Vocal Cord Botox Injections to Treat Asthma???

Yup... It's true...

A clinical trial is under way in Australia to see if botox injections to the vocal cords can improve the shortness of breath some asthmatics have. Though nobody disputes that asthma is a pulmonary problem, it is not uncommon that the vocal cords in asthmatics may be dysfunctional exacerbating the breathing problem.

What is meant by dysfunctional? It's when the vocal cords come together when the person is trying to breath. It is also known as paradoxical vocal cord motion, vocal cord dysfunction, or laryngospasm at its worst. Read more here.

Botox injections will paralyze the vocal cord muscles preventing the vocal cords from coming together thereby allowing easier airflow into the lungs... or at least that's the hope. This procedure is commonly performed in patients suffering from spasmodic dysphonia and the technique used to treat these patients would be the same as that proposed for asthmatics. Watch a video here on how this is performed.

What's the downside? Aspiration, breathy voice, and trouble swallowing are common but temporary side effects. Problem is if aspiration occurs in a patient with significant pulmonary compromise, it can potentially be devastating leading to asthma exacerbation and even pneumonia.

Read a news article regarding this clinical trial here.

Video of Exercise Induced Vocal Cord Dysfunction

Vocal cord dysfunction (also known as paradoxical vocal cord movement) is a condition where the true vocal cords (TVC) do not move the way they are supposed to. Normally, the vocal cords move apart (abduct) when breathing and come together (adduct) when talking.

Vocal cord dysfunction is when the vocal cords adduct (come together) when breathing resulting in shortness of breath and at its worst, complete airway obstruction resulting in stridor known as laryngospasm.

The video shown here shows a patient with exercise induced vocal cord dysfunction (her breathing attacks occur only with exercise). The first part of the video shows this patient at rest breathing normally. The latter half of the video shows the patient after exercising and suffering from a mild case of vocal cord dysfunction.

Note how the vocal cords come together briefly with inhalation causing the patient to perceive inadequate breathing.

Treatment depends on finding the trigger and addressing the trigger whether it be allergy, reflux, etc. If all possible triggers have been ruled-out, neuropathic medications like neurontin and elavil can be tried. If the side effects are unacceptable or the medications just do not work, botox injections to the vocal cords can be performed.

Speech therapy can also be pursued in order to learn coping mechanisms to help a patient deal with an attack when it happens.

What Is a Pulmonary Stress Test?

At least in the ENT world, a pulmonary stress test is a very useful test when evaluating a patient with symptoms of shortness of breath, stridor, and/or wheezing that occurs only when exercising. The most common reason for an ENT evaluation in these patients is to determine whether paradoxical vocal cord motion is occurring or some other pathology such as tracheomalacia or laryngomalacia. Usually, the patient has already undergone extensive pulmonary testing for asthma and allergies with everything being normal. Even use of inhalers has not been found to be helpful.

The most difficult part of the evaluation in these patients is to perform the exam WHEN the patient is actually having symptoms (ie, during exercise). Doing an evaluation when without symptoms usually results in a normal exam (not surprisingly).

That's where the pulmonary stress test comes in. The philosophy behind this test is to allow for an evaluation when the patient is actually having symptoms.

Under a controlled situation, the patient is asked to start exercising on a treadmill or bicycle. Heart rate, EKG, respiratory rate, etc are all monitored during exercise. When symptoms of stridor or shortness of breath occur, the ENT performs a fiberoptic laryngoscopy exam on the spot to evaluate vocal cord motion and laryngeal structure. In some cases, even awake bronchoscopy may be performed to look for tracheomalacia.

Our office in cooperation with Fauquier Hospital offers this service.

Image taken from wikipedia.