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A 25 year old woman with acute stridor presents to the ED in severe respiratory distress...
A Young Woman with Acute Stridor
Jess Mason MD, Scott Weingart MD, Matt Tabbut MD, and Ryan Naso RN
Take Home Points
❏ Paradoxical vocal cord motion is also known as Munchausen’s stridor.
❏ Some cases are thought to be psychogenic but half of patients will have another diagnosis such as asthma or GERD.
❏ Patients may be given ketamine.
CASE
A 25 year old female at work developed a tickling sensation in her throat followed by a sensation that she couldn’t breathe. She felt she was only able to draw one in every few breaths in. EMS arrived on scene. Her lungs were clear but she had high pitched stridor. A breathing treatment with albuterol did not help. She was tachycardic with a respiratory rate in the 30s. She was afebrile. Her oxygen saturation as 100%.
● Differential diagnosis? Foreign body. Anaphylaxis. Epiglottitis. Angioedema. Laryngeal edema. Pneumothorax.
● Racemic epinephrine was given. The airway equipment was ready at bedside.
● Bedside ultrasound did not show any pneumothorax or edema. There were no other signs of anaphylaxis.
● Lateral x-ray of the neck showed focal edema at the hypopharynx.
● How do you evaluate the stridulous patient?
○ Bring them to a place where you can manage the airway if you need to. Gather all your equipment and RSI medications. Get your failed airway equipment.
○ Examine the patient. Look in their mouth for angioedema, trismus and foreign body. Is the patient febrile? Do they have signs of toxicity? Listen to the lungs. Is there wheezing? Listen to their neck.
○ Stridor due to upper airway obstruction is usually inspiratory stridor.
● They gave the patient lorazepam. She felt more relaxed. ENT and anesthesia were contacted for fiberoptic endoscopy. The patient was given a lidocaine nebulizer and they prepared for an awake intubation.
● When they looked in with the scope, they saw paradoxical vocal cord dysfunction. These patients should have good oxygen saturation. However, don’t miss a more serious diagnosis.
● This condition was first described as Munchausen’s stridor and was related to stress and anxiety. Not all of these cases are driven by psychology. About half will have another underlying condition such as asthma or one that irritates the vocal cords like GERD.
● You can use 5ml of 1:1000 epinephrine (1 mg/mL), put it in the nebulizer and give it to the patient.
● If they still have stridor and you are suspicious the cause is not organic, you can take a look with a short rhinoscope. This is a skill we all should have. Prepare for it like you would an awake intubation with topical anesthetic. Spray a nostril with topical anesthetic. Use viscous lidocaine as lubrication. You can use a nasal trumpet to dilate the nostril.
● You won’t see any unusual anatomy aside from the vocal cords held in adduction throughout the patient’s respiratory cycle. Paradoxical vocal cord dysfunction is the airway emergency that isn’t. It is a functional disorder of the vocal cords. The etiology is not well understood. It is often attributed to psychiatric disorders. It often presents as a conversion disorder. Even though you know it is psychogenic, they have no volitional control. It may sometimes be a Munchausen’s disorder. Have sympathy for these patients.
● Treat them like they have a real respiratory disorder. Try non-invasive interventions and anxiolytics. Keep the patient in a place where you can intubate them if you are wrong. Have the patient take a deep breath and count from 1 to 10 in a single breath. Alternatively, patients can blow through a straw. This might help open up the vocal cords. If all else has failed, you can give ketamine.
● If the patient is given ketamine and has paradoxical vocal cord dysfunction, their symptoms should immediately improve. The patient will maintain their respiratory drive with ketamine, so if you are wrong, the patient is set up for an awake intubation or nasopharyngoscopy. Have everything you need to manage the patient’s airway before you give the patient ketamine.
● The ketamine worked.
