Does Treatment of Paradoxical Vocal Fold Movement Disorder Decrease Asthma Medication Use? - sbccp

Does Treatment of Paradoxical Vocal Fold Movement Disorder Decrease Asthma Medication Use? - sbccp
The Laryngoscope
C 2016 The American Laryngological,
Rhinological and Otological Society, Inc.

Does Treatment of Paradoxical Vocal Fold Movement Disorder
Decrease Asthma Medication Use?

                   Scott Kramer, MD; Brad deSilva, MD; L. Arick Forrest, MD; Laura Matrka, MD

       Objectives/Hypothesis: To determine whether diagnosis and treatment of paradoxical vocal fold movement disorder
 (PVFMD) leads to decreased asthma medication use. Secondary objectives include determining initial rate of asthma medica-
 tion use, characterizing symptom improvement, and correlating with pulmonary function testing (PFT).
       Study Design: Prospective observational study.
       Methods: Patients newly diagnosed with PVFMD at a single institution were recruited to participate. Medication ques-
 tionnaires were completed at the initial visit, at the first return visit for therapy, and at 6 months. PFTs were reviewed when
       Results: Sixty-six patients were recruited; the study was closed early because findings reached significance. Fifty-six
 patients (85%) were taking asthma medication at presentation. Forty-four patients presented with PFTs, and two-thirds were
 normal. Forty-two patients completed follow-up questionnaires; 79% decreased asthma medication use (P < .001), and 82%
 reported symptom improvement. Seventy-seven percent of patients participated in therapy and 23% did not, with equal rates
 of decrease in asthma medication use between these groups. Outcomes did not vary based on PFT pattern (i.e., obstructive
 vs. nonobstructive, P 5 .75).
       Conclusions: Diagnosis and treatment of PVFMD lead to a decline in asthma medication use. This decrease occurred
 alongside symptom improvement and irrespective of PFT findings. Use of asthma medication in this patient population is
 high, at 85%.
       Key Words: Paradoxical vocal fold movement, vocal cord dysfunction, asthma.
       Level of Evidence: 4.
                                                                                             Laryngoscope, 127:1531–1537, 2017

INTRODUCTION                                                                effect on their dyspnea, and the inhaled medication
      Paradoxic vocal fold movement disorder (PVFMD)                        causes laryngeal irritation that worsens their symptoms
is a disease characterized by intermittent episodes of                      and prompts further inhaler usage, propagating the
dyspnea, cough, and stridor. This clinical constellation is                 cycle. No studies have previously determined the effect
nonspecific, and many patients with PVFMD are initial-                      of diagnosis and treatment of PVFMD on asthma medi-
ly tested and treated for asthma before a proper diagno-                    cation use.
sis is reached.1–3 Early diagnosis and treatment is                              It can be difficult to distinguish PVFMD from asth-
critical, because undiagnosed PVFMD has been linked                         ma; furthermore, asthma and PVFMD frequently coex-
with very high healthcare costs, and efficacious therapy                    ist, with varying symptomatic contributions from each
is available.4,5 Asthma is one of the most common mis-                      entity.9 Patients who are referred for PVFMD evaluation
diagnoses, and patients referred to the otolaryngologist                    by pulmonologists have often been told they have a
for PVFMD evaluation may already be taking asthma                           degree of asthma, but with symptoms out of proportion
medication.6–8 Patients with PVFMD who use asthma                           to asthma alone. It can be unclear what proportion of
medications may in fact worsen their dyspnea, second-                       their symptoms is due to asthma versus PVFMD. Some
ary to a vicious chemical-physiologic cycle. In this cycle,                 patients undergo pulmonary function testing (PFT) and
patients use asthma medication without significant                          are prescribed asthma medications, but are still not
                                                                            definitively given the diagnosis of asthma.
                                                                                 The primary objective of this study was to deter-
       From the James Care Voice and Swallowing Disorders Clinic, The
Ohio State University, Wexner Medical Center, Columbus, Ohio, U.S.A.        mine if the treatment of PVFMD leads to decreased use
       Editor’s Note: This Manuscript was accepted for publication          of asthma medication. A secondary objective is to deter-
September 27, 2016.                                                         mine if diagnosis and education alone (absent the com-
       A portion of this research was presented at the American
Broncho-Esophageal Association Annual Meeting, Las Vegas, Nevada,
                                                                            pletion of any formal therapy) has any effect on
U.S.A., May 14, 2014.                                                       medication use. Tertiary objectives are to determine 1)
       The authors have no funding, financial relationships, or conflicts   symptomatic response to diagnosis and treatment of
of interest to disclose.
       Send correspondence to Laura Matrka, MD, Ohio State University,      PVFMD, 2) the percentage of patients presenting for
Wexner Medical Center, Eye and Ear Institute, Suite 4000, 915 Olentangy     PVFMD evaluation who are already using asthma medi-
River Road, Columbus, OH 43212. E-mail:
                                                                            cation, 3) any differences in the above outcomes based
      DOI: 10.1002/lary.26416                                               on PFT patterns.

Laryngoscope 127: July 2017                                                 Kramer et al.: Treatment of PVFMD and Asthma Medication
MATERIALS AND METHODS                                                  data collection, the Ohio State University Institutional Review
                                                                       Board approved the study protocol. Patients newly diagnosed
Study Design                                                           with PVFMD ages 13 to 80 years were recruited to participate
     This is a prospective observational cohort study of 66            in a consecutive manner. Diagnosis of PVFMD was made based
patients conducted at the JamesCare Voice and Swallowing Dis-          upon previously described guidelines.10 All patients diagnosed
orders Clinic at The Ohio State University, Wexner Medical             with PVFMD underwent flexible transnasal laryngoscopy and
Center from July 1, 2013 to July 1, 2014. Prior to beginning           demonstrated evidence of all of the following: 1) inappropriate

                              Fig. 1. Initial medication questionnaire completed at the time of diagnosis.

Laryngoscope 127: July 2017                                           Kramer et al.: Treatment of PVFMD and Asthma Medication
Fig. 2. The follow-up questionnaire shown is completed at first postdiagnosis visit and at 6 months.

adduction of vocal folds during quiet respiration, breath hold-         Data Collection
ing, counting tasks, or after physical exertion or odor presenta-             Upon diagnosis and subsequent consent to participate in
tion as described by Forrest et al.10; 2) full abduction at some        the study, patients completed a medication questionnaire (Fig. 1)
point during the exam, ruling out paresis or paralysis; 3) no evi-      examining their use of short-acting and long-acting b-agonists,
dence of another cause of airway obstruction. If evidence of            inhaled or oral corticosteroids, inhaled corticosteroid/b-agonist
inappropriate movement was not observed at rest or with the             combinations, leukotriene inhibitors, and inhaled anticholinergic
provocative respiratory tasks, patients were challenged with            medications. Patients were then educated on the features of
either exercise or odor presentation, if either was noted as a          PVFMD, using the video of their laryngoscopy to illustrate key
symptom trigger for the patient.                                        aspects, and they were offered a course of laryngeal control ther-
      Exclusion criteria for study participation included: 1) sys-      apy. Laryngeal control therapy was performed by a licensed
temic corticosteroid use for another disease besides asthma or          speech language pathologist (SLP) with specialized training in
chronic obstructive pulmonary disease, 2) evidence of other             the treatment of PVFMD. A second medication questionnaire
laryngeal pathology affecting vocal fold mobility, 3) previous          (Fig. 2) was completed at the start of the first return visit for
treatment or diagnosis of PVFMD, and 4) inability to partici-           laryngeal control therapy to capture any effect from the initial
pate in laryngeal control therapy for cognitive reasons. Whether        visit and its associated education alone. The same follow-up
a patient was definitively diagnosed with asthma in addition to         questionnaire was completed at approximately 6 months follow-
PVFMD did not affect eligibility, for reasons noted above. When         ing diagnosis, whether or not therapy had been completed.
available, PFT results were reviewed for evidence of an obstruc-        Patients were also questioned on subjective symptom improve-
tive pattern; PFT results had no bearing on diagnosis or eligibil-      ment and the number of completed laryngeal control therapy ses-
ity to participate. The study was initially designed to recruit         sions. PFT results were collected and tabulated when available.
200 patients. However, due to the significance of results at an         Diagnosis of obstructive airway disease was based on the forced
interval analysis time point, the decision was made to report           expiratory volume in 1 second (FEV1), forced vital capacity
results early and close the study.                                      (FVC), FEV1/FVC ratio, and the pulmonologist’s interpretation.

