OBJECTIVE:Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) commonly co-exists with asthma and can start after viral infections. In this setting evidence suggests that dysfunctional breathing may induce the disorder but this possibility has not been researched. We therefore postulated that dysfunctional breathing can induce VCD/ILO, more so in people with asthma and after viral infections. METHODS:Eight healthy control subjects, 16 people with asthma and eight people who had recent COVID-19 infection (three with asthma) were recruited. Video-recorded laryngoscopy was performed at tidal breathing and during controlled hyperventilation (used as a proxy for dysfunctional breathing). VCD/ILO was diagnosed by laryngoscopy using accepted criteria and correlated with study cohorts, clinical attributes, asthma severity and spirometry. RESULTS:Overall, 32 subjects were studied. Hyperventilation was verified in all subjects. None of the healthy control group or people with mild asthma developed VCD/ILO during or after hyperventilation but one person with moderate/severe asthma had clear evidence of VCD/ILO. In contrast, in people who had COVID-19 infection, hyperventilation induced VCD/ILO in 3/8 people (38%). CONCLUSION:These proof-of-concept studies suggest that hyperventilation can provoke VCD/ILO in asthma and after a recent viral infection. How and why VCD/ILO develops is not known and these preliminary findings should prompt further studies of links between dysfunctional breathing, asthma, and viral infections.

Vocal cord dysfunction/inducible laryngeal obstruction is highly variable. Standard clinical symptoms and questionnaires cannot predict laryngoscopic diagnosis in a "lung disease" population. https://bit.ly/3QUtsbB.

Introduction Currently there is no consistent and widely accepted approach to the diagnosis of vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO). Harmonised diagnostic methods are vital to enable optimal diagnosis, advance management and enable research. We aim to obtain consensus on how expert clinicians recognise and diagnose VCD/ILO. Methods and analysis Two-round modified Delphi, with workshop validation. Ethics and dissemination Institutional Board Review was obtained from the Monash Health Human Research Ethics Committee. The dissemination plan is for presentation and publication. Registration details Registered at Australia and New Zealand Clinical Trials Registry ACTRN12621001520820p.

IntroductionVocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) is an important medical condition but understanding of the condition is imperfect. It occurs in healthy people but often co-exists with asthma. Models of VCD/ILO pathophysiology highlight predisposing factors rather than specific mechanisms and disease expression varies between people, which is seldom appreciated. Diagnosis is often delayed, and the treatment is not evidence based.Areas coveredA unified pathophysiological model and disease phenotypes have been proposed. Diagnosis is conventionally made by laryngoscopy during inspiration with vocal cord narrowing >50% Recently, dynamic CT larynx was shown to have high specificity (>80%) with potential as a noninvasive, swift, and quantifiable diagnostic modality. Treatment entails laryngeal retraining with speech pathology intervention and experimental therapies such as botulinum toxin injection. Multidisciplinary team (MDT) clinics are a novel innovation with demonstrated benefits including accurate diagnosis, selection of appropriate treatment, and reductions in oral corticosteroid exposure.Expert opinionDelayed diagnosis of VCD/ILO is pervasive, often leading to detrimental treatments. Phenotypes require validation and CT larynx can reduce the necessity for laryngoscopy, thereby fast-tracking diagnosis. MDT clinics can optimize management. Randomized controlled trials are essential to validate speech pathology intervention and other treatment modalities and to establish international standards of care.

