Paradoxic vocal fold motion (PVFM), also known as vocal cord dysfunction, is abnormal movement of the vocal cords when breathing in.
This usually presents as a feeling of throat closing, chest tightness, or shortness of breath during exertion or any anxiety-provoking situation.
On physical exam, a small, thin, flexible scope is passed through the nose and used to examine the voice box. We look for inward movement of the vocal cords while breathing in.
This can be difficult to capture in the clinic, so the patient may be referred for an exercise test, in which exercise is performed to the point of intensity necessary to elicit symptoms, and then the flexible scope is passed to examine the voice box.
The physician will also want to rule out other causes such as GERD, asthma, allergy, structural abnormalities, or cardiac issues.
Treatment typically includes voice therapy with a speech and language pathologist, as well as biofeedback and behavior modification with a psychiatrist trained in these specific modalities.
Pediatric paradoxical vocal-fold motion: Presentation and natural history
Validation of the Dyspnea Index in adolescents with exercise-induced paradoxical vocal fold motion
Velopharyngeal insufficiency (VPI) is an inability to effectively seal the nose from the mouth during speech. Children with VPI often speak in a very nasal tone, such that with certain sounds air will leak from the nose, making the words hard to understand. It occurs for a variety of reasons, from problems with the soft palate that children are born with to children who have had surgical repair of a cleft palate. Because of this wide range of causes, approaches to diagnosis and treatment may vary and often must be tailored to the individual child.
VPI may initially present due to problems with understanding speech. Further diagnosis may be suspected after a clinical speech evaluation is performed by a speech-language pathologist. Formal diagnosis is usually obtained by nasometry (a computer-based measuring tool that examines the amount of airflow at the nose during speaking) and videofluoroscopy (special x-ray performed during speech). In some cases, a small, thin, flexible scope is passed through the nose and used to examine the back of the nose and palate during speaking.
In general, some children have problems with anatomy that may require surgery first. While other children have problems with function that may benefit from a special form of voice therapy. Overall, most children will have some form of special speech therapy for this condition, even if it occurs after surgery.
Current Ongoing Clinical Research
We are actively recruiting children with VPI, 22Q anomalies, and midline carotid arteries to characterize the success of a new surgical technique. We are also recruiting children with VPI to assess the role of real-time MRI imaging to help us best choose between the various surgical options and achieve better vocal outcomes. For more information, please email email@example.com.
Use of imaging to evaluate course of the carotid artery in surgery for velopharyngeal insufficiency
Stress velopharyngeal incompetence: Two case reports and options for diagnosis and management
Furlow double-opposing z-plasty
Vocal Fold Immobility
In children with vocal fold immobility (VFI) either one or both vocal folds are not moving properly.
Symptoms of vocal fold immobility can include hoarseness, breathing issues, and/or problems with swallowing. With swallowing, liquids or solids may head toward or into the airway (penetration/aspiration) causing further breathing problems.
Vocal fold immobility can occur for a variety of reasons. Your child's history is very important is helping with diagnosis.
- Was your child born with this condition?
- Was it the result of a surgery during which the nerve that controls the vocal fold was injured?
- Is there a mass or growth pressing on the nerve?
- Is the nerve working, but the joint that allows the vocal fold to move may be stuck (perhaps due to local trauma or a prior use of a breathing tube)?
To answer these questions, the physician may need to perform an endoscopy
, a procedure in which a small scope is passed into the airway while the patient is asleep. In other cases, an imaging study
of the child’s head, neck, and chest (such as an MRI
) is done. Finally, a special study that tests the muscle function of the vocal cord may be considered, which is also done while the patient is asleep, usually at the same time as the endoscopy.
Because of this wide range of causes, approaches to treatment may also vary. Some cases of VFI will resolve over time, but management of the symptoms is necessary while waiting for recovery.
Those with one vocal cord not moving may have voice or swallowing problems. If these symptoms are severe, a short-term solution would include a temporary surgical procedure with injection of a slowly dissolving material that moves the vocal cord into a better position. If the movement does not recover, certain surgeries can provide a more long-term option such as thyroplasty or nerve reinnervation (see nerve reinnervation surgical video here).
Those with both vocal cords not moving often have significant trouble breathing and may require a tracheostomy for a short time. If neither vocal fold regains function, then these children are candidates for procedures to help open the airway (vocal cordotomy, arytenoid lateralization, and airway reconstruction) and work toward removing the tracheostomy if it is present.
Current Ongoing Clinical Research
We are actively recruiting children with VFI to identify the ideal age for nerve reinervation. For more information, please email firstname.lastname@example.org.
Current trends in practices in the treatment of pediatric unilateral vocal fold immobility: A survey on injections, thyroplasty, and nerve reinnervation
Vocal fold medialization in children
Surgery for pediatric vocal cord paralysis: A retrospective review
Intraoperative laryngeal electromyography in children with vocal fold immobility
Intraoperative laryngeal electromyography in children with vocal fold immobility: A simplified technique
Surgery for pediatric vocal cord paralysis: A meta-analysis