Laryngoscope 127: July 2017                                            Kramer et al.: Treatment of PVFMD and Asthma Medication
Fig. 3. The asthma medication score decreases after diagnosis alone and after therapy, regardless of how much therapy is completed.
Data included are only from time points with at least two responses. “Partial therapy” and “Full therapy” lines are closely overlapping.

Statistical Analysis                                                   Seventy-two percent (18 of 25) of those completing a full
     Patients were assigned a numerical score based on the fre-        course of therapy (two or more sessions, as determined by
quency with which they used medications. The frequency inter-          the therapist) demonstrated a decrease in asthma medica-
vals are detailed in Figures 2 and 3. Subjects were assigned           tion use, compared with 100% (five of five) of those com-
values of 1, 2, 3, or 4 for each increasing frequency interval.        pleting a partial course; the decrease in medication use
For example, a patient using a short-acting b-agonist less than        was significant, but the difference between the two groups
2 days per week received one point, whereas a patient using the
                                                                       was not. Nine patients completed no laryngeal control
same medication more than two days per week received two
points. Once numerical values were assigned, the values from
                                                                       therapy, and eight of those (89%) showed decreased asth-
each category were added together to form an aggregate score           ma medication use. The mean decrease in asthma medica-
(asthma medication score). The asthma medication scores for            tion score was 2.68 for patients completing a full therapy
each subject were compared at each time point for which data           course, 2.60 for patients completing a partial therapy
were available. Asthma medication scores were compared using           course, and 3.44 for patients completing no therapy (P 5
the paired-samples t test or one-way analysis of variance. Nomi-       .71; Fig. 3). The mean asthma medication score decreased
nal variables were compared using v2 analysis. Data were               from 4.62 to 3.29 after patients received a diagnosis alone,
analyzed using SPSS software (IBM, Armonk, NY).                        before any treatment (P 5 .03).

                                                                       Asthma Medication Use at Presentation and
Patient Characteristics                                                Symptom Improvement
     Sixty-eight patients were identified as eligible to                    Fifty-six patients (84.8%) were using asthma medi-
participate during the study period. Two were excluded                 cation at the time of presentation. Fifty-four patients
because of chronic systemic corticosteroid use for dis-                (82%) reported symptomatic improvement of their symp-
eases besides asthma or chronic obstructive pulmonary                  toms after diagnosis and/or treatment of their PVFMD.
disease. Eighty-five percent were female, and the medi-                Ninety-two percent of patients completing a full therapy
an age was 42 years. Forty-two patients completed                      course reported improved symptoms, compared with 60%
follow-up questionnaires, 40 of whom completed ques-                   of patients completing a partial course and 66.7% of
tionnaires at least 6 months out from diagnosis (Table                 patients completing no therapy (P 5 .09). Baseline asth-
I). The remaining two completed follow-up question-                    ma medication score was not significantly different
naires at the initial therapy visit but not thereafter.                between these groups.

Diagnosis and Treatment of PVFMD Decreased                             PFT Data Did Not Impact Asthma Medication
Asthma Medication Use                                                  Use or Symptoms
    Overall, the mean asthma medication score decreased                   Forty-four patients (66%) had PFT data available;
from 4.85 at diagnosis to 2.40 at last follow-up (P < .001).           57% of these demonstrated no evidence of asthma,

Laryngoscope 127: July 2017                                           Kramer et al.: Treatment of PVFMD and Asthma Medication
                                                                    Follow-up Data.
                                                      Asthma Medication Score                                    Symptoms (%)
                                           Baseline        After Diagnosis      6 Months     P Value     Improved        Unchanged    P Value

Therapy completed
  None (n 5 9)                                6                 NA                 2.3         .71         66.7            33.3        .09
  Partial, 1 session (n 5 5)                 4.6                NA*                2                        60              40
  Complete, 2 or more (n 5 25)               4.6                3.17              1.92                      92                  8
PFT result
  No obstructive pattern (n 5 25)            5.08               3.17              2.29         .75         70.6            29.4        .43
  Obstructive disease (n 5 19)               5.53                5                2.85                     83.3            16.7
Total                                        4.62               3.29              2.03
session. Of course, even if symptom severity was initially     symptomatic improvement may be under- or over-
less for this subgroup, they did not have less pathologic      reported by this study. However, by reaching out to all
PFT results; the incidence of an obstructive pattern on        patients at the 6-month point, whether they had been
PFT was the same (P 5 .24). Finally, it is possible that       lost to follow-up or not, we attempted to avoid this bias.
poor compliance explains the lack of difference among
these groups; many of those participating in therapy
may have been noncompliant with the daily laryngeal            Implications and Future Directions
control exercises outside of therapy appointments, and               This study highlights the importance of diagnosing
therefore gained little additional benefit beyond that of      and treating PVFMD. Patients properly diagnosed and
the education and instruction given at the initial visit.      treated use less asthma medication and have improved
     Eighty-five percent of patients referred to us were       symptoms, avoiding the hassle, cost, and side effects of
being treated with asthma medication, 43% of those             taking superfluous medication. Although we do not specif-
with PFT performed had an obstructive pattern, and the         ically counsel patients regarding asthma medication use,
majority was female. These characteristics are compara-        results of this study have led many in our practice to rou-
ble with other series of PVFMD patients.3,4 The median         tinely recommend that the patient revisit his or her asth-
age of 42 years is also on par with the subjects of the        ma medication regimen with the pulmonologist once
aforementioned studies (42.6 and 45, respectively).            symptoms are improving. Future directions include an
Although PVFMD has been described specifically in              expansion of this study to our pediatric population, which
young athletic persons, it is clearly not restricted to this   is currently underway. Other studies might include a
demographic.                                                   cost-analysis of diagnosis and treatment of PVFMD ver-
     Although many patients had previously undergone           sus the cost of a missed diagnosis; the cost of the initial
PFT, our subjects were not initially stratified based on       visit, flexible laryngoscopy procedure, and speech therapy
PFT results or a preexisting diagnosis of asthma. There        is likely much less than the cost of inappropriate medica-
are several reasons for this. First of all, a diagnosis of     tion usage, missed work, emergency service utilization,
asthma does not exclude the possibility of PVFMD. Sug-         and multiple medical visits. Further research might focus
gestive PFT results, and even a positive methacholine          on PVFMD in patients with chronic obstructive pulmo-
challenge test, cannot rule out PVFMD. Additionally,           nary disease, laryngopharyngeal reflux, or allergic rhini-
some patients referred by a pulmonologist have PFT             tis and their use of disease-specific medication. We
suggestive of obstructive disease but do not have a clear      encourage otolaryngology and nonotolaryngology practi-
diagnosis of asthma. They may have symptoms incom-             tioners to have a high suspicion for this disorder in
pletely controlled by inhaled b-agonists, or their symp-       patients with otherwise unexplained dyspnea.
tom severity is out of proportion to PFT findings.
Additionally, patients with asthma undergoing PFT who          CONCLUSION
are already controlled on proper medication may have                Diagnosis and treatment of PVFMD leads to a
nondiagnostic results. The authors felt that if a referring    decline in use of asthma medication. This decrease in
pulmonologist was not able to give a definitive diagnosis      medication use occurs even as symptoms improve.
of asthma based on the available information, it would         Decreased use of asthma medications is seen immediate-
be inappropriate for us to do so. Thus, PFT data do not        ly after the initial diagnostic visit for many patients,
impact patient eligibility. Results were compared
                                                               typically with further decrease in medication use and
between the group of patients with obstructive pattern
                                                               symptomatic improvement as therapy proceeds.
on PFT and those without an obstructive pattern, but it
                                                                    This is the first study, prospective or otherwise, to
should be clear that this is not the same as a comparison
                                                               demonstrate a decrease in asthma medication use with
between patients with coexisting asthma and those with-
                                                               diagnosis and treatment of PVFMD. Future endeavors
out. PFT results did not impact asthma medication use.
                                                               should examine the overall expense of misdiagnosed
In other words, both patients with PFT evidence of
                                                               PVFMD, including the cost of asthma medication and
obstruction and those without evidence of obstruction
                                                               emergency care, and compare this with the cost of diag-
significantly decreased their asthma medication scores.
                                                               nosing and treating PVFMD.

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Laryngoscope 127: July 2017                                                      Kramer et al.: Treatment of PVFMD and Asthma Medication
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