The differential diagnosis of paradoxical vocal fold movement (PVFM) and its distinguishing features.

During the respiratory cycle of higher animals and human beings, the vocal folds partially abduct with inhalation and partially adduct with exhalation (Ward, Hanson, & Berci, 1981). This phasic vocal fold movement is physiological and allows the unimpeded movement of air into the lungs during inspiration while helping to maintain the alveolar patency of the lungs by providing positive airway pressure during expiration.

Some patients who present with dyspnea, stridor, and airway obstruction have paradoxical vocal fold movement (PVFM). PVFM is characterized by inappropriate adduction of the vocal folds during inspiration (Appleblatt & Baker, 1981; Maschka et al., 1997; Mathers-Schmidt, 2001; Murry, Tabaee, & Aviv, 2004). The persistence and the degree of inappropriate glottal closure with PVFM determines the degree of obstruction. In some patients, the problem is constant and severe, requiring airway intervention; in others, the problem is intermittent and relatively mild.

In addition to the term PVFM, there have been a number of other terms used in the literature to identify this complex and often confusing disorder in adults and children, including Munchausen’s stridor (Patterson, Schatz, & Horton, 1974), vocal cord dysfunction (Christopher et al., 1983), paradoxical vocal cord motion (Martin, Blager, Gay, & Wood, 1987; Sandage & Zelazny, 2004), and irritable larynx syndrome  (Andrianopoulos, Gallivan, & Gallivan, 2000; Morrison, Rammage, & Emami, 1999). Maschka et al. (1997) and Mathers-Schmidt (2001) provided classifications and discussions of some of the causes of this condition.

In this article, we provide a concise differential diagnosis for PVFM in adults (see Appendix A). We reserve the term PVFM to refer to inappropriate vocal fold adduction during inspiration, and we present differentiating features of specific etiologies. We offer a new classification of PVFM because accurate diagnosis is a prerequisite for effective treatment.

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Jamie A. Koufman, Voice Institute of New York and New York Medical College; Christie Block, Private Practice, New York, and New York University

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