MIL13155 1208..1212

Objectives: Several etiologies for vocal cord dysfunction (VCD), a syndrome of dyspnea, noisy breathing, and inspiratory vocal cord closure are suggested; there is no consensus on the predisposition to its development. One previously identified psychiatric etiology is combat stress. Methods: A retrospective review of military personnel evaluated at Landstuhl Regional Medical Center with a new VCD diagnosis post-deployment was conducted. Medical records were reviewed for existing pulmonary, sinus, esophageal, or psychiatric disorders and determined their VCD evaluation. Results: Forty-eight patients were identified with VCD symptoms after combat deployment. For military personnel with VCD, symptoms were associated with several etiologies. Fifty-two percent reported symptoms were related to high stress/anxiety, whereas 39% reported symptoms during exercise; 16% had onset with acute respiratory illness and 7% were trauma related. The combination of a truncated inspiratory flow volume loop and negative methacholine challenge had a 72% positive predictive value. Conclusions: Common etiologies with VCD onset during deployment are anxiety/stress, exercise, or combination of factors. Spirometry with abnormal flow volume loop plus negative methacholine challenge testing offers a reasonable predictive value for diagnosing VCD. For deployed military with these findings, laryngoscopy for upper airway disorders should be conducted. INTRODUCTION Vocal cord dysfunction (VCD) is a well-described syndrome defined by dyspnea, noisy breathing, and the presence of paradoxical vocal cord closure, primarily during inspiration, in the majority of patients. Although several etiologies for VCD have been suggested based on typical presenting symptoms, there has been no established consensus on predisposing factors for development of symptomatic VCD. In the majority of cases, it is generally because of local glottic irritants (gastroesophageal reflux disease [GERD], postnasal drip, or various chemical exposures), exercise, or a wide assortment of psychiatric etiologies. It is frequently misdiagnosed as asthma in the clinical setting and is a commonly diagnosed condition in military personnel. A study of exertional dyspnea in military personnel demonstrated that 12% of patients evaluated had evidence of VCD most of which was exerciserelated. Emotional stress is frequently mentioned as a common precipitant of psychogenic VCD and may play an additional role in the mechanism for exercise-induced symptoms. Several studies highlight the importance of emotional stressors as a primary trigger in psychogenic VCD. Gavin et al conducted a case–control study of pediatric VCD and asthma patients and found VCD patients tended to have significantly higher levels of anxiety and more anxiety-related diagnoses. Other stressors such as competitive sports in young female athletes have been noted frequently as a trigger in exercise-induced VCD. In a military population, the majority of VCD patients have been young females between the ages of 20 and 40 often with a concomitant psychiatric diagnosis. The association between VCD and combat deployment has been previously described only as case reports. During the First Gulf War in 1991, two cases of deployed females with new onset respiratory symptoms that persisted post-deployment were described. In both patients, spirometry was normal between episodes and bronchoprovocation testing was negative as part of the evaluation for VCD. The objective of the study was to review VCD cases diagnosed at the level III evacuation center for U.S. military personnel from Operations Iraqi Freedom/Enduring Freedom (OIF/OEF) to provide an analysis of the causative factors and results of pulmonary evaluation of VCD for these deployed military personnel. METHODS This study was conducted as a retrospective review of Department of Defense (DoD) medical records after obtaining written approval from the Brooke Army Medical Center Institutional Review Board. An investigator assigned to Landstuhl Regional Medical Center (LRMC) in southwest Germany during the review period (January 2005 to June 2009) identified from inpatient and outpatient medical records those patients diagnosed with VCD at the time of laryngoscopy. LRMC serves as the primary evacuation hospital for all U.S. military personnel for OIF/OEF who require a higher level of care not available or adequate in theater. After identifying these patients, the DoD electronic medical record was reviewed to identify essential clinical data concerning the diagnostic evaluation of VCD. *Pulmonary/Critical Care Service, Department of Medicine, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam