1. Vocal Cord Dmg From Gerd Video
2. Vocal Cord Damage From Acid Reflux

Medically reviewed by Drugs.com. Last updated on Jan 16, 2020.

Jul 18, 2017 The University of Pittsburgh Voice Center advises monitoring the timing, type and amount of food consumed and avoiding alcohol, mint and caffeine as a way of minimizing acid reflux that can cause vocal cord damage 3. Vocal cord dysfunction, also known as paradoxical vocal fold movement, is part of irritable larynx syndrome - an upper airway disorder with a range of symptoms, all related to excess irritation of the delicate voice box. During a VCD attack, your vocal cords close involuntarily when they should be open as you inhale, and you may feel as if you.

• Health Guide

What Is It?

1. Vocal Cord Dysfunction (VCD) means that your vocal cords do not act normally. With VCD, instead of your vocal cords opening up when you breathe in and out, your vocal cords close. This closing of your vocal cords makes it harder to get air into or out of your lungs. Common signs and symptoms of VCD.
2. Acid reflux (GERD). Vocal Cord Dysfunction means that your vocal cords do not act normally. It is also called paradoxical vocal fold motion disorder. With VCD, instead of your vocal cords opening when you breathe in and out, your vocal cords close. When your vocal cords close, it makes it.

The vocal cords are two bands of elastic muscle tissue. They are located side by side in the voice box (larynx) just above the windpipe (trachea). Like other tissues in the body, vocal cords can be strained and damaged. Vocal cords are also subject to infections, tumors and trauma.

When you are silent, the cords remain open. They create an airway through which you breathe.

When you speak, the air you exhale from your lungs is forced through the closed vocal cords. This causes them to vibrate. They vibrate faster for higher-pitched sounds, slower for lower-pitched sounds.

Strained vocal cords generally aren't noticed until the problem becomes severe. People who use their voices for a living or who shout or scream frequently are at particular risk. People who work in noisy environments that require shouting to communicate are also at risk.

Common vocal cord disorders include:

• Vocal cord nodules. These are small, hard, callus-like growths caused by vocal abuse. They occur in pairs, with one nodule on each vocal cord at the site of greatest irritation. They sometimes are called singer's, screamer's or teacher's nodules.

• Vocal cord polyps. Polyps are small, soft growths that usually appear alone on a vocal cord. They are caused most often by vocal abuse or long-term exposure to irritants, such as chemical fumes or cigarette smoke.

• Contact ulcers. This is a less common disorder. Contact ulcers are erosions and sores on the vocal cords. They tend to occur in people who consistently use great force when beginning to speak, instead of gradually increasing force and loudness. For example, contact ulcers may affect people who work as public speakers.

  Ulcers also can be caused by gastroesophageal reflux disease (GERD), or heartburn. Reflux is when acidic stomach contents flow back up the esophagus and irritate the larynx.

• Laryngitis. Thisis a swelling of the vocal cords caused by inflammation or infection. Swollen vocal cords vibrate differently than usual, changing the typical sound of your voice. You can lose your voice if the inflammation is so severe that you can't make a sound.

Laryngitis can be caused by:

• Vocal abuse

• Allergies

• Viral infection

• Reflux of stomach acids

• Exposure to irritating substances, such as cigarette smoke or too much alcohol

• Vocal cord tumors. Tumors can be cancerous or noncancerous. Noncancerous tumors can be caused by a virus. Or they may be unusual growths of body tissue that cause voice problems. Cancerous tumors are most likely to occur in smokers and people who drink too much alcohol. Cancerous tumors are life threatening if not caught and treated early.

• Vocal cord paresisand vocal cord paralysis. Vocal cord paresis occurs when one or both vocal cords don't open and close properly, changing voice quality. When one or both vocal cords don't move at all, this is called vocal cord paralysis. If both vocal cords are paralyzed and remain in the closed position, breathing can be difficult.

