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February 25, 2012

Hiccups and Laryngospasm

So one day I was having some bad hiccups... you know, the obnoxious kind complete with strangled noise and chest jerks.

However, this experience unlike the numerous prior episodes of hiccups triggered an intellectual brainstorm about breathing and stridor in general.

FACT:
Hiccups (aka singultus) are due to brief, intermittent, and involuntary diaphragm contractions against a closed glottis. For the layperson, this means during a hiccup:
  • Your body takes a quick breath inwards (inhalation)
  • Your body brings the vocal cords together
  • Both above actions occur simultaneously, involuntarily, and briefly 
Which brought me to consider another disorder called laryngospasm which is the most severe form of vocal cord dysfunction. In this particular condition, the vocal cords come together involuntarily just as in hiccups... BUT, it may last for seconds to minutes while the breathing is still voluntary. At worst, it results in complete airway obstruction causing a loud high-pitched squeal called stridor (check out this movie below). Click here for more information about this condition.




FACT:
Laryngospasm is due to sustained and involuntary vocal cord closure WHILE the person voluntarily tries to breath. For the layperson, this means during a laryngospasm attack:
  • Your body tries to breath voluntarily
  • Your vocal cords involuntarily closes for a sustained period of time
  • The above actions occur simultaneously
So... when you get down to it, the only difference between hiccups which is common and afflicts many people and laryngospasm which is rare is: 1) how long it lasts for and 2) whether the diaphragmatic movement is voluntary or involuntary.

Which got me thinking... is there actually a medical condition that is BOTH a hiccup and laryngospasm at the same time?

In fact, there is... though I must preface by saying there has been only one case report (that I'm aware of) of this super-rare condition called "Diaphragmatic Flutter with Stridor."

Reported back in 1995, the journal Chest reported a 13 years old girl who presented with rapid stridulous panting that occurred only during inspiration while awake (symptoms disappeared while asleep). Laryngoscopy showed an abnormal closed glottis. ECG noted noncardiac electrical activity due to involuntary diaphragmatic contractions occurring at a rate of 200/min. Fluoroscopy of her diaphragm revealed rapid myoclonic contractions of the left hemidiaphragm.


In essence, she was "hiccuping" 200 times per minute while having a sustained laryngospasm attack. The suffering this child and her family must have gone through must have been unbelievable and I'm sure tracheostomy must have been entertained at some point.

Treatment (cure) ultimately was achieved by crushing the patient's left phrenic nerve.

So let's take a look at all three conditions in table format:

Diaphragm Contraction
Vocal Cord Closure
Timing
Hiccups
Involuntary
Involuntary
Brief
Laryngospasm
Voluntary
Involuntary
Sustained
Diaphragmatic Flutter
Both
Involuntary
Sustained

The common theme between all three disorders is the involuntary vocal cord closure resulting in airway obstruction. The variation in presentation is utterly dependent on whether the diaphragm contraction is involuntary or not and how long the "attack" lasts for.

References:
Diaphragmatic Flutter Presenting as Inspiratory Stridor. 10.1378/chest.107.3.872 CHEST March 1995 vol. 107 no. 3

Laryngospasm and Other Forms of Vocal Cord Dysfunction. Fauquier ENT.

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Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids. Google+ Christopher Chang, MD Bio

1 comment:

  1. Thank you for this informative post. I was not aware of the last one, Diaphragmatic Flutter. Now I understand the differences. Now, I just need to read the treatments for this.

    ReplyDelete

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