Use of Botulinum Toxin Type A to Avoid Tracheal Intubation or Tracheostomy in Severe Paradoxical Vocal Cord Movement

doi:10.1378/chest.118.3.874

Chest

Volume 118, Issue 3, September 2000, Pages 874-876

https://doi.org/10.1378/chest.118.3.874 Get rights and content

Paradoxical vocal cord movement (PVCM) is characterized byparadoxical adduction of the vocal cords during inspiration and /orexpiration. Patients with severe forms of PVCM can present with acutedyspnea. In this article, we describe a patient with severe PVCM whohad required tracheal intubation or tracheostomy at multiple occasionsand who presented with acute hypercapnic respiratory failure. Usingsedation and intralaryngeal injection of botulinum toxin type A, wecould avoid more invasive intervention. Our observation shows thatbotulinum toxin type A should be considered in the acute care settingfor severe PVCM.

Section snippets

Case Report

A 35-year-old woman was admitted for respiratory distress after 1week of increasing dyspnea, despite treatment with inhaledcorticosteroids and bronchodilators. The patient had been treated forsuspected asthma since childhood. During the last 6 years, the patienthad experienced six similar episodes. Tracheal intubation was performedon four occasions, and tracheostomy was performed twice. During thelast episode, the respiratory obstruction resolved completelyimmediately after intubation. PVCM was

Discussion

The clinical presentation of PVCM ranges from mild dyspnea toacute respiratory distress. The condition should be considered in theacute care setting since it is frequently confused or associated withasthma.¹ The case reported here provides an example ofsevere PVCM with acute hypercapnic respiratory failure.

PVCM typically disappears during sleep. In our patient, airflowlimitation resolved during acute attacks culminating in syncope orafter IV sedation. This phenomenon provides a rationale for

References (6)

JP Hayes et al.
Three cases of paradoxical vocal cord adduction followed up over a 10-year period
Chest
(1993)
MH Marion et al.
Stridor and focal laryngeal dystonia
Lancet
(1992)
KB Newman et al.
Clinical features of vocal cord dysfunction
Am J Respir Crit Care Med
(1995)

There are more references available in the full text version of this article.

Cited by (54)