  Vocal cord paresis and paralysis can have several causes, including:

  • Surgical trauma, most often from thyroid surgery, but also from any neck or chest surgery

  • Head or neck trauma

  • Trauma during birth

  • A neurological disease (such as Parkinson's disease or multiple sclerosis)

  • Stroke

  • A tumor

  • A viral infection

  • Some debilitating diseases, such as myasthenia gravis

  Paresis also can result from weakened vocal cord muscles. Vocal cord muscles can be weakened temporarily as a side effect of inhaled corticosteroid medicine sprays. They may also weaken after extended treatment with an artificial respirator (ventilator) in a hospital.

Symptoms

Symptoms can vary, depending on the vocal cord disorder.

• Vocal cord nodules

  • Hoarseness

  • Low-pitched voice

  • Breathy voice

  • Singers may notice a loss of vocal range.

• Vocal cord polyps

  • Hoarseness

  • Low-pitched voice

  • Breathy voice

• Contact ulcers

  • Some throat pain while talking

  • Possible hoarseness

  • A voice that tires easily

• Laryngitis

  • A change in the sound of the voice, from hoarseness to croaking or complete loss of voice

  • If due to an infection:

    • Fever

    • Throat pain

    • Malaise

    • A feeling of having to clear your throat

• Vocal cord tumors

  • Hoarseness

  • With large tumors, possibly trouble breathing or swallowing

• Vocal cord paresis

  • Changes in the voice:

    • Hoarse

    • Breathy

    • Change of pitch

    • Unable to get louder

  • Discomfort from the strain of trying to move paralyzed cords

  • Possible breathing difficulties

Diagnosis

Your doctor will ask about your medical history. The doctor will listen to the quality of your voice and then inspect your vocal cords. This is usually done by holding a small mirror at the back of your mouth. To get a better view, the doctor may use a small, flexible lighted tube with a camera at the end. The tube is inserted through the nose to the larynx.

You will need to make certain sounds so your doctor can see your vocal cords in action. The examination may be videotaped so your doctor can analyze it later. This is all that is needed to diagnose most cases of laryngitis, vocal cord nodules and polyps.

In some cases, your doctor may recommend an acoustic analysis. This is a series of tests that measure the quality of your voice, including its pitch stability, range and intensity. Often, these tests are used when vocal cords are paralyzed or if a growth must be removed surgically. Using the test results, doctors and voice therapists can judge the amount of improvement after treatment.

Cancer of the larynx can look similar to a noncancerous growth or a contact ulcer. If an abnormality is found on the vocal cords, your doctor may do a biopsy. A biopsy involves removing a tiny sample of the affected vocal cord tissue so it can be examined in a laboratory.

Additional tests, such as computed tomography (CT) scans, may be required in some cases of vocal cord paralysis or cancer.

Vocal Cord Dmg From Gerd Video

Expected Duration

• Vocal cord nodules – If you don't do anything to change your vocal cord abuse, nodules can last a lifetime. They can even come back after they are surgically removed. With proper voice training with a certified therapist, nodules can disappear within six to 12 weeks.

• Vocal cord polyps – With rest, some vocal cord polyps will go away on their own within a few weeks. Most, however, have to be removed surgically.

• Contact ulcers – It can take a long time for contact ulcers to heal. Some doctors recommend resting your voice for a minimum of six weeks. If the ulcers are caused by acid reflux, the reflux problem must be treated to keep your vocal cords healthy.

• Laryngitis – Laryngitis caused by a viral infection usually goes away within one to three weeks. Laryngitis from vocal abuse usually goes away on its own in a few days with voice rest.

• Vocal cord tumors – Noncancerous tumors generally do not go away. They must be removed surgically. Cancerous tumors must be treated immediately to prevent the cancer from spreading. Untreated cancer of the larynx leads to death.

• Vocal cord paresis or paralysis – In some cases, the voice returns on its own within a year. If not, the condition is likely to be permanent. Surgery may be done to try to improve speech.

Prevention

To help prevent disorders caused by vocal abuse (including laryngitis, vocal cord nodes and polyps, and contact ulcers), you need to learn how to talk without straining your vocal cords. A voice therapist can teach you how to do this. Look for a licensed and certified speech-language pathologist who specializes in voice.

To prevent disorders related to acid reflux (including contact ulcers and laryngitis), see your doctor to treat the reflux. Medications can help to control stomach acid. Lifestyle changes also help some people. Changes include:

• Eating smaller meals to avoid overfilling the stomach

• Not eating or snacking three to four hours before sleeping to make sure all food is well digested before you lie flat

• Raising the head of your bed a few inches to keep your head and upper chest higher than your stomach

• Avoiding alcohol, caffeine, fatty foods, chocolate and peppermint, which may trigger heartburn

To help prevent vocal cord disorders caused by irritation (including laryngitis and vocal cord polyps), avoid smoking, drinking or inhaling chemical irritants. To help prevent vocal cord cancer, quit smoking and limit your consumption of alcoholic beverages.

If you use an inhaled corticosteroid medicine to treat asthma or other lung disease, you may be able to prevent vocal cord muscle weakness. Use a spacer device that catches large medicine droplets too heavy to be carried deep into your lung airways. These large droplets can otherwise settle in your throat and trachea, where they can cause side effects.

If you have viral laryngitis, cover your mouth when coughing and wash your hands often to prevent others from getting your infection.

Treatment

For vocal cord disorders resulting from vocal abuse, there are two main treatments:

• For short-term relief, rest your voice. Speak or make sounds only when absolutely necessary. Try not to talk or whisper at all for a couple of days.

• For long-term relief, voice therapy. Learn the proper way to speak to avoid straining your vocal cords.

If rest and therapy don't resolve the disorder, other treatments are available. They are based on the type of disorder:

• Vocal cord nodules may require surgical removal.

• Most vocal cord polyps require surgical removal.

• A contact ulcer may require surgical removal if it does not go away on its own after a minimum of six weeks of voice rest. You also may need voice therapy and treatment for acid reflux.

• Laryngitis caused by a virus needs rest and fluids. Antibiotics are not helpful to treat routine infections.

• Vocal cord tumors require surgical removal if they are noncancerous. They generally will not return.

  Treating cancerous tumors depends on the extent of the cancer. In the early stages, radiation, chemotherapy, surgery to remove a portion of the larynx or a combination of treatments may be needed. Some voice will remain after these procedures.

  In later stages of cancer, the entire larynx, including the vocal cords, must be removed (laryngectomy). You will need to learn a new speech method, using a special valve inserted surgically between the trachea and the esophagus. This allows air to be sent up the esophagus, creating enough vibrations for understandable speech.

• People with vocal cord paresis or paralysis may be able to learn how to speak in different ways through voice therapy.

  If improvement is not satisfactory, surgery may be recommended to change the position of the affected vocal cord. Surgery can also add bulk by injecting the vocal cord with collagen, body fat or some other substance.

  These types of procedures are recommended more often when one of the vocal cords is paralyzed. Both techniques bring the paralyzed cord closer to the cord that is not paralyzed. This allows the cords to vibrate enough to make sounds.

  For people with two paralyzed vocal cords, the goal of treatment is to improve breathing. The most common procedure is a tracheotomy. This procedure creates a hole in the neck below the level of the vocal cords. A breathing tube is placed into the hole.

• Vocal cord muscle weakness due to inhaled corticosteroids may require a change in medicines. That is, if using a spacer device does not prevent symptoms.

When To Call a Professional

See your doctor if you:

• Lose your voice for more than a few days

• Are hoarse for more than two weeks

• Have hoarseness accompanied by:

  • Difficulty swallowing

  • A lump in the throat

  • Unexplained pain

  • Coughing up blood

Prognosis

• Vocal cord nodules. Nodules can come back if vocal abuse continues. This is true whether they disappear with voice rest and voice therapy or are surgically removed.

• Vocal cord polyps. Polyps may be removed successfully with surgery. But they can return if you don't have voice therapy and don't stop inhaling irritating substances.

• Contact ulcers. With rest, treatment of reflux and retraining the voice, most contact ulcers go away without complications in weeks or months.

• Laryngitis. Most cases of laryngitis go away within a few days to a few weeks, depending on their cause.

• Vocal cord tumors. Noncancerous tumors usually do not return after they are surgically removed. You usually regain your normal voice.

  Cancerous tumors can be very serious. The earlier they are detected and treated, the better the likelihood of survival and cure. Your voice may change dramatically, depending upon the extent of the cancer and the type of treatment.

• Vocal cord paresis. Many instances of vocal cord weakness improve over time. This may take many months.

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• Vocal cord paralysis. Some cases go away within a year on their own. But many people require surgery to restore their voice, and many need voice therapy. With proper treatment, most people with one-sided vocal cord paralysis will regain good voice quality and control. People with two-sided vocal cord paralysis must relearn how to use their voices after they have had surgery to assist their breathing.

External resources

National Institute on Deafness and Other Communication Disorders
National Institutes of Health
31 Center Drive, MSC 2320
Bethesda, MD 20892-2320
Toll-Free: 1-800-241-1044
TTY: 1-800-241-1055
http://www.nidcd.nih.gov/

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

Abstract

Vocal cord dysfunction is an asthma mimic. Diagnosis of this condition requires a high index of suspicion if unnecessary treatments are to be avoided. We describe the findings from our case series of 62 patients (age range 18 to 90 years) in whom the diagnosis was confirmed. Our findings show low-dose amitriptyline to be very effective in 90% of cases, with rapid benefit for those patients whose symptoms had been present for less than 12 months. This treatment, in conjunction with psycho-therapeutic and behavioral therapies may reduce unnecessary hospital admissions. Future studies may show whether this treatment regimen may reduce demands on the speech and language therapists.

Introduction

Vocal cord dysfunction (VCD) is an asthma mimic, which may present in association with asthma or be misdiagnosed as asthma., The literature reports an average delay of 4 years to the correct diagnosis in such cases. There is a female predominance, with quoted ratios of 40 female:1 male.5 81% of patients are Caucasian with a common age range of 14 to 60 years.

Diagnosis requires a high index of suspicion and the following factors may hold clues to determining a correct diagnosis:,

1. Suspect if asthma suddenly deteriorates or becomes unresponsive to previous treatments.

2. Attacks of wheezing worse by day, which may be surprisingly short lived.5

3. Steroid “pseudo-resistance” is demonstrated; where patients previously responsive to steroids appear to no longer respond.

4. Attacks that are provoked by exercise.5

5. Pungent smells, hyperventilation, stress or cough may be precipitants of an attack of wheeze.

The literature recognizes 3 patterns of VCD

1. Exercise-induced VCD where symptoms are limited to exercise.

2. Spontaneous VCD where there is a sudden onset of symptoms without exercise.

3. Persistent VCD where adduction of the vocal cords in both inspiration and expiration is observed. This is usually associated with an emergency admission.

Observation or history taking may reveal an attack of sudden onset occurring spontaneously or with exercise and of a brief duration. There may be tightness in the throat, with a flexed neck during attacks. A change in voice quality, due to misuse of the vocal cords may be present. Attempts to measure lung function may show variable results, depending on the degree of vocal cord adduction during each measurement. If the vocal cord adduction is severe an intense audible stridor, which is predominantly inspiratory can be heard. This would suggest that persistent cord adduction is occurring. Asymptomatic periods may occur. Chest tightness and breathlessness on exertion, with a cough would suggest exercise-induced VCD. This often occurs at a set distance. These distances can be very short, sometimes <10 m. There may be a feeling of trapped mucus around the vocal cord area, resulting from the interruption of the normal mucociliary clearance due to cord adduction.

In normal movement of the vocal cords, there is inspiratory abduction (opening) followed by a brief expiratory phase adduction (closing) of 2 mm from the fully abducted position to generate physiological autoPEEP., This is the positive end expiratory pressure generated in part by the vocal cords to prevent early airway closure. The cords then open again for inspiration. Voluntary cord adduction in a sustained manner during inspiration is impossible in the healthy normal subject., Abnormal inspiratory vocal cord adduction may have pathological (cerebral) causes such as Arnold-Chiari malformation and cerebral aqueduct stenosis or even drug induced brain stem dysfunction. This has also been noted in motor neurone disease, myotonic disorders, Parkinson’s disease and laryngeal breathing dystonias.

In non-organic VCD, inspiratory adduction of the anterior two-thirds of the cords can produce a diamond-shaped opening in the posterior segment. This can generate the pitch of wheeze similar to asthma, but the wheeze is loudest over the larynx and is usually audible. The chest x-ray is often normal, but some patients with persistent adduction can induce acute hyperinflation and use accessory muscles, if adduction is severe. Presentation to intensive treatment unit in status asthmaticus, even with a silent chest, has been described. Intubation often finds normal airway pressures and therefore extubation usually follows within a short time. In the acute setting of possible status asthmaticus, it is difficult to take a different course of action. Once recognized, it is appropriate for these patients to be treated with heliox (a mixture of oxygen 24% and helium) and light anxiolytics.,

The results of measured lung function are variable, with obstructive, restrictive or normal values appearing, depending upon the activity of the VCD. Arterial blood gases are usually normal, unless persistent adduction of the vocal cords occurs in which a silent chest may be produced.,

Failure to recognize the condition of VCD, leads to the prescription of unnecessary medication with associated adverse effects., Repeat admissions for what is a benign condition is undesirable and reinforces the undiagnosed problem.

Vocal Cord Damage From Acid Reflux

Physicians managing patients with VCD recognize the importance of psychological stresses on clinical symptoms., VCD is associated with a high rate of co-morbid psychiatric disorders. One survey found that 73% of 95 patients with VCD had a psychiatric diagnosis., It has also been suggested that patients with this condition have an increased rate of childhood trauma or abuse.,5

Treatment to relieve symptoms is recommended before attempting to deal with the psychological stress., Without this symptom relief, addressing psychological conditions can aggravate vocal cord dysfunction. Treatments to date include: “panting” and other behavioral techniques to encourage abduction of the vocal cords, with such patient education performed by a speech and language therapist. Tranquillizers are also recommended. The literature describes variable resistance breathing systems which consists of facemasks with one-way valves to induce inspiratory drag. This reduces inspiratory stridor and gives psychological relief, which may reduce reinforcement of the attack and offer a solution. Historical treatments included tracheostomy. Botulinum injections have been proposed as a treatment, but no randomized controlled studies have yet been published.5,

Examination of vocal cords in the absence of symptoms may show normal movements. However, in persistent VCD the vocal cord adduction may be seen at any time. Breathing is often reported by relatives to improve during sleep and to deteriorate when mental stress occurs. The condition itself, if unrecognized, leads to increased anxiety and a consequent increase in the VCD severity. Some patients may show more than one of the 3 patterns of VCD described. Without a high index of suspicion, the condition may be overlooked in asthmatics. A routine auscultation over the vocal cord area is a useful screen during acute admissions and outpatient reviews. It is especially indicated if asthma becomes worse or appears steroid unresponsive. Even B₂ agonists can aggravate symptoms in individuals with VCD, a feature not noted frequently in true asthma attacks. During vocal cord inspection, if adduction of the cords is visible only in expiration, this must be interpreted with caution, as it is likely to be a physiological and adaptive mechanisms and not VCD. The paradoxical movements must be those of inspiratory adduction. If the flow volume loops are measured during an attack abnormalities will be demonstrated. Twenty-five percent of subjects may show variable but persistently abnormal loops. In these patients, extra thoracic obstruction must be excluded. Fifty percent of subjects can have VCD by exercise.5,

It is important for the respiratory technician to print all flow-volume loops, as there is a risk that any loops of an unusual appearance, may be disregarded as an error and not be recognized as related to VCD. Flutter of the inspiratory loop and brief changes in the expiratory loop causing flattening (top hat effect) are described. From the flow volume loop, visible flattening of the inspiratory portion is seen and indicates upper airway obstruction, which could include other causes such as subglottic stenosis and vocal cord dysfunction. This makes inspection of the cords essential. From the flow-volume loop, if the maximum mid expiratory flow is divided by the maximum mid inspiratory flow and has a value of >1.5 this suggests vocal cord dysfunction.

Method

The patients

The study describes 62 consecutive patients. Age range 18 to 90 years (17 male/45 female) in whom VCD was suspected and confirmed. In 40%, previous stable asthma had been present but a change in clinical circumstances had occurred. This had taken the form of treatment resistance, or hospital admission for an asthma attack. Others were referred to outpatients with a new suspected asthma, which appeared unresponsive to their GP’s treatment.

History and physical findings

A history of asthma-like symptoms was sought and past asthma patterns established with spirometry and peak flows recorded. Skin tests for atopy were performed if atopic symptoms were present. Specific enquiry was made into possible symptoms of VCD. These included frequent attacks of audible wheezy noises (or stridor), occurring during exercise or associated with stress, or brief daytime attacks with or without recognized triggers. Voice changes, throat tightness and a feeling of mucus adhering around the vocal cord area were enquired about. The limitation of exercise and the walking distance before symptoms occurred were established. A walking test was performed, so that observation and auscultation of the chest and vocal cord area could be performed.

Anxiety and assessment

Although a formal assessment of mood was not undertaken, recent life events were discussed, including enquires about any work stress or trauma that may have preceded the symptoms. Significant insomnia was found in 95% of confirmed cases.

Fiber-optic examination of the cords

This was undertaken for each case, with attempts to establish likely triggers before the examination. This would allow examination of the cords, followed by “a stress” to induce VCD. In a large number of cases the “stress” was through exercise, especially climbing stairs. In others cases, pungent smells, including perfume, brought by the patients to the fiber-optic test were used as triggers. Many were induced by the lignocaine preparation for the fiber-optic examination and the anxiety associated with the investigation. Careful inspection of the cords for vocal cord disease, especially tumors and paralysis was as important as assessing movement. Two patients with vocal cord cancers were identified, and excluded from this study however this emphasized the importance of inspecting all cords. The cord movement was inspected during the induced wheeze/stridor when the patient was asked to take deep breaths in and out despite their condition. The inspiratory and expiratory phase of respiration was determined by a hand placed on the sternum, so that simultaneous cord inspection and the phase of respiration were accurately assessed. Adduction during the inspiratory phase was confirmation of vocal cord dysfunction. Acid reflux around the epiglottis and vocal cord area was also noted and treated if present.

Methacholine test

Patients with a significant history of asthma and vocal cord symptoms had a methacholine test to assess bronchial hyper-reactivity, if it was doubtful that their inhaled therapy was optimal.

Amitriptyline treatment

Tricyclic antidepressants have no previously described benefit in VCD. However, the authors had noted that a low dose of amitriptline for night sedation, often led to a rapid improvement in the symptoms of VCD. The starting doses were low, 10 mg 2 to 3 hours before bed, which were increased by 10 mg each week until adequate sleep was induced. Many of the patients in this series were already on long term selective serotonin reuptake inhibitors (SSRIs). If this was the case, the SSRI was maintained and amitriptyline was added to it. Patients with protracted symptoms with treatment resistance and anxiety affecting their quality of life were referred to liaison psychiatry. During the course of our investigations, if the patients were judged to have previously undiagnosed anxiety related or depressive illness, they were referred to the local liaison psychiatry service for further management.

Referral to speech therapy

There is a high prevalence of abnormal voice quality in vocal cord dysfunction and behavioral treatment offered by voice specialist speech and language therapists (SLT, speech pathologists) is an encouraging option. Significant subjective and objective improvements in symptoms have been recorded in studies of the characteristics of laryngeal respiratory disorders and their treatment, via a combination of medical management and respiratory retraining.,

In the study, 43 patients were referred to the SLT. Those who had not previously had their vocal cords examined were seen for nasoendoscopy with the ear-nose-throat (ENT) surgeon in the joint ENT/SLT clinic for further assessment of laryngeal structure and function.

Therapeutic approaches were predicated on explanatory discussion of laryngeal mechanisms and vocal cord function in normal respiration and phonation. The causes and effects of abnormal/paradoxical vocal cord movement were discussed in relation to patients’ presenting symptoms. Possible chemical triggers and psychosocial aspects were also discussed. Patients benefited from reassurance that VCD is caused by central chemo-reflex changes, which can be reversible via behavioral techniques.

Specific therapeutic techniques aimed to encourage vocal cord abduction and to divert attention away from the larynx included:

• Sip and swallow routines.

• Pursed lip breathing.

• Blowing against finger held to the lips.

• Nasal only breathing.

• Abdominal breathing.

The success of treatment depended heavily upon patients’ response to the opportunity to discuss and understand their symptoms and to bring them under voluntary control.

Patients who did not benefit from voice therapy were those who, at the time of treatment, were unable to meet the challenge of changing maladaptive respiratory behaviors.

Results

Table 1 shows the patients’ demographics. All patients had VCD confirmed at fiber-optic examination. Two patients had vocal cord tumors and are excluded from further analysis.

Table 1

Patient demographics: the case series and the percentage with prior asthma, insomnia, and anxiety at diagnosis

In the case series, previous asthma was higher in women (64%) than men (31%). All patients described significant insomnia and awareness of anxiety symptoms (including panic) which was twice as common in women (72%) than men (31%). Life events and work stress affected up to 40% of the series with 65% of women already prescribed an antidepressant.

Most patients’ symptoms were intermittent or exercise-induced but 16% were more persistent and appeared a feature in older women with chronic asthma and anxiety. Amitripty-line had beneficial effects on insomnia and improved reported anxiety particularly in men.

The response to amitriptyline and the mean dose required is shown in Table 2.

Table 2

The response to amitriptyline: responses and doses of amitriptyline required and its benefit, treatment failures and side-effects

There was an identical approach to treatment in all patients. This involved initially starting a 10 mg dose of amitriptyline 2 hours before bed for the first week. Patients were instructed to increase the dose by 10 mg each week (maximum dose 75 mg) until sleep was restored. Once sleep improved, VCD appeared to show rapid improvement in most patients. We learnt that inspection of the cords was necessary before treatment, as many patients’ symptoms had resolved from the start of treatment and before the fiber-optic examination just 5 to 7 days later.

The response to amitriptyline was higher in men (94%) than women (82%), but insomnia improved in all patients. Anxiety also improved in >90% of patients. Eight patients who had long-standing persistent VCD, which had not been recognized early, were difficult clinical management problems. While they did show some improvement with amitriptyline, the VCD did not cease even though its severity did diminish. In these patients help with liaison psychiatry was necessary.

The response to amitriptyline was sufficient on a mean dose of 20 mg, which is low enough to not have significant side-effects or interaction with other ongoing antidepressant therapy. Some patients did require a full dose of 75 mg for benefit, but this was the minority. We found that many patients once improved, were able to reduce the dose of amitriptyline within a few weeks to 10 mg without relapse, and continued this dose for the minimum 6-month period suggested by us. Re-enforcing the nature of the condition and demonstrating the paradoxical movement of the cords at fiber-optic examination did prove helpful in allowing the patient to take charge of the condition with advice from the SLT.

