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DISABLEMENT MODEL CASE STUDY 

 

37 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                          Volume 2 – Issue 2 – June 2019 
 

 
 

Exercise Induced Laryngeal Obstruction in a Collegiate Runner: A 
Case Report of a Novel Therapy 
Cody Inskeep, MS, LAT, ATC1; Todd Olin, MD, MSCS2; Robert Arthur MS, LAT, ATC, CSCS3 
1Biotix Health, Centennial, CO; 2Pediatric Exercise Tolerance Center, Denver, CO; 3Indiana State University, Terre Haute, IN 

 

 
ABSTRACT 

A 23-year-old male Division I distance runner presented with 
several years of exertional stridor (high-pitched inspiratory 
noise caused by airflow obstruction), previously diagnosed as 
exercised-induced laryngeal obstruction (EILO), a condition 
formerly known as vocal cord dysfunction and exercised-
induced paradoxical vocal fold motion.  Over the course of 
roughly 3 years, the patient had previously failed 
conventional and invasive respiratory therapies for EILO 
including respiratory retraining, inspiratory muscle training, 
reflux suppression, allergy suppression, amitriptyline, 
performance psychology, and injection of botulinum toxin to 
the larynx.  At a referral center that specializes in the 
treatment of EILO, the patient's diagnosis was confirmed 
through the use of a new procedure called continuous 
laryngoscopy during exercise.  He underwent three sessions 
of therapeutic laryngoscopy during exercise (which relies on 
real-time laryngoscopy footage as biofeedback during 
exercise) and concurrently learned novel breathing 
techniques to address the problem. It is common to 
misdiagnose exercise induced respiratory problems based on 
patients-described symptoms alone. Athletic trainers should 
be able to recognize EILO cases and feel comfortable 
contacting and collaborating with expert providers on 
appropriate treatment.  This case is also important in that it 
documents a treatment failure of laryngeal injection of 
botulinum toxin for EILO, something not previously reported 
in the literature. 
 
Key Phrases 
Exercise induced laryngeal obstruction, vocal cord 
dysfunction, respiratory 
 
Correspondence 
Cody Inskeep, Briotix Health, 9000 E Nichols Ave #104, 
Centennial, CO 80112 
E-mail: cody.inskeep@briotix.com 
Twitter: @CodyI85 
 
Full Citation 
Inskeep C, Olin T, Arthur R. Exercise induced laryngeal 
obstruction in a collegiate runner: A case report of a novel 
therapy. Clin Pract Athl Train. 2019;2(2):37-44. 
https://doi.org/10.31622/2019/0002.5.1.    

 
Submitted: March 3, 2019  Accepted: June 10, 2019  
 
 
 

INTRODUCTION 

Exercise-induced shortness of breath is common 

in athletes, with up to 70% of athletes reporting 
a degree of respiratory distress during 
exercise.1,2 While asthma, a disease of the small 
airways, is the most commonly-identified 
respiratory disease among athletes, between 5% 
and 8% of all adolescents and young adults 
struggle because they are experiencing airway 
obstruction at the level of the larynx (Video 1), a 
condition different than asthma.3 This upper 
airway obstruction is known as exercise-induced 
laryngeal obstruction (EILO), a condition 
previously referred to as vocal cord dysfunction 
and paradoxical vocal fold motion. It is 
characterized by airway obstruction that occurs 
at a glottic or subglottic level only during 
exercise (Video 2), often causing shortness of 
breath that can be visualized by athletic 
trainers.4,5 Among athletes, EILO has been often 
misdiagnosed as asthma, whereby in a cohort of 
91 athletes referred for asthma symptoms, 31 
(35.2%) were actually diagnosed with EILO.5 