Clinical Characteristics and Impact of Inducible Laryngeal Obstruction in the UK National Registry
2024, Journal of Allergy and Clinical Immunology: In Practice
Inducible laryngeal obstruction (ILO) describes inappropriate laryngeal closure during respiration, with airflow obstruction occurring at the glottic and/or supraglottic level, leading to breathlessness.
There is a paucity of data describing the demographics and impact of ILO. We aimed to report the clinical and demographic features of ILO in individuals entered prospectively in the UK national ILO registry.
Data were entered into a Web-based registry from participants with endoscopically confirmed ILO who were attending four established UK-wide specialist ILO centers between March 2017 and November 2019. All patients provided written informed consent.
Data from 137 individuals were included. Most (87%) had inspiratory ILO and required provocation during endoscopy to induce symptoms. There was a female predominance (80%), mean age 47 years (SD, 15 years). The most common comorbidities included asthma (68%) and reflux (57%). Health care use was high: 88% had attended emergency health care with symptoms at least once in the previous 12 months and nearly half had been admitted to the hospital. A fifth had required admission to critical care owing to ILO symptoms. Patient morbidity was substantial; 64% reported impaired functional capacity (≥3 on the Medical Research Council Dyspnoea Scale) and a third stated that symptoms affected working capability.
We describe the first multicenter prospective characterization of individuals with endoscopically diagnosed ILO. Analysis of our multicenter data set identified ILO as associated with a high burden of morbidity and health care use, comparable to severe asthma. These data will support the development of health care resources in the future and guide research priorities.
Inductible laryngeal obstruction
2023, Revue Francaise d'Allergologie
L’obstruction laryngée inductible (c.-à-d. par un stimulus externe) est la terminologie consensuelle pour décrire la fermeture paroxystique et épisodique du larynx à l’origine de problèmes respiratoires avec des sous-catégorisations en lien avec le ou les inducteurs de la crise, et les résultats laryngoscopiques concernant les modalités de l’obstruction. Ce nouveau cadre a permis la révision des résultats publiées sous les différentes dénominations antérieures et d’améliorer les connaissances sur les modalités diagnostiques et thérapeutiques. Ainsi une obstruction laryngée inductible désigne une obstruction inappropriée, transitoire et réversible du larynx en réponse à des facteurs déclencheurs externes. Cause importante d’une variété de symptômes respiratoires, elle peut imiter l’asthme. Cependant, malgré les progrès récents, le mécanisme physiopathologique reste inconnu et les algorithmes de diagnostic et de traitement validés ne sont pas encore établis.
Inductible laryngeal obstruction (i.e. by an external stimulus) is the consensual terminology to describe the paroxysmal and episodic closure of the larynx at the origin of respiratory problems with sub-categorizations related to the inducers of the crisis, and laryngoscopic results regarding the modalities of obstruction. This new framework allowed the revision of the results published under the different previous names and improved knowledge on diagnostic and therapeutic modalities. Thus, an inducible laryngeal obstruction refers to an inappropriate, transient and reversible obstruction of the larynx in response to external triggers. An important cause of a variety of respiratory symptoms, it can mimic asthma. However, despite recent progress, the pathophysiological mechanism remains unknown and validated diagnostic and treatment algorithms are not yet established.
The Vocal Fold Dysfunction Questionnaire: Validity and Reliability of the Persian Version
2018, Journal of Voice
The aim of this study was to develop, validate, and assess the reliability of the Persian version of Vocal Cord Dysfunction Questionnaire (VCDQ_P).
The study design was cross-sectional or cultural survey.
Forty-four patients with vocal fold dysfunction (VFD) and 40 healthy volunteers were recruited for the study. To assess the content validity, the prefinal questions were given to 15 experts to comment on its essential. Ten patients with VFD rated the importance of VCDQ_P in detecting face validity. Eighteen of the patients with VFD completed the VCDQ 1 week later for test-retest reliability. To detect absolute reliability, standard error of measurement and smallest detected change were calculated. Concurrent validity was assessed by completing the Persian Chronic Obstructive Pulmonary Disease (COPD) Assessment Test (CAT) by 34 patients with VFD. Discriminant validity was measured from 34 participants. The VCDQ was further validated by administering the questionnaire to 40 healthy volunteers. Validation of the VCDQ as a treatment outcome tool was conducted in 18 patients with VFD using pre- and posttreatment scores.
The internal consistency was confirmed (Cronbach α = 0.78). The test-retest reliability was excellent (intraclass correlation coefficient = 0.97). The standard error of measurement and smallest detected change values were acceptable (0.39 and 1.08, respectively). There was a significant correlation between the VCDQ_P and the CAT total scores (P < 0.05). Discriminative validity was significantly different. The VCDQ scores in patients with VFD before and after treatment was significantly different (P < 0.001).
The VCDQ was cross-culturally adapted to Persian and demonstrated to be a valid and reliable self-administered questionnaire in Persian-speaking population.
Acute Management of Paradoxical Vocal Fold Motion (Vocal Cord Dysfunction)
2017, Annals of Emergency Medicine
Paradoxical vocal fold motion disorder, also commonly termed vocal cord dysfunction, is a poorly understood cause of acute upper airway obstruction. Patients with paradoxical vocal fold motion frequently present to the emergency department (ED) with acute respiratory distress and stridor. Lack of familiarity with this disorder may lead to delayed diagnosis or misdiagnosis and unnecessary intubations or surgical airway procedures. Although long-term management of paradoxical vocal fold motion is well described, there is a paucity of information about acute evaluation and management. This article aims to summarize the ED presentation and management of paradoxical vocal fold motion.
Paradoxic vocal fold movement disorder
2014, Otolaryngologic Clinics of North America
Vocal Cord Dysfunction
2013, Immunology and Allergy Clinics of North America
Citation Excerpt :
A more invasive and rarely used treatment approach involves intralaryngeal injection of botulinum toxin type A. This toxin acts by preventing acetylcholine release at nerve endings, resulting in chemical denervation, which paralyzes the vocal fold in the open position.11,30,40 Although this technique has been used to successfully treat ALBD and spasmodic dystonia,11,32 a review by Morris and colleagues in 200640 found only 9 reported cases of botulinum toxin used to treat VCD.

View all citing articles on Scopus

View full text

Chest

Selected ReportsUse of Botulinum Toxin Type A to Avoid Tracheal Intubation or Tracheostomy in Severe Paradoxical Vocal Cord Movement

Section snippets

Case Report

Discussion

Chest

Lancet

Clinical features of vocal cord dysfunction

Am J Respir Crit Care Med

Selected Reports
Use of Botulinum Toxin Type A to Avoid Tracheal Intubation or Tracheostomy in Severe Paradoxical Vocal Cord Movement