Dear Dr. Roach: I’m a 71-year-old man, and seven or eight years ago, I was diagnosed with asthma using the challenge test. I was prescribed Symbicort, which helped me exercise a little better. (Exercising is the only time I can tell I have asthma.) A couple years later, I was diagnosed with paradoxical vocal cord motion disorder (PCVM) by the use of a camera inserted through my nose. The idea recently occurred to me that I may not be getting the full benefit of Symbicort because of PVCM. The primary treatment for PVCM seems to be speech therapy, which did not help at all.
The only other treatment I’ve been able to find are Botox injections into the vocal cords, but there doesn’t seem to be a lot of literature on this procedure. Do you have an opinion on PVCM reducing the effect of Symbicort, and are you aware of other treatments for PVCM?
D.D.
Very early in my career, I had a patient with inducible laryngeal obstruction (ILO, also called paradoxical vocal cord motion) that had been mistaken for asthma until she, like you, had direct observation of the larynx during an episode.
It turns out that she didn’t have asthma at all, but there are people who have both asthma and ILO. When this happens, asthma is still treated the same way it’s treated in everyone else, and inhaled steroids like Symbicort are the usual first-line treatment for people who have more than the very mildest of symptoms.
Normally, the vocal folds (“cords”) open wide when you breathe in. But in people with ILO, the vocal folds come together so tightly that it’s hard to breathe in and out, and a sound very much like wheezing can be heard.
I do not think your ILO is keeping Symbicort from working. If air is getting into your lungs, then Symbicort will, too; it is a powerful anti-inflammatory medicine. The fact that you felt better on it is good evidence of its effectiveness. With any given episode that you have, though, it may be difficult to tell whether it’s asthma or ILO causing the symptoms. An acute asthma attack is treated with a different inhaler (such as albuterol), whereas an attack of ILO can often be stopped by panting. Very severe episodes can be treated with positive airway pressure (CPAP) or by a helium/oxygen mixture.
If a trigger for ILO can be found, then it should be avoided. Common triggers include airway irritants like cleaning chemicals, dust or smoke, and strong perfumes. Speech-language pathologists have several tools at their disposal to help. This is not the most common diagnosis, so you may do better with a different speech-language pathologist who has more experience with ILO.
I have never seen Botox used for ILO, but in a study on patients who weren’t getting good results with the standard treatment, 85% got better after an average of four injections. There are possible side effects in this case, including voice changes and trouble swallowing.
Email questions to [email protected].