At presentation, EILO symptoms often mimic those 
of exercise-induced asthma (EIA) with patients 
commonly complaining of “wheezing” in 
association with their dyspnea (despite the field 
observations that they are experiencing 
inspiratory stridor).6,7 EILO may be clinically 
distinguished from EIA by the time course of 
symptoms.  EILO generally is characterized by 
symptoms that are isolated to high intensity 
exercise and rapidly resolve.8  In contrast, EIA 
generally develops over several minutes and 
requires up to an hour to resolve.9  In clinical 
settings, the physical examination of patients with 

mailto:cody.inskeep@briotix.com
https://doi.org/10.31622/2019/0002.5
https://vimeo.com/clinat/review/344404886/2102213062
https://vimeo.com/clinat/review/344405909/6548cdbac3


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Copyright © Indiana State University   Clinical Practice in Athletic Training 
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EILO and EIA are generally normal.10  The 
similarities between asthma and EILO and the 
common practice of relying solely on clinical 
history to differentiate the conditions may lead 
to misdiagnosis, inappropriate management, and 
ineffective interventions.7 However, identification 
of ineffective therapeutic trials with 
bronchodilators such as albuterol (almost 
universally used in the treatment of EIA) can be 
helpful in directing athletic trainers and other 
healthcare providers towards alternative 
diagnoses such as EILO.  

The mechanisms of EILO are still unclear and 
current models hypothesize a variety of possible 
disease contributors. These factors may include 
laryngeal mechanical insufficiency, neural 
dysfunction, and a psychological component.7 
Continuous laryngoscopy during exercise (Video 
3), a procedure which features endoscopic 
visualization of the larynx throughout an entire 
bout of intense exercise, is currently the gold 
standard for diagnosis of EILO because 
characteristic upper airway obstruction can be 
visualized while field symptoms are reproduced 
in the exercise lab.11-13 Other methods to identify 
the condition indirectly including post-exercise 
laryngoscopy and exercise flow volume loop 
analysis are used in practice, but present serious 
limitations to EILO identification.10  

 Standard treatment algorithms do not currently 
exist for EILO although a number of therapies 
are used in practice.10 Removal of irritants and 
triggers from the athlete’s environment, speech 
therapy, psychological interventions, 
pharmacological interventions, botulinum toxin 
injections, supraglottic surgery, and inspiratory 
muscle training have mixed results with no single 
treatment or combination of treatments showing 
consistent effectiveness.10 The most common 
treatments appear to be traditional breathing 
techniques taught in speech therapy. However, 
traditional breathing techniques often do not 
provide relief from exertional dyspnea and are 
often difficult to perform during high-intensity 
exercise.10 Therapeutic laryngoscopy during 

exercise (TLE) is a newly developed procedure 
that features laryngeal visualization during 
respiratory retraining that occurs simultaneous to 
exercise.12 It has also been found that after the 
application of traditional breathing techniques, 
inappropriate glottic adduction still exists during 
therapeutic laryngoscopy (TLE) treatments.14 In 
response to the observation of inconsistent 
success with traditional therapies and lack of 
treatment protocols, novel and alternative 
treatment techniques should be explored.  

The EILO biphasic inspiration (EILOBI) techniques 
represent such a novel and alternative treatment. 
They were developed through observations 
made during TLE and designed for use in high-
intensity exercise.15 The EILOBI techniques help 
trigger laryngeal abduction which reduces the 
degree of upper respiratory obstruction in 
athletes with EILO.16 The following case describes 
a patient who was unresponsive to many common 
treatments for EILO, including Botulinum toxin 
injections, and found the greatest symptom relief 
with the EILOBI technique This case is important 
because relief from traditional therapies may not 
yield the most relief and alternative methods 
provide better results. Consulting a specialist is 
the best avenue for patient care.  

