The Journal of the Arkansas Medical Society Med Journal June 2020 | Page 10

Case Study
by Musa Yilanli, MD; 1 Aparna Das, MD; 1 Veronica Raney, MD; 1 Nihit Kumar, MD 1
1. Department of Child and Adolescent Psychiatry, , UAMS, Little Rock, Ark.
Treatment with Hydroxyzine for Paradoxical Vocal
Cord Dysfunction
Abstract
Paradoxical vocal cord dysfunction (VCD) is
associated with several psychiatric conditions.
Early intervention for ongoing anxiety problem is
reported to be beneficial for patients in reducing
symptoms of VCD. While there is extensive literature
supporting the use of psychological interventions,
the evidence for the use of medications is
limited. The aim of this case report is to expand
the evidence base about the medication options
that can be used to treat VCD. We present a case
with paradoxical vocal cord dysfunction who was
successfully treated with hydroxyzine and psychoeducational
intervention.
Introduction
Paradoxical vocal cord dysfunction (VCD), or paradoxical
vocal-fold motion, (PVFM) is an insufficiently
understood medical condition. It was first
described by Patterson et al. in 1974, who named
it Munchausen’s stridor 1 . It is a functional disorder
of the vocal cords that leads to acute upper
airway obstruction. 2 The presentation of the disease
frequently mimics an episode of asthma as
patients experience several similar symptoms including
coughing, breathing problems, or inspiratory
stridor 2 . The exact incidence and prevalence
is not known as the condition is frequently misdiagnosed
as asthma or other medical condition,
or remains undiagnosed. Based on the available
literature, certain trends are noted; there is greater
prevalence in females 2, 4, 5 , and there is wide age
range from 14.5 to 33 years for the occurrence of
this disorder 2 .
It is important to get a detailed physical history
with physical examination and extensive work-up
to rule out laryngeal causes of VCD such as paralysis,
granulomas, or airway malacia. Once the
organic causes have been ruled out, the triggers
for PVFM may be broadly divided into psychological
factors (accounting for 70% of the cases)
and hypersensitivity reaction or other neurological
disorders (accounting for the remaining 30%
of the cases). 2,5 A multidisciplinary approach is
essential to the management of PVFM/VCD dysfunction.
Most teams have pulmonologists, otorhinolaryngologists,
speech and language pathologists,
and psychologists or psychiatrists. 5 From
a psychiatric standpoint, it is important to do a
comprehensive psychiatric evaluation taking into
account and thoroughly investigating a history of
clinical depression, history of abuse and personality
disorder, and other somatoform disorders.
Treatment for VCD begins with accurate diagnosis
and subsequent family education about
the disease. Alleviating symptoms is highly recommended
before dealing with disease-related
stressors because the new medical diagnosis
and poor symptom control may easily cause significant
anxiety. There is extensive evidence for
several psychotherapeutic treatment options including
biofeedback, hypnosis, and cognitive-behavioral
therapy (CBT). However, there is dearth
of literature regarding the use of medications for
the management of PFVM. We present a case of
paradoxical VCD that was successfully treated
with hydroxyzine along with early psychoeducational
intervention.
Case Report
A 16-year-old Caucasian male with history of
seasonal allergies and sports-induced asthma
presented to Emergency Department (ED) with
intermittent choking spells, coughing, and difficulty
swallowing. Patient reported that his symptoms
had started as daily dry cough and then he
had started experiencing choking episodes that
lasted about a minute. During these episodes,
patient felt he could not breathe and his throat
was closing up. His symptoms had gradually
worsened, and he had started to fear drinking
and eating. After the first emergency visitation,
esophagogastroduodenoscopy (EGD) was done
that showed erosive changes and the presence of
an esophageal stricture, which was dilated during
EGD. Patient was diagnosed with Gastro esophageal
reflux disease (GERD) and was started on
omeprazole, sucralfate, and hyoscyamine. After
the EGD, patient continued to avoid eating and
drinking due to fear/feeling of food getting stuck.
Patient then started to experience choking episodes
at night time that woke him up; these episodes
were accompanied by intense fear. Patient
presented back to ED when Otolaryngologist/ENT
was consulted and flexible scope done, which
revealed healed pharyngeal lesions with significant
inflammation and post cricoid edema. Vocal
cords were mobile and the supraglottic anatomy
was normal. Patient was sent home with reassurance.
The following day, patient presented to
a different ED with complaint of obstruction on
the left side of his throat that he could feel when
swallowing. Patient was admitted to general pediatrics
for further investigation. He was put on
clear liquid diet briefly and his upper gastrointestinal
study revealed normal anatomy. Patient was
then switched to regular diet and psychiatry was
consulted for evaluation of anxiety as a potential
contributor to his symptoms. During evaluation,
patient endorsed somatic symptoms as well as
symptoms of social anxiety. He stated he did
not want to lie down supine on the bed, which
could exacerbate his spasmodic episodes. He
was interested in taking an as-needed medication
to help him deal with his fear and so was started
on hydroxyzine 25 mg at bedtime for anxiety and
sleep. On follow-up the next day, patient stated
he was able to sleep better with this medication
and he only had one mild episode during the
night. Speech therapist worked with the patient
on breathing and relaxation techniques to help
during laryngospasm episodes. During hospitalization,
patient and family education with constant
reassurance was provided by psychiatrist. Patient
was discharged after three days of hospital stay.
Patient was contacted over the phone a week after
his discharge for follow up and he denied having
any further episodes.
Discussion
Our patient received a new diagnosis of GERD
with a prior history of sports-induced asthma
and seasonal allergies. Even after being started
on treatment of GERD, he continued to have intermittent
choking episodes that would wake up
him up from sleep, and his condition continued
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