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Interrelationship between feelings of control, activity limitations, and anxiety. Values reported are phi coefficients indicating the strength of the correlation between the 3 binary variables, namely: (a) increased control over PVFM symptoms; (b) reduced anxiety related to PVFM symptoms; and (c) having experienced improvement for at least 1 of the 13 daily activities on the survey.
Source publication
Objective:
Paradoxical vocal fold motion (PVFM) is responsive to behavioral therapy, often resulting in a remission of symptoms, but little is known about whether treatment is beneficial with regard to PVFM-associated psychological symptoms or functional limitations. The goal of the study was to identify patient perceptions of the impact of treatm...
Context in source publication
Context 1
... date, with a few exceptions, there have been very few discussions regarding features associated with control of symptoms [9,10]. The association between feelings of control, reduced anxiety, and reduced activity limitations is depicted in Figure 3. We hypothesize that these 3 characteristics are interconnected and mutually reinforcing. ...
Citations
... The primary treatment for EILO is therapy with a speech-language pathologist (SLP; Burke, 2012;Drake et al., 2017;Mahoney et al., 2022;Nacci et al., 2011;Reitz et al., 2014;Schonman et al., 2022;Slinger et al., 2018). Sometimes referred to as respiratory retraining, therapy with an SLP generally consists of education regarding the nature of EILO, establishing lower thoracic breathing patterns (Chen et al., 2017), developing mastery of rescue breathing techniques (Johnston et al., 2018;Reitz et al., 2014;Shaffer et al., 2018), and learning to utilize these techniques in the context of patient triggers (Fujiki et al., 2023). ...
Purpose
The purpose of this study was to examine the influence of exercise-induced laryngeal obstruction (EILO) on adolescents.
Method
Twenty patients (< 17 years) diagnosed with EILO participated in this study. Patients completed semistructured interviews examining their experience with the health care system, treatment, and the effects of EILO symptoms on quality of life. Interviews were analyzed using a combination of directed and conventional content analyses. Researchers identified seven overarching themes either prior to or during analysis, and 24 subthemes were inductively identified from patient interviews using open, axial, and selective coding.
Results
On average, patients went 1.9 years between symptom onset and EILO diagnosis. Patients described symptom onset as frightening and confusing. Even after initially reporting symptoms to a medical provider, patients went an average of 10.5 months before diagnosis. Patients perceived that delays in diagnosis prevented efficient management and allowed symptoms to escalate. Patients reported that EILO detrimentally influenced athletic performance, forcing them to pace themselves or cease participation altogether. Social and academic effects of EILO included missed classes, difficulty in physical education courses, and resentment from teammates if athletic performance declined. Both athletes and nonathletes indicated that EILO elicited feelings of fear, frustration, dread, guilt, and embarrassment. Patients reported that therapy with a speech-language pathologist (SLP) effectively addressed symptoms; however, employing rescue breathing techniques was often more difficult than anticipated.
Conclusions
Physical and emotional sequelae associated with EILO may have widespread influence on patient quality of life. Therapy with an SLP reportedly ameliorated EILO symptoms; however, patients indicated that delayed diagnosis allowed negative effects to intensify prior to treatment.
... Kim et al., 2022;Neumann & Romonath, 2012;Witzel et al., 1988). In the area of voice, endoscopic biofeedback training has been found to lead to improvements in respiratory retraining outcomes in people with paradoxical vocal fold motion (Bastian & Nagorsky, 1987;Chiang et al., 2013;D'Antonio et al., 1987;Drake et al., 2017;Marcinow et al., 2014;Van Lierde et al., 2004). ...
Purpose
Endoscopic biofeedback training is a type of augmented extrinsic feedback that provides information about physiological processes and bolus flow information through the use of flexible endoscopy. The goal of this tutorial is to describe why and how to incorporate endoscopic biofeedback training into cough and swallowing treatment when working with people with dystussia and dysphagia.
Method
In this tutorial, we will review the diagnostic advantages and limitations of flexible endoscopic evaluation of swallowing as it relates to biofeedback training. We will then (a) review what is known about endoscopic biofeedback training in the field of speech-language pathology; (b) identify which airway protective behaviors clinicians might be best suited for endoscopic biofeedback training; and (c) provide a guide, including sample scripts and video demonstrations, that clinicians can use to aide in the implementation of endoscopic biofeedback training.