Patient Information 

A 23-year-old male NCAA Division I distance 
runner (Cross-Country, 3k steeplechase, 5k) with 
a history of childhood asthma, allergic rhinitis, 
and supraventricular tachycardia status post 
ablation presented to the healthcare team 
(Primary Care Physician, Immunologist, 
Performance Psychologist, Ear Nose and Throat 
Specialist, Pulmonologist) with several years of 
exertional dyspnea.  Several months after an 
initial diagnosis of and treatment for asthma, he 
continued to experience exertional dyspnea.  In 
the context of characterizing the dyspnea as 
stridor and the response to treatment as minimal, 
he was diagnosed with EILO.  In addition to EILO, 
a few potential disease contributors were 
identified.  He was found to have 

https://vimeo.com/clinat/review/344406522/e29b93bf25
https://vimeo.com/clinat/review/344406522/e29b93bf25


Exercise Induced Laryngeal Obstruction in a Collegiate Runner: A Case Report of a Novel Approach 

 

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Copyright © Indiana State University   Clinical Practice in Athletic Training 
ISSN Online 2577-8188  Volume 2- Issue 2 – June 2019 
 

gastroesophageal reflux (GERD) and was 
treated with acid suppression medication and an 
inlet patch procedure.  He was also found to 
struggle with anxiety and was treated by a local 
performance psychologist.  Despite appropriate 
treatment of hypothesized disease contributors 
(allergic rhinitis, gastroesophageal reflux, and 
anxiety) and conventional treatment for EILO 
(respiratory retraining) with speech and 
language pathologists, he continued to struggle 
with exertional stridor for several months.  For 
this reason, he was also treated with inspiratory 
muscle training with a POWERbreathe®, 
amitriptyline, and laryngeal botulism toxin 
injections on 3 occasions.  A POWERbreathe® is 
an Inspiratory Muscle Training device used for 
improving the strength and endurance of the 
muscles used to breathe in; amitriptyline is a 
prescription drug used to treat depression, 
anxiety, and nerve pathologies; and botulism 
toxin injections are used to reduce excess muscle 
activity caused by dystonia. Despite these 
interventions which were sequentially introduced 
over several months, the patient continued to 
struggle with the primary symptom of exertional 
stridor through the time of his presentation at the 
final referral center roughly 5 years after 
symptoms began. 

Activity and Participation  

Patient reported occasional “wheezing” while 
running which progressed into full breathing 
attacks during his junior and senior years of high 
school that reduced his ability to run during races 
to a jog.  Over time, these symptoms increased in 
terms of frequency and severity.  When symptom 
free, which often occurred during practice, he 
was able to complete a mile in slightly more than 
4 minutes. When symptoms occurred, he was 
often unable to complete races. 

Differential Diagnosis and Evaluation 

The differential diagnosis of exertional stridor 
includes all causes of fixed and dynamic intrinsic 
and extrinsic obstruction of the upper airway. 

EILO occurring at a glottic or supraglottic level is 
the most likely lesion. Additionally, laryngeal 
webs, subglottic and tracheal stenosis, and 
compression from large vessels or masses can 
cause stridor. Prior to presentation at the 
Pulmonologist computed tomography of the chest 
and swallow evaluations excluded extrinsic 
compression. Previous exercise testing excluded 
exertional hypoxemia. Continuous laryngoscopy 
during exercise at the final referral center 
confirmed the diagnosis of EILO affecting both 
glottic and supraglottic structures.   

Body Structure and Function 

The patient was usually asymptomatic at the time 
of evaluation by athletic trainers in the clinic. The 
patient described periodic symptoms commonly 
associated with EIA or EILO, mainly “wheezing” 
with dyspnea. The few times athletic trainers 
were able to evaluate the patient during an 
episode, he presented with stridor, difficulty 
breathing, and altered voice pitch. These 
symptoms subsided within minutes of ceasing 
activity.  

Environmental and Personal Factors 

The patient comes from an affluent, supportive 
family who encouraged and modeled being 
physically active. He had goals to serve in a 
special-forces unit since he was a child. The 
student-athlete has a history of seeking treatment 
for anxiety that was relatively successful.  

INTERVENTIONS 

After diagnosis confirmation with continuous 
laryngoscopy during exercise, the patient 
performed three sessions of therapeutic 
laryngoscopy during exercise (TLE), described 
below. During the sessions, the patient learned 
one version of the EILOBI (EILO biphasic 
inspiratory) breathing techniques as well as a 
framework for managing some of the cognitive 
behavioral contributors to EILO. 



