surrounding adenoid dency cystic toward

tissues. local

Generally are
recurrence,

recognized its infiltrative

and

characteristics nature,
a usually prolonged

of a ten-

Functional

Laryngeal
by Panting*
M.D. , F.C.C.P

Obstruction

carcinoma

Relieved
Arthur F. Pitchenik,

natural course of the disease. Adenoid cystic carcinoma of the lung does not appear to be associated with smoking. The common clinical manifestations are, of course, related to bronchial symptoms such as cough, shortness of breath, wheezing, and hemoptysis. The chest roentgenogram is often normal or shows only subtle abnormalities. Although
the tumor is limited to the control, site of its origin
local

for a relatively
can

long

time

and

although

proper

therapy
cystic

often

be
often

adequate

for local

adenoid

carcinomas

metastasize treatment
has been
13 patients

to distant of choice,
low According

organs. Resection of the tumor is the but the rate of complete resectability
to the Mayo experience,4 only 3 of

the

with a diagnosis of adenoid cystic carcinoma of bronchus were able to undergo a complete resection
of extension Therefore, of the in addition tumor into the therapy, surrounding radiation to surgical

because tissues.

treatment therapy,

often play an important role as an adjuvant as a means of controlling inoperable and residual tumors. Because local recurrence and pulmonary metastases are frequently seen even after curative resection the primary tumor, surgery alone may not be adequate, and adjuvant radiotherapy is recommended in patients with

should as well

of

adenoid

cystic

carcinoma.5

In fact,

one
over

large

series

reported

a mean
tumors

survival
frequently

of8.3 is guarded.

years The

after
or recur

curative

persist

the prognosis
percent

survival

resection.4 As the as long as 30 years, rates reported are 75

years.5

man presented with a two-day history of dyspnea and inspiratory stridor. A chest computed tomographic scan of the neck, direct laryngoscopy, and bronchoseopy excluded organic upper airway obstruction. Laryngospasm occurred during the bronchoscopy. Although flow volume loops revealed severe upper airway obstruction (inspiratory and expiratory), airway resistance measured plethysmographically (during panting) was normal. Because of this observation, panting was recommended for relief of the patients recurrent attacks offunctionallaryngeal obstruction. The panting maneuver immediately and completely relieved all 25 to 30 subsequent attacks. After the patient recovered clinically, a flow volume loop was repeated and was found to be normal. The marked discrepancy between severe flow limitation (as detected by flow volume loops) and normal airway resistance (measured plethysmographically) may be a diagnostic test for functional laryngeal obstruction, and panting may be an effective emergency measure for its relief. Relief by panting may also suggest the diagnosis. A second patient with an almost identical symptom complex is described, in whom the panting maneuver was also dramatically successful in promptly aborting recurrent severe attacks of airway obstruction and stridor. (Chest 1991; 100:1465-67) severe recurrent roentgenogram, aryngeal dysfunction causing acute airway obstruction is probably much more common than appreciated. It is often misdiagnosed and treated as acute asthma or acute organic upper airway obstruction. Some patients have received
ryngeal

A 49-year-old

at five years

and

55 percent

at ten

CONCLUSION

To our knowledge, chial adenoid cystic

bronchial
has spite shown

this is the first report of an endobroncarcinoma that was treated with endowith
recurrences.

brachytherapy
a

a good
As

response.

This
now

patient

unnecessary
A

emergency

endotracheal

intubation

or

typical
local

slow-growing since
such

course
he

of the disease
has survived

in

tracheotomy.57b0

of multiple

more
thorough;

than

seven
he
however,

years
received

the first diagnosis,

have been surgical

the surgical
excellent management
and

were
panting

obstruction immediately
maneuver

patient with paroxysmal functional laris described in whom 25 to 30 attacks and completely relieved by panting. The
was suggested as a mode of treatment

treatments

must

successful

was insufficient to eradicate operative radiation treatment

when the surgical margins are

the disease completely. Postmight be useful, particularly

not ample.

because airway resistance (measured plethysmographically during panting) was normal despite the fact that flow volume loops (measured during forced inspiratory and expiratory capacity maneuvers) revealed severe upper airways obstruc-

lion. The
limitation

marked

discrepancy

between

inspiratory

flow

REFERENCES 1
Cleveland carcinoma RH, Nice CM Jr. Ziskind

scribed J.
Primary adenoid 1977; cystic 122:597lung. Jr. Surg The 1972; Radiology cystic JT. carcinoma Beattie Ann Sanderson 1978; Experience Thorac DR.

and airway in two patients

obstruction,

resistance has with nonorganic

previously been deacute upper airway

it was

(inspiratory)

and on this basis,

suggested

(cylindroma) VB, Surg AD, potential AA, Payne Thomas 1986; Huvos

of the JM. 28:97-100 AG,

trachea.

600
2 Sweeney Contemp 3 Turnbull malignant 14:453-62 4 Conlan cystic 5 Pearson
neoplasms

Adenoid Goodner

ofthe EF

ofbronchial WS, (cylindroma) Woolner

adenoma. LB, Surg JD. carina.

as a diagnostic test for this condition. This is supported by similar pulmonary function findings in our patient. Although there is a physiologic basis for it, a literature review reveals no previous reports that document that panting symptomatically relieves functional laryngeal obstruction and thereby suggests the diagnosis at the same time.
CASE A 49-year-old REPORT

Adenoid of

carcinoma FG,
of

and Cooper and

mucoepidermoid

carcinoma 76:369-77 with Cardiovasc primary

the bronchus.

J Thorac
Todd the TRJ, trachea

Cardiovasc

businessman
attacks that the

presented
of inspiratory attacks felt

with
life

a two-day
and threatening

history
inability and and

of
to were

severe breathe.

recurrent He stated

crowing

Thorac

Surg

1984;

88:511-18

*Fmm

the Pulmonary

Division,

University
Miami.

of Miami

Veterans

Administration Medical Centers, Reprint tvquests: Dr. Pitchenik, VA Medical Center, 1201 NW 16th

Mmonary
Street,

Section (11JF), Miami 33125

Miami

CHEST

I 100

I 5 I NOVEMBER,

1991

1465

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FLOW

FIGURE 1 . Flow volume loop showing expiration). A forced vital capacity residual volume.

typical plateau pattern of upper breath was followed by a forced and by the a attacks.
(ie,

airway obstruction (inspiration inspiratory capacity breath told like to breathe a dog as as rapidly he did sign in ofan and

and from shallowly as possible

sometimes recumbent

brought position. every

on He six

or

made had

worse for the deeper and

by past

coughing ten years for

lie

was

similar

self-limiting voice lie was appeared examination limits except deep

milder and several

attacks had weeks

to

R1tIt

the
attack

body

box

during
obstruc-

approximately
mild had nonproductive no history persn. attacks

months and

plethysmography)
tiOll.

at the earliest and patients occasion. with prevented associated obstruction of a dry to cough throat, to clear one completely daughter The

ofairway

cough episodes Results were and

oVer

From then on, all subsequent

immediately by the on both not

prior to the present

anxious between

ofstridor. of physical normal neck During expiratory respectively; revealed (Fig

a lifetime

nonsmoker,

were observed in

attacks (approximately aborted by panting. on patient his several however, his and since throat. He multiple stated attacks weeks, the hoarseness, was a methacholine occasions that

25 to 30) This was and by and (1#{128}, of still the for

ofallergy

or asthma, within the a computed limits. forced

to he a chronically performed for mild of the stridor A chest neck forced and percent breathing value) ol)struction other The paramratio ratio rate in 0.5 resistance cm l1201[is flow was rate of of in of vital and inspiration.

the author
maneuver

the panting

and aberted
symptoms After subsided;

of dyspnea the attacks patient and referred

heard
were

on auseultation within normal (FVC), were and flow volume and of upper (FEF5O measured per minute
was

during

that it was
lightheadedness upper complained frequent speech test airway

of hyperventilation

roentgenogram

tomographic
volume the

(CT) scan

or paresthesias).

a symptomatic ofpredicted),

period, in 1 s (FEy1), 2. 15 L(52 maximum normal airway time,

vital capacity
FEV1IFVC ofpredicted),

intermittent

3.74

L (71 percent

need therapy,

57 percent, loopS

polysomnography, for concomitant through time, with these repeated

challenge

capacity
multiple (inspiratory eters

was 79 lJmin
expiratory) airway

(48 percent

of predicted
severe 1). During were flow percent) alsi rates was peak 10 forced was inl/lJmin expired upper this

(to evaluate At this

hyperreactive
spirometry and

airway
flow

disease)
subsequently volume

but
loops

did not follow subsided. were normal.

his symptoms

obstruction

positive.12 at 50 expiratory (17.1

forced
capacity FEV liters

expiratory
in

to inspiratory percentlFiF50 milliliters FEV 1 .5 (FEVI/PEFR) (2.0). 1 .2

percent flow volume airway

1 (1 .4), the

DISCUSSION

to the was to the

ml/Llmin) s

The
laryngeal

patient

described
He

had

typical

findings
with

of functional
attacks

and the ratio of the

(FEy/FEy03)

obstruction.

