Case Presentation:
A 24‐year‐old woman with no significant medical history was admitted for stridor. One month before, the patient had an uncomplicated laparoscopic cholecystectomy. She had an EGD 3 days before admission. The EGD was remarkable only for mild gastritis. Immediately after the EGDshewasstridorous. She was given nebulization and discharged home. She continued to have stridor and hence visited the emergency room. A CT scan of the neck and chest done in the ER was normal, and hence she was discharged. The following day she was seen by an ENT specialist. He noted that her vocal cords were normal and suggested that she might have a subglottic problem. Because she continued to have stridor, she was admitted for further evaluation. She did not have any fever, chills, nausea, vomiting, or hoarseness of voice. She did not have a history of asthma or psychiatric problems. She was not taking any medication and did not smoke. The patient's vital signs were normal. She was not in distress and did not use her accessory muscles for breathing. She had an obvious inspiratory stridor. It was well heard in the upper lung fields. The lower lung fields were normal. The rest of the physical exam was also normal. The results of a chest x‐ray, routine labs, and ABG were normal. ACT scan of the neck including carina was normal. Visualization of the cords during bronchoscopy revealed adduction of the cords during inspiration. The results of a pulmonary function test was consistent with her having variable extrathoracic upper airway obstruction, with flattening of the inspiratory loop. Thus, the patient was diagnosed with paradoxical vocal cord movement. She was treated with speech therapy and breathing exercise with good results.
Discussion:
Paradoxical vocal cord movement (PVCM) producing airway obstruction is a relatively uncommon and sometimes confusing condition that affects the larynx. PVCM most commonly occurs in women between the ages of 20 and 40. Most of these patients have significantly higher levels of anxiety. Some have a history of psychiatric illness during adolescence. As in our patient, stridor occurs because there is inappropriate closure of the vocal cords during inspiration, resulting in functional airway obstruction. Stridor usually resolves completely when the patient is asleep.
Conclusions:
Hospitalists need to be aware of this condition because some patients are wrongly diagnosed with impending upper airway obstruction and end up intubated. Others develop iatrogenic Cushing's syndrome after long‐term high‐dose glucocorticoid treatment for refractory asthma. Early recognition of PVCM by hospitalists can prevent multiple hospital admissions and unnecessary intubations.
Author Disclosure:
A. V. George, None; M. Brescia, None.