Exercise-induced Vocal Cord Dysfunction Presenting as Asthma in Pediatric Patients: Toxicity of Inappropriate Inhaled Corticosteroids and the Role of Exercise Laryngoscopy

Abstract

Chevalier Jackson, M.D., noted, and it is often reiterated, that "not all that wheezes is asthma." This is often the case in pediatric patients in whom there is a broad differential diagnosis for chronic respiratory symptoms. Children and adolescents with chronic respiratory symptoms require thoughtful and complete evaluation to avoid misdiagnosis with the potential for harm due to inappropriate medical therapy. This is particularly true of patients with vocal cord dysfunction, which is a common mimic of asthma. In this report, we present the case of an adolescent female athlete with exercise-induced vocal cord dysfunction misdiagnosed as asthma. Significant adrenal suppression resulted due to high doses of inhaled corticosteroids. The diagnosis of exercise-induced vocal cord dysfunction was confirmed by performing a flexible laryngoscopy during a maximal cardiopulmonary exercise test. We review our experience with a technique of combined exercise testing and real-time flexible laryngoscopy in athletes with atypical dyspnea and discuss the potential side effects of inhaled corticosteroids in pediatric patients. (Pediatr Asthma Allergy Immunol 2003;16 [4]:215-224.)

The Effect of Exercise on Respiratory Resistance in Athletes With and Without Paradoxical Vocal Fold Motion Disorder

“…The presumed primary source of the increased resistance is within the laryngeal airway (because none of the athletes had a diagnosis of lower airway disease), which is detectable by the APD . These results are congruent with reports from direct observation of changes in glottal area during exercise among athletes with PVFMD (Beaty et al, 1999;Heinle et al, 2003;Røksund et al, 2009;Tervonen et al, 2009).…”

“…As mentioned in the introduction, exercise-induced laryngomalacia is considered one cause of dyspnea (Christopher & Morris, 2010;Dion, Eller, & Thomas, 2012;Heinle et al, 2003;Richter, Rutter, deAlarcon, Orvidas, & Thompson, 2008;Røksund et al, 2009;Tervonen et al, 2009). To examine the present data for laryngomalacia, the primary investigator retrospectively reviewed laryngoscopic examinations of the athletes with PVFMD after the exercise challenge to determine whether symptoms were related to prolapsed laryngeal and supralaryngeal structures.…”

“…Various mechanisms have been implicated for this disorder, the most common and most literal of which is inappropriate adduction of the vocal folds (Andrianopoulos, Gallivan, & Gallivan, 2000;Mathers-Schmidt, 2001;Sandage & Zelazny, 2004). Another documented mechanism is prolapse of laryngeal structures into the airway, also known as exercise-induced laryngomalacia (Christopher & Morris, 2010;Heinle, Linton, & Chidekel, 2003;Hicks, Brugman, & Katial, 2008). In this article, the term PVFMD will be used regardless of mechanism to be consistent with current literature, although the results will be interpreted with consideration to specific mechanism.…”

Use of videography in the diagnosis of exercise-induced vocal cord dysfunction: A case report with video clips

“…3,5,10 The standard to prove the diagnosis of EIVCD is a formal exercise challenge test with pulmonary function tests and flow-volume loops followed by rhinolaryngoscopy. [1][2][3][4][5][6][7][8]10 The patient is generally challenged on a treadmill or with bicycle ergometry in a pulmonary function laboratory. However, in some patients, especially elite athletes, neither form of challenge may adequately simulate their exact stimulus to reproduce symptoms.…”

“…The gold standard for the diagnosis of VCD is visualization of the vocal cords in the symptomatic patient (see this article's Video Clip E1 in the Online Repository at www.jacionline.org) performed by a clinician skilled in rhinolaryngoscopy. [1][2][3][4][5][6][7][8] Laryngoscopy reveals paradoxic vocal cord movement, especially during inspiration (see this article's Video Clip E2 in the Online Repository at www.jacionline.org). However, arranging a challenge such as this may not always be easily coordinated logistically with an exercise laboratory and may not be readily available in some hospitals.…”