BACKGROUND: Whereas differences in inducible laryngeal obstruction (ILO) presentation on the basis of age have been observed within pediatric populations, age-based differences in adult populations are lacking.
OBJECTIVE: To describe differences in ILO on the basis of age in adults.
METHODS: Patients aged older than 16 years with confirmed ILO (vocal cord adduction > 50% during inspiration) by means of provocation-challenge rhinolaryngoscopy by their treating allergist were included. An investigator-designed questionnaire was administered using Research Electronic Data Capture with corresponding medical data collection. χ2 tests, Student\'s t tests, analysis of variance, Cochran-Armitage test for trend, and Fisher\'s exact test were used.
RESULTS: The median age of the 67 patients was 50 years. P values less than .05 were considered significant. Those aged younger than 50 years (n = 31; mean age 35.6 years) reported more symptoms vs age 50 years and older (n = 36; mean age 61.8 years), including shortness of breath at rest and exertion (84% vs 39%, 94% vs 72%), throat tightness (81% vs 50%), chest tightness (81% vs 47%), and difficulty getting air in (81% vs 56%). Those aged younger than 50 years had an increased history of anxiety (68% vs 33%), asthma (55% vs 31%), positive methacholine challenge (52% vs 22%), increasing triggers with time (87% vs 43%), higher Pittsburgh Vocal Cord Dysfunction Index Scores (6.9 vs 5.5), and inspiratory curve flattening (48% vs 24%). Additional age-based subdivisions confirmed significant trends with the lowest reported ILO characteristics and symptoms in those aged 65 years and older.
CONCLUSIONS: A high index of suspicion for ILO should be maintained in older adults since they may report less typical ILO symptoms and anxiety associations that prompt ILO evaluation.

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OBJECTIVE: Speech pathology is the first-line treatment for inducible laryngeal obstruction (ILO) and involves behavioral techniques to address symptoms and modify maladaptive laryngeal postures. Benefit from speech pathology is reliant on patients engaging in treatment sessions, regular home practice, and generalizing techniques to everyday activities. There is limited research exploring engagement in speech pathology treatment for ILO, particularly from the patient perspective. This study aimed to explore the experiences of living with ILO and how this experience may impact the way patients engage in speech pathology treatment.
METHODS: Qualitative study.
METHODS: Semistructured interviews were completed with seven participants exploring their experiences living with ILO, their diagnostic process and their experiences with speech pathology treatment. Data were analyzed using reflexive thematic analysis to determine shared meanings across participants and themes were developed.
RESULTS: Three major themes were identified - Life with ILO, Challenges of Speech Pathology Treatment, and What Matters to Me. Patients\' reports of living with ILO and interacting with speech pathology suggested that these experiences impacted their readiness to start treatment and persist through the challenges of the treatment. Engagement appeared to be positively associated with significant ILO symptom burden and life impact, confidence in the diagnostic process, recommendation for speech pathology treatment, a tailored intervention by a patient-perceived expert in the field and working in a partnership with the speech pathologist to develop a sense of agency. Patients indicated their engagement was negatively influenced by competing time demands, social embarrassment when using symptom relief techniques and laryngeal exercises, and a low ILO symptom burden and life impact.
CONCLUSIONS: The reasons behind engagement in speech pathology treatment for ILO appear to be a complex interaction between previous experiences of living with ILO including the diagnostic process and the experience of speech pathology treatment. A patient-centered approach to therapy may help to maximize engagement by exploring readiness and expectations for treatment. The greater understanding of the patient experience provided through this study may allow speech pathologists to devise meaningful ways to maximize engagement in treatment for people with ILO.

When approaching a case of apparent drug allergy, the consulting clinician should consider a broad differential diagnosis. This article presents a series of cases that could be commonly referred to an allergist for assessment as \"drug allergy,\" however, a real diagnosis exists that mandates a different diagnostic and treatment strategy, including a case of inducible laryngeal obstruction, multiple drug intolerance syndrome, viral rash, seizure due to metastatic malignancy, and hemophagocytic lymphohistiocytosis initially diagnosed as drug reaction and eosinophilia with systemic symptoms. The initial misdiagnoses of these patients delayed or interfered with their medical care, emphasizing the importance of accurate diagnoses for the benefit of our patients.

