Functional Dysphonia/ Muscle Tension Dysphonia (MTD)

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Functional Dysphonia/Muscle Tension Dysphonia
(MTD)
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Muscle Tension Dysphonia A Functional Voice
Disorder

• What is a functional voice disorder?
• Voice disorder in the absence of
  structural/neurological pathology
• Pathology insufficient to explain the degree of
  dysphonia
• Voice disorder based on abuse/misuse causally
  linked to anatomical abnormalities

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Functional dysphonia vs. muscle tension dysphonia
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Muscle Tension Dysphonia (MTD)

• Presumed Etiology
• Excess or dysregulated activity of the intrinsic
  and extrinsic laryngeal muscles
• Possible Sources
• Technical misuse of the vocal mechanism
• Learned adaptations following upper respiratory
  infection
• Compensation for underlying vocal fold pathology
• ? laryngeal tone 2 to laryngopharyngeal reflux
• Psychological/personality factors

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Muscle Tension Dysphonia (MTD)

• Key Features
• Laryngeal/paralaryngeal hypertonicity
• stiff larynx
• Larynx in unnatural position high in neck
• Laryngeal muscle cramping
• No unique voice quality/glottic configuration
• Pre-treatment MTD samples

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Muscle Tension Dysphonia (MTD)

• Some Trends
• Occurs predominantly in women (90 )
• May account for gt 10 of cases referred to
  multidisciplinary voice clinics
• Often the most severely affected voices
  encountered
• Commonly follows URI symptoms
• Past history of voice problems (80)
• Varies in response to treatment

Roy et al. (1997)
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Recognizing Muscle Tension Dysphonia

• Patient history
• Auditory-perceptual Features
• Laryngoscopic Features
• Direct clinical examination
• Manual assessment of laryngeal musculoskeletal
  tension
• Primary or Diagnostic therapy

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Patient History

• Vocal symptoms
• Can have a sudden onset
• May have had periods of resolution
• May have developed along with a URI
• Symptoms suggestive of excess musculoskeletