Paradoxical Vocal Fold Motion: Symptoms, Triggers and Treatment

01What

What happens in paradoxical vocal fold motion?

Normally, the vocal folds open wide when we breathe in and come together when we speak or swallow. In paradoxical vocal fold motion, they move towards each other during breathing in, narrowing the airway. In some people, the tissues above the vocal folds collapse inward instead. An international consensus on nomenclature recommended the umbrella term inducible laryngeal obstruction to describe these problems, with subtypes based on location and trigger.

02Symptoms

Symptoms

• Sudden difficulty breathing in.
• Tightness or a choking feeling in the throat.
• Noisy breathing when breathing in (stridor), sometimes mistaken for wheeze.
• Coughing or throat clearing.
• Hoarseness or voice changes during episodes.
• Panic and anxiety during attacks.
• Symptoms that start and stop quickly, often within minutes.

03Triggers

Common triggers

• Exercise: especially high-intensity sport in teenagers and young adults.
• Irritants: smoke, perfume, cleaning products, chlorine.
• Reflux: stomach acid irritating the larynx; see laryngopharyngeal reflux.
• Postnasal drip and upper airway irritation.
• Cold or dry air.
• Stress and anxiety.
• Talking, laughing or singing in some people.

04Asthma

Is it asthma or vocal cord dysfunction?

• Location: throat tightness suggests the larynx; chest tightness suggests asthma.
• Breathing: difficulty breathing in suggests vocal cord dysfunction; difficulty breathing out is more typical of asthma.
• Timing: exercise-induced laryngeal obstruction usually peaks during exercise and settles within minutes of stopping; exercise-induced asthma often worsens after exercise.
• Response: asthma inhalers usually do not help vocal cord dysfunction.
• The two conditions can coexist, so assessment is important.

05Diagnosis

How it is diagnosed

The joint statement on inducible laryngeal obstruction from the European Respiratory Society and European Laryngological Society recommends visualising the larynx with laryngoscopy during symptoms. For exercise-related symptoms, continuous laryngoscopy during exercise, using a thin camera passed through the nose while the person runs or cycles, is the preferred test. Breathing tests, allergy assessment and evaluation for asthma may also be done. A normal examination at rest does not rule out the condition.

06Techniques

Breathing techniques that help

• Relaxed throat breathing: drop the shoulders, relax the jaw and tongue, and breathe in gently through the nose.
• Sniff and blow: two quick sniffs in through the nose, then a slow exhale through pursed lips.
• Pursed-lip exhale: breathe out slowly as if blowing through a straw.
• Low, belly breathing: let the abdomen expand on the in-breath.
• Tongue position: resting the tongue on the floor of the mouth can help open the throat.
• Practise these when well, so they are easier to use during an episode.

07Treatment

Treatment

Treatment usually starts with education and breathing retraining by a speech-language pathologist or respiratory physiotherapist, who teach techniques to keep the larynx open. Managing triggers, such as treating reflux, postnasal drip or allergies, is also important. Inspiratory muscle training and psychological support may help some people. For severe exercise-induced laryngeal obstruction involving the tissues above the vocal folds, surgery is occasionally considered. The international statement emphasises an individual, multidisciplinary approach.

08Athletes

Exercise-induced laryngeal obstruction in athletes

Young athletes, particularly in high-intensity sports such as running, rowing, swimming and team sports, may develop noisy breathing and throat tightness at peak effort. It is often misdiagnosed as exercise-induced asthma. Correct diagnosis allows targeted breathing techniques and avoids unnecessary asthma medicines. Many athletes improve with training in breathing control and gradual exercise.

09During

What to do during an episode

• Stop or reduce the activity if exercising.
• Try to stay calm and remind yourself that the episode will pass.
• Use your practised breathing technique: relaxed throat, sniff in, slow exhale.
• Sip water if your throat feels dry.
• Use your asthma inhaler if you have also been diagnosed with asthma.
• Seek emergency help if breathing does not improve.

10Related

Related throat symptoms

Some people with vocal cord dysfunction also have chronic cough, throat clearing or a sensation of a lump in the throat, often linked to a sensitive larynx. Speech-language pathology approaches for these symptoms overlap. See constant throat clearing for related strategies.

11Children

Vocal cord dysfunction in children and teenagers

Teenagers, particularly those involved in competitive sport, are among the most commonly affected groups. Symptoms may appear during races, matches or intense training and are frequently treated as asthma without improvement. Parents and coaches can help by noting when symptoms occur, whether they involve breathing in or out, and whether inhalers help. A specialist assessment with laryngoscopy during exercise can clarify the diagnosis, and breathing retraining is often very effective in young people.

12Anxiety

The role of anxiety

Anxiety can be both a trigger and a consequence of episodes. Feeling unable to breathe is frightening, and fear can tighten the throat further. Learning slow, relaxed breathing and understanding that episodes pass can break this cycle. Psychological support may help people with high anxiety. Breathing techniques for anxiety are described in deep breathing for anxiety.

13Summary

Key points to remember

• The vocal folds close when they should open, causing difficulty breathing in.
• It is often mistaken for asthma, and the two can coexist.
• Laryngoscopy during symptoms confirms the diagnosis.
• Breathing techniques and trigger management are the main treatments.