Vocal cord dysfunction

Key points

• VCD is an increasingly recognised co-existing feature in asthmatics.

• VCD may arise from an alteration in the autonomic balance between the glottis and central control areas, with potential aggravation from direct laryngeal insult, laryngeal hyperresponsiveness and psychological factors.

• There is significant psychiatric co-morbidity in VCD patients.

• The classical appearances at laryngoscopy are adduction of the anterior two thirds of the vocal cords with the creation of a posterior glottic chink during inspiration.

• The current gold standard for diagnosis rests with laryngoscopy at the time of an attack of symptoms, with the role of challenge testing as a diagnostic strategy not clear at present.

• Treatment involves directing attention away from the inspiratory phase of breathing and oropharyngeal muscle use towards active expiration using anterior abdominal muscles along with psychiatric input if necessary.

Educational aims

• To be aware of the possible co-existence of VCD in patients with poorly controlled asthma.

• To recognise the various clinical presentations of VCD.

• To be aware of the unanswered questions regarding the pathophysiology of VCD.

• To be aware of treatment strategies for VCD.

Summary Recently, there has been increasing recognition and understanding of vocal cord dysfunction (VCD), a condition characterised by abnormal adduction of the vocal cords, most often during inspiration, leading to airway obstruction and associated symptoms. VCD is recognised as a co-existing factor or an alternative diagnosis in patients with asthma, but the true prevalence and incidence are not entirely clear. VCD may arise from interrelationships between laryngeal hyperresponsiveness and autonomic imbalance. Diagnosis can be difficult and, although challenge testing may be helpful, there is no non-invasive alternative to direct visualisation of the larynx during an attack as a current gold standard. This review aims to summarise current understanding of the epidemiology, proposed underlying pathophysiological mechanisms, diagnosis and treatment of this disorder.