Vocal cord dysfunction (VCD) is a condition of paradoxical adduction of the vocal cords during the inspiratory phase of the respiratory cycle. VCD often presents as stridorous breathing, which may be misdiagnosed as asthma. The mismanagement of this disorder may result in unnecessary treatment and iatrogenic morbidity. An association with psychogenic factors has been reported, and a higher incidence of anxiety-related illness has been demonstrated in patients with VCD.
Definitive diagnosis of VCD is made by visualization of adducted cords during an acute episode using nasopharyngeal fiber-optic laryngoscopy. Diagnosis can be problematic, because it may be difficult to reproduce an attack in a controlled setting. To maximize diagnostic yield during laryngoscopy, provocation of symptoms using methacholine, histamine, or exercise challenges have been used. We report a case of an 11-year-old boy, wherein hypnotic suggestion was used as an alternative method to achieve a diagnosis of VCD.
The patient was admitted to the pediatric intensive care unit for elective fiber-optic laryngoscopy to confirm a diagnosis of VCD. The patient had a 4-year history of refractory asthma, severe gastroesophageal reflux disease (GERD) for which he had undergone a Nissen fundoplication, and suspected VCD.
At 9 years of age the patient began manifesting monthly respiratory distress episodes of a severe character different from those that had been attributed to his asthma. Typically, he awoke from sleep with shortness of breath and difficulty with inhalation. He described a “neck attack” during which he felt as if the walls of his throat were “beating together.” The patient was at times noted by his mother to exhibit a “suckling” behavior before onset of his respiratory distress episodes. On 4 occasions the patient became unconscious during an attack and then spontaneously regained consciousness after a few minutes. On these occasions, he was transported by ambulance to the hospital and the severe difficulty with inhalation resolved within a few minutes on treatment with oxygen and bronchodilators. Sometimes he was noted to manifest wheezing for several hours, which was responsive to bronchodilator therapy.
Given the severity of the patient's disease, it was imperative to determine whether VCD was a complicating factor. It was proposed that an attempt be made to induce VCD by hypnotic suggestion while the patient underwent a fiberscopic laryngoscopy to establish a definitive diagnosis. The patient and his mother gave written consent for this procedure. He was admitted for observation to the pediatric intensive care unit for the induction attempt. The patient requested that no local anesthesia be applied in his nose before passage of the laryngoscope because he wanted to eat right after the procedure. Therefore, the nasopharyngeal laryngoscope was inserted while he used self-hypnosis as the sole form of anesthesia. He demonstrated no discomfort during its passing. Once the vocal cords were visualized, the patient was instructed to develop an episode of respiratory distress while in a state of hypnosis by recalling a recent “neck attack.” His vocal cords then were observed to adduct anteriorly with each inspiration. The patient then was asked to relax his neck. When he did, the vocal cords immediately abducted with inspiration, and he breathed easily. After removal of the laryngoscope, the patient alerted from hypnosis and said he felt well. He reported no recollection of the procedure, thus demonstrating spontaneous amnesia that sometimes is associated with hypnosis.
Because the diagnosis of VCD was confirmed, the patient was encouraged to use self-hypnosis and speech therapy techniques to control his symptoms. He also was referred for counseling.
To our knowledge this is the first description in the medical literature of the use of hypnotic suggestion for making a diagnosis of VCD. The potential utility of hypnosis in this case was suggested by the widely reported relationship of VCD to anxiety disorders and other psychological factors.
The use of hypnosis for widespread diagnosis of VCD has its limitations. Although the patient in this report was able to achieve several hypnotic phenomena, not all patients respond to hypnosis as readily. Because children may be more adept at hypnosis than adults, use of hypnosis to diagnose VCD may not be as effective in older patients. The instructor in hypnosis must have adequate training. Importantly, inducing VCD with hypnosis in an inappropriate setting might be dangerous. In this case, we chose to perform the diagnostic procedure in a pediatric intensive care unit given the risk of inducing severe respiratory distress with hypnosis.
This case was complicated by an atypical presentation of VCD with concurrent diagnoses of asthma and GERD. Unlike the patient in this report, VCD is typically characterized by stridor and by the absence of nocturnal symptoms. However, a recent case series presented 4 patients with laryngoscopically confirmed VCD who presented with nocturnal symptoms. The coexistence of VCD with asthma is well recognized. As in this patient, the presence of asthma may complicate and delay a definitive diagnosis of VCD. The presence of GERD is also a common finding in pediatric patients with VCD. However, neither asthma nor GERD could entirely account for the symptoms of this patient, because he experienced serious respiratory distress despite aggressive therapy for asthma and reflux, including a fundoplication.
The most widely used preventive treatment for VCD is speech therapy, which focuses on relaxed throat breathing and abdominal breathing. These techniques also can be used to terminate episodes of VCD. Psychotherapy also has benefited some patients by helping patients to identify and manage issues of primary and secondary gain associated with VCD. The high prevalence of anxiety-related disorders in patients with VCD has led to the suggestion that anxiolytics may benefit patients, although this is not generally used as a first-line therapeutic option. The patient in this report demonstrated an ability to control VCD with hypnosis, as has been reported previously for other patients.
In conclusion, we found that in our patient with life-threatening respiratory distress, hypnosis could be used to achieve a diagnosis of VCD as well as an effective therapeutic measure. hypnosis, vocal cord dysfunction, asthma, gastroesophageal reflux.