We write to communicate as a Correspondence our follow-up experience in the conduct of a randomized controlled trial (RCT) to evaluate speech pathology treatment for vocal cord dysfunction (VCD)/inducible laryngeal obstruction (ILO). Our previously published work in Respirology has highlighted the role of speech pathology treatment in VCD/ILO.1, 2 Evidence for speech pathology intervention is largely based on observational data and a RCT was subsequently commenced. This study had to be terminated prematurely due to a number of difficulties that merit reporting here to inform and improve future studies in the field. VCD/ILO due to vocal cord adduction during inspiration causes respiratory symptoms, chiefly breathlessness.3, 4 This is particularly debilitating in patients with co-existing airways disease such as asthma, often leading to overtreatment with oral corticosteroids.5 The most prevalent treatment utilizes speech pathology therapy6 but RCT-based evidence is needed to verify the efficacy of this approach in VCD/ILO. A randomized, single centre, single blind, placebo-controlled trial was designed. Eligible patients with newly diagnosed VCD/ILO3 were recruited from our VCD Multidisciplinary Team (MDT) clinic.2 Eligible patients were naïve to treatment and randomized to either speech pathology treatment or placebo. They were informed that they will be assigned randomly to speech pathology treatment (current care but not yet proven to work) or ‘placebo’ that will entail alternative training exercises not used in speech pathology treatment. Three individual therapy sessions over a period of 6 weeks were done prior to a follow-up assessment at the VCD MDT clinic. Statistical power calculations indicated that 26 patients per group were needed to analyse the co-primary outcomes: health care utilization and changes in the vocal cord dysfunction questionnaire (VCDQ). By February 2020, eight participants were recruited and randomized to active treatment or placebo. However, the COVID -19 pandemic intervened, face-to-face interactions were not possible due to lockdown restrictions and the study was suspended. Speech pathology treatment was then provided via virtual consultation to all recruited participants. In July 2021, with lockdown restrictions easing, the study recruitment was recommenced. Over a three-month period, 10 patients were recruited and randomized. However, several obstacles were encountered (see Table 1) and it became clear that the RCT as envisaged was not feasible. We thus terminated the RCT and provided standard speech pathology therapy to all recruited participants. 1. Participants in both treatment (1 of 4) and placebo groups (2 of 4) were able to identify their treatment group by doing their own research reading on the internet (‘Dr Google’), and explanations from other clinicians such as their GP's. 2. Some patients were concerned about face-to-face review by speech pathologists during community spikes in COVID infections. 3. Participants with no clinical improvement in the placebo group asked to withdraw from the RCT (they may also have become aware of their treatment allocation). 4. Speech pathologists delivering therapy were hesitant to provide placebo speech therapy for participants with severe VCD symptoms. This was particularly challenging in patients with increased anxiety in the context of the pandemic. 5. Speech pathologists faced professional and operational difficulties in constructing and delivering of the placebo intervention. It is possible that a measure of ambivalence diluted this aspect of the intervention. 6. Some GPs were not happy for their patients to potentially receive placebo therapy when they had severe symptoms. Although we could not proceed with this RCT, the information gained and the challenges we encountered provide valuable insights to help to inform alternative research designs for investigation and verification of the effectiveness of this treatment modality. One of the reasons for failure was that participants in both treatment and placebo groups were able to identify their treatment allocation by doing their own research and reading on the internet (‘Dr Google’). This knowledge then prompted some of them to request withdrawal from the study. These developments resulted in inadvertent unblinding of participants, compromising the integrity of the RCT. Other patient and external factors, alone or in combination, also contributed to failure as outlined in Table 1. Termination of the RCT was disappointing and unexpected. However, lessons that were learnt can help to guide design of future studies. Investigators should be aware of the possible contamination by online resources, as well as the professional and operational difficulties faced by speech pathologists in constructing and delivering placebo interventions. It is possible that a measure of ambivalence diluted this aspect of the intervention and greater preparation and training may have helped. One feasible alternative would be to consider stepped wedge cluster randomized controlled trials7 that can allow robust evaluation of speech therapy intervention in VCD. Another potential improvement to the study would be to design a credible placebo therapy and to gain involvement of participants' GPs (General Practitioners) to encourage sustained participation. Given advances in diagnostic modalities for detection of VCD,8 ascertaining optimal treatment and advancing evidence-based care is a key priority in this neglected condition. Joo Koh: Conceptualization (lead); data curation (lead); formal analysis (lead); funding acquisition (lead); investigation (lead); methodology (lead); project administration (lead); resources (lead); software (lead); validation (lead); visualization (lead); writing – original draft (lead). Philip G. Bardin: Conceptualization (equal); data curation (equal); formal analysis (equal); funding acquisition (equal); investigation (equal); methodology (equal); project administration (equal); resources (equal); software (equal); supervision (lead); validation (equal); visualization (equal); writing – review and editing (lead). Malcolm Baxter: Conceptualization (equal); data curation (equal); formal analysis (equal); methodology (equal); project administration (equal); supervision (equal); writing – review and editing (equal). Paul Leong: Conceptualization (supporting); formal analysis (equal); supervision (equal); writing – review and editing (equal). Adriana Avram: Conceptualization (supporting); funding acquisition (supporting); methodology (equal); project administration (supporting); writing – review and editing (supporting). Laurence Ruane: Conceptualization (supporting); data curation (supporting); formal analysis (supporting); investigation (supporting); methodology (equal); project administration (equal); resources (supporting); software (supporting); validation (supporting); writing – review and editing (supporting). Debra Phyland: Conceptualization (equal); formal analysis (equal); investigation (equal); methodology (equal); project administration (equal); resources (equal); supervision (equal); writing – review and editing (equal). Martin MacDonald: Conceptualization (equal); investigation (supporting); methodology (supporting); project administration (supporting); resources (supporting); supervision (supporting); writing – review and editing (supporting). Kenneth K. Lau: Conceptualization (equal); data curation (equal); formal analysis (equal); investigation (equal); methodology (equal); project administration (equal); resources (equal); software (equal); validation (equal); writing – review and editing (equal). Elizabeth Leahy: Conceptualization (supporting); funding acquisition (supporting); methodology (equal); project administration (supporting); writing – review and editing (supporting). None declared. The study received ethics approval from Monash Health Human Research Ethics Committee. (ERM Reference Number 53909, Monash Health HREC Ref: RES-19-0000563A). Informed patient consent was obtained from all participants. The data that support the findings of this study are available from the corresponding author upon reasonable request.

BackgroundVocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) is characterized by breathlessness and often mimics or accompanies severe asthma. The disorder occurs intermittently, and the diagnosis is established by using laryngoscopy. Dynamic computed tomography (CT) imaging of the larynx at low-radiation doses has the potential to provide an alternative method to make the diagnosis of VCD/ILO.MethodsWe report two case series: in series A, laryngoscopy (diagnostic standard) and CT imaging of the larynx were each performed within 1 hour of each other (n=31), and in series B, the procedures were performed on separate days 4 to 6 weeks apart (n=72). Diagnosis of VCD/ILO by laryngoscopy used conventional criteria, and diagnosis by CT imaging was based on vocal cord narrowing in excess of a validated normal threshold. In each series, we evaluated the accuracy of CT imaging of the larynx to establish a diagnosis of VCD/ILO compared with laryngoscopy.ResultsIn series A, the sensitivity of CT imaging of the larynx was 53.8%, and specificity was 88.9%; in series B, the sensitivity of CT imaging of the larynx was 76.2%, and specificity was 93.3%. At a disease prevalence of 30% (which was known to be the case in our clinic), the positive predictive value was 67.5% in series A and 83% in series B. Negative predictive values were 81.8% and 90.1% in series A and B, respectively, and false-positive rates were 11.1% and 6.7%.ConclusionsWhen the population prevalence was assumed to be 30%, low-dose CT imaging of the larynx detected VCD/ILO with negative predictive values greater than 80% in both series settings and agreed with each other within 9 percentage points. Positive predictive values for laryngeal CT imaging varied substantially between the settings of the two case series. (Supported by Monash Lung and Sleep Institute and Grant APP ID 1198362 and others.)

Multidisciplinary team (MDT) care is a model that enables individualized management of complex conditions.1 Using this approach in vocal cord dysfunction (VCD) assists diagnosis and treatment, leading to reduced general practice (GP) visits and emergency hospital attendance.2 However, benefits on another key outcome, oral corticosteroid (OCS) prescriptions, have not been reported. We now detail findings in a new cohort demonstrating for the first time that OCS burden in patients with VCD is also significantly reduced by using this MDT approach to guide management.

Vocal cord dysfunction or inducible laryngeal obstructions (VCD/ILO) is a poorly understood, complex disease of the so-called middle airway.1 The condition can have a formidable impact on quality of life with recurrent health-care presentations for acute symptoms, particularly breathlessness. It has long been evident that clinical patterns of VCD/ILO are heterogeneous, with myriad names describing the condition.2,3 Exploration of the condition's diversity might shape scientific, clinical, diagnostic, and management approaches.

