MUSCLE TENSION DYSPHONIA

Muscle tension dysphonia (MTD)

Muscle tension dysphonia (MTD)Voice disturbance without structural or neurologiclaryngeal pathology.Excessive tension in intrinsic and/or extrinsic laryngeal muscles.Primary MTD

vocalizing or speaking in which the muscles in the neck are tense and when no other lesion or paralysis is seen.

Secondary MTDa compensatory method of vocalizing due either to a paralysis, paresis or muscular weakness causing the person to squeeze other parts of the larynx to help produce sound.

Muscle tension dysphonia (MTD)10 to 40%, female, professional voice users.

(1) Technical misuses of vocal mechanism in the context of extraordinary voice demands,

(2) Learned adaptations after URI,(3) Increased pharyngolaryngeal tone secondary to LPR,(4) Extreme compensation for minor glottic insufficiency

and/or underlying mucosal disease,(5) Psychologic and/or personality factors that tend to

induce elevated tension in the laryngeal region.In response to stress, conflict, anxiety, depression, or inhibited emotional expression,Conversion reaction, hysteria, hypochondriasis, and various situational conflicts or personality dispositionsHowever, research evidence to support these various psychologicmechanisms has seldom been provided.

Muscle tension dysphonia (MTD)

Muscle tension dysphonia (MTD)Breathy or harsh with use through the day and recovers with rest.

severe vocal restrictions or complete loss of voice by Thursday or Friday, with a weekend barely providing sufficient recovery time.

Fine control in the middle vocal frequencies is lost first and whispering or shouting later.Organic changes in vocal cords may occur secondary to such faulty use or overloading.

Causes of laryngeal irritationPost nasal drip, sinus disease, etc.. tobacco smoke.Laryngo-pharyngeal reflux (LPR)

10% of general population, 46% of professional voice users.heartburn, acid tastes in mouth, nocturnal coughing, halitosis.swelling of laryngeal mucosa frequent throat clearing and coughing.reflex increase in muscle tension in the pharynx and larynx.

Causes of laryngeal irritation

Globus -- “a lump in the throat”.spasm of muscles of lower pharynxsore throat, vague rawness or dry feeling localized to the area of the larynx or below.the neck muscles can become tender with the ache extending up the neck muscles to behind the ear.the symptoms resolve during eating because swallowing allows the muscles to relax.intermittent hoarseness or “voice fatigue”, returns to normal at certain times of the day.globus can be precipitated by a post nasal drip or LPR.

HistoryThe amount / type of voice use at home, socially, at work.Daily behavior.Recent URI.Medications.Neurologic disorders

generalized dystonia or myasthenia gravis.Laryngeal trauma or neural injury.

Prior neck surgery or trauma.TMJ disorders, cervical myalgia, or muscular fatigue.GERD and LPR.Endocrinopathies.

Hypothyroidism.Any psychiatric history.Exposure to irritants

tobacco smoke, alcohol, caffeine, dairy products, chocolate, mints and occupational irritants.

HistorySufferers belong to a particular group.

their career and lifestyle have not altered, their voice has deteriorated.

‧ TeachersSpeak above background noise in rooms with poor acoustics and dust.Teaching is a stressful jobTeachers rarely have received any education about voice care or use.

‧ Singers and actorsLifestyle with many adverse effects upon voice and health.

‧ People talking on the telephone all dayoften use an inappropriate pitch, have few rests or appropriate drinks and limited vocal recovery time.office atmosphere may be dry due to air-conditioning.

‧ Aerobics instructorsShout above the music level to be heard and to motivate.

Examination

Thorough clinical examination to exclude organic laryngeal pathology.Body posture may be poor, raised overall body tension (including the neck and laryngeal muscles) with MTD.Elevation of the larynx and hyoid bone due to increased tone in the thyrohyoid and tongue base muscles.Tense and tenderness of the thyrohyoid / cricothyroid muscle.Difficult to move the larynx up and down and from side to side.Laryngeal elevation may occur on phonation.

Gentle downward traction on the larynx after massage of the tender areas reduction of the hoarseness.

ExaminationIndirect laryngoscopy (mirror examination)

to confirm the vocal folds at the same level.mucosal colour and inflammation.

interarytenoid area alone LPRpetiole (back of the epiglottis) excessive coughingsupraglottic post nasal dripgeneralized inflammation smoking, alcohol and gross reflux.

Videostroboscopic laryngoscopydetailed assessment of the vocal fold symmetry and regularity ofvibration, glottal closure, amplitude of vocal fold excursion, mucosal wave and non-vibrating portions of the vocal folds.

Fibreoptic laryngoscopythe nasal cavities and post nasal spacethe vocal range and limits, the changing shape of the larynx.

The clinical features

The clinical features

Management

1. Posture and muscle usageThe compensatory laryngeal hyperfunction and the causes need to be identified and removed by re-education.The voice needs to be sustained by correct breath support in a relaxed and unstrained manner.Less laryngeal effort:

a thorough explanation of anatomy and physiology of vocal tract.reassurance with patient’s own laryngeal video that there is no serious pathology.laryngeal “deconstriction” exercises in addition to altering the focus of resonance and tongue and mouth placement.improvement in overall body posture and muscle relaxation particularly in the head, neck, back and shoulders.

Management2. Behavioural

An understanding of the environmental and behavioural aspects of voice use.Environment:

poor acoustics/amplification, dry air, dust or smoke, background or competing noise (bars, sporting arenas, large family gatherings, airplanes and buses), inadequate rest.

Personal behavior:smoking/alcohol/caffeine, whispering, shouting or screaming (ie. sporting events or night clubs), poor timing or types of eating, throat clearing or coughing, dehydration, voice use at a lower or higher pitch than is comfortable.

Management3. Laryngo-pharyngeal reflux

Acid reducing drug (ie. Zantac or Losec) doubled dose + gastric emptying drug pH monitoring surgery of G-E junction

“Lifestyle” advice chart.

4. Post-nasal dripAllergic rhinitisCPS

Management5. Psychological platform

A normal stress responseto speak to a group of people

Heavier psychological loadincreased muscle tension.benefit from counselling

to know how to identify and understand past behavioral patterning and learn new behavior.release of emotional blocks and negativity.

relaxed, self-confident and more outgoing voice is one of the major beneficiaries.

Voice therapySymptomatic voice therapy

identification and elimination of vocally abusive behaviors.auditory feedback, head positioning, laryngeal massage, relaxation.

Psychogenic voice therapyemotional and psychosocial issues.

Etiological voice therapyrecognition and elimination of the cause of the voice disorder,may be multifaceted.

Physiologic voice therapybiofeedback, use of acoustic and aerodynamic analysis.

Eclectic voice therapycombination of therapeutic approaches.

speech therapy + botulinum injection,voice therapy + psychotherapy.

Multimodal approach is frequently essential, since many of these voice disorders have psychogenic overlay.

Voice therapy