Diagnosis and Management of Vocal Cord Dysfunction

Case Study

A 28-year-old female is referred to a nurse practitioner at an asthma and allergy clinic. She is reporting intermittent dyspnea on exertion, which resolves quickly with rest and distraction, and a sensation of heaviness over the larynx and choking. Her symptoms are precipitated by postnasal drainage, stress, and gastroesophageal reflux. She frequently clears her throat. She denies hoarseness, dysphagia, chest tightness, chest pain, or wheezing. She notes nasal congestion and clear rhinitis on exposure to strong fragrances and inhaled irritants like wood-stove smoke.

A previous chest x-ray was normal. Skin testing was nonreactive for perennial and seasonal allergies, and her immunoglobulin E was normal. She has no food allergies and denies a history of angioedema, urticaria, or anaphylaxis. Her primary care provider (PCP) has seen her once a year on average for acute sinusitis, which has responded well to antibiotics. A past trial of Advair (fluticasone and salmeterol) from her PCP did not change her symptoms, and she was weaned off the medication. When she uses ProAir (albuterol), it does not seem to help, but she likes to carry it with her "just in case" she needs it. She feels her reflux is controlled when she takes her medication consistently. She takes Xanax (alprazolam) on occasion for anxiety and reports occasional insomnia. Mucinex (guaifenesin) 1200 mg twice daily thinned her secretions but did not seem to help her symptoms significantly. She denies being pregnant. She has no cardiac history and no previous history of asthma.

Current Medications

• Astepro 0.15% (azelastine) 2 sprays per nostril daily

• Rhinocort aqua 32 mcg (Budesonide) 2 sprays per nostril daily

• Nexium 20 mg (esomeprazole) daily

• Xanax 0.5 mg (alprazolam) daily prn

• Rozerem 8 mg (ramelteon) qhs prn

• ProAir (albuterol) 2 puffs qid prn (uses once a month)

• Ortho-novum 1/35 mg (estrogen and progestin) one tablet daily

Laboratory Studies

• CBC with differential: within normal limits

• Immunoglobulin E: 41.3 (0.0–378.0) IU/mL

• Nasal smear: no eosinophils seen, few WBCs/LPF 54% neutrophils, 6% lymphocytes, 40% epithelial cells

Review of Systems

• General: Negative for fever, chills, night sweats, loss of appetite or weight loss

• HEENT: Negative for headaches, sore throat, blurred vision, problem with hearing or sinus congestion

• Respiratory: Negative for wheezing

• Cardiovascular: Negative for chest pain, palpitations, or pedal edema

• Integumentary: Negative for skin rashes or other skin lesions

• Hematologic: Negative for easy bruising or bleeding

• Musculoskeletal: Negative for joint pain or swelling

• Neurologic: Negative for numbness, weakness, and balance or coordination difficulties

• Social history: Smokes 2 cigarettes a week on average. Denies alcohol or illicit drug use. Married with 2 children and works full time. Denies a history of recent travel

• Family history: Negative for asthma

• Height: 67.5"

• Weight: 203 lbs

• Temp: 97.8F

• BP: 132/70

• Pulse: 72

• Respirations: 18

Physical Examination

• General: alert and oriented in no acute distress, able to speak in complete sentences, no stridor noted, no dyspnea noted on exertion or at rest

• HEENT: normocephalic, no scalp lesions or tenderness, face symmetric, light reflex symmetric, conjunctivae clear, sclera white without lesions or redness, pupils equal reactive to light and accommodation, tympanic membranes and canals clear with intact landmarks, no nasal deformities, nasal mucosa mildly erythematous with mild engorgement of the turbinates, no nasal polyps seen, nasal septum midline without perforation, no sinus tenderness on percussion, pharynx clear without exudate, uvula rises on phonation, oral mucosa and gingivae pink without lesions

• Neck: supple without masses or thyromegaly; trachea is midline

• Chest: lungs clear to auscultation with normal respiratory movement and no accessory muscle use, normal AP diameter

• Heart: regular rate and rhythm, no murmur

• Skin: no rashes, hives, swelling, petechiae, or significant ecchymosis.

• Lymph: no palpable cervical, supraclavicular or axillary adenopathy

Diagnosis

• Vocal cord dysfunction. Patient has not responded to Advair (fluticasone and salmeterol) in the past and was weaned off that medication. She indicates her symptoms are located primarily over the larynx and are associated with exercise and postnasal drainage, her symptoms resolve quickly with rest and distraction, her spirometry values are normal without obstruction, and there is flattening of the inspiratory flow loop and no reversibility after bronchodilator, which is highly suggestive of VCD. (Note: there is no ICD 9 code for VCD, but upper respiratory hypersensitivity may be used, as well as episodic wheezing and shortness of breath.)

• Perennial nonallergic rhinitis, principally irritant provoked, is responsive to current medications.

• Gastroesophageal reflux generally well controlled when she takes her Nexium (esomeprazole); reflux likely contributing to her vocal cord symptoms.

Plan

1. Continue present medications as above. She was encouraged to perform deep breathing exercises instead of using her rescue inhaler. (For liability reasons her rescue inhaler was not discontinued at this time.)

2. Nasal saline lavage twice a day as needed for postnasal drainage or nasal mucoid congestion was recommended.

3. Diaphragmatic breathing exercises, musculoskeletal relaxation measures, nasal saline lavage, and gastroesophageal reflux prevention and treatment to reduce her vocal cord symptoms were discussed.

4. A speech therapy referral and ENT referral were offered. Exercise challenge testing was discussed, but the patient declined.

5. Smoking cessation was strongly advised and community resources for assistance were discussed.

6. Patient was reassured that her condition was not life threatening, and she verbalized an understanding of control measures.

7. A return visit was scheduled for 6 months with the plan to discontinue her bronchodilator at that time.

Journal for Nurse Practitioners. 2010;6(9):675-682. © 2010 Elsevier Science, Inc.

Cite this: Diagnosis and Management of Vocal Cord Dysfunction - Medscape - Oct 01, 2010.