Hysterical stridor: a report of two cases. (Original Article).
Stridor Stridor Definition
Stridor is a term used to describe noisy breathing in general, and to refer specifically to a high-pitched crowing sound associated with croup, respiratory infection, and airway obstruction. as an initial symptom of a conversion reaction (hysteria) is rare. We report cases of hysterical stridor in two older women, unrelated and unacquainted, from the same rural community in Oman. Once the diagnosis was made, both patients were successfully treated with a single dose of an anxiolytic anxiolytic /anx·io·lyt·ic/ (ang?ze-o-lit´ik)
2. an antianxiety agent.
A drug that relieves anxiety. . We also review the literature on hysterical stridor and discuss the diagnostic dilemmas and therapeutic options.
Somatoform disorders are characterized by physical symptoms for which no adequate medical explanation can be found. Symptoms and complaints are serious enough to cause significant emotional distress or impair a patient's ability to function in social and occupational roles. These disorders have been grouped under the term hysteria (Gr. hystera womb), as they were once incorrectly thought to affect only women.
One subtype of somatoform disorder is called conversion disorders. They are characterized by one or more unexplained neurologic complaints, such as paralysis, blindness, and mutism Mutism Definition
Mutism is a rare childhood condition characterized by a consistent failure to speak in situations where talking is expected. The child has the ability to converse normally, and does so, for example, in the home, but consistently fails . By definition, conscious malingering Malingering Definition
In the context of medicine, malingering is the act of intentionally feigning or exaggerating physical or psychological symptoms for personal gain. and factitious disorders are excluded. (1) In this article, we describe two cases of conversion disorder in older women that manifested as stridor. We also discuss the diagnostic dilemma posed by this essentially benign condition, and we review the treatment options.
Patient 1. A 62-year-old woman from a rural community was escorted to the Ibri Regional Referral Hospital in Oman by her primary care physician on June 12, 2002, for evaluation of a 1-day history of stridor. In view of the severity of her stridor and the presence of signs of respiratory distress (i.e., tachypnea tachypnea /tach·yp·nea/ (tak?ip-ne´ah) very rapid respiration.
Rapid breathing. Also called polypnea. and flaring of the alae nasi), she was transferred to the emergency department for intensive monitoring.
An awake fiberoptic laryngoscopy revealed that the patient had a normal larynx but paradoxical vocal fold movement during inspiration. Findings on radiologic investigations and blood gas parameters were within normal limits. Nevertheless, empiric treatment with an injectable steroid and nebulized epinephrine under monitoring was administered.
When these medications failed to relieve the stridor, preparations were made for surgical intervention. However, at that point, the patient's son remarked that his mother had experienced a similar episode of stridor 2 weeks earlier when she had gone to the hospital to visit her sister, who had been injured in an automobile accident. That episode of stridor had subsided spontaneously. The son then reported that the current episode had been precipitated when his mother had been informed that the same sister had been involved in another accident as she returned home after discharge. At that point, we considered a diagnosis of hysterical stridor.
As a trial, we gave the patient a 5-mg dose of the anxiolytic midazolam under careful monitoring. This resulted in almost instantaneous relief of her stridor. The patient was discharged after an overnight stay and a consultation with a psychiatrist. No comorbid psychiatric condition was identified.
Patient 2. A 53-year-old woman from the same rural community came to the ENT ENT ears, nose, and throat (otorhinolaryngology).
ear, nose, and throat
ear, nose and throat.
ENT Ears, nose & throat; formally, otorhinolaryngology outpatient department on June 19, 2002, with a complaint of aphonia aphonia /apho·nia/ (a-fo´ne-ah) loss of voice; inability to produce vocal sounds.
n. of 2 days' duration. Our attempt to examine her vocal folds by indirect laryngoscopy provoked an attack of severe and unrelenting stridor.
The patient was transferred to the emergency department for monitoring. An awake fiberoptic laryngoscopic examination revealed an essentially normal larynx and mildly paradoxical vocal fold movement. Having seen a case of hysterical stridor just 1 week earlier, our index of suspicion index of suspicion Medtalk A phrase broadly used to indicate how seriously a particular disease is being entertained as a diagnosis; as an example, there is a high IOS that rapid and unexplained weight loss in an elderly Pt is due to pancreas CA, and a low IOS that was high. Again, 5 mg of midazolam was administered intravenously under careful monitoring. The patient's symptoms resolved immediately.
The patient was kept overnight, and a psychiatric evaluation the next day revealed that she had a major depressive illness, consequent to the death of her husband. She was discharged on an antidepressant antidepressant, any of a wide range of drugs used to treat psychic depression. They are given to elevate mood, counter suicidal thoughts, and increase the effectiveness of psychotherapy. and is being followed up by her primary care physician because a recurrence of her symptoms is deemed likely.
