Vocal cord dysfunction (VCD) can look and feel a lot like asthma. It’s a condition in which your vocal cords close instead of opening as you inhale.

You can’t see your vocal cords in a mirror, but you can feel them. Put your hand on the front of your throat and swallow. That hard ball that moves up and down when you swallow is your voice box, or larynx. Vocal cords are folds of tissue that stretch across your voice box.

As you breathe in, your vocal cords open to let air go through into your lungs, then narrow as you breathe out. If you have VCD, your vocal cords suddenly close when they’re not supposed to, cutting off your air supply. Often this occurs during exercise or when you’re emotionally upset or crying – just when you need air the most.

What are VCD triggers?

VCD can be set off by factors often associated with asthma, including:

• Exercise
• Stress
• Cigarette smoke
• Perfume and other strong scents
• Upper respiratory infections
• Air pollution
• Cold air

Who has VCD?

Overall prevalence of vocal cord dysfunction  is not known, but small studies indicate it is common in teenagers, particularly females who play sports that involve intense running. Some believe this is due to the effect of puberty on the developing larynx.

What are the symptoms of VCD?

Symptoms include:

• Wheezing or stridor (a high-pitched sound)
• Chronic cough or throat clearing
• Shortness of breath
• Upper chest or throat tightness
• Intermittent hoarseness

How Is VCD diagnosed?

The most accurate way to identify VCD is to use a laryngoscope – a flexible tube with a tiny camera inserted down the back of the throat to view the vocal cords. However, it must be done while symptoms are actually occurring. Doctors have patients exercise on equipment to induce symptoms, then use a spirometer to measure patient lung function. When VCD is occurring, the spirometer reading will show very different results from those seen with asthma.

VCD may be linked to chronic irritation of the throat making vocal cords sensitive. The irritation could come from postnasal drip caused by chronic nasal and/or sinus congestion or from gastroesophageal reflux, where stomach acids leak up into the esophagus.

How is VCD treated?

Beyond treating an underlying throat irritation such as gastroesophageal reflux disease (GERD), there is no specific medication available to treat VCD. However, many patients are referred to a speech pathologist.

A speech pathologist can help VCD patients learn to create muscle memory in the larynx to normalize breathing, especially during physical activity. For example, athletes with VCD must learn to breathe with their jaw relaxed and mouth open, using small, rapid inhalations and then exhaling through pursed lips.

Hives or welts, also known as urticaria, are itchy, raised, pink or reddish bumps on the skin. About a quarter of the general population can have hives during their life. Hives often appear without warning and may start at any age.

Angioedema is swelling below the surface of the skin and fatty tissue. Areas of swelling may be painful. Angioedema usually occurs in the face, throat, hands and feet. Swelling can also occur in the abdomen or other areas of the body. Throat swelling can be life threatening and requires immediate medical attention. It is important to understand that angioedema is a medical term to describe swelling. It can be found with many different disorders. Angioedema can occur with or without hives. There are several different ways swelling can occur. Understanding the underlying mechanism of swelling or the specific disease is important in figuring out the best treatment.

Hives:
•    Are itchy and can occur anywhere on the body including the face, arms and legs, groin, chest or back.
•    May range in size from just a few millimeters to several centimeters.
•    Usually fade individually within a 24-hour period and the skin returns to normal without leaving any marks or bruising.

Doctors will classify your hives based on how long you have had them. This helps doctors think about possible causes of your hives. When hives occur for less than six weeks, we call this acute urticaria. When hives last longer than six weeks, we change the name to chronic urticaria. Sometimes hives can occur with angioedema.  

There are two types of chronic urticaria: chronic inducible urticaria and spontaneous urticaria. Neither form of chronic urticaria is dangerous. Chronic inducible urticaria is caused by an environmental trigger such as heat, cold or pressure applied to the skin. The most common form of inducible urticarias is called dermatographic urticaria. It can occur in all age groups. Dermatographic urticaria is triggered by shearing forces against the skin, such as scratching or pressure from tight clothing, resulting in the linear appearing hives. Stroking or scratching the skin with a firm object will elicit the response in five to seven minutes. Hives can last from 15 minutes to three hours. 