Adverse effects of amitriptyline and duration of treatment

The initial dose was low (10 mg), in order to avoid over sedation and a dry mouth. The treatment period was 3 to 6 months to establish new vocal cord patterns and break old habits. The mean dose required was 20 mg at bedtime, but the range of doses used is shown in Table 2.

Discussion

This case series demonstrated a reproducible benefit of low-dose amitriptyline in patients with VCD. The mean dose required was 20 mg taken 2 to 3 hours before bed. In the majority of patients this resulted in symptom resolution within 1 week. At outpatient review at 4 weeks there was resolution of the problem in most cases with reduced anxiety and greatly improved length and quality of sleep. The high percentage of patients already taking SSRIs indicated that the presence of emotional problems had been recognized, but these drugs did not appear to influence VCD. The addition of low-dose amitriptyline, without withdrawal of the SSRI, did not lead to therapeutic problems. It became clear from the series that resolution was quickest in those with a shorter duration of VCD (less than 3 months), where symptoms could abate in 1 to 7 days regardless of prior asthma. This emphasizes the importance issue of inspection of the cords before commencing treatment and early recognition to confirm the diagnosis before starting treatment. In patients with the condition for 3 to 12 months prior to diagnosis, resolution was likely by 4 weeks. There were few treatment failures, but when they did occur the patients were generally female and older (>60 years) with co-morbid asthma and psychological problems. Spontaneous attacks and exercise-induced vocal cord symptoms appeared to resolve well with a longer duration of amitriptyline

Insomnia, which was significant, was present in over 90% of all cases of proven VCD and appeared to be associated with the condition. Questioning patients can frequently define an initiating stress in their life, particularly in those without prior difficult asthma.

Referral to speech and language therapy is extremely helpful, but resources are limited and regional waiting times vary. Therefore the treatment with amitriptyline could serve to indicate more precisely those patients who would benefit more from such therapy. This series demonstrated that the age range of patients is greater than that published in the literature, with cases occurring into the 90th year often following traumatic events.

Our findings suggest that low-dose amitriptyline (10 to 20 mg) could be a cost effective treatment in patients with VCD. Initial treatment, even in mild cases needs to be for 3 to 6 months. This should re-establish a healthy vocal cord pattern. In other cases of more persistent VCD, indefinite prophylactic treatment may be warranted with the aim of improving quality of life and avoiding unnecessary hospital admissions and treatments.

This case series is the first to identify the use of amitriptyline in VCD, but clearly this is not a randomized controlled trial and did not formally measure psychiatric morbidities in each patient. The severity of asthma was assessed, but not by a standardized protocol.

Although the study indicated that low-dose amitriptyline is associated with an improvement in the symptoms of VCD, the mechanism of action is unknown. Amitriptyline was prescribed in doses that are generally sub therapeutic for anxiety and depressive disorders, yet sleep benefit with a secondary effect on the cords was observed. It may act directly on the nervous control of the cords. Low-dose amitriptyline is commonly used by the rheumatologists to treat neck spasms and headaches. The drug is known to have several sites of action in the nervous system, one of which may include muscle relaxation. VCD has been described in 2 case reports after prolonged stimulation of the vagal nerve by implanted devices. This suggested that the vagus may have a role in the condition. Clinical benefit has been described in 6 patients with exercise-induced VCD who inhaled the anticholinergic drug ipratropium prior to exercise., It is known that amitriptyline has anticholinergic affects also.

The findings would support the need for a randomized controlled trial to fully assess an active and control arm. This could include stratification of the VCD to intermittent, frequent and severe. It could also assess fully, anxiety levels, asthma status, life events and outcomes in the active and control groups.

Footnotes

Disclosures

The authors report no conflict of interest in the submitted manuscript.

References