We are very pleased to welcome Kathleen T. Cox, Ph.D., CCC-SLP,
as our guest host for the SLP chat tongight, Monday, February 7, 2005.
Dr. Cox will be addressing the topic of Paradoxical Vocal Fold Dysfunction.

Kathleen T. Cox, Ph.D., CCC-SLP is Assistant Professor in the
Department of Communication Sciences and Disorders at East Carolina
University.  Dr. Cox teaches graduate level courses in Laryngectomy
Rehabilitation, Cleft Lip & Palate Speech Disorders, Voice Disorders,
and Swallowing Disorders. In addition to her teaching duties, she
mentors master's and doctoral students in research projects within
these areas.  She provides clinical care and clinical supervision in
the East Carolina University Speech-Language and Hearing Clinic for
patients of all ages.  Her graduate students in the clinic routinely
provide voice, resonance, and clinical evaluations of swallowing under
her supervision.  In addition to her on-campus clinical work, Dr. Cox
also provides advanced voice diagnostics at Eastern Carolina ENT-Head
and Neck Surgery, Inc. where she has been instrumental in the development
of the Eastern Carolina Voice Center.  She has been providing clinical
services, primarily voice care, since .  Her bachelor's degree in
speech-language pathology is from Ithaca College. She received her M.A.,
and PhD in speech-language pathology at The Ohio State University where
her specialty was care of the voice and treatment of voice disorders,
the role of the larynx in respiratory disorders, and understanding a
specific respiratory disorder called "paradoxical vocal fold dysfunction".  
She is currently involved in two research projects investigating
paradoxical vocal cord dysfunction.

<Robin> Thank you all for being here!  We are chatting tonight about Paradoxical Vocal Fold Dysfunction
          with guest host Kathleen T. Cox, Ph.D., CCC-SLP.
<Kathy Cox>  Hello everyone!
<Robin> Dr. Cox, please define Paradoxical Vocal Fold Dysfunction and give us some background information.
<Kathy Cox>  Paradoxical Vocal Fold Dysfunction (we'll call it PVFD) from now on, is basically a respiratory
          disorder involving the larynx.  That's one reason why SLPs have become involved in it's study & care.
<Kathy Cox>  Descriptively, it is the abnormal closure of the vocal folds during respiration - either inspiration
          or expiration.
<Kathy Cox>  Many patients come to the SLP (or MD) with complaints similar to asthma - attacks of breathing
          dysfunction sometimes accompanied by dysphonia (hoarseness).
<Kathy Cox>  When we examine the larynx, we find that the vocal cords are abnormally closing during one or both
          of the phases of respiration and often, are completely adducted.
<Kathy Cox>  The patients will be inhaling (and exhaling although inhalation spasms are more common) through a
          tiny "chink."  that's the hallmark sign  - inhalation through a chink or diamond shaped glottis created
          by abnormal or "paradoxical" closure of the vocal fold.
<Robin> Tell us about the population you find this in.
<Kathy Cox>  Initially, when this disorder first began appearing in the literature, many people believed it was
          present primarily in women and women in the health professions.  In my dissertation back in 1996, I did not
          find the health professions finding, but did find that more women than men tend to present with the disorder.
<Kathy Cox>  There appears to be 2 peaks - high schoolers (both men & women) and then women in their 40's.
<AdrienneFSU>  Is it hormone related?
<Kathy Cox> To my knowledge, there have been no research studies examining the role of hormones specifically for
          PVFD.  However, we do know that some research studies have elucidated a connection between hormones and motor
          function, particularly in women during their pre-menstrual phase.  So, my thought is that for some patients,
          maybe there could be hormonal connection.  Definitely something we hope to learn!
<Kathy Cox>  There have now been more well defined etiologies for PVFD, so we are finding new populations all the
          time, actually.
<bobbespeech>  Do a lot of your patients of high school age play sports?
<Kathy Cox>  YES!  I find that the literature, my own clinical practice, and colleagues clinical practice finds
          that the high schooler with PVFD is often OVER-acheiving in sports, activities, events, etc. - but sports
          are definitely a common thread.
<bobbespeech>  That's my experience also--in addition dancers andthe performing arts.
<Kathy Cox>  That's what I hear all the time - high school patients are excellent at everything they do...involved
          in more than the average student - with very involved parents.
