WHAT is ILO?!

April 1, 2021

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WHAT IS ILO?

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As noted during my fun episode with @ootvoicebox podcast, AIR IS LIFE. For real though, IT IS…& it is the FOUNDATION for your voice. So what happens when your lungs are healthy but you can’t breathe right? The larynx/voicebox plays a HUGE role in healthy breathing patterns, as it is a highly sophisticated “entrance valve to the lungs & also the narrowest passage of the airway tree” (Roksund, O.D. et al., 2017). READ ON for a ton of great info on ILO (see below)!

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“The joint ‘Task Force on Inducible Laryngeal Obstructions’ established by the European Respiratory Society (ERS), European Laryngology Society (ELS), and the American College of Chest Physicians (ACCP) was the first attempt to institute an authoritative nomenclature in this field of respiratory medicine. The statement published in 2015 proposed an umbrella term for laryngeal obstructions: inducible laryngeal obstructions (ILO) causing breathing problems” (Roksund as above). Inducible Laryngeal Obstruction (ILO) describes a narrowing or inappropriate obstruction of the true vocal folds (VF) &/or the supraglottic structures (above the VFs) in response to a trigger or stimulus. When this phenomenon occurs during exercise, it is termed exercise-induced laryngeal obstruction (EILO). ILO replaces older terms like vocal cord dysfunction (VCD) & paradoxical vocal fold motion (PVFM); ILO is more descriptive as it includes pathologies affecting the supraglottic structures & not only the VFs. In the past (as early as 1869), ILO was also described as psychogenic, Munchausen stridor, functional laryngeal obstruction, emotional laryngeal wheezing, irritable larynx syndrome, & factitious asthma (among others).

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Multiple triggers are reportedly associated with ILO including odors, reflux, exercise, irritants, & anxiety—& are often classified into three groups: psychogenic, irritant induced, & exertional. Symptoms may include dyspnea, stridor wheezing, dysphonia, throat tightness/discomfort, chest tightness, noisy breathing, cough, &/or anxiety. It is important for your medical provider(s) to rule out asthma, reflux, &/or upper airway obstructions if these symptoms persist.  Of note, the diagnosis of ILO is often assumed to be asthma or anxiety related until an extensive work-up is completed after typical treatments do not prove beneficial. Interestingly, ILO is also a frequent co-morbidity of asthma (up to 30% of patients) which requires additional management (Severe Asthma Toolkit).  Airway obstruction inside the thoracic cage produces expiratory symptoms (exercise induced asthma) with symptoms peaking 3-15 minutes after stopping exercise, while obstruction outside the thoracic cage produces inspiratory symptoms (E-ILO) with symptoms peaking during exercise or just after stopping (Roksund as above).

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In healthy people, the VFs are ABDUCTED (open) during inspiration (inhale), & this is followed by a slight ADDUCTION (closing) during expiration (exhale), allowing air movement to & from the lungs. When ILO is present, there is a brief adduction of the VFs during inspiration—sometimes noted with audible inspiratory sounds, exacerbated during exercise, &/or caused by a supraglottic obstruction. During laryngoscopy (ideally performed while the patient is symptomatic), it is often captured that the VFs adduct during inspiration with a collapse of the supraglottic structures towards the endolarynx. Findings with laryngoscopy include VF narrowing, supraglottic narrowing, obstruction, &/or collapse of the supraglottic structures. Laryngoscopy-related findings are very important for correct treatment and further management, as visualizing what is taking place in the upper airways often allows the patient’s symptoms to be properly understood and acknowledged. “Video recorded verification of laryngeal obstruction may be of value not only as a diagnostic tool, but also as a therapeutic measure (biofeedback). Simply observing their own malfunctioning larynx directly on a film is of help in a majority of patients with mild or moderate disease. The recordings are also highly educational in the process of providing direct advice with real-time visual feedback to the patient as regards what is a rational breathing pattern during exercise (or in general), and how changes may influence the patency of the larynx” (Roksund as above).  In a 2-5 year follow-up study, Maat et al. (2009) found that most patients felt being assigned a diagnosis and to actually see what took place in their larynx was important for a perception of safety in relation to exercise and to maintain a reasonable level of physical activity.

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**YOU CAN HEAR HOW EXCITED I GET IN THIS VIDEO BECAUSE THE PATIENT STARTED WITH ILO INCLUDING VERY MINIMAL OPENING OF HER AIRWAY WHEN SHE WAS TRYING TO INHALE, AND WE RE-ROUTED THE DYSFUNCTION WITH A FEW DIFFERENT TECHNIQUES IN A PROGRESSIVE FASHION AND ENDED UP WITH ADEQUATE OPENING & CLOSING OF HER VFS, AN IMPROVED VOICE (SHE WAS APHONIC BEFORE FOR MONTHS), AND IMPROVED CONFIDENCE/EASE RELATED TO BREATHING IN GENERAL.** This is my goal with all ILO patients (as capturing the ILO and re-routing it to a more optimal pattern on endoscopy provides such monumental feedback for the patient), but it’s not always possible (hence why I was so grateful this happened and felt compelled to share)!

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The majority of patients with ILO respond well to voice/airway-related therapy, & other cases (if a supraglottic pathology is found) respond to supraglottoplasty. Symptoms can be reduced through adequate hydration/improving the laryngeal environment, reducing exposure to irritants, reducing phonotraumatic behaviors, stress management, breathing recovery exercises/breathing techniques, & general relaxation techniques. The importance of consistency of practice cannot be said enough, especially within the beginning stages of ILO/airway therapy. I always recommend patients set cell phone alarms to help them remember to practice their breathing cycles at least 10 times, every hour on the hour of every day (AND to institute the techniques at the first sign of an “episode” or even when the patient thinks that an episode MIGHT occur). Identification of triggers is also a very crucial step in the therapeutic process. This therapy is often quick and extremely effective—it is all about awareness and improving the patient’s control of their own airway and breathing patterns.

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**I was REALLY excited to actually be able to capture this ILO episode on video during a stroboscopy and utilize biofeedback and therapy techniques to relax the mechanism and re-route the breathing pattern. Therefore, during and after diagnostics, the therapeutic process was already initiated and a transition of ownership/control of breathing was handed back to the patient before they walked out the door. Always a goal and such a great learning experience for the patient.**

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BREATHE on my friends. And reach out if you have any airway-related symptoms or would like to improve control of your breathing. 

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