Vocal Cord Dysfunction – PediaCast 069
The Interview Edition
Dr Karen McCoy is a Pediatric Pulmonologist at Nationwide Children’s Hospital. Today, she stops by PediaCast to discuss vocal cord dysfunction and its confusion with asthma.
Announcer: This is PediaCast.
Announcer: Welcome to PediaCast, a pediatric podcast for parents, the interview edition. And now direct from Bird House Studios, here’s your host, Dr. Mike.
Dr. Mike Patrick: Hi everyone and welcome to PediaCast. This is episode 69 for Thursday, October 25th 2007. And today we have Dr. Karen McCoy coming along to talk about vocal cord dysfunction and its oftentimes confusion with asthma. So it will be an interesting discussion coming up here in just a few minutes.
You know thanks to TiVo. We actually don’t have TiVo anymore. It’s a Time Warner DVR kind of deal. We’ve been recording this season of Grey’s Anatomy and those of you who have been PediaCast listeners for a long time know that last winter I did a semi-regular segment on my attempt to make Grey’s Anatomy a better show by sprucing up the medical component of the program.
And we finally got around to watching first episode of this season. So I know I’m a little late to the party. That’s nothing new. So what a dimension is that starting with this season there’s certainly not much of a change with that. I mean I love the characters and the drama. There aren’t a lot of shows on TV that I watch. I do practice what I preach in of course with full time medical practice and doing this podcast especially now that it’s daily, there’s not a lot of time that’s left over to watch TV.
But Grey’s Anatomy is one that we have liked in the past and you know I like the characters, I like the drama. And actually I think that part of it is fairly realistic as far-fetched to some of it may seem. It’s not that far off the charts really. But I have to question; do they even have a medical adviser? And if they do, the guy or gal has to be a wimp. You know I mean because there’s obvious things in the medical part of the show that are just so wrong.
And you know if they have a medical adviser that’s worth his or her salt, I’m sure that they’re bringing some of these things up. And then the writers and the producers, and directors just say, “We’re going to do it our own way anyway.” But you know you could still have great drama and make it interesting and still be medically accurate. So let me give me you an example. First of all I would have scratched the whole deer scene. OK.
So you’ve got Izzie and this group of her new interns. There’s got to be some other way to do this. Than her rescuing a deer in the back of the pick-up truck. And the other thing too is if the deer had some problem that you could shock it, you know obviously it wasn’t helping the deer’s heart because the deer would have been blinking, and sort of semi-smiling before they shocked the thing. And then when you shock a patient with paddles, with electricity, the person doing it says “clear” right?
Well they’re not only saying “Clear don’t touch the patient,” they’re saying “Clear don’t touch the bed or the cart” that the patient is on either because that can conduct electricity. And so you know she says clear, enter by steps away and she’s in the back of the pick-up truck which is all metal. OK someone would have had shocked her after she shocked herself. OK, but I seriously digress. Yes this is the medical podcast and we’re going to talk about vocal cord dysfunction with Dr. Karen McCoy and that’s coming up here in just a minute.
Dr. McCoy is a pediatric pulmonologist at Nationwide Children’s Hospital. And I recorded the interview before this part of the show. And Dr. McCoy informed me after the interview that I did make one little mistake in my introduction of her. I mentioned that she is the Director of the Fellowship Training Program at Nationwide Children’s Hospital in pediatric pulmonologisy. And actually she is the Co-director of the Fellowship Training Program along with Dr. Elizabeth Allen. So she wanted Dr. Allen to have due credit and I know both of these physicians personally, they’re great pulmonologists and we certainly don’t want to leave out any credit where credit is due.
Alright don’t forget if you have a topic that you would like us to talk about here on PediaCast, an idea, a line on an interview, a new story, anything that relates to parenting and pediatrics, just go to the website at PediaCast.org and click on the Contact link. You can also e-mail me at email@example.com or call the voice line. We haven’t had any voice callers in quite some time. So if you want to get a bump up on your question, we usually do take audio questions ahead of the ones that are written especially if they’re good ones.
