A 24-year-old elite female athlete presents with episodic dyspnea and chest tightness during high-intensity training, often accompanied by inspiratory stridor. She has been treated for presumed asthma without improvement. Spirometry with flow-volume loop shows flattening of the inspiratory limb with normal expiratory flow. Flexible laryngoscopy performed during an acute episode reveals paradoxical adduction of the vocal cords. The pattern marked **D** in the diagram suggests this vocal cord pathology. Which of the following is the most appropriate initial management for this condition?

Explanation

## Why Speech therapy with diaphragmatic breathing exercises and trigger identification is right Vocal cord dysfunction (VCD) / paradoxical vocal fold motion is characterized by episodic adduction of the vocal cords during inspiration, causing the inspiratory plateau pattern on flow-volume loop (marked **D**). The diagnosis is confirmed by flexible laryngoscopy showing paradoxical adduction during symptoms. Initial management is conservative and focuses on speech therapy with diaphragmatic breathing techniques, panting, pursed-lip breathing, and identification of triggers (exercise, anxiety, GERD, postnasal drip). This patient's presentation—young female athlete with episodic symptoms, prior misdiagnosis as asthma, and laryngoscopic confirmation of paradoxical adduction—is classic for VCD. Speech therapy and breathing retraining are first-line and highly effective (Dhingra ENT 7e Ch 50; Harrison 21e Ch 287). ## Why each distractor is wrong - **Immediate tracheostomy to secure the airway**: Tracheostomy is reserved for bilateral vocal cord paralysis (paramedian cords causing airway obstruction) or life-threatening airway compromise. VCD is episodic and responsive to conservative management; tracheostomy is not indicated and would be inappropriate overtreatment. - **Injection laryngoplasty with hyaluronic acid for permanent medialization**: Injection laryngoplasty is used for unilateral vocal cord paralysis (RLN injury) to medialize the immobile cord. VCD involves *dynamic* paradoxical adduction during inspiration, not static cord immobility, so medialization is not the mechanism of treatment. - **Thyroid surgery with intraoperative nerve monitoring**: Thyroid surgery is the most common cause of recurrent laryngeal nerve (RLN) injury leading to unilateral vocal cord paralysis. This patient has VCD with bilateral cord function (paradoxical adduction), not RLN injury, so thyroid surgery is not indicated. **High-Yield:** VCD is episodic paradoxical vocal cord adduction during inspiration (inspiratory plateau on flow-volume loop), often misdiagnosed as asthma; diagnosis confirmed by laryngoscopy during symptoms; treatment is speech therapy + trigger management, NOT surgery or medialization. [cite: Dhingra ENT 7e Ch 50; Harrison 21e Ch 287]