Stridor is a sign of upper airway obstruction, and it merits immediate attention on the part of the emergency resuscitation team. While attempts should be made to diagnose the cause of stridor, concurrent management should be aggressive, given the life-threatening nature of this condition. Medical measures (e.g., a corticosteroid and nebulization nebulization /neb·u·li·za·tion/ (neb?u-li-za´shun)
1. conversion into an aerosol or spray.
2. treatment by an aerosol. with racemic racemic /ra·ce·mic/ (ra-se´mik) optically inactive, being composed of equal amounts of dextrorotatory and levorotatory isomers.
adj. Abbr. epinephrine) and/or surgical measures (e.g., intubation intubation /in·tu·ba·tion/ (in?too-ba´shun) the insertion of a tube into a body canal or hollow organ, as into the trachea.
endotracheal intubation , cricothyrotomy, and tracheostomy) should be part of the emergency department treatment protocol. (2)
Anecdotal reports and reviews in the pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children.
Of or relating to pediatrics. , (3-8) pub monary, (9-15) psychiatric, (16,17) and otolarynologic (18-26)literature describe a psychosomatic illness that manifests as spontaneously resolving stridor. This is a conversion type of somatoform disorder, for which a variety of synonyms has been used in the literature (table). (2) In this disorder, awake fiberoptic examination will reveal a normal larynx and paradoxical vocal fold movement--that is, adduction adduction /ad·duc·tion/ (ah-duk´shun) the act of adducting; the state of being adducted.
adduction ( during inspiration or excessive adduction of the vocal folds during expiration. (27) Consequently, the patient might experience inspiratory stridor, expiratory stridor, or an overlapping stridor with features of both. (2) Flow-volume loops will reveal a pattern of variable extrathoracic obstruction with diminished peak inspiratory in·spi·ra·to·ry
Of, relating to, or used for the drawing in of air.
pertaining to or used in the inspiration of air into the lungs. flow. (27)
Although the etiology is most often functional, organic causes should be ruled out. A classification scheme proposed by Maschka et al attempts to incorporate all causes, both organic and functional: (1) brainstem compression, (2) cortical or upper motor neuron upper motor neuron
A motor neuron whose cell body is located in the motor area of the cerebral cortex and whose processes connect with motor nuclei in the brainstem or the anterior horn of the spinal cord. injury, (3) nuclear or lower motor neuron lower motor neuron
A motor neuron whose cell body is located in the brainstem or the spinal cord and whose axon innervates skeletal muscle fibers. Also called final motor neuron. injury, (4) vocal fold movement disorders, (5) gastroesophageal reflux, (6) factitious factitious /fac·ti·tious/ (fak-tish´-us) artificially induced; not natural.
Produced artificially rather than by a natural process. or malingering disorders, and (7) somatization/conversion disorder. (28) It has been shown that sedation in the emergency department and general anesthesia in the operating room cause the vocal folds to relax in patients with functional stridor, but it has no such effect in patients with organic vocal fold paralysis; therefore, sedation or anesthesia can be used to differentiate the two entities. (2)
Clinically, the diagnosis of conversion disorder is one of exclusion. (29) Misdiagnoses and delays in diagnosis have led to unnecessary tracheostomies and intubations in many cases. (17) A high index of suspicion for conversion disorder manifesting as stridor should reduce unnecessary interventions. (27)
The two patients described in this article came to us within 1 week of each other. Although they lived in the same rural community, they were unrelated and unacquainted with each other. Awake fiberoptic intubation in both cases revealed paradoxical vocal fold movements. The severity of symptoms in the first patient resulted in the administration of an injectable steroid, and she was on the verge On the Verge (or The Geography of Yearning) is a play written by Eric Overmyer. It makes extensive use of esoteric language and pop culture references from the late nineteenth century to 1955. of undergoing a tracheostomy when her son reported her previous episode of stridor. With regard to the second patient, a higher index of suspicion enabled us to avoid unnecessary medication. Both patients responded well to anxiolytic therapy. Only one of them (patient 2) had a comorbid condition (depression) and lacked an identifiable precipitating factor. Hence, she is undergoing close follow-up by her primary care physician.
The fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders Diagnostic and Statistical Manual of Mental Disorders /Di·ag·nos·tic and Sta·tis·ti·cal Man·u·al of Men·tal Dis·or·ders/ (DSM) a categorical system of classification of mental disorders, published by the American Psychiatric Association, that delineates objective (DSM-IV DSM-IV
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). This reference book, published by the American Psychiatric Association, is the diagnostic standard for most mental health professionals in the United States. ) lists five specific somatoform disorders: (1) somatization disorders, which are characterized by many physical complaints that affect many organ systems, (2) hypochondrias, which are characterized by a belief by the patient that some specific disease exists, (3) body dysmorphic disorder Body Dysmorphic Disorder Definition
Body dysmorphic disorder (BDD) is defined by DSM-IV-TR as a condition marked by excessive pre-occupation with an imaginary or minor defect in a facial feature or localized part of the body. , which is characterized by a false or exaggerated belief that some body part is defective, (4) pain disorder, which is characterized by pain that is solely related to or significantly exaggerated by psychological factors, and (5) conversion disorder, which is characterized by one or more neurologic complaints (e.g., paralysis, blindness, and paresthesias Paresthesias
A prickly, tingling sensation.