presented

recurrent

Nevertheless, normal lI2OfUs) cm

measured (predicted routinely Direct

by used

plethysmography value, during is 1 to 2 Ifs).

at 0.9 (panting period

normal
laryngoscopy

an asymptomatic

normal.

bronchoscopy performed several days later was difficult because the patients hypopharynx and glottis repeatedly closed when the hronchoscpe neared it. Fiheroptic bronchoscopy eventually revealed normal upper airways; however, this procedure had
to be the vocal forceful rapidly bronchoscpe On terminated and was withdrawal were seen to breathe. of functional with every loops upper
sugjested

Fiberoptic

of severe dyspnea with inspiratory stridor. Chest roentgenogram, CT scan of the neck,direct laryngoscopy, and bronchoscopy ruled out upper airway compression, stenosis, obstructing tumors, and vocal cord paralysis. Laryngospasm, however, occurred during the bronchoseopy. Although flow volume loops revealed the typical plateau pattern of severe inspiratory and expiratory upper airway obstruction (Fig 1),
airway
panting)

resistance

measured normal. It
was

plethysmographically

(during

because passed of the

the through

patient his

developed to 50 percent vocal from during was and stridor, cords the

marked when into his the

laryngospasm trachea.

oxyhemoglobin

desaturation l)mnchosc()pe (adducted)

trachea,

cords

to be opposed laryngeal (5 mg three of time severe the were

the patients made and he

effirts

A diagnosis was treated

obstruction
times next essentially At this time, as a possible few daily) days. the laryngeal

diazepam

reassurance. nevertheless, flow and still these maneti-

The
volume showed ver

recurrent

attacks
at this
to

continued

2 to 4 h for airway obstruction.

Repeated panting to abort

that prompted the recommendation for the emergency relief of the patients laryngeal obstruction. It has been suggested that functional laryngeal obstruction is a conversion disorder focused on the larynx.23 However, the reasons why certain patients are predisposed to these attacks and the exact pathophysiologic basis for the laryngeal dysfunction are unknown. It is known that glottic opening decreases during exhalation until near complete closure at
was
residual volume.1314 Therefore, a person predisposed to

the latter observation that panting be tried

unchanged way

was

the patient

functional laryngeal obstruction may be most vulnerable after he forcibly exhales to low lung volumes. During panting
Laryngeal Obstruction
ReteVed

1466

by Panting

(Aithur

E. Pitchenik)

Downloaded From: http://journal.publications.chestnet.org/ on 04/30/2013

at functional residual capacity, there is significantly greater electromyographic activity in the posterior cricoarytenoid muscle (the principal abductor of the vocal cords) and there is a sustained increase in the glottic width compared to peak
values Further,

4 Cormier airway 5 Patterson organic 6 Rogers 7 Kellman

important

YF, Camus obstruction: Dis 1980; R, Schatz laryngeal JH, Stell ofstridor. RM, cause NH, syndrome. Leopold PM.

F, Desmeules description 121:147-49 M

,

MJ. Non-organic and a diagnostic

acute approach. stridor: 4:307-10 vocal motion:

tipper
Am noncords an

Rev Respir

Horton

M . Munchausens Clin Allergy movement 1974; 92:157-58 vocal 1982; upper head stridor RC, Neck cord of the

ofthese
panting

measurements

made

during

tidal
in
in

breathing. glottic

obstruction. Paradoxical

prevents
volumes.16
patients4

respiratory
Most and as

swings

width
in

at various lung two previous

during have panting). attacks
normal

importantly
confirmed

(as reported
our

as a cause

J Laryngol
DA. SR.
ofstridor.

Otol 1978;
Paradoxical

patient),
patients

Laryngoscope
Functional Otolaryngol inspiratory

92:58-60

of functional

laryngeal
therefore, that

obstruction,

8 Appelblatt a new

Baker Arch

airway
Stirg

obstruction:
1981; 107:

airway

resistance

(a measurement
the

made
panting

during
maneu-

It

is surprising,

305-06
9 RogersJH. Otol 10 Myears
versus

ver has not previously that relieves these

suggests Previously their cause. described

been documented as a simple measure frightening attacks and thereby also

treatment for

Functional 94:669-70 Martin DW,

in children. MK.

J Laryngol
Functional and

1980;

RJ, Eckert

Sweeney

functional

obstruction includes having the patient inhale oxygen mixture (70 percent helium and 30 percent oxygen) as a temporizing measure for acute attacks. This is followed by psychiatric support and/or speech therapy directed at a conversion disorder. The speech therapist trains the patient in relaxed diaphragmatic breathing that diverts
#{176}

laryngeal a helium-

organic Vocal cod paralysis: rapid diagnosis nulation. Laryngoscope 1985; 95:1235-37
Downing ET, Braman SS, Fox MJ, to JG. Corrao diagnosis. of Chest WM. physiological 1111, Liss HP, approach Weg

decan-

11

Factitious 1982; airway 68:796-

asthma: 248:2878-81 12 Rotman obstniction

JAMA upper 1975;

Diagnosis

by pulmonary

ftiiiction

testing.

