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Dr. Bryson is joined by his Voice Center colleague Claudio Milstein, PhD to discuss exercise-induced laryngeal obstruction, a recently-identified condition affecting younger athletes. Dr. Milstein also shares some novel techniques and therapies used in our Voice Center.

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Breathing Easy: Understanding Exercise-Induced Laryngeal Obstruction

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center in our Head and Neck Institute. You can follow me on Twitter @PaulCBryson and you can get the latest updates from our institute by following @CleClinicHNI. That's @CleClinicHNI. Today I'm looking forward to talking with Dr. Claudio Milstein, speech scientist and my colleague now for many years in Cleveland Clinic's Voice Center. Dr. Milstein, welcome to Head and Neck Innovations.

Claudio Milstein: Thank you, Paul it's great to be here and thank you for inviting me to participate in this exciting podcast.

Paul Bryson: Let's start by having you share some background on yourself for our listeners, where you're from, where you trained, and how you've come to Cleveland Clinic.

Claudio Milstein: All right. Well you probably can hear my accent, which is not from Alabama, but I was born in Buenos Aires Argentina. I started med school in Buenos Aires and I then shifted gears. I went in to study Speech Pathology because I was really interested in voice and I thought I was going to learn everything there was to learn about voice in Speech Pathology. Well, I was kind of wrong because when I finished I didn't know much more than I knew before I started. So I was teaching at the time at the med school in Buenos Aires and I was teaching at the National School of Drama Voice for Actors and Singers and I had so many more questions about the inner works of the voice. So I decided to do research and learned about the possibility of doing a focused PhD program in the United States. So I moved to Tucson, Arizona at the University of Arizona to get my PhD and it was a really fascinating road.

From there I ended up doing a post doc at the Massachusetts Eye and Ear Infirmary in Harvard Med School in Boston. And I was also a research assistant at MIT and that was a phenomenal learning experience, opened a lot of doors. From there then I started getting job offers, kind of stayed here. My initial thought was going back to Argentina but they were really interesting opportunities here so I stayed. One day out of the blue, I got a call from the former director of the Voice Center, our colleague Doug Hicks who I didn't know at the time. And he told me that there was an opening and they knew about me from talks that I'd given at different conferences and they wanted to see if I wanted to interview. I came to interview, they offered me a job and I really learned about the great institution that the Cleveland Clinic is, and decided that that was where I wanted to be and that was a long, long time ago.

I've been here many, many years and the Cleveland Clinic has been really wonderful. They really supported me on my path and I developed my skills and continued to do research and doing a lot of clinical work here. And then we were very fortunate that you joined our team also a number of years ago and we've been working together since. It's good to be here talking about our past and present history.

Paul Bryson: No, I love that. Thank you so much for sharing that. I don't think I knew all of those... I didn't quite know the whole journey, sort of your educational experience and I didn't know all the steps along the way and so it's fun to hear you describe it. I have to say we've shared a lot of patient care together over the years and it's fun to hear you talk about your curiosity with the voice and treating voice disorders. There's so much to it. We're going to focus today on this concept of exercise induced laryngeal obstruction. But before we dive into that, I like to talk about just the diversity of things that we see together from some of the movement disorders, the neuro laryngology to some of the atypical laryngeo configurations and things that we've seen over the years.

And so to hear you say you're interested in voice, it almost doesn't do the organ as much justice as I think we see together because there's so much that we see that it does and sometimes doesn't do. And as we talk here now about some of the upper airway physiology and some of the upper airway difficulties that you help patients with, it's just interesting to me to reflect on how diverse a patient group that we see.

Claudio Milstein: Yeah, I really think that we have probably one of the most interesting practices in the country. We have a phenomenal team. Our Voice Center sees the most complex patients and there's never a boring day. We have collectively many, many years of experience together and not a week goes by that one of us is scratching his head and says, hey, have you seen this before? And we call on each other and say, no, no, this is something that we have not encountered. And that makes working as a team here so rewarding and so exciting. And as you say, the initial thing that got me into this path is voice, but the larynx is such a complex organ and there's so much more than just sound production. So, that really makes it really fascinating.

Paul Bryson: Well, we'll change gears and get into this other area of expertise that you've developed over the years. So we know exercise has many benefits, but we're seeing that it can sometimes cause breathing problems, especially in younger athletes. These are folks that aren't our typical patient that have a lot of medical comorbidities. Can you share with the listener what are some of these conditions that you're more frequently seeing with breathing in athletes?

Claudio Milstein: There are three main conditions that I see routinely in the clinic of athletes that they were healthy with no comorbidities and all of a sudden they start having trouble breathing, particularly when playing sports. One of those patient groups is the long COVID athletes healthy before contracting COVID, even a mild infection. But then they have lingering symptoms for a very long time and they get really exhausted and with significant shortness of breath with mild physical activity, where prior to the infection they were athletes at the top of their game. The other condition is what we'll call and we'll talk more in detail about that is the inducible laryngeal obstruction and the more the word gets out on this condition, the more patients get referred to our clinic. And the third one, which is a newer small child of inducible laryngeal obstruction as I call it, is a breathing pattern disorder. And also we'll go a little further into that later on. But these are the main three conditions that I see for athletes that are having trouble breathing when they're playing sports.

Paul Bryson: Can you walk us through exercise induced laryngeal obstruction, diagnose it? What's your approach to treatment? Maybe just tell us a little bit more about that.

Claudio Milstein: Sure. So inducible laryngeal obstruction is a functional disorder. What does that mean? It means that there is no anatomical problems, there is no pathology that you can see. When you look at the larynx it looks healthy, it seems to be functioning okay until you put the larynx into certain actions and that's where the malfunction or the dysfunction becomes more evident. And there are several other functional disorders in the larynx that affect every single one of the laryngeal functions. When it affects voice, it's a functional dysphonia. When it affects swallowing, it's called muscle tension dysphagia. When it affects breathing, it's called inducible laryngeal obstruction.

So it's interesting because this is a condition that until the mid-eighties not many people knew about and it's still relatively unknown. So there are two major groups of inducible laryngea; obstruction, one which is irritant induced. So the trigger is either acid reflux or any kind of let's say strong smells, perfumes, chemicals, or anything that the patient is exposed to that triggers that reaction, where the larynx basically starts constricting narrowing the airway and resulting in shortness of breath. It can be from mild to severe and when it's severe, patients can end up with frequent visits to the emergency room. The other big group for inducible laryngeal obstruction is that where the symptoms are triggered by physical activity or exercise. And the patient populations seem to be a little different. For the chemical induced or irritant induced is older patients, let's say in their mid-forties and up. And for the exercise induced that tend to be younger adults or kids, I see patients from age seven, eight and up.

Paul Bryson: I think you mentioned earlier that this can be frequently misdiagnosed or that patients will sometimes report to the emergency department just given the severity of symptoms and how bad they can feel during an attack or an episode. Can you share a little bit more about the concept of misdiagnosis or perhaps incomplete understanding?

Claudio Milstein: This is a condition that given that it's relatively new, the understanding of its frequently misdiagnosed for other conditions. For the irritant induced, usually it's misdiagnosed for angioedema or anaphylaxis. These are the severe cases that end up in the emergency room. For the sports induced, the most common misdiagnosis is asthma and sports induced asthma. And most patients that come to the clinic for evaluation have been given in the past a diagnosis of sports induced asthma, but the problem is that the treatments for asthma and the asthma inhalers don't seem to help. So they continue to seek something that will make them better and that's how they end up in the clinic.

Paul Bryson: And I suspect maybe their pulmonary function testing and some of the other traditional metrics that they would diagnose asthma with would be inconclusive or within what would be interpreted as the normal range. So they perhaps carry the diagnosis but have not had success or resolution of symptoms with traditional treatments.

Claudio Milstein: And it gets a little bit more complicated because inducible laryngeal obstruction can coexist with asthma. So that's why we work very closely with pulmonary analogy colleagues because the asthma aspect of it needs to be managed from them and the more functional issue is managed from our standpoint.

Paul Bryson: Yeah, it's interesting. And other podcasts that we've done on head and neck innovations, we've talked about tumor micro environments and things like that, and I sometimes think of the larynx and upper airway as its own micro environment of allergens and sensory dysfunction and motor issues and it's sort of a whole milieu, if you will, of things to try to uncover and treat.

Claudio Milstein: Absolutely. So one thing that we haven't done yet is actually describing what happens with this condition-

Paul Bryson: Yeah, go on, what happens?

Claudio Milstein: ... exercise induced laryngeal obstruction. So what happens is that there's some kind of sensory malfunction that triggers... The movement of the vocal chord starts almost in reverse. So in general, when we breathe, the vocal chords tend to abduct or come apart to leave more space for air to go into the airway. And when we play sports or do intense physical activity, that separation of the vocal falls is usually greater because we need more oxygen and therefore there is a larger space to get air. In this condition, the vocal cords start actually closing during the inhale and reducing the space that we have for breathing resulting in that sensation of shortness of breath. And oftentimes the condition is intense enough and the narrowing of the airway is significant enough that the patients start noticing a stridor or a sound during the inhale produced by that approximation of the vocal cords.

Paul Bryson: And so it can be quite dramatic when these are happening, people can hear the sound, and if they're in a sports environment, perhaps their teammates or other opponents might hear them breathing.

Claudio Milstein: Well, it's not just the stridor that can be frightful for the patient, the family and teammates. But also once it starts, it's usually accompanied by some other symptoms that can include dizziness and nausea and blurry vision. And in more extreme cases, a vasovagal reaction. And these kids when it's severe enough can also be rushed to the emergency department because the condition is frightful.

Paul Bryson: Yeah, and over time you can imagine the distress that the patient or athlete feels, the parents, other teammates, real significant quality of life issue for everyone involved.

Claudio Milstein: Absolutely. And they start noticing, and most of these are competitive athletes and they start realizing that their performance is suffering and they are not being able to play at the top of their game. And I've seen anybody from high school kids playing just for fun all the way to Olympic athletes and the performance is severely affected.

Paul Bryson: Can you walk us through the treatment approach?