ABSTRACTBackground and objectiveMultidisciplinary team (MDT) clinics use an integrated approach to individualize care of complex medical conditions. Vocal cord dysfunction (VCD) is a challenging condition that is likely to benefit from MDT clinics but this has not been researched.MethodsA prospective observational cohort study of a novel VCD MDT clinic was conducted in patients with suspected VCD. Relevant questionnaires, medical history, physical examination, spirometry, dynamic computerized tomography (CT) larynx and laryngoscopy were utilized and patients were allocated to treatment pathways depending on putative diagnosis. Speech pathology intervention with laryngeal retraining (LR) was offered and if LR therapy failed botulinum toxin injection was offered. Primary outcome was reductions in healthcare utilization.ResultsOverall, 80 consecutive patients were included in analyses. A definitive diagnosis of VCD was made in 56 of 80 (70%) patients. After LR (n = 35), emergency department (ED)/hospital admissions declined significantly in the subsequent 12 months (P = 0.001). General practice visits also reduced (P < 0.001). Botulinum toxin injections were administered in 21 patients unresponsive to LR therapy and both general practice and ED/hospital visits declined (P < 0.001 and P = 0.01, respectively) after injection.ConclusionA multidisciplinary approach to VCD confers benefit and can be used to allocate appropriate management leading to a reduction in healthcare utilization.

Introduction: Vocal cord dysfunction (VCD) causes vocal cord narrowing during inspiration resulting in airflow obstruction and breathlessness. In asthma VCD can be found in up to 20% of stable asthmatics but few studies have examined coexisting VCD in exacerbated asthma and none in COPD. We hypothesised that VCD may occur frequently during acute asthma and COPD exacerbations. Method: Overall 34 patients with asthma exacerbations and 37 patients with exacerbations of COPD were studied in the emergency department (ED). All patients had a previous diagnosis of asthma or COPD confirmed by lung function. Asthma chronic disease severity was based on GINA and exacerbation severity based on a validated score. COPD chronic disease severity was based on GOLD criteria and exacerbation severity was based on BAP-65. Dynamic computerised tomography (CT) imaging was done as soon as possible after ED admission and VCD was diagnosed using 320-slice CT of the larynx. Results: In the overall group (n=71) VCD was detected in 20 cases (28%). Patients with COPD had VCD more often (14/37, 37.8%) than asthmatics (6/34, 17.6%, p=0.03). There were no associations between asthma or COPD, acute disease severity and presence of VCD. Patients with COPD had more VCD if they had severe/very severe chronic COPD (10/14, 71%) as opposed to mild/moderate (4/14, 31%). Conclusion: Surprisingly VCD was more frequently detected in COPD than in asthma. VCD should be considered a contributing factor during exacerbations of both diseases. Further studies are needed to determine how much VCD contributes to acute symptoms and to examine effective treatments for VCD in these clinical contexts.

Background: In 2012 clinical management of children having adenotonsillectomy (AT) for suspected obstructive sleep apnea (OSA) at our tertiary centre changed based on previous research: children with severe obstructive sleep apnea (OSA) at increased risk of post-operative respiratory adverse events (AE) identified using home overnight oximetry or polysomnography (PSG) were managed post-operatively in a high nurse/patient ratio unit in the ward (high acuity unit, HAU) rather than in the intensive care unit (ICU) as previously.Objectives: To examine the post-operative respiratory AE post AT in HAU.Methods: A retrospective audit was performed of children having AT on the HAU list from Oct 2012-Sept 2014, identifying clinical information, pre-operative testing for OSA and post-operative course.Results: 343 children underwent elective adenotonsillectomy at our tertiary centre in the study period; of whom 79 had surgery on the HAU list (16F; median age 4.2 year (range 1.2-14.7); median weight-forage centile 77.9% (IQR 44-98.7%)). 75 had moderate/severe OSA by oximetry (n = 44) or PSG (n = 31) criteria. 77 of 79 children had oxygen therapy in the recovery room (median 20 min, IQR 15-40 min). 18 (23%) had at least one AE outside the recovery room, which were observed (n = 2) or treated with oxygen therapy (n = 14) or repositioning (n = 2). Obesity increased the risk of an AE (10/25 obese vs 8/54 non obese, p = 0.01), as did the presence of a major comorbidity (5/9 with comorbidity vs 13/70 without, p = 0.03). There were no admissions from the HAU to ICU. 63 patients (83%) stayed only one night in hospital (median 1 d, range 1-5 d).Conclusions: In a cohort of children with known moderate-severe OSA, post-operative AE after AT were all managed in the HAU. Post-operative care in HAU provides safe and effective care for high-risk children post-AT, minimizing admissions to ICU. (C) 2016 Published by Elsevier Ireland Ltd.