Often the cause of chronic spontaneous urticaria is not fully known, but it is not usually caused by allergies. This is a constant finding of medical authorities and researchers around the world. The absence of an identifiable trigger can be frustrating for patients. Sometimes chronic hives may be autoimmune in nature or related to an autoimmune condition including autoimmune thyroid disease, rheumatoid arthritis or systemic lupus erythematosus, but in these cases, there are usually other signs of the autoimmune disease, such as joint pain or fevers. 

Antihistamines are frequently an effective form of treatment for chronic urticaria. Spontaneous remission can occur in two to three years.

Medications will help your itching and reduce hives. Medications will not “cure” hives but can help to completely resolve them. Antihistamines are the best initial medication to treat your hives. Sometimes, a combination of several antihistamines or a high dose of one antihistamine may be recommended.

Older antihistamines such as Benadryl (sedating antihistamines) may make you sleepy, cause dryness and only last for several hours. Newer non-sedating antihistamines are less likely to make you sleepy. They have fewer side effects and last much longer. Non-sedating antihistamines (shown below) are often the first medication doctors will prescribe for your hives. High dosages, up to four times the recommended dose, are often well tolerated and can help control your itching. This will also help to prevent the use of other medications that have more side effects.

About 50% of chronic spontaneous urticaria (hives over six weeks with no identifiable cause) will respond to antihistamine as discussed above. For those who do not improve on antihistamines, 65% respond to omalizumab. Omalizumab is an FDA approved treatment of chronic urticaria. This medication is injected under the skin once a month. Another injectable medication that has FDA approval for the treatment of chronic urticaria is dupilumab, which can help reduce itching and hives. Most recently, a novel oral tyrosine kinase inhibitor called remibrutinib has received FDA approval to treat chronic spontaneous urticaria in adults. Corticosteroids, such as prednisone or prednisolone may help hives. These are not ideal treatments for long-term use but may have a role to relieve severe symptoms for a few days. Other medications that can be used include cyclosporine, which has been shown to improve symptoms in 54-73% of patients and can be an option for those patients that don’t improve with newer agents. If these medications do not help, in rare cases, under the supervision of a specialist, your treatment team may also consider other medications that affect the immune system. 

Your doctor will outline a treatment plan that allows you to increase treatment during an outbreak of hives or swelling and reduce medications when the hives or angioedema are not as bothersome.

Chronic hives can last for many years but will often go away. Hives will resolve in half of patients within one to two years and 80-90% of patients will improve within five years. Even if a patient’s hives improve, it is not unusual to see the hives recur months to years later.

The treatment of angioedema is dependent on whether or not it is mediated by histamine (associated with hives). If it is associated with hives, antihistamines, like the ones listed below, or steroids can help. If it is related to medication, your doctor will usually talk to you about stopping or changing your medication. If is related to hereditary angioedema, the treatment is different and involves very specialized medications. 

Mold is a type of fungus that produces spores that float through the air. It can grow on almost anything when moisture or damp environments are present. It can be found indoors and outdoors. They grow as networks of interlocking filaments that spread on and into organic matter, leading to its decomposition. When clusters of these filaments become large enough, they are visible as fuzzy growths of mold or mildew. Bread mold is a familiar example. Mold is also a common cause of allergy and asthma symptoms.

Molds are found primarily in warm, dark and damp locations. Unlike plants, which use energy from the sun to produce food, molds obtain their energy by digesting other organic matter. To do so, they need moisture. Mold grows outdoors, and, if the humidity is high enough, indoors as well. They do not have the clearly defined seasons that pollens do, but are at their peak during months of high humidity, and are absent in outdoor air only if there is snow on the ground. They can grow on grass and on the bark of trees, and are plentiful in fallen leaves and other decaying vegetation. Indoors, they live in areas of high humidity, such as basements or poorly ventilated bathrooms.

Recommendations to Decrease Mold Exposure:

Clean Your Home

• Use diluted bleach to eliminate visible mold growth in showers and on shower curtains.
• Avoid carpets in bathrooms or use only washable throw rugs.
• Remove any carpeting that has been installed directly on basement concrete floors. Use wipeable, vapor-barrier materials, such as tile or vinyl flooring. Mold-allergic people should not sleep in basement level bedrooms.

Control Your Air

• Keep humidity under 50% by using air conditioning — possibly supplemented with dehumidifiers — in the summer. Use a gauge to measure indoor humidity. Small air dryers may be used to prevent mold growth in closets.
• Avoid over-humidification. Either do not use a humidifier in the winter, or if you do, limit its output so that humidity remains under 50%. Use only humidifiers that have a heating element that prevents mold from growing in the unit itself.
• Allow moisture to escape from the home. Ventilate the shower and cooking areas. Vent your clothes dryer outdoors. Open windows when outside humidity is low.
• Do not store firewood indoors and avoid live Christmas trees. Do not repot plants indoors. Mold lives on the bark of trees and in soil.

Avoid Outdoor Exposure

• Avoid greenhouses, antique shops, summer cottages, and musty hotel rooms.
• Wear a facemask, and possibly goggles, if you must cut grass, rake leaves, work in a barn, or be exposed to compost.

Commonly Tested Molds

Alternaria: Indoors these are found in basements and damp areas such as windows, doorways, and humidifiers. Outside this mold can be present in wooded areas, grasses, and in organic debris such as leaves and mulch.

Aspergillus: Indoors these are common in closed environments such as humidifiers, evaporative coolers, basements, attics, and barns.

Drechslera: Commonly found on plant debris, soil, and a variety of substances indoors in tropical to subtropical areas. The fungi will survive for several years in dead clippings or infected grass plants. It is an opportunistic pathogen to certain plant/ grass and animal species.

Bipolaris: Very common outdoors, especially in tropical and subtropical areas, and occasionally found indoors. Outdoor the fungus grows best on wood mulch, leaf piles, decaying vegetation and in soil.  Indoors it thrives in damp rooms, crawl spaces, and doghouses.

Cladosporium: High levels are found in most rooms inside homes, but their numbers are often increased in damp areas like basements, bathrooms, crawl spaces and closets.

Penicillium: High levels in damp areas like basements where they colonize foods, clothing, paper, and leather. 

Stemphylium: A common indoor and outdoor fungus with peak levels in warm humid areas or in places with rainy periods. Outdoors it is a soil fungus found in wooded areas, mulch, leaf piles, home gardens and in farm crop areas (especially tomatoes, asparagus, and cabbage fields).

The first approach in managing seasonal allergies should be to avoid the allergens that trigger symptoms. Avoid triggers by making changes to your home and to your behavior:

• Monitor pollen and mold counts. Weather reports often include this information during allergy season or visit pollen.com. Rain washes pollen away, but pollen counts can soar after rainfall. On a day with no wind, airborne allergens are grounded. When the day is windy and warm, pollen counts surge.
• Stay indoors as much as possible when pollen counts are at their peak and when wind is blowing pollens around.
• In spring and summer, during tree and grass pollen season, levels are highest in the evening. In late summer and early fall, during ragweed pollen season, levels are highest in the morning,
• Keep windows and doors shut at home and in your car during allergy season.
• Avoid using window fans that can draw pollens and molds into the house.
• Wear glasses or sunglasses when outdoors to minimize the amount of pollen getting into your eyes.
• Try not to rub your eyes; doing so will irritate them and could make your symptoms worse.
• Don’t hang clothing outdoors to dry; pollen may cling to towels and sheets.
• Change sheets and pillowcases at least every two weeks
• Before bed, be sure to change and remove clothing worn outside as they will likely be contaminated with allergens.
• Take a shower, wash your hair and change your clothes after you’ve been working or playing outdoors.
• Wear a NIOSH-rates 95 filter mask when moving the lawn or doing other chores outdoors, and take appropriate medication beforehand.
• If you have a history or prior seasonal problems, allergist’s recommend starting medications to alleviate symptoms two weeks before they are expected to begin.
• Moving to another climate to avoid allergies is usually not successful—allergens are virtually everywhere.