Exercise Induced Laryngeal Obstruction in a Collegiate Runner: A Case Report of a Novel Approach 

 

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Copyright © Indiana State University   Clinical Practice in Athletic Training 
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OUTCOMES 

Although intermittent results were noticed with 
traditional respiratory therapy interventions, the 
patient noticed significant improvements after the 
series of therapeutic laryngoscopy during 
exercise sessions and with the EILOBI techniques. 
He routinely uses them during all of his runs. He’s 
no longer a collegiate athlete but still averages 
50 miles per week.  The patient still has 
symptoms albeit they’re less frequent and severe 
from a respiratory perspective if his GERD is 
controlled but has periods of respiratory distress.  
He does note, however, that if he misses a day 
of GERD medication his breathing while running 
is difficult for reasons related to pain. 

DISCUSSION 

We present a case of an elite male athlete with 
EILO who struggled with delays in diagnosis and 
poor responsiveness to conventional and invasive 
therapies for EILO including traditional 
respiratory retraining with trigger suppression 
and Botulinum toxin injections to the larynx. 

This is an important case because it highlights 
that the EILOBI breathing techniques can result in 
successful treatment of EILO in elite athletes 
previously unresponsive to therapy.  Secondarily, 
although previous literature seems to suggest a 
very high success with botulinum toxin injections, 
this report underscores a concern for treatment 
failures.17 

This patient made major improvements with the 
use of the TLE procedure. In this procedure, 
patients are able to visualize their upper airway 
during intense exercise, with the ability to use the 
images as biofeedback during respiratory 
retraining teaching sessions (Figure 1).  
Additionally, the procedure enables thoughtful 
discussion about cognitive behavioral features 
which may be suspected in the event that EILO 
episodes trigger at somewhat unusual times. The 
procedure naturally enables complex teaching 

necessary to learn the EILOBI breathing 

techniques.8 

Figrure 1: Therapuetic Laryngoscopy During 
Exercise.  

The EILOBI breathing techniques feature a high 
resistance and low resistance phase of inspiration 
that can be performed rapidly.15 The techniques 
were discovered fortuitously during the 
endoscopic evaluation of patients who had 
previously not responded to conventionally used 
breathing techniques.  Many of the conventional 
respiratory retraining strategies focus on slow 
breathing in the use of the diaphragm- concepts 
not compatible with the high respiratory rates 
and engagement of abdominal muscles that 
accompany intense exercise with athletes.15 The 
techniques are challenging yet important to learn 
and require a thoughtful teaching strategy. 
Nonetheless, in appropriately selected patients, 
like ours, that demonstrated a high degree of 
motor coordination, the techniques can minimize 
or eliminate symptoms.   

CLINICAL BOTTOM LINE  

It is common to diagnose and treat exercise-
induced respiratory problems based on patients-
described symptoms alone which may lead to 
misdiagnosis as asthma with subsequent 
inappropriate management, and ineffective 
interventions. Athletic trainers have a very unique 
perspective because they may be present during 
events with the opportunity to visually distinguish 
inspiratory stridor from other respiratory 
phenomena.  Observation of characteristic field 
events or videos of characteristic episodes can 



Exercise Induced Laryngeal Obstruction in a Collegiate Runner: A Case Report of a Novel Approach 

 

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Copyright © Indiana State University   Clinical Practice in Athletic Training 
ISSN Online 2577-8188  Volume 2- Issue 2 – June 2019 
 

be helpful in terms of raising suspicion of EILO.  
Continuous laryngoscopy during exercise can 
provide definitive diagnosis of EILO. Traditional 
breathing techniques learned from speech 
therapists often do not provide relief from 
exertional dyspnea and are difficult to perform 
during high-intensity exercise.  The EILOBI 
breathing techniques were designed specifically 
to address these concerns. After this case 
presentation, athletic trainers should be able to 
recognize their very unique perspective on 
events that can occur in the field, clinically 
suspect EILO cases based on inspiratory stridor, 
and feel comfortable contacting and 
collaborating with expert providers on 
appropriate treatment. 

PATIENT PERSPECTIVE  

My breathing problems began during my 
sophomore year of high school. I had been a 
tennis player who occasionally ran until I took up 
running full time during my freshman year of high 
school where I was able to make it to the state 
regional meet. I had been a diagnosed asthmatic 
since I was 8 years old and occasionally used an 
inhaler during wheezing episodes. Despite 
wheezing at times, I was still a competitive tennis 
player who was ranked in the top 5 in the state.  

At the conclusion of my freshman season we 
wanted more answers so I saw an immunologist. I 
tested positive for multiple allergens. We were 
excited for this news as we thought we had 
found the reason for my breathing issues that 
were starting to develop. Initially I had thought 
my issues were from pre-race anxiety but the 
confirmation of having multiple allergies seemed 
like a more likely cause. I started getting routine 
allergy shots which led to a sophomore track 
season where I had very few breathing issues. 

My junior and senior year of high school were 
drastically different. I routinely had significant 
breathing issues during multi-race days, some of 
which would reduce my pace to a jog with bad 
wheezing. There was no consistency to causes to 

these issues; high- and low-pressure races, time 
of year, nothing was consistent. During this time 
my race anxiety seemed to escalate and I would 
sometimes puke before or after races. By this 
time, I had been to the doctor multiple times and 
had been told I was anemic, had asthma, and 
was over training.  

During my freshman year of college in 2013, I 
had very few breathing attacks early in the 
season; however, when I did have them they 
were severe and the severity seemed to be 
getting worse. As the season progressed the 
breathing attacks became more frequent, which 
was a pattern for my entire college career. I can 
only think of one season where the first real 
workout of the year didn’t go amazing. I chalked 
this pattern up to being less stressed coming out 
of the summer but when I thought about my 
anxiety levels before a fast workout, there didn’t 
seem to be any correlation. It seemed as though 
the more fit I got through the season, the worse 
and more frequent my attacks would become.  

By the spring season during my freshman year I 
was able to run workouts in practice very well 
but struggled during competition. From the 
outside it appeared as if I was overtraining and 
couldn’t handle the pressure while racing. I don’t 
have any hard feelings for anybody who thought 
that because it seemed pretty obvious but I knew 
there was something more to it. It has always 
torn me apart on the inside trying to prove that I 
knew I was fit. During this time I became very 
callused emotionally and really struggled with 
the fact that I couldn’t push my body to its 
physical limits although I knew I had more in me. 
From this point on was the loneliest and toughest 
part of my life but it didn’t stop me from putting 
in the work or trying to figure out a solution.  

Starting my sophomore year, the pattern 
continued where I would run well early in the fall 
semester and trail off as the season progressed. 
Additionally, early during the fall of 2014 my 
heartrate was very irregular and high which led 
to being diagnosed with Supraventricular 



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ISSN Online 2577-8188  Volume 2- Issue 2 – June 2019 
 

Tachycardia (SVT) so I ended up having a 
cardiac ablation procedure. We had hoped this 
may have been a contributor to my breathing 
issues but shortly after I started running again I 
realized it was unrelated. I made it through the 
season racing slightly better than my freshman 
year until the outdoor track conference meet 
where I had such severe breathing attacks that 
my pace was reduced to a jog and I finished last 
in two races.  

Naturally after years of hearing that I’m 
overtraining and I’m a “head-case”, I started 
overanalyzing everything I was doing looking for 
a cause to my running issues. During the summer 
between my sophomore and junior year of 
college I came up with a brilliant solution- I 
would get so fit that I could overpower my 
breathing problems; unfortunately, that didn’t 
work either.  