Rheumatoid arthritis (RA) can affect any synovial joint including laryngeal joints. The disease is usually diagnosed clinically but the ‘gold standard’ for diagnosing laryngeal RA is laryngoscopy. The procedure is semi-invasive, requires a skilled operator, specialised equipment and is often not performed. In this case study, we demonstrate for the first time that fixed vocal cord narrowing in a patient with RA who presented with breathlessness and can be diagnosed by means of novel non-invasive methodology: dynamic 320-slice multi-detector CT (320-MDCT) larynx. CT studies revealed abnormal adduction and fixation of the vocal cords and supported a strong presumptive diagnosis of RA larynx in the absence of other causes. This advanced imaging modality may be valuable for simple, non-invasive evaluation of laryngeal function in RA, to monitor progression of disease and for follow-up of patients with RA larynx.

Background and ObjectiveAbnormal vocal cord movement may coexist with asthma and cause additional upper/middle airway obstruction. The condition may be a form of muscular dystonia that could contribute to asthma resistant to optimised treatments. Botulinum toxin causes temporary paralysis of muscle and may be an effective local treatment that improves asthma control.MethodsIn an observational study, we evaluated the benefits of unilateral vocal cord injection with botulinum toxin in 11 patients (total 24 injections). Subjects had asthma resistant to optimised treatment and abnormal vocal cord movement. Responses after botulinum toxin treatment were assessed using asthma control test (ACT) scores, vocal cord narrowing quantified by computerised tomography (CT) of the larynx and spirometry. Side-effects were recorded.ResultsACT scores improved overall (9.1 +/- 2.4 before and 13.5 +/- 4.5 after treatment; difference 4.4 +/- 4.2; P < 0.001). There was also an improvement in airway size on CT larynx (time below lower limit of normal at baseline 39.4 +/- 37.63% and improved to 17.6 +/- 25.6% after injection; P = 0.032). Spirometry was not altered. One patient experienced an asthma exacerbation but overall side-effects were moderate, chiefly dysphonia and dysphagia.ConclusionsAlthough a placebo effect cannot be ruled out, local injection of botulinum toxin may be an effective treatment for intractable asthma associated with abnormal vocal cord movement. Further mechanistic studies and a double-blind randomised controlled trial of botulinum toxin treatment are merited.

Objectives: To assess the outcome of type II thyroplasty in the treatment of adductor spasmodic dysphonia (ASD). Study Design: Prospective case series. Methods: Thirteen patients with the diagnosis of ASD who were previously treated successfully with botulinum toxin therapy were recruited. Type II thyroplasty as described by Nobuhiko Isshiki was performed on all the patients. A self-rating assessment of the degree of severity and vocal effort were recorded and compared preoperatively and during postoperative follow-up. Results. There were four early failures in our series, with two caused by friable thyroid cartilage. In the early postoperative period, after excluding the early failures, six (66.7%) and seven (77.8%) patients had moderate-good improvement in symptom severity and vocal effort, respectively. During the follow-up period, a further five patients had deterioration of voice quality and were classified as failures. Of these five patients, two patients had reversal of their procedure. At the end of the follow-up period (mean follow-up period of 12 months), six (66.7%) and five (55.5%) patients sustained improvement in symptom severity and vocal effort, respectively. However, only two (22.2%) and three (33.3%) patients had moderate-good improvements in symptom severity and vocal effort, respectively, after 12 months. Conclusions. Botulinum toxin injection remains the gold-standard treatment for ASD in our center. Potential patients for type 11 thyroplasty need to be carefully selected and counseled by a multidisciplinary team of otolaryngologists, neurologists, and speech pathologists.