Voice Presentation - PVFM

Case Study

Therapy
Workshop

Overview

01

Table of contents

Case history, evaluation, diagnosis,
treatment, and results

Video example of techniques & LPRD,
overview, discussion, and quiz

Final thoughts and questions

02

03

PVFM

VFs close partially or fully when they

should be open. Disorder of the larynx -

respiratory issue

LPRD

Inflammatory reaction of the
pharynx/larynx/respiratory
organs due to acid reflux

Asthma

Airway becomes inflamed, narrows,
swells, and/or produces extra mucus,

which makes it difficult to breathe

Terms to Know

Case 6.4

01

Sara

18-year-old college

freshman

Introduction

Sara is a high-achieving 18-year-old college

freshman with a swim scholarship.

She is referred to an SLP for suspected paradoxical

vocal fold motion (PVFM) after experiencing

breathing problems during practice.

Sara reports having breathing “attacks” and throat

tightness. She believes symptoms are due to her

asthma and allergies.

(Stemple & Hapner, 2019)

Referred by pulmonologist and sports
medicine physician

●Diagnosed with asthma 2 years ago

●Attacks are consistent

●Trouble inhaling

●Throat tightness

●No attacks outside swim

Case History

(Stemple & Hapner, 2019)

Personal considerations:

●Allergies: pollen, mold, and dust mites

●No medical conditions/surgeries

●Takes OTC antacids and asthma medication

●4-5 carbonated, caffeinated beverages per
day, eats high-protein snacks

●200 meter freestyle

●First year of college

●Scholarship consideration

●High-achiever – Olympics

Case History cont.

(Stemple & Hapner, 2019)

CAPE-V

Visual Imaging

Evaluation

-Twitching of arytenoid
cartilages at rest

-VF tissue smooth but
edematous bilaterally

Patient’s vocal quality was
judged to be WNL and
consistent with informal
findings

(Stemple & Hapner, 2019)

Visual Imaging Cont.

Evaluation

-Posterior laryngeal edema & interarytenoid tissue changes observed

-During maximum inhalation VF narrowed 50-60% width of glottis

-Asked to imitate breathing attack - complete VF adduction, glottal
narrowing. Asked to breathe deeply through nose

(Stemple & Hapner, 2019)

The following diagnoses were

concluded:

LPRD

Dynamic endoscopic laryngeal

assessment was reviewed with an

otolaryngologist - clinical signs of LPRD

PVFM

Medical information + patient’s

description of breathing attacks +
dynamic endoscopic assessment

Diagnosis

(Stemple & Hapner, 2019)

Treatment

(Stemple & Hapner, 2019)

Counseling

Dietary Changes

03

01

Counseling Sara about the
differences between
asthma and PVFM

List of foods that exacerbate
reflux and influence breathing
attacks

Breathing Recovery Exercises

Step-by-step implementation of
exercises adapted for swimming to
ultimately stop breathing attacks

02

Results

Final patient remarks

Most excited to report:

-Time has improved!

-No longer has anxious about scholarship!

-8 weeks later, no longer experiences breathing
difficulties when swimming

-Also, no longer experiences throat tightness.

Final clinic visit

(Stemple & Hapner, 2019)

Patient Experience

There is not one known cause of PVFM, but it may be triggered by:

●Acid reflux

●Exercise

●Breathing in cold air

●Smoke or pollen

●Emotional stress

●Physical stress when exercising

What can cause PVFM?

●Narrowing of larynx

●Shortness on inhalation

●Throat tightness

●Asthma medications do
not work

PVFM vs. Asthma

ASHA – PVFM is often mistaken for asthma. Here are some key differences.

●Narrowing of airway

●Shortness on exhalation

●Chest tightness

●Asthma medications
would work

PVFM

Asthma

(Gerd and LPR: Chicagoland’s best ent, 2018)

LPRD

GERD

●Hoarseness

●Difficulty swallowing

●Throat clearing

●Globus sensation

●Acid goes up larynx

●Difficulty with sensation

of drainage

●Persistent heartburn

●Acid regurgitation

●Nausea

●Hoarseness in morning

●Trouble swallowing

●Chest pain

Treatment Recommendations

●Diet Changes

●Behavior changes

●Medications

●Body awareness training

●Training lower abdominal/rib cage

expansion during inhalation

●Rapid, deep nasal sniff inhalation

Breathing
Techniques

LPRD Reflux

Reduction

Let’s Practice!

Thank You!

Questions?

References

Gerd and LPR: Chicagoland’s best ent. Ear, Nose and Throat Specialists of Illinois. (2018, September 10).

https://entillinois.com/for-patients/services/throat/gerd-and-lpr/

Sung, C. K. (n.d.). Laryngopharyngeal Reflux (LPR) protocol. Stanford Medicine Voice & Swallowing Center.

https://med.stanford.edu/content/dam/sm/ohns/documents/voicecenter/resources/Stanford_ENT_Clinic-LPR_P
rotocol.pdf

Stemple, J. C., & Hapner, E. R. (2019). Voice Therapy: Clinical Case Studies (5th ed.). Plural Publishing.

The Ohio State University. (n.d.). Paradoxical vocal fold dysfunction (PVFD) - osumc.edu. The Ohio State University

Comprehensive Cancer Center.
https://healthsystem.osumc.edu/pteduc/docs/ParadoxicalVocalFoldDysfunctionPVFD.pdf