BACKGROUND: Inducible laryngeal obstruction (ILO) describes inappropriate laryngeal closure during respiration, with airflow obstruction occurring at the glottic and/or supraglottic level, leading to breathlessness.
OBJECTIVE: There is a paucity of data describing the demographics and impact of ILO. We aimed to report the clinical and demographic features of ILO in individuals entered prospectively in the UK national ILO registry.
METHODS: Data were entered into a Web-based registry from participants with endoscopically confirmed ILO who were attending four established UK-wide specialist ILO centers between March 2017 and November 2019. All patients provided written informed consent.
RESULTS: Data from 137 individuals were included. Most (87%) had inspiratory ILO and required provocation during endoscopy to induce symptoms. There was a female predominance (80%), mean age 47 years (SD, 15 years). The most common comorbidities included asthma (68%) and reflux (57%). Health care use was high: 88% had attended emergency health care with symptoms at least once in the previous 12 months and nearly half had been admitted to the hospital. A fifth had required admission to critical care owing to ILO symptoms. Patient morbidity was substantial; 64% reported impaired functional capacity (≥3 on the Medical Research Council Dyspnoea Scale) and a third stated that symptoms affected working capability.
CONCLUSIONS: We describe the first multicenter prospective characterization of individuals with endoscopically diagnosed ILO. Analysis of our multicenter data set identified ILO as associated with a high burden of morbidity and health care use, comparable to severe asthma. These data will support the development of health care resources in the future and guide research priorities.

BACKGROUND: Asthma and vocal cord dysfunction (VCD), also known as inducible laryngeal obstruction (ILO), may coexist, resulting in worse outcomes for patients. The experience of people with VCD/ILO and coexisting asthma is unknown.
OBJECTIVE: We sought to determine whether coexistent VCD/ILO and asthma have deleterious impacts on quality of life.
METHODS: We undertook a descriptive qualitative study using one-to-one semistructured interviews with 30 purposively recruited adult participants with a prior confirmed doctor asthma diagnosis and laryngoscopy-confirmed VCD/ILO. A thematic and content analysis was conducted to explore the data.
RESULTS: Participants were mostly female (63%), mean ± SD age 63 ± 12 years. Four themes were identified: trapped voice, altered life, knowledge about VCD/ILO, and looking for solutions. Participants reported their voice being trapped in their throat or the voice being suddenly cut off when talking or singing. Self-reported VCD/ILO symptoms including throat tightness and breathlessness were highlighted by participants. The second theme described how patients struggle to communicate or tended to shorten conversations. Insufficient knowledge and existing confusion regarding whether asthma was causing the breathlessness was described in the third theme. Looking for solutions depicted participants\' diagnostic journey and how they sought an explanation for the symptoms.
CONCLUSIONS: People with asthma and coexisting VCD/ILO experience a substantial burden affecting the quality of life. These data describe the impact on patients with coexisting conditions and should be used to increase clinician awareness of the experience of VCD/ILO from patients\' perspectives to support a personalized approach to care.

A young woman with historically mild asthma experienced worsening breathlessness and cough with competitive ice skating. Despite optimizing and escalating treatment for her eosinophilic asthma, and addressing known exacerbating factors, her symptoms remained uncontrolled and refractory to bronchodilators and oral corticosteroids. Objective testing suggested her presentation was out of keeping with asthma alone, and she was suspected to have comorbid dysfunctional breathing and/or inducible laryngeal obstruction. Evidence was required to confirm the diagnoses, assess each condition\'s contribution to her symptom burden, and guide therapy. As exercise was a predominant trigger, she proceeded to cardiopulmonary exercise test with continuous laryngoscopy during exercise (CPET-CLE). Testing confirmed the presence of two forms of inducible laryngeal obstruction and evidence of hyperventilation predominant dysfunctional breathing. This case highlights the importance of identifying coexisting conditions in difficult-to-treat asthma, and the value of structured multidisciplinary assessment in referral centres for such individuals.

BACKGROUND: Inducible laryngeal obstruction causes narrowing of the laryngeal aperture in response to external triggers. Outcomes are measured in inducible laryngeal obstruction to monitor changes in health status over time.
METHODS: This study is a scoping review based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. The review will be guided by the following research question: \'What health outcomes are measured in studies including people with inducible laryngeal obstruction?\' The research question was validated using the Population-Concept-Context framework according to the methodology for Joanna Briggs Institution Scoping Reviews. Relevant peer-reviewed studies and grey literature conducted over the last 40 years will be identified from electronic databases including AMED, CINAHL, Embase, EMCARE, MEDLINE, OVID, PubMed and PsycINFO. The search strings \'inducible laryngeal obstruction\', \'ILO\', \'vocal cord dysfunction\', \'VCD\', \'paradoxical vocal fold motion\', \'PVFM\', \'outcome\', \'measure\', \'measurement instrument\', \'assessment\', \'scale\', \'questionnaire\' will be combined using Boolean logic. An independent reviewer will conduct title screening; two independent reviewers will conduct abstract and full article screening, followed by data extraction by two reviewers. Analyses will be conducted appropriate to the findings.
CONCLUSIONS: The review will document evidence of health outcomes measured in inducible laryngeal obstruction, identifying measurement characteristics and potential utility. Collating studies may identify gaps in coverage, the need for novel tools, and for standardisation for clinical and research purposes.
CONCLUSIONS: What is already known on the subject Inducible laryngeal obstruction causes narrowing of the laryngeal aperture in response to external triggers. Outcomes are measured in inducible laryngeal obstruction to monitor changes in health status over time. Currently, there are no standardised outcome measures for measuring the effects of interventions in inducible laryngeal obstruction (ILO). What this paper adds to existing knowledge Assessment of health can be measured in a variety of ways. Physiological, radiological and biochemical measurements of impairment are more common historically but there are a lot of outcomes of other factors now including subjective measures of functional status and health-related quality of life, with data collected directly from patients. This study will allow us to scope the literature to see the health outcomes being measured in ILO to attempt to standardise and develop future health outcomes. What are the potential or actual clinical implications of this work? The review will document evidence of health outcomes measured in inducible laryngeal obstruction, identifying measurement characteristics and potential utility. Collating studies may identify gaps in coverage, the need for novel tools and for standardisation for clinical and research purposes.

OBJECTIVE: Determine whether variable extrathoracic airflow limitation (VEAL) is observed in patients with negative methacholine challenge tests (MCT).
METHODS: Electronic medical records of patients undergoing MCT at Jesse Brown VA Medical Center between January 2017 and December 2019 were reviewed. Only patients with negative MCT were selected. Pertinent demographic, clinical, and pulmonary function tests (PFT) and MCT data were abstracted from each record. Spirometric flow-volume loops recorded during each test were inspected by one co-author to determine the first inhaled methacholine concentration at which FEF50/FIF50 was either > 1 or further increased if baseline FEF50/FIF50 after nebulized saline (vehicle) already exceeded 1. Student\'s t-test was used for statistical analysis. P < 0.05 was considered statistically significant.
RESULTS: One hundred and twenty-seven consecutive patients with normal baseline PFT and negative MCT were identified. Thirteen patients (10.2%) had negative MCT and FEF50/FIF50 > 1 after testing. They were predominately obese (BMI, 31.3 ± 6.6), non-smoking (10), White (8) males (9) aged 51.3 ± 14.1 years (mean ± SD) referred for symptoms suggestive of asthma (n = 7) or for chronic cough (n = 6). Five had obstructive sleep apnea, three gastroesophageal reflux disease, and two chronic rhinosinusitis. FEF50/FIF50 increased significantly from 0.72 ± 0.21 after nebulized saline (vehicle) to 1.21 ± 0.13 after inhaled methacholine (p < 0.001). Median inhaled methacholine concentration eliciting these responses was 1.0 mg/mL (range, 0.25-16 mg/mL).
CONCLUSIONS: VEAL is observed in a subset of patients with a negative MCT. This phenomenon should be recognized and reported to the referring healthcare providers and its clinical significance addressed as indicated.