Early during my junior season in 2015 I started 
having consistent throat pain, so I returned to the 
immunologist. She suggested I might have Vocal 
Cord Dysfunction (VCD) which seemed to fit after 
looking into it on my own. I had unexplained 
voice cracks during conversations that didn’t 
align with puberty, I stuttered on and off which 
developed around the same time as my 
breathing issues got worse, and I developed a 
habit cough that would get worse with running at 
times. I worked with multiple Speech Pathologists 
and eventually ended up with a pathologist who 
worked specifically with athletes. Following a 
speech therapy session there were good and 
bad days of running still. I ended up being 
tested for GERD and tested positive. I was super 
excited for this diagnosis as well since GERD had 
been linked to causing VCD. Unfortunately, 
treating the GERD didn’t seem to help my 
breathing attacks much.  

During the summer of 2016, I ran 100 miles a 
week for 10 weeks straight and was feeling 
okay. I was still having breathing attacks but I 
felt like I had some control over them as I was 
still using a POWERbreathe® device most of the 

time. Like the previous college years, the fall 
season started out great but went downhill fast. I 
started seeing a sports psychologist in the fall of 
2016 who worked with an NBA team in the area 
as well but this also didn’t seem to have any 
lasting effect. After the GERD treatment failed to 
have any real effect, I got a series of three 
Botox injections. At first, I felt like these injections 
helped but it was very short-lived and also had 
no lasting effect. During this time, I also started 
taking amitriptyline which also seemed to have 
very little effect on the breathing issues.  

In the spring of 2017 I was referred to the 
National Jewish Hospital (NJH) in Denver, CO. 
Due to classes, I ended up scheduling a series of 
appointments over a ten-day period that 
summer. By this point the self-doubt and the 
inability to do what I had dreamed of being the 
best at were taking a toll on me. It was at this 
time where I started having breathing difficulties 
in everyday life. Stairs were harder to get up. I 
would often have to cut off a friend mid-
conversation just to catch my breath after 
climbing just one flight. I couldn’t talk on long runs 
anymore because I would mumble and slur my 
words. These speech difficulties got worse to 
where I would have difficulty just having 
conversation while walking long distances across 
campus. I would often be light-headed and dizzy 
after long easy runs; I couldn’t wait until Denver.  

During my ten-day stent in Denver that summer, I 
saw a myriad of doctors at NJH. Three inlet 
patches were found in my throat. I ended up 
having ablation therapy on the patches and it 
was thought that I would be back to running 
without issue in 2-3 months. In conjunction with the 
ablation therapy I was also put on Nexium which 
didn’t help much either. There was one physician 
at NJH that was doing research on vocal cord 
disorders but he was on vacation during this trip 
so I scheduled to see him in December of 2017.  

In the Fall of 2017, I started my last cross-
country season in college and I was mentally not 
into it. Before I knew it, I was back at NJH in 



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December. I had one more ablation procedure 
on a small portion of one inlet patch and saw the 
physician who was researching vocal cord 
disorders (Dr. Olin). I went through a series of 
treatment sessions with Dr. Olin where I was 
taught how to breathe during exercise. To this 
day, this has been the single greatest help to my 
breathing.  

The Spring of 2018 was a turning point in my 
life. I began to put life after college as a priority 
while continuing to run. Since then, I have only run 
a few 100-mile weeks while continually 
averaging 50 miles per week. There is no doubt 
that the breathing techniques I learned with Dr. 
Olin have helped. I still have breathing issues 
although they’re not as frequent or severe. I 
continue to have heartburn, albeit less severe. If I 
miss a day of taking Nexium then I notice my 
breathing is worse. 

SUPPLEMENTAL VIDEOS 

Video 1: Example of Exercise-Induced Shortness of 
Breath  

Video 2: Visualization of Airway Obstruction 

Video 3: Continuous Laryngoscopy During Exercise 

 

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https://doi.org/10.1097/01.mlg.0000184528.16229.ba
https://doi.org/10.1097/01.mlg.0000184528.16229.ba
https://doi.org/10.1002/lary.20558
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https://doi.org/10.1016/j.jvoice.2017.08.020
https://doi.org/10.1016/j.jvoice.2017.08.019
https://doi.org/10.1016/j.jvoice.2017.08.019