Conclusions
Endoscopic biofeedback training for cough and swallowing habilitation and rehabilitation may be a useful addition to a speech-language pathologist's therapeutic armamentarium. However, more research is needed to comprehensively characterize the long-term effects on endoscopic biofeedback training on cough and swallowing treatment-related outcomes.
Supplemental Material
https://doi.org/10.23641/asha.25043579
... 23 The primary treatment for ILO is respiratory retraining therapy with a speech-language pathologist (SLP). [35][36][37][38][39][40][41][42][43] The reduction of cost may reflect the efficacy of this intervention and subsequently reduced medical visits and pharmaceutical use. 44 A reduction in cost may also extend to pediatric patients, who undergo an average of 3.4 therapy sessions prior to discharge. ...
Purpose
Diagnosing pediatric induced laryngeal obstruction (ILO) requires equipment typically available in specialist settings, and patients often see multiple providers before a diagnosis is determined. This study examined the financial burden associated with the diagnosis and treatment of ILO in pediatric patients with reference to socioeconomic disadvantage.
Methods
Adolescents and children (<18 years of age) diagnosed with ILO were identified through the University of Madison Voice and Swallow Outcomes Database. Procedures, office visits, and prescribed medications were collected from the electronic medical record. Expenditures were calculated for two time periods (1) pre‐diagnosis (first dyspnea‐related visit to diagnosis), and (2) the first year following diagnosis. The Area Deprivation Index (ADI) was used to estimate patient socioeconomic status to determine if costs differed with neighborhood‐level disadvantage.
Results
A total of 113 patients met inclusion criteria (13.9 years, 79% female). Total pre‐diagnosis costs of ILO averaged $6486.93 (SD = $6604.14, median = $3845.66) and post‐diagnosis costs averaged $2067.69 (SD = $2322.78; median = $1384.12). Patients underwent a mean of 3.01 (SD = 1.9; median = 2) procedures and 5.8 (SD = 4.7; median = 5) office visits prior to diagnosis. Pharmaceutical, procedure/office visit, and indirect costs significantly decreased following diagnosis. Patients living in neighborhoods with greater socioeconomic disadvantage underwent fewer procedures and were prescribed more medication than those from more affluent areas. However, total expenditures did not differ based on ADI.
Conclusions
Pediatric ILO is associated with considerable financial costs. The source of these costs, however, differed according to socioeconomic advantage. Future work should determine how ILO diagnosis and management can be more efficient and equitable across all patients. Laryngoscope , 2024
... 53 Speech therapy addressing EILO/ILO/EILO+ is comprised of education regarding the condition, rescue techniques, and application of these techniques. 12,54,55 This therapy has generally been reported to be effective, 44,53,[56][57][58] and pediatric EILO/ILO/EILO+ patients have required an average of 3.4 therapy sessions before symptoms are sufficiently reduced for discharge. 42 However, understanding the manner in which EILO/ILO/EILO+ patients with varying symptom triggers respond to treatment may allow for optimization and individualization of therapy. ...
Purpose:
To compare clinical profiles of pediatric patients with Induced Laryngeal Obstruction (ILO), Exercise Induced Laryngeal Obstruction (EILO), and EILO with non-exertion related secondary triggers (EILO+).
Methods:
A retrospective observational cohort design was employed. Four-hundred and twenty-three patients <18 years of age were identified from the electronic medical record of a large children's hospital. All patients underwent evaluations with a laryngologist and speech-language pathologist and were diagnosed with EILO/ILO. Patients were divided into 3 groups based on dyspnea triggers reported in initial evaluations. Groups consisted of patients with EILO (N = 281), ILO (N = 30), and EILO+ (N = 112). Patient demographics, EILO/ILO symptoms, endoscopy findings, medical comorbidities, medical history, and EILO/ILO treatment information were extracted and compared across EILO/ILO subtypes.
Results:
Patients with EILO experienced higher rates of hyperventilation (P < .001), sore throat (P = .023), and chest pain (P = .003). Patients with ILO were significantly younger in age (P = .017) and presented with increased rates of nighttime symptoms (P < .001), globus sensation (P = .008), self-reported reflux symptoms (P = .023), and history of gastrointestinal conditions (P = .034). Patients with EILO+ were more likely to be female (P = .037) and presented with higher prevalence of anxiety (P = .003), ADHD (P = .004), chest tightness (P = .030), and cough (P < .001).