<bobbespeech>  The "A" type of personality!
<Kathy Cox>  Initially, too, many reports in the literature indicated it was totally a psychological disorder.
          I don't agree with that based on what we know now...YES, the type "A" personality applies to many of these
<Kathy Cox>  There is, in many patients, a definite "psychological" component to PVFD - stress, anxiety, fear,
          can all trigger these vocal fold attacks.  We don't really know the mechanism for it yet.
<Kathy Cox>  Then, in other patients, it is an organic issue - a response to asthma, reflux, allergies or
          neurological conditions.
<bobbespeech>  To complicate things, sometimes these kids have asthma in addition to PVCD.
<Robin> Typically, do patients go to an ENT or allergist for the assessment followed by a referral to SLP?
<Kathy Cox>  I actually think that many people are sent to an SLP either by way of an ENT or a pulmonologist.
          Many of these patients are seeking out help for what they believe, and many of their health care providers
          believe to be asthma...but they find that the asthma medications & regimens don't work...so then they start
          suspecting the UPPER airway as opposed to the lower airway (which is truly asthma).
<bobbespeech>  My primay referrals are allergists.
<Kathy Cox>  I do have some allergists that I work with that are very good at finding the disorder or suspecting it
          I should say....
<Kathy Cox>  Sometimes the allergists will refer on to ENT or pulmonary rather than SLPs first....
<Robin> Are most allergists aware of this condition?
<Kathy Cox>  My gut feeling is probably not - I don't think most emergency rooms/departments are familiar with this. 
          Many of these patients show up to the ER with complaints of breathing difficulty and they are given asthma
          treatments for days at time....then, finally someone will hear the "wheezing" or stridor is coming from the
          throat not from the chest. Then they call SLP or ENT for a consult for "vocal cord dysfunction" or
          "laryngeal asthma.".
<bobbespeech>  Many ENT's just keep giving asthma medications. I once had a 14 year old on 15 meds for asthma--
          and it was PVCD!!
<AdrienneFSU>  wow!
<Kathy Cox>  Many of these patients are highly medicated for asthma - one of the treatment outcomes the SLP can
          work towards is helping to reduce the number of medications they are on...the SLP doesn't instruct the
          patient to decrease medications, but can communicate with the MDs about progress so the MDs can determine
          when to try to wean patients off of asthma medications.
<snehal>  Wheezing is a sign of lower respiratory tract constriction...
<Kathy Cox>  Yes, wheezing is typically associated with the lower airway and I do not typically use that term
          when describing the attacks of PVFD.  I use laryngeal noise or stridor.  I like to differentiate between
          asthma and PVFD as much as possible.
<snehal>  Yes..that is the point...most SLP's use wheezing and stridor interchangeably.
<snehal>  Where as stridor could be a sign of PVCD ...but NEVER wheezing!!
<Robin> Once you are given the referral, what your evaluation consist of?
<Kathy Cox>  Once I am given a referral, I start with reviewing medical records (hopefully I will have these
          prior to the patient showing up!)  Then I begin the interview process.
<Kathy Cox>  My interview can take anywhere from 20 minutes to an hour depending upon the complexity of the patient
          and whether or not I have medical records prior.
<Robin> What are some of the important questions you ask in your interview?
<Kathy Cox>  In my interview, I make sure to cover many areas:  history of breathing disorder/symptoms, whether
          or not there is a real diagnosis of asthma, when the diagnosis of asthma was made, history of reflux,
          allergies, and other laryngeal issues.
<Kathy Cox>  I always talk to the patient about stressors in their life as well as any possible neurological
<Kathy Cox>  After a thorough interview, I typically proceed with laryngeal imaging - either stroboscopy if there
          is a dysphonia present and I want a view of vocal fold vibration or laryngeal endoscopy if the strobe is
          not critical. Either way, i want to examine gross structure of the larynx, movement (adduction/abduction)
          and determine if I see any "paradoxical" motion during respiration or glottic narrowing.
<Kathy Cox>  You can find symptoms in the larynx even when the patient is NOT in an acute or apparent attack.
          Many times they maintain glottic narrowing in between attacks.
<Kathy Cox>  I only proceed with acoustic analysis or aerodynamic analysis if I perceive dysphonia or feel that
          those measurements would help support my suspicions.
<AdrienneFSU>  Does the frequency and duration of attacks vary?