And that number is 347-404-KIDS. Speaking of questions, I do want to mention this real quick. I get a lot of questions. I mean I get multiple emails everyday with questions. I don’t say to discuss you to discourage you from writing because we try to take a variety of topics that relate to all age groups from infants up through college-age students. So we really try to cover everything and get a nice variety of topics.
So if I don’t get to your question, please don’t be offended. It’s just I get so many that there’s no possible way that I would be able to get to all of them. And an ideal world would answer every single question, but I just can’t do that. So, but please continue to write in because your question, maybe the one that fits in with the theme of the show we’re doing or when we do a listener show, or it may really round out, be something that other parents wanted to hear about.
So I am kind of picking and choosing. It doesn’t mean your question was not a good question and so please don’t be offended by that if we don’t get to the one that you sent in. We could do listener shows every single day but I really honestly I answer questions all day long at the office too. And by doing the interviews and presenting research, and the news. It really makes it easier to produce these things and stay involved with it from your host point of view. Yes I’m going to be selfish there a little bit.
And with that in mind, we’ll be back with Dr. Karen McCoy to talk about vocal cord dysfunction right after this short break.
Alright welcome back to the show. Dr. Karen McCoy is the chief of Pediatric Pulmonary Medicine at Nationwide Children’s Hospital and an Associate Professor of Pediatrics at the Ohio State University College of Medicine. She’s the principal investigator for the Cystic Fibrosis Therapeutic Development Center and for the Asthma Clinical Research Center. She serves as the Director of Nationwide Children’s Fellowship Training Program and Pediatric Pulmonology. And most noteworthy of all at least for the next 20 minutes or so she’s our guest on PediaCast.
Dr. Mike Patrick: Welcome to the show, Dr. McCoy.
Dr. McCoy: Hi, great to be here.
Dr. Mike Patrick: Great. Now today’s topic is a problem that’s probably unknown to most moms and dads. And actually I’ll bet that there are a lot of health care professionals who have not heard of this disorder before either. We’re going to talk about vocal cord dysfunction. So I guess could you start by just letting folks know exactly what this is?
Dr. McCoy: Well you know the vocal cord’s job is to open up maximally when a person is taking a breath in, to get the most air flow through. When the vocal cords fail to do that or even narrow during a breath in or inspiration then that leads to what we call paradoxical vocal cord motion or vocal cord dysfunction.
Dr. Mike Patrick: OK so they basically get in the way…
Dr. McCoy: Yeah
Dr. Mike Patrick: … Of the air flow coming in. Because of that, what sort of symptoms and signs do you usually see?
Dr. McCoy: Well the symptoms and signs are really quite none specific which is one of the things that makes it challenging to get people to think about this. They are: cough, wheezing, dyspnea or shortness of breath usually with the person if asked, being able to tell you that they think the area that they’re blocked at is somewhere near the throat or neck. We also hear stridor, the individual may report in intermittent hoarseness that goes along with this or they may not.
Dr. Mike Patrick: OK now how many kids would you say we’re talking about that have this disorder? I mean is it very common or is it something that I guess being at a referral center you probably see this more than most primary care doctors are going to see it but it is something that we come across pretty often?
Dr. McCoy: Well clearly we do see it more commonly than would be seen in most primary care practices. But I think it is really unfair to say that we understand the prevalance of this disease. It’s under diagnosed considerably. And so we usually see a group of youngsters who have it or carrying a diagnosis of asthma that is not responding to medication.
Dr. Mike Patrick: OK and do you see it more often in boys versus girls? Or is it about the same?
Dr. McCoy: Well there are not too many pediatric studies but in a couple that has been done and those you know limiting to those that are under 18, the average age that’s reported is about 14 1/2 years.