Conclusions:
Patients with EILO, ILO, and EILO+ present with overlapping but unique clinical profiles. A prospective study is warranted to determine the etiology of these differences and clarify how the efficacy of EILO, ILO, and EILO+ treatment can be maximized.
Level of evidence:
4.
... Previous research suggests that speech therapy addressing EILO is effective in reducing symptoms in adults (Lillie et al., 2014;Murry et al., 2006;Ryan et al., 2009;Slinger et al., 2018). Preliminary research into therapy outcomes for children and adolescents also suggests improvements in EILO symptomology (Drake et al., 2017;Maturo et al., 2011). For example, M. D. Sullivan et al. (2001) documented therapy outcomes from 20 adolescent female athletes (aged 12-17 years). ...
Purpose:
This study examined treatment outcomes of speech-language pathology intervention addressing exercise-induced laryngeal obstruction (EILO) symptoms in teenage athletes.
Method:
A prospective cohort design was utilized; teenagers diagnosed with EILO completed questionnaires during initial EILO evaluations, posttherapy, 3-month posttherapy, and 6-month posttherapy. Questionnaires examined the frequency of breathing problems, the use of the techniques taught in therapy, and the use of inhaler. Patients completed the Pediatric Quality of Life (PedsQL) inventory at all time points.
Results:
Fifty-nine patients completed baseline questionnaires. Of these, 38 were surveyed posttherapy, 32 at 3-month posttherapy, and 27 at 6-month posttherapy. Patients reported more frequent and complete activity participation immediately posttherapy (p = .017) as well as reduced inhaler use (p = .036). Patients also reported a significant reduction in the frequency of breathing problems 6-month posttherapy (p = .015). Baseline PedsQL physical and psychosocial scores were below normative range and were not impacted by therapy. Baseline physical PedsQL score significantly predicted frequency of breathing difficulty 6-month posttherapy (p = .04), as better baseline scores were associated with fewer residual symptoms.
Conclusions:
Therapy with a speech-language pathologist for EILO allowed for more frequent physical activity following therapy completion and decreased dyspnea symptoms 6-month posttherapy. Therapy was associated with a decrease in inhaler use. PedsQL scores indicated mildly poor health-related quality of life even after EILO symptoms improved. Findings support therapy as an effective treatment for EILO in teenage athletes and suggest that dyspnea symptoms may continue to improve following discharge as patients continue using therapy techniques.
... If PVFM was diagnosed at the evaluation, treatment was initiated, and additional therapy was recommended. As described previously, behavioral therapy includes education regarding PVFM, training in preventative and rescue breathing strategies to dilate the glottis, as well as voice therapy for those in whom dysphonia has been identified [16][17][18][19]. The goals of subsequent treatment sessions are to ensure accurate and consistent usage of both preventative and rescue breathing strategies and their generalization across settings. ...
... In fact, the prevalence of vocal hyperfunction in this population can be useful for treatment purposes. By targeting vocal quality, clinicians can demonstrate to patients that they can control laryngeal function, not only for voice but also breathing, and use this observation to promote feelings of self-efficacy [16]. ...
... There is a need for research examining the association between symptoms of dysphonia, cough, and PVFM in the adolescent population, how they are best managed, and the factors associated with treatment success [2,11]. In our clinical practice, we have found that targeting dysphonia during PVFM treatment often results in better treatment outcomes, regardless of whether the patient initially complains of or even perceives dysphonia, and have adopted this model with our adult and pediatric patients [16]. This finding requires confirmation from a longitudinal study with the systematic use of validated measures. ...
Objective:
Associations between dysphonia and paradoxical vocal fold motion (PVFM) have been previously reported in adults, but it is unclear whether similar associations exist for adolescents. The goals of this study were to identify the prevalence and severity of voice disorders in adolescent patients with PVFM, identify differences between those with and without clinician-identified dysphonia, and investigate what factors were associated with voice handicap in this population.
Methods:
A retrospective review of eligible adolescent patients diagnosed with PVFM over a 1-year period at a single institution was undertaken. Data collected from the medical record included demographic background, medical history and workup, patient- and family-reported symptoms, and findings from the laryngeal examination. The presence or absence of clinician-diagnosed dysphonia was used to subdivide the sample for analysis.
Results:
Forty-eight patients with PVFM were included. The sample was primarily female (73%) with a median age of 15 years. Few patients had voice complaints (5%), but clinician-diagnosed dysphonia was common (52%) and ranged from mild to moderate. Vocal hyperfunction was frequently observed (55%), but anatomic abnormalities associated with dysphonia were rare (6%). Adolescents with dysphonia were significantly older, more likely to have vocal hyperfunction on laryngoscopy, and more likely to return for therapy than those without dysphonia. No notable differences existed in the number of behavioral therapy sessions or in the likelihood of completing treatment between the two groups. The majority of participants (79%) had at least one "confounding factor" (i.e., were currently taking a medication for asthma, allergies, or reflux, or had a laryngeal abnormality) but this did not differ significantly between those with and without dysphonia. A minority of individuals (28%) had abnormal scores on the Voice Handicap Index (VHI). Age was positively correlated with dysphonia severity but no other significant associations were observed.
Conclusion:
Although voice complaints are rare, dysphonia among adolescents with PVFM is common and can occur in the absence of laryngeal abnormalities and medical comorbidities, typically as a result of vocal hyperfunction. Dysphonia does not appear to be a barrier to PVFM treatment and may be a useful target in therapy.
... So kann zum Beispiel eine rein zwerchfellbetonte Atmung während einer Attacke zur sofortigen Besserung des Atemnotgefühls führen. Erlebt der Patient, dass er selbst seine Atemnot durch veränderte Atemmuster reduzieren oder beseitigen kann, ist der wesentliche therapeutische Schritt getan (16,17). ...
Importance
Patients with induced laryngeal obstruction (ILO) present with a variety of behavioral health profiles. Identifying these profiles is crucial in that behavioral health conditions may affect treatment duration and outcomes.
Objective
To characterize the prevalence of anxiety, depression, posttraumatic stress disorder (PTSD), and physical somatic symptoms in adult and pediatric patients with ILO and determine the factors associated with anxiety, depression, PTSD, and physical somatic symptoms in patients with ILO?
Design, Setting, and Participants
This cross-sectional study included a nonprobability sample of 83 adult and 81 pediatric patients diagnosed with ILO at outpatient adult and pediatric otolaryngology clinics between 2021 and 2023. Exclusion criteria included a comorbid respiratory diagnosis other than asthma, head or neck cancer, or neurological impairments. Recruitment took place between September 2021 and March 2023. The analyses were run in January 2024.
Main Outcome Measures
Patients were prospectively screened for anxiety, depression, PTSD, and somatic physical symptoms. In addition, any past behavioral health diagnoses were extracted from the medical record. Comorbidities, ILO symptoms triggers, and onset details were gathered from ILO evaluations. Adult patients completed the Screen for Adult Anxiety Related Disorders (SCAARED), depression (Patient Health Questionnaire [PHQ]-9), and somatic physical symptoms portions of the Patient Health Questionnaires (PHQ-15), and the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5). Pediatric patients completed the Screen for Child Anxiety Related Disorders (SCARED), depression (PHQ-9A) and somatic physical symptoms portions of the Patient Health Questionnaires for Adolescents (PHQ-15A), and the UCLA PTSD Reaction Index brief screeners.
Results
Eighty-three adult patients participated in this study (mean [SD] age, 45.8 [14.3] years; 64 female, 19 male). Eighty-one pediatric patients participated (mean [SD] age, 13.83 [2.55] years; 67 female, 14 male). Adult and pediatric patients with ILO screened positive for elevated rates of anxiety (53 adults [63%]; 49 children [60%]), depression (27 adults [32%]; 25 children [30%]), and PTSD (29 adults [34%]; 13 children [16%]). Most of the patients with anxiety and depression symptoms were formally diagnosed prior to ILO evaluation, with rates of previously diagnosed anxiety, depression, and PTSD also above published norms. Adults were twice as likely as children to present with PTSD (odds ratio, 2.1; 95% CI, 0.05-4.48). Elevated rates of physical somatic symptoms were also evident, with 38 adults (45%) and 32 children (39%) scoring in the moderate to severe range.
Conclusions and Relevance
This study found high rates of adult and pediatric patients with ILO screened positive for anxiety, depression, and PTSD symptoms. Future work should investigate how behavioral health and ILO treatments can best be coordinated to maximize treatment outcomes.
