Assessing Reflux
A condition that physicians typically see in conjunction with PVFM is laryngopharyngeal reflux, said Dr. Aviv. He and his colleagues have found that laryngopharyngeal reflux is associated with reduced laryngeal sensitivity, which in turn may trigger PVFM.1 Reflux may also cause some damage to the vagus nerve, which supplies motor impulses to the vocal folds, he said.
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May 2009Because reflux may contribute to PFVM, asking patients what they have eaten before an episode and examining their posture during increasing physical activity levels is an important part of determining what could be aggravating the condition, said Dr. Mathers-Schmidt.
In addition to reflux, PVFM can worsen with sinusitis and postnasal drip, said Dr. Mirza. Viral infection and chest congestion many also irritate the vocal folds, she said.
Psychological Component to Disease
Practitioners should also take into account that PVFM appears to be associated with an emotional component of being an overachiever, said Dr. Klaben.
High-anxiety situations can trigger an episode, agreed Dr. Mirza, and for athletes, this often means performance anxiety during sporting events.
I worked with a teenager who set very high standards for herself academically and athletically, said Dr. Mathers-Schmidt. The girl was silently talking to herself during sporting events and putting a large amount of pressure on herself to succeed, which in turn, reportedly caused her to tighten her larynx, triggering PVFM episodes.
Moreover, the anxiety that results from breathing difficulty can compound PVFM, said Dr. Klaben.
With visualization, patients actually become aware of what happens to their vocal folds when they breathe in and out and learn to develop better control of their vocal fold movement.
-Natasha Mirza, MD
Treatment of PVFM
While PVFM may be challenging to diagnose, a number of treatment options exist that help the majority of patients overcome the condition.
Dr. Aviv and his colleagues have found that respiratory training in conjunction with management of laryngopharyngeal reflux with proton pump inhibitors is effective for patients with cough and PVFM.2 If patients are not treated for the reflux component, they probably will not experience improvement, he said.
This approach to therapy has a success rate of around 90%, added Dr. Aviv. If patients don’t get better, they probably do not have PFVM, but have a combination of other conditions such as a tumor, vocal fold paralysis, nerve injury, or asthma, he added.
Respiratory training may include inspiratory muscle exercises that make inhaling under controlled conditions difficult, said Dr. Mathers-Schmidt. This teaches patients to breathe optimally against resistance and strengthen their inspiratory muscles. Patients gradually build up muscle strength and learn to maintain an open airway in about five to six weeks, she explained.