<Kathy Cox>  YES, the frequency & duration of attacks can vary tremendously.
<Kathy Cox>  Some people will come to you after 2 attacks in 5 years, but they were scary and they want to figure
          out what is happening.  Other people will have "shortness of breath" or dyspnea on a regular basis and end
          up in your clinic as a last resort when they do not test positive for asthma or other respiratory disorders.
<Kathy Cox>  One of my goals with these patients is to decrease the frequency & severity of attacks.  I do not tell
          them we can eliminate them completely, because in some people we do not.
<bobbespeech>  Will you share some therapy techniques with us?
<Kathy Cox>  Sure.  Some of my therapy techniques are "talk therapy" and reassurance and some are laryngeal exercises.
<Kathy Cox>  I actually like to call the therapy "laryngeal control therapy" rather than speech therapy.
<Kathy Cox>  We are typically not treating speech, we are treating their control of the larynx during respiration. 
          However, there is no billing code for laryngeal control therapy, so we bill it as speech therapy and that's
          what patients understand.  But I do explain the laryngeal control concept to them.
<bobbespeech>  Do you use the breathing techniques as recommended by Denver Jewish?
<Kathy Cox>  Yes, I do recommend the techniques recommended by the center in Denver.  I call them positive pressure
          exercises because we are basically teaching the patients to increase pressure in the oral cavity to decrease
          it at the level of the vocal folds.  If we increase constriction in the oral cavity, constriction in the
          larynx should relax.  That's why inhalation and exhalation on /s/ is so common.  Asthmatics have been using
          pursed lips breathing for years and years and the positive pressure exercises are derived from those concepts.
<Kathy Cox>  I usually start the therapy process with the education phase - what is PVCD, why is it, etc.  Then we
          cover their triggers.
<Robin> What are some typical triggers?
<Kathy Cox>  Typical triggers can be inhalants (perfume, chemicals, strong odors of any kind) or reflux (irritating
          the larynx), or stress, or exercise.  In some people we can never identify distinct triggers. That can be
          frustrating or a sign that it's a neurological condition in that person.
<snehal>  What are some of the newer therapy techniques tried?...other than breathing excrcises?
<Kathy Cox>  I don't think that there are any "newer" techniques that I'm aware of right now....I think we are
          becoming better at understanding WHY the breathing techniques work and why specific ones should be applied
          in specific situations...for specific people.
<Kathy Cox>  I think in some severe cases, ENTs are more likely to try BOTOX in the larynx to assist in opening the
          airway...but that can present dysphagia issues.
<Robin> Dr. Cox, could you give us specific examples of some of these breathing techniques and in which situations
          you would apply them?
<Kathy Cox>  Sure.  I use a combination of nasal breathing, pursed lips breathing, /s/ breathing - with extreme
          effort.  I think that many clinicians teach their patients to do these exercises too gently.
<Kathy Cox>  The key is to create constriction AWAY from the larynx (in the nose with nasal breathing, or in the
          articulatory area with pursed lips or /s/ breathing).  We want to create resistance away from the glottis
          so that resistance at the glottis decreases.
<Kathy Cox>  So, I would recommend to some patients, say athletes, that they do a breathing warm up of pursed lips
          breathing prior to exercise and that they exhale on /s/ while exercising to maximize this effect.
<bobbespeech>  I find that some very basic voice techniques with placement in the "mask" area alleviates most of
          these "strangulated " symptoms immediately.
<Kathy Cox>  I do agree that for some patients "mask resonance" or frontal focus can be helpful in taking the
          focus away from the larynx...same concept, different technique.
<bobbespeech>  I combine the breathing with the voice exercises.
<Kathy Cox>  I definitely think it's time for all of us PVFD clinicians, though, to do some well controlled research
          studies to find out what exactly are these exercises doing PHYSIOLOGICALLY to change the laryngeal postures.
<Kathy Cox>  Why does /s/ breathing work - exactly?  For example, in my lab, we are starting a study of this.  When
          one of our lab assistants does /s/ productions, her glottis closes completely.  Why does this help patients
          with airway constriction?
<Kathy Cox>  We need to find out what is the normal posture of /s/ production for example before we can really
          understand PVFD treatments.
<Kathy Cox>  In my own practice, I see many of these patients who also have asthma.
