By Laurie Ross
Nine-year-old Ellie Carson lives to play soccer. To her, happiness is flying down the field after the ball.
For a while, though, it looked like she might have to stop chasing her dream.
Ellie was having trouble keeping up. Just minutes into a game she would begin to wheeze and feel short of breath. As symptoms slowed her down, she became frustrated and upset. That would make it even harder to breathe and she would have to come off the field.
The wheezing and shortness of breath were classic exercise-induced asthma symptoms, so Ellie’s pediatrician prescribed an inhaled bronchodilator for her to use before practice and games to prevent breathing problems.
When that treatment didn’t work, Ellie and her medical care team tried different combinations of asthma and allergy medications to help her breathe, including corticosteroids to treat airway inflammation. Still, game after game and practice after practice, Ellie would have to come off the field.
Determined to find out what was wrong with her daughter, Yvonne Carson took Ellie to see a pediatric pulmonologist, Sunil Kapoor, MD, of the Pediatric Lung Center in Fairfax, Virginia. Dr. Kapoor says he listened to Ellie’s story and checked her lungs but was pretty sure from the outset that what was causing Ellie’s difficulties wasn’t asthma, but a very good imitation: vocal cord dysfunction (VCD).
Following the Clues
“Vocal cord dysfunction,” explains Dr. Kapoor, “looks and feels a lot like asthma. However, since asthma medications weren’t helping Ellie, I suspected she had VCD. It’s a process where your vocal cords move the wrong way when you inhale – closing instead of opening – and it’s closely related to stress, anxiety and exercise. Ellie fit the profile of many of my VCD patients: a very competitive, high achieving, young female athlete.”
You can’t see vocal cords when you look down your throat in the mirror – but you can feel where they live. Put your hand on the front of your throat and swallow. That hard ball that moves up and down when you swallow (on guys it’s called the Adam’s apple) is your voice box, also called the larynx. Vocal cords are folds of tissue that stretch across your voice box. As you breathe in, your vocal cords open to let air go through into your lungs, then narrow as you breathe out. Most of us can’t control this opening and closing, but we do learn to use our vocal cords to talk and sing – it’s the vibration of our vocal cords that makes these sounds.
If you have vocal cord dysfunction, your vocal cords suddenly close when they’re not supposed to, cutting off your air supply. Often this happens during exercise or when you’re emotionally upset or crying – just when you need air the most!
Symptoms of VCD include
- wheezing or stridor (a high-pitched sound)
- chronic cough or throat clearing
- shortness of breath
- upper chest or throat tightness
- intermittent hoarseness
Diagnosing vocal cord dysfunction is tricky because it so closely resembles asthma – and will often occur alongside asthma – and because the symptoms may seem random. It may happen to an athlete during a game but not a practice, for instance. Or it may happen outside of exercise, when the person is laughing or crying.
In addition to stress and exercise, VCD can be set off by other factors often associated with asthma, including cigarette smoke, perfume and other strong scents, upper respiratory infections, air pollution and cold air.
The most definitive way to identify VCD is to use a laryngoscope (a flexible, fiber optic tube and tiny camera inserted into the back of the throat) to view the vocal cords. However, it must be done while the symptoms are actually occurring – an uncomfortable technique Dr. Kapoor hesitates to use with his young patients. Instead, he has the patient exercise on equipment in his office to induce symptoms, then he uses a spirometer to measure patient lung function. When VCD is occurring, the spirometer reading will show very different results from those seen with asthma.
Some patients may have both asthma and VCD. According to Susan Brugman, MD, one of the leading VCD experts at the National Jewish Medical and Research Center in Colorado, “In my experience with adolescents, 30 to 40 percent of those with VCD also have some degree of asthma.”
Michael Mellon, MD, a pediatric allergist with the Southern California Permanente Medical Group in San Diego, says, “It’s important to look at the overall pattern of symptoms. Patients with exercise-induced asthma will usually have symptoms of asthma at other times (with an upper respiratory infection, for instance, or during allergy seasons) whereas VCD patients may have extreme episodes of difficult breathing in only very isolated situations such as competitive sports or exercise.”
Pointing to a Cause
There’s no single cause for this vocal cord miscue. Dr. Brugman says one aspect is the stress factor. “I see pediatric patients, most of whom are adolescents for whom the vocal cords have become their stress organ,” she explains. “It’s similar to stress-related migraine headaches or irritable bowel syndrome.”