Dr. Mike Patrick: OK and equal between males and females or they didn’t really looked at that?
Dr. McCoy: Very not equal. I mean it turns out that in these studies as in the adults or mixed studies some have mixed pediatric and adult patients. There is preponderance of females than among the under 18 crowd this is somewhere 80 plus percent being girls.
Dr. Mike Patrick: OK, now what about with asthma, do you see very many kids who would have both asthma and vocal cord dysfunction or is it usually they don’t go together?
Dr. McCoy: They often go together which is one of the things that make it so hard. The physician knows that a child has asthma and he’s been being treated for asthma. But then this other creeps in and estimates would suggest that about in among refractory asthma patients in other words failing to respond to treatment that as many as 30% have a combination of both. And maybe 10% don’t have asthma at all but just have vocal cord dysfunction.
Dr. Mike Patrick: So what causes this exactly? Or do we know?
Dr. McCoy: Well you know, do we know at the microscopic level? No we don’t. But in terms of what actually happens in the vocal cords, it seems that there is a spasm or failure of the abducting or opening muscles at the larynx for opening the vocal cords when the person is breathing in. And so that leaves the vocal cords somewhat narrowed or although you know mostly close in fact. And then the aperture or opening for air flow becomes quite smaller leading to all of the symptoms and so forth.
Dr. Mike Patrick: So is this something that a defect that they would be born with? Do we think this is a genetic disorder? Or is there is something that happens later in life that could cause that muscle to fail.
Dr. McCoy: Well at least presenting this way, it does not seem to be present at birth.
Dr. Mike Patrick: OK.
Dr. McCoy: So it seems that now is whether the person is congenitally more susceptible to this happening, we don’t know. But it does seem that it takes a few years. I think about the youngest patient that I’ve seen is around eight years old.
Dr. Mike Patrick: OK. And then when you have a kid with refractory asthma who’s not getting better with treatment, what other conditions should parents and doctors think about that could be causing recurrent wheezing or shortness of breath that we go beyond vocal cord dysfunction and asthma?
Dr. McCoy: Well the list is so long that it really would take up all of our time. I think that there are some things that we can do to say. Alright, do we believe that this is an upper airway obstruction as vocal cord dysfunction or anything that’s outside of the chest? You know neck up so to speak. Or do we believe that it’s inside the chest as an asthma? And that often points us in a direction of where we need to go next.
Dr. Mike Patrick: OK now what about diagnosing this condition, how do you tell that it’s vocal cord dysfunction from your standpoint?
Dr. McCoy: Well the first thing you to have to do is be suspicious that it might be there. ‘Cause if we don’t think of it. The presentation is often so non-specific that a lot of times people will go down a pathway very far down the pathway towards treating asthma and expose the child to a lot of unnecessary treatment and even procedures. But once you say, “You know asthma should respond to the asthma medications.” And if there is anything about the child’s presentation that says, “You know it just doesn’t look like, the child is too well oxygenated every time.” They raise your suspicion in some way and say they failed medicine that should work then you can go after that in the way of diagnosing. It can be very helpful to do simple pulmonary function test to help us exclude asthma as the cause.
Dr. Mike Patrick: So unless they have a combination of asthma and vocal cord dysfunction, the pulmonary function test should be normal if they just have vocal cord dysfunction. Is that true?
Dr. McCoy: If they have vocal cord dysfunction and they are experiencing an episode then they often will have a lower flow rate through inspiration.
Dr. Mike Patrick: OK.
Dr. McCoy: Whereas asthma is an expiatory disease almost entirely.
Dr. Mike Patrick: Sure. Let’s say you have a kid and you decided this is what they have, what do you do to treat it?