Mentioned in: Autoimmune Disorders ) that cannot be explained by any known neurologic disorder. (30) In addition, the diagnosis of a conversion disorder requires that psychological factors are associated with the initiation or exacerbation of symptoms. These disorders occur more often in wo men than in men and more often in adolescents and young adults than in older adults. Conversion disorders are also frequently associated with comorbid conditions such as depression, anxiety, or schizophrenia. (1) Initial airway symptoms include aphonia, dysphonia dysphonia /dys·pho·nia/ (-fo´ne-ah) a voice impairment or speech disorder.dysphon´ic
Difficulty in speaking, usually evidenced by hoarseness. , dyspnea with or without stridor, apnea, and apparent unconsciousness. (27) The acute manifestations of conversion disorders usually resolve spontaneously within a few days, although some cases take weeks to resolve. Resolution is facilitated by insight-oriented supportive or behavioral therapy in the setting of an authoritative therapeutic relationship. Symptoms can recur during periods of stress. A good prognosis is associated with the presence of an identifiable stressor, a sudden onset of symptoms, a good premorbid premorbid /pre·mor·bid/ (-mor´bid) occurring before development of disease.
Preceding the occurrence of disease. adjustment, and a lack of comorbid psychiatric or medical disorders. (1)
Table Synonyms for hysterical stridor * Adult spasmodic croup Atypical asthma Benign vocal fold dysfunction Emotional laryngeal wheezing Emotional laryngospasm Episodic laryngeal dyskinesia Expiratory laryngeal stridor Factitious asthma Functional abduction paresis Functional inspiratory stridor Functional upper airway obstruction Functional vocal fold paralysis Laryngismus fugax Munchausen's strider Nonorganic upper airway obstruction Paradoxical vocal fold motion Pseudoasthma Psychogenic stridor Psychogenic upper airway obstruction Psychosomatic stridor Respiratory glottic spasm Transient laryngeal spasm * Based on information published by Snyder and Weiss. (2)
The authors thank the director of General Health Services, the superintendent of Planning and Training for the Al Dhahira Region, and the medical superintendent of the Ibri Regional Referral Hospital for permitting and facilitating this report.
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adj upper airway obstruction presenting as refractory wheezing Wheezing Definition
Wheezing is a high-pitched whistling sound associated with labored breathing.
Wheezing occurs when a child or adult tries to breathe deeply through air passages that are narrowed or filled with mucus as a . J Pediatr 1986;109:1067-70.
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la·ryn·geal or la·ryn·gal
Of, relating to, affecting, or near the larynx. dyskinesia dyskinesia /dys·ki·ne·sia/ (-ki-ne´zhah) distortion or impairment of voluntary movement, as in tic or spasm.dyskinet´ic
biliary dyskinesia . Clinical and psychiatric characterization. Chest 1986;90:716-21.
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(22.) Myears DW, Martin RJ, Eckert RC, Sweeney MK. Functional versus organic vocal cord paralysis Vocal Cord Paralysis Definition
Vocal cord paralysis is the inability to move the vocal cords and the resulting loss of vocal cord function.
Description : Rapid diagnosis and decannulation. Laryngoscope 1985;95:1235-7.
(23.) Pender DJ. Laryngismus fugax: Transient laryngeal spasm secondary to brain stem isehemia. Laryngoscope 1984;94(11 Pt 1):1497-500.
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(28.) Maschka DA, Bauman NM, McCray PB Jr., et al. A classification scheme for paradoxical vocal cord motion. Laryngoscope 1997;107(11 Pt 1):1429-35.
(29.) Lund DS, Garmel GM, Kaplan GS, Tom PA. Hysterical stridor: A diagnosis of exclusion diagnosis of exclusion Decision-making A disease or clinical nosology that is extremely rare, and often unresponsive to therapy, the diagnosis of which is seriously considered only when all other possible–potentially treatable conditions–eg 'growing . Am J Emerg Med 1993;11:400-2.
(30.) Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, D.C.: American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential world-wide. Its some 148,000 members are mainly American but some are international. , 1994.
From the Department of Otolaryngology (Dr. Nayar and Dr. Zanak) and the Department of Psychiatry (Dr. Ahmed), Ibri Regional Referral Hospital, Al Dhahira Region, Sultanate of Oman.
Reprint requests: Dr. Ravi C. Nayar, Head, Department of Otolaryngology, Ibri Regional Referral Hospital, P.O. Box 46, Postal Code 516, Al Dhahira Region, Sultanate of Oman. Phone: 968-650-855, ext. 222; fax: 968-489-725; e-mail: email@example.com