99
13 14 Staiiescu opening Baeir among resistance 15 Brancatisano
posterior

conscious

attention

away

from

a massive

breathing

effort

at

the laryngeal level. Such therapy is effective, but it involves a more gradual and preventive biofeedback program . It is much less applicable for the energency treatment of an untrained patient during an acute attack. In contrast, panting
is easier for the physician to describe and much easier for

DC, Pattijn J, Clement J, Vande Woestijne and airway resistance. J Appl Physiol 1972; H, Wanner in humans. TP,
cncoarytenoid

KP Glottis 32:460-66 Relationship

A,

Zarzecki

S.

Sackner

MA. and

glottis

opening,

respiratory

flow, 1977; LA. vocal

upper

airway
activity of

J Appi Physiol
Dodd
DS,
muscle

43:603-11
Respiratory cords in humans. movements

Engel and

the patient to perform in such a situation. The relief afforded by panting was immediate and complete in our patient with each recurrent attack, and was effective until his attacks
subsided over the next attacks few weeks.

AppI Physiol
16 Braiicatisano of the vocal

1984; cords.

57:1143-49 PW,

T, Collett

Engel

LA. Respiratory
1983; 54:1269-76

Appi

Physiol

We
because

were

recently

consulted
of sudden

by

a 31-year-old
and severe

woman

of three

inspiratory

stridor period.
threatening. performed
normal

that occurred on separate days Each attack lasted approximately

over a two-week 5 mm and felt life

Results of chest and laryngologic examination during an asymptomatic period were within limits. A chest roentgenogram was normal, including

Resolution of Ventricular Tachycardia and Endocardial Tuberculoma following Antituberculosis Therapy*

Thdraig Stephen
C.

a clear tracheal with a symptom

she over was the

Thereafter,

column. Because this patient presented complex almost identical to our first patient, instructed to pant at the first sign of an attack. she had six additional attacks on separate days
air

ONeill,

M.D.; M.D.;

Roxann and

Rokey,

M.D.,

F.C.C.P; M.D.

Greenberg,

Antonio

Ibczfico,

next

month.

She

stated

that

after

she

learned

to

perform the panting maneuver properly (ie, after the second of these attacks), all four subsequent attacks were promptly and completely aborted by panting. She is currently asymptomatic six weeks after her last aborted attack of functional upper airway obstruction.
ACKNOWLEDGMENT: The author thanks Dr. Elio Donna, and Martha Block, and Theresia Munis for technical assistance and Dr. Adam Wanner for review of this manuscript. REFERENCES 1 Rodenstein
wheezing:

woman presented with sustained ventricular and was found to have an endocardial mass by echocardiography and by magnetic resonance imaging. The diagnosis of cardiac endocarclial tuberculoma was made, and she was treated with antituberculous therapy and an antiarrhythmic drug for one year After a year, the mass was no longer present, and with all antiarrhythmic medications stopped, ventricular tachycardia could no longer be induced by electrophysiologic study. There has been no clinical reCurrenCe. (Chest 1991; 100:1467-69)
tachycardia

A 23-year-old

W
DC. Respir Emotional Dis 1983; Paradoxic Med FB, laryngeal 127:354vocal 1987; *Fmm Rev

hile disease
1980s. the

tuberculosis among during

remains urban

a major

public

health

prob-

DO,
a new

Francis
syndrome.

C,

Stanescu
Am

1cm in underdeveloped
this declined

countries,
residents
and

the

incidence
United States

of
again

in the only

56
2 Martin cord 8:332-37 3 Christopher KL, Wood II RP, RJ, Blager motion FB, Gay ML, Wood II RE Semin CR, in presumed asthmatics. Respir

in the

the 1960s Extrapulmonary

1970s

to increase

manifestations
Sections

of tuberculosis
of Cardiology Ben Taub SM 1249, and General Houston

Department

of Medicine,

Eckert

RA, Souhrada
N Engl

JF. Vocal-cord 1983; 308:1566-70

dysfunction

Blager presenting

Raney

as asthma.

Med

Infectious Diseases, Baylor College ofMedicine, hospital, The Methodist Hospital, Houston. Reprint requests: Dr Pacifico, 6550 Fannin, 77030

CHEST

I 100

I 5 I NOVEMBER,

1991

1467

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