Claudio Milstein: Yeah. The treatment that we are currently doing at the Voice Center of the Cleveland Clinic is a treatment protocol that actually I developed over years of working with this condition. And it has two components. One component is a retraining of the respiratory system to work in a way that doesn't create any extra tension in the torso, in the shoulders, in the strap muscles. And the second component of the treatment is a learning of how to voluntarily open the glottis or the vocal cords when they are closing up. So you retrain yourself into breathing in a different way, which is more relaxed and without any involvement of the upper torso. And at the same time you learn how to pay attention to the very early signs that your larynx is about to start acting up, and you learn what to do to open up the vocal cords so you can continue doing intense physical activity without the respiratory system being affected.

Paul Bryson: As you look at it, is this something where I'm sure everybody's different, but this retraining, this sort of control and adaptation that some of the patients or adjustments that the patient makes, is this something that you've seen to be reasonably intuitive for the athlete? Is it something that they're used to training? Does it take a similar commitment as they go through this rehabilitation to hopefully get back to their prior level of performance?

Claudio Milstein: Well, what is great about this treatment is that it's short term. Usually it takes three to four respiratory retraining sessions for the symptoms to improve significantly or to resolve, It does require daily training. So for the training sessions, they learn a bunch of exercises that need to be repeated over and over and over until they develop good muscle memory and they can start eliminating respiratory habits that they have ingrained and they can introduce healthier respiratory form. But for most people the improvement is very quick and quite dramatic. So they go from being fearful of doing physical activity to go back to playing to the top of their game and that's quite remarkable to see.

Paul Bryson: I'm sure it's very gratifying, and I know it's very gratifying to see the work you've been doing. I noticed with this Milstein method as I'll call it, maybe it's called something else, but I understand you have an assessment tool for it. Are you able to share anything about this validated instrument or are you attempting to validate this instrument to help measure your outcomes in treatment with this approach?

Claudio Milstein: Sure. So one of the things that we found out is that there's a condition called breathing pattern dysfunction. This is something that is usually looked at by pulmonary specialists in patients with COPD or asthma. And the assessment tools for this condition is looking at patients at rest when they are just sitting or standing. It's an observational tool of looking at respiratory patterns. Now, there was no assessment of this kind of breathing pattern in athletes or in people where you're taxing the respiratory system. So I developed this tool to observe breathing patterns when you really tax the system by doing high ventilatory output tasks of heavy breathing.

And then developed a tool to rate it to give you a score to see whether the score is high enough to indicate that they have a breathing pattern dysfunction or not. So we compared a large number of athletes with inducible laryngeal obstruction and with breathing pattern disorder to a group of athletes with no breathing problems. And we implemented this rating tool on both and we saw that there was a significant difference in the scores for each of the six different parameters that evaluate how somebody's breathing when you're taxing their respiratory system.

That is something that now we're doing with pretty much all our patients. We are rating their breathing patterns using this tool. We just submitted this for publication, it is not validated yet, but after the first publication on describing this method for evaluating breathing, then we're going to continue with other studies to validate it.

Paul Bryson: Yeah, fantastic. I really commend you on this work. I love the observational component and seeing some of the perhaps limitations of the current observational method and then applying it to what you're seeing in these patients. That's fantastic. As we wrap up any take home messages for the listeners? We could talk on and on, maybe we'll get to have another topic for another time, but any take home messages regarding this work that you're doing, any?

Claudio Milstein: Sure. There are many. The first one is if you know somebody that is having trouble breathing when they're playing sports and they are not getting better when they use inhalers, maybe bring up the possibility that maybe what they have is not asthma. A lot of times just listening to what the problem is or asking the right question. Most of the time for somebody with asthma, they will have more trouble breathing out. Now with inducible laryngeal obstruction, the difficulty is with inhale, breathing in and if you just ask that simple question is one that may start gearing you towards the right diagnosis. This is something that we're sharing with our pulmonary colleagues also to learn the differentiation between wheezing and stridor, because when athletes develop some kind of noisy breathing, they will all say, well, I wheeze and with just a couple of simple questions. Well, is this an actual wheeze on the exhale or is it stridor that it's a noisy breathing when you breathe in? So very, very simple take home messages that can allow pretty much anybody to start figuring out what kind of a problem they're dealing with.

Paul Bryson: That is great. It's been a real pleasure to chat with you today. For our listeners, to learn more about the Cleveland Clinic Voice Center, please visit ClevelandClinic.org/voice. That's ClevelandClinic.org/voice. And to speak with a specialist or submit a referral to our Head and Neck Institute, please call 216.444.8500. That's 216.444.8500. Dr. Milstein, thanks for joining Head and Neck Innovations.

Claudio Milstein: Dr. Bryson, it has been fun talking to you. I really appreciate the invitation to participate in this podcast and hopefully it was a topic that's interesting to some of our listeners, and they will be on the lookout for this kind of condition. Thank you much.

Paul Bryson: Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website at clevelandclinic.org/podcasts, or you can subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. Don't forget, you can access realtime updates from Cleveland Clinic Head and Neck Institute experts on our consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.

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Head and Neck Innovations

Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in Otolaryngology – Head and Neck Surgery.
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