<Kathy Cox>  In my first sessions, I will teach them how to use their inhalers correctly - with a good deep
          inhalation with a spacer.
<Kathy Cox>  Many times, their attacks cease that week!  Did I "fix" their "PVFD?  No..I taught them how to use
          their asthma medications better - which then opened their airway - which then stopped the secondary behavior
          of glottic narrowing or PVFD.
<Kathy Cox>  We need to do research to differentiate those kinds of findings.
<Robin> How often do you see patients for treatment?
<Kathy Cox>  I see patients typically once a week to start with until we get them out of their "severe" status if
          that's what they were in....fewer if they are not in an emergent need...more frequent if they are debilitated
          by their disorder.  Sometimes I want to see them in an acute attack, so I will have them stop in on a moment's
          notice when they are in an attack.
<Kathy Cox>  Most patients I believe I can see improvement in 3-6 sessions (of course that is always individualized).
<Robin> What does a patient present like when they are in an acute attack?
<Kathy Cox>  In an acute attack, you could see someone who is walking around, talking, and comfortable - but just a
          "noisy" breather....or you could see someone who is struggling to breathe with great fear of these "noises"
          who thinks they are going to die if they don't catch a breath.  There's a wide range.
<Kathy Cox>  Often, the patients can phonate comfortably despite the respiratory struggle.
<Kathy Cox>  It is sometimes painful to hear and watch these attacks - they can be loud!
<Robin> These patients must be so relieved when the therapy techniques start to work!
<jacqui>  I have been seeing a teen who also has asthma.
<Kathy Cox>  Yes, these patients are often quite frustrated when they meet us, and are often quite grateful when
          we offer some help - at minimum, education about PVFD.
<Kathy Cox>  I typically provide educational materials, handouts, articles, in the first session or in the diagnostic
          session so that they can start understanding why this noise isn't asthma.
<Robin> It might take some convincing!
<Kathy Cox>  Yes, some people are very skeptical.
<Kathy Cox>  But, when you offer them something else to try - when they believe they have tried everything, they
          are often open minded and receptive.
<AdrienneFSU>  Would this be a life-long condition for people?
<Kathy Cox>  Many of these patients are on disability and are overwhelmed by their poor respiratory status.
<Kathy Cox>  If the diagnosis is accurate and the SLP gets to work quickly, we can really offer help to these patients.
<Kathy Cox>  It's critical to make sure asthma & reflux & allergies are evaluated though.
<Kathy Cox>  Since those disorders can either trigger or co-occur with PVFD, we have to make sure they are
          investigated to ensure we are not using behavioral therapy in a situation that requires medication.
<Kathy Cox>  I have found one of my most helpful treatment options is to offer counseling with a good therapist who
          understands that physical symptoms can be the result of stress.
<Kathy Cox>  Many of these patients, if they don't have stress as a trigger, are very stressed from being chronically
          ill.  Finding the right counselor to talk to them about whether stress is actually a trigger or not can be
<Robin> Will any of these patients totally rid themselves of PVFD given the therapy techniques you've taught them?
<Kathy Cox>  Yes, many patients do eliminate the overt exacerbations.  I'm wondering though, and hope my research
          will figure it out, if they actually have a larynx in a constant state of "irritability" and at any moment
          can begin PVFD again....so we minimize attacks, but do we really resolve the underlying condition?  I'm not
<Kathy Cox>  More research is definitely needed - but that's true about so much in SLP!
<Robin> This sounds like a fascinating area of study.
<AdrienneFSU>  What is the prevalence of this disorder?
<AdrienneFSU>  Granted, many go undiagnosed.
<Kathy Cox>  Many patients do go undiagnosed - but I'm concerned that we are over-diagnosing it too.  Once
          allergists or pulmonologists find out there is an SLP in town willing to treat this population, they
          often over-run us with referrals of people who are really severe asthmatics - and our breathing exercises,
          while may offer some comfort, are not treating the asthma.
<Kathy Cox>  The prevalence, I don't think has been studied well enough for us to put a number on it....in my
          practice I see a lot of it -because I'm in a small town and people know I treat it....
<Kathy Cox>  Other clinicians may see someone with PVFD once a month or one patient every 6 months.
<Kathy Cox>  I did hear a statistic once that pulmonology estimates that 10% of asthmatics probably don't have
          asthma, but have PVFD.  Would be interesting to find out if that's true!
<AdrienneFSU>  yeah!
<Robin> I'm sure that they would be happy to stop taking all their asthma medications if that was the case!
<Kathy Cox>  You are right - many asthma medications have side effects.  But I definitely stress to patients that
          they cannot stop taking them until their MD prescribes new doses.  It is not the domain of SLPs to change
          medication schedules.
<Kathy Cox>  The problem is that asthma can bring on so many other dysfunctions in the system.  When you haven't
          had a good lower airway for years, your upper airway will try to compensate...so is the PVFD a disorder or
          a compensation?
<Robin> very good point
<jacqui>  I wanted to know if there are oral motor difficulties with some of your patients. I have been seeing a
          teen who finds it very difficult to relax. She also found it difficult to open her mouth wide and can't
          open her mouth wide enough to yawn or eat an apple. Is such oral motor difficulty very unusual?
          We have been working on relaxation.
<Kathy Cox>  Does she have PVFD?
<jacqui>  Yes she does. She also has asthma.
<Kathy Cox>  Muscle tension can be a big part of this disorder....Massage would be a great technique for her.
          The Source for Oral Motor Exercises is a great workbook with lots of exercises to get the jaw moving better.
<jacqui>  We have been doing a lot of oral motor exercises. She finds it very difficult to relax.  She says it
          feels uncomfortable. I thought she might do well working with a PT for a while.
<Kathy Cox>  You're probably right that PT or even OT could be a good resource for you.  I would also make sure
          it's not a neurological issue causing spasms of the jaw muscles.
<jacqui>  That is a good idea. I did refer her for a PT evaluation. Thank you for your ideas.
<Kathy Cox>  I'm curious to find out where SLPs are getting their PVFD education and skills in treating it.
<Kathy Cox>  I'm actually sending out a survey to 1000 SLPs this month to ask that very question! Maybe some of
          you are on my list.
<Robin> Earlier in the chat bobbe referred to a protocol from a hospital in Denver.
<Kathy Cox>  The National Jewish Center for Respiratory and Immunological Diseases is in Denver.
<Kathy Cox>  This was one of the first hospitals to publish reports of treatment techniques - from an SLP named
          Florence Blager. Many regard her ideas as some of the first.
<Kathy Cox>  Most of the treatment techniques (breathing exercises) do come from her suggestions. I have modified
          them to my usage based on my beliefs and understanding of physiology.  Now it's time to test them in the
          research & clinic setting!
<Kathy Cox>  National Jewish frequently holds conferences for both clinicians & scientists in this area. 
          Definitely a place to keep an eye on for new findings in this area of SLP.
<Kathy Cox>  There was also a great review article in AJSLP a few years ago: Paradoxical Vocal Fold Motion:
          A Tutorial on a Complex Disorder and the Speech-Language Pathologist's Role, American Journal of
          Speech-Language Pathology, Volume 10, Issue 2. Pages 111 - 125. May 2001.  That would be a great place
          for a clinician to start when doing a "self-check" on PVFD.
<Robin> Dr. Cox, is there anything else about PVFD that you'd like to share with us?          
<Kathy Cox>  I think the best information I can offer to the SLPs is that they must be an advocate for their
          own knowledge in this area - attend asthma conferences & workshops, ask pulmonologists about their tests
          & evaluations, go observe a day in a pulmonology clinic. The more you know about asthma & respiratory
          functions, the better a clinician you'll be with the PVFD population.
<Kathy Cox>  Many graduate programs in SLP don't delve that much into respiration, so the clinician must continue
          the self learning after graduation....
<AdrienneFSU>  Well you certainly helped with that tonight!
<AdrienneFSU>  Thanks for all the great info!
<Kathy Cox>  I'm glad you found it helpful.
<Robin> Thank you, Dr. Cox, for sharing your expertise with us.
<allyson_msu>  Thank you, very informative!
<AB>  Thank you
<susan>  It was very informative
<Trudy>  Good night & thanks!
<Robin> This is a fascinating area of study with lots of research possibilities.
<Kathy Cox>  I'm very grateful that you asked me to participate. I always enjoy sharing in our profession.
<Robin> You have given us a lot of information, thank you so much!
<Robin> and thank you all for being here tonight
<Kathy Cox>  My pleasure!  I hope you all have a great night.