Dr. McCoy: Well one of the things that we do, there are some morbid types of conditions that maybe associated. There are also some sort of highly associated situational thing. I mean lot of the kids that are defined are in organized sports and have some social stressors either they’re high strong or there’s been some stressors in their family life and so forth. Exercise and due symptoms should be a clue. And then we often see youngsters having gastroesophageal reflux flare their condition up. Another couple of things that can sometimes make it worst are low-grade sinus infections that are not very obvious to people and rhinitis. So the first things we do is try to eliminate those things by treating them relatively non-specifically; deacidify the stomach acid, take care of rhinitis if it seems to be a big problem or even a trial a treatment of sinus infection to see if we can make the symptoms go away. ‘Cause a lot of times we arrive at this in kids who just started having trouble on the heels of an infection and they may be different. They may have just irritative issues that have caused that muscular abnormality to occur.
Dr. Mike Patrick: So in those kids that are really temporary and may go away just by treating what the underlying cause was to begin with.
Dr. McCoy: Yes. Yes. But then if we go back to this sort of profile of the youngster who has got this and we eliminate the asthma as a cause for their distress, then we go on to visualizing abnormality with a scope showing that the vocal cords when there are symptoms are actually narrowed in inspiration. And then interestingly enough, most of these cases are settled in the sub-acute phase by voice therapy and retraining the child to pick-up on the early symptoms and control their breathing better.
Dr. Mike Patrick: I see that’s it. So is it slowing their breathing down that makes it but I guess did not as sharp in burst of inspiration?
Dr. McCoy: Yeah. I’m sorry slowing the process down is a big part of it. So learning to just kind of ease of and slow the inspitory flow, breathing more from the diaphragm is often helpful. And they are coached by speech therapist to do this and actually put in their triggering situations to prove that they can do it.
Dr. Mike Patrick: Right and this is probably something to the speech therapist, only certain speech are going to be trained, I would imagine to deal with this, like in a children’s hospital. ‘Cause there’s a lot of small towns with community hospitals and speech therapist but this probably isn’t something that they’re going to have to come across very often.
Dr. McCoy: Right most of the time it’s found at a Laryngeal Control Center that may be present in larger cities, in the offices of the Laryngologist as well as medical centers, children’s hospitals and so forth. But in smaller places, then it’s likely that people are going to have to get that specialized care at a bigger center.
Dr. Mike Patrick: OK. I think one of the biggest questions I think on parents’ minds is going to be what would you advise parents if they have a child with asthma, it’s been diagnosed by their pediatrician, or their family practice doctor with asthma. Things aren’t getting better and they’re going down this road and they hear this and think, “Well this sounds like maybe it’s what my kid has.” But their doctor doesn’t necessarily has not heard of this. So what do you advice at those parents do to get their kids some help?
Dr. McCoy: Well I think anytime asthma therapy does not appear to be achieving control of the asthma, it’s time to ask someone else to look at the child. Perhaps a pediatric pulmonologist, perhaps a laryngologists who see the pediatric practice. Those are good sources of help to make sure that thing you know things are going right and pulmonary function test can be so helpful to us in saying that the asthma is controlled.
Dr. Mike Patrick: Right. Right.
Dr. McCoy: There may be asthma but it’s controlled and if those changes of asthma are not being seen at the time then that can’t be causing the distress.
Dr. Mike Patrick: Very great, great advice. Well we appreciate you stopping by today to talk about vocal cord dysfunction and there’s so many pediatric pulmonary diseases out there. Maybe in a few months we’ll have you back if you don’t mind and talk about asthma or even cystic fibrosis something like that.
Dr: McCoy: I’d love to.
Dr. Mike Patrick: Alright thanks goe out this week to Dr. Karen McCoy for stopping by and talking with us about vocal cord dysfunction. Also thanks to Vlad over at Vladstudio.com for providing the art work for the website and our feed. And also the T-shirts at the PediaCast Shop. So please support Vlad at Vladstudio.com. His prints would make wonderful additions to your child’s bedroom or nursery. Also reminders the Poster Page is available at the website so please check that out at PediaCast.org.
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