(a) Pre-Diagnosis Medical History 1999 (10 yrs old) – experienced unexplained shortness of breath 2000-2001 (11-12 yrs old) – unexplained vomiting, frequent stomachaches 2003 (13 yrs old) – Frequent URIs, chronic coughing, VCD diagnosis at NJMRC (b) Surgical History (i) Tonsillectomy, June 2004 (ii) Appendectomy, January 2005 (iii) Cholecystectomy, April 2006 (c) Patient Medications* (number of prescriptions in indicated calendar year) 2002: ipratropium bromide (2), cephalexin, azithromycin (2), cefuroxime (3), montelukast sodium, fexofenadine, fluticasone, benzonatate (3), hydrocodone, promethazine (2), prednisone 2003: ipratropium bromide, azithromycin, cefuroxime (2), levaquin, lansoprazole, fexofenadine, benzonatate, alprazolam, lorazepam, viscous lidocaine 2004: ipratropium bromide, cefuroxime, amoxicillin, zithromax, accuhist, tramadol, hydrocodone, prednisone, lorazepam (2), promethazine, viscous lidocaine, differin 2005: cefuroxime, azithromycin, nitrofurantoin, esomeprazole magnesium (4), accuhist, azelastine, hydrocodone (2), lorazepam, viscous lidocaine (2) 2006: albuterol, erythromycin, cefuroxime (3), azithromycin, levaquin, esomeprazole magnesium (2), chlorphemramine (2), hydrocodone (2), oxycodone, prednisone (2), promethazine (2) 2007: cefuroxime, hydrocodone, prednisone *medications not related to suspected VCD symptoms/causes omitted
Mild laryngospasm Characterization: Partial or complete closure of larynx, preventing inspiration or expiration. Triggers: Stress, odors, post nasal drip, LPR, extreme physical pain or fear. Patient is usually warned by what she describes as “twitchiness” of vocal cords Frequency: Every 15-30 minutes while triggers present Duration: 5 to 30 seconds, patient remains conscious; oxygen saturations unchanged Acute Treatment: Removal of triggers; Breathing techniques, as instructed by speech pathologists Severe laryngospasm Characterization: Complete closure of larynx completely preventing inspiration or expiration. When episodes occurred frequently, observation of patient during sleep occasionally revealed laryngospasms without the patient waking; patient may become unconscious while sleeping. Very little stridor, usually no warning. Triggers: Same as above; occasionally none Frequency: Every 5-15 minutes Duration: 30 to 150 seconds, patient becomes unconscious Acute treatment: Occasionally, patient was able to force cords open by inhaling/exhaling forcefully through a straw. With repeated spasms, patient weakens to the point that this was not possible. Cycle continues until heliox is administered. Hospitalizations/VCD clinic visits 2002: April, May: Acute treatment of laryngospasms November 14-17, December 11-13: Acute treatment of laryngospasms 2003: January: Initial VCD diagnosis; Ph probe placed, indicating slight amount of reflux; patient treated for vasomotor rhinitis, recommendation for breathing exercises and speech therapy given May 1: CMC, Dallas (TX); Acute treatment of laryngospasms October: NJMRC, Denver (CO); VCD follow-up 2004: January 9-13, March, May 9-11: Acute treatment of laryngospasms June 17-18: Tonsillectomy August: Ph probe placed, with similar findings; suggested treatment regimen for conditions which trigger attacks; recommend continuation of speech therapy
2005: January: Findings, as reported to family: Throat and nose examined; no extreme problems with vocal cords; cords appeared normal, with only slight redness at posterior of pharynx; reflux appears minimal; after review of chart from WFUBMC, could not determine presence of reflux problem Recommendations given to family: Continue speech therapy, “keep a straw handy”; prescriptions given to treat acid reflux; control postnasal drip and stress; stated 98 percent of patients will be able to open the vocal cords once they close, even if completely closed, by using the straw to create a pressure differential January: Appendectomy March: Cardiac monitoring for symptoms of PSVT; unable to capture arrhythmia on 24 hour monitor, no definitive diagnosis October 17-18: Acute treatment of laryngospasms 2006: February 15: Acute treatment of laryngospasms April: Cholecystecomy Patient treated and released from ED Patient seen in clinic Following each diagnosis and treatment recommendation, the patient and her family explicitly followed the outlined plan, including aggressive treatment for her triggers. The patient returned to normal life, but attacks continued. The patient was regularly seen and treated by one PCP, two pediatric pulmonologists, one Allergy-Immunologist, and one Speech Pathologist. Additional physician consults were obtained with a laryngologist, gastroenterologist, cardiologist, and four different speech therapists. Regular sessions were continued with the speech pathologist to practice breathing techniques for two years. The patient’s PCP and physicians from CMC who treated her regularly were unable to determine the reason for the extreme VCD episodes. Throughout aggressive treatment for triggers, VCD episodes did not improve, and continued to worsen over the 4 year span.
Summary: Patient experienced mild and severe laryngospasms from Fall 2002 through Spring 2006, despite following the advice of every VCD professional. Every treatment plan was similar, with no relief from the serious episodes. The symptoms did not vary, and overall no improvement was seen with the severe attacks. In all tests, only a slight amount of acid reflux was detected. In all cases, recommendations were to eliminate stress, reflux, and postnasal drip. The patient diligently followed directions, including relaxed throat breathing, lifestyle changes to reduce stress, changes in eating habits including diet restrictions, nasal rinses, and prescriptions for reflux and postnasal drip. Serious episodes still occurred every 2 to 3 months, requiring heliox to break the cycle. The physicians ordering heliox treatment (CMC) could find no reason why the cycle was broken successfully once hospitalized, only to repeat several months later, sometimes without identifiable triggers Conclusion: In April, 2006, tests revealed that the gallbladder was functioning at 19 percent of normal. The patient’s surgeon performed a cholecystectomy, and reported the gallbladder was normal size and shape, with no stones present. The patient’s mother, maternal grandmother, and maternal aunts also had similar surgeries. During the entire course of mild and severe VCD attacks, it appears that gallbladder functioning was decreasing while laryngospasms worsened. Currently, the patient is over one year post-op and has not had a single severe laryngospasm requiring hospitalization to treat the symptoms.

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Breathing is not Optional. Vocal Cord Dysfunction
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Breathing is not Optional. Vocal Cord Dysfunction
Last Modified: 7/7/08 2:53 PM