VCD may also be linked to chronic irritation of the throat that makes the vocal cords sensitive. The irritation could come from postnasal drip caused by chronic nasal and/or sinus congestion or from gastroesophageal reflux, where stomach acids leak up into the esophagus. In some people, Dr. Brugman says, the acids travel all the way up to the top of the esophagus, where it meets the windpipe and larynx. “Even a small amount of this fluid spilling over onto the larynx can cause severe irritation and prompt the vocal cords to close,” she explains.
Dr. Kapoor agrees. “Quite often, people with vocal cord dysfunction don’t realize they have reflux,” he says, “because they don’t experience the classic heartburn symptoms. This kind of ‘silent’ reflux that affects the upper airways is so common among my VCD patients that I give the majority of them a trial run with reflux medications.”
Beyond treating an underlying throat irritation such as reflux or sinusitis, there is no specific medication available to treat VCD. However, many patients are referred to a speech pathologist (therapist).
“When people think of speech therapy, they tend to think about learning to pronounce r’s and s’s correctly,” says Susan Miller, PhD, CCC-SLP, assistant professor of otolaryngology at the Georgetown University Hospital and a certified speech-language pathologist. “But your voice is an instrument you play by learning to control your breathing and the vibration of your vocal cords. A speech pathologist can help you learn to relax your breathing. And we can teach you techniques that help keep the vocal cords from tightening in the first place.”
Dr. Miller specializes in treating vocal cord dysfunction. She’s also a runner, which helps her understand athlete patients like Ellie. “Vocal cord dysfunction is very much a learned behavior which may have begun with a physical cause, such as silent reflux or sensitivity to an odor,” she explains. “It is very disturbing to patients, especially if they are athletes who have experienced very loud wheezing or even vomiting during exercise. They become embarrassed and afraid that it will happen again. That fear and stress tends to set it off again – whether through tensing the muscles or through reflux, since stress can influence reflux. Then it becomes a self-fulfilling prophecy.”
Dr. Miller says athletes with VCD have to learn new ways to breathe. “Many athletes have been taught to relax by breathing in through the nose and exhaling through the mouth. But when you run or exercise heavily, you can’t do this – you don’t get enough air. So you need a different technique. I teach them to breathe with their jaw relaxed and mouth open, using small, rapid inhalations, then exhaling through pursed lips.”
She also teaches them to reduce reflux by not eating acidic foods like orange juice, soda, chocolate or pizza before exercise. In fact, Dr. Miller thinks one reason so many teenagers have VCD is that they tend to eat a lot of junk food; even the power bars that athletes eat before exercising can cause problems if they contain chocolate.
Dr. Miller taught Ellie about dietary changes that could reduce her reflux and helped her learn to relax her breathing while exercising. According to Ellie’s mother, the techniques are working.
“It’s been a struggle,” says Yvonne. “It’s so easy to assume the breathing problems are asthma and to medicate without testing for anything else. We just kept pushing to find answers. Finally, we’re seeing improvements. Ellie still takes medicine for her allergies and watches what she eats before games. She’s also learned to use her breathing technique on the field while she’s running. She knows she can’t wait till there’s a problem, but has to control it early on. I remind her that she has to control it herself and I try to give her confidence that she can. I think the confidence is a big part of the control, since it allows less room for the anxiety.”
Separating the Symptoms
Vocal cord dysfunction (VCD) is often mistaken for asthma, especially exercise-induced asthma (EIA). This is no surprise, since symptoms of the two conditions are so similar. There are some differences, however, that you might notice. If you suspect you have VCD, consult this chart and talk with your physician.
Timing of symptoms
|less than 5 minutes after beginning exercise||5-10 minutes or more after beginning exercise|
|in throat||middle or lower chest|
Wheezing or high-pitched sound
|when breathing in; hoarse voice||when breathing out
|symptoms can recur immediately and more severely when exercise resumes||symptoms tend to be less severe when exercise resumes (after bronchodilator use)|
|may take less than 10 minutes||usually takes up to an hour without medication|
|bronchodilator won’t help||bronchodilator will help|
First published: Allergy & Asthma Today, Volume 6, Issue 1
Updated: February 2009