. Validated questionnaires heighten detection of difficult asthma comorbidities. J Asthma. 2016;7:0. doi:10.1080/02770903.2016.1212369.
Roth DF, Abbott KV, Carroll TL, Ferguson BJ. Evidence for primary laryngeal inhalant allergy: a randomized, double-blinded crossover study. Int Forum Allergy Rhinol. 2013;3(1):10–8. doi:10.1002/alr.21051.
Woolnough K, Blakey J, Pargeter N, Mansur A. Acid suppression does not reduce symptoms from vocal cord dysfunction, where gastro-laryngeal reflux is a known trigger. Respirology. 2013;18(3):553–4. doi:10.1111/resp.12058.
Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308–328; quiz 329. doi:10.1038/ajg.2012.444.
Fowler SJ, Thurston A, Chesworth B, Cheng V, Constantinou P, Vyas A, et al. The VCDQ—a questionnaire for symptom monitoring in vocal cord dysfunction. Clin Exp Allergy. 2015;45(9):1406–11. doi:10.1111/cea.12550.
Andrianopoulos MV, Gallivan GJ, Gallivan KH. PVCM, PVCD, EPL, and irritable larynx syndrome: what are we talking about and how do we treat it? Voice. 2000;14(4):607–18.
Guglani L, Atkinson S, Hosanagar A, Guglani L. A systematic review of psychological interventions for adult and pediatric patients with vocal cord dysfunction. Front Pediatr. 2014;2:82. doi:10.3389/fped.2014.00082.
Yonas MA, Lange NE, Celedón JC. Psychosocial stress and asthma morbidity. Curr Opin Allergy Clin Immunol. 2012;12(2):202–10. doi:10.1097/ACI.0b013e32835090c9.
Rosenberg SL, Miller GE, Brehm JM, Celedón JC. Stress and asthma: novel insights on genetic, epigenetic, and immunologic mechanisms. J Allergy Clin Immunol. 2014;134(5):1009–15. doi:10.1016/j.jaci.2014.07.005.
Huntley A, White AR, Ernst E. Relaxation therapies for asthma: a systematic review. Thorax. 2002;57(2):127–31.
Varney V, Parnell H, Evans J, Cooke N, Lloyd J, Bolton J. The successful treatment of vocal cord dysfunction with low-dose amitriptyline—including literature review. J Asthma Allergy. 2009;2:105–10.
Gibson P, Wang G, McGarvey L, Vertigan AE, Altman KW, Birring SS; CHEST Expert Cough Panel. Treatment of unexplained chronic cough: CHEST Guideline and Expert Panel Report. Chest. 2016;149(1):27–44. doi: 10.1378/chest.15-1496. This is a very important update that reviews the treatment of chronic unexplained cough.
Maillard I, Schweizer V, Broccard A, Duscher A, Liaudet L, Schaller MD. Use of botulinum toxin type A to avoid tracheal intubation or tracheostomy in severe paradoxical vocal cord movement. Chest. 2000;118(3):874–7.
Woisard V, Liu X, Bes MC, Simonetta-Moreau M. Botulinum toxin injection in laryngeal dyspnea. Eur Arch Otorhinolaryngol. 2017;274(2):909–17. doi:10.1007/s00405-016-4289-6.
Baxter M, Uddin N, Raghav S, Leong P, Low K, Hamza K, et al. Abnormal vocal cord movement treated with botulinum toxin in patients with asthma resistant to optimised management. Respirology. 2014;19(4):531–7. doi:10.1111/resp.12271.
Doshi DR, Weinberger MM. Long-term outcome of vocal cord dysfunction. Ann Allergy Asthma Immunol. 2006;96(6):794–9. doi:10.1016/S1081-1206(10)61341-5.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
Dr. Andrej Petrov declares that he has no conflict of interest. Dr. Russell Traister declares that he has no conflict of interest. Dr. Merritt Fajt declares that he has no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
This article is part of Topical Collection on Allergic Asthma
Rights and permissions
About this article
Cite this article
Fajt, M.L., Traister, R.S. & Petrov, A.A. Vocal Cord Dysfunction and Asthma. Curr Treat Options Allergy 4, 329–341 (2017). https://doi.org/10.1007/s40521-017-0138-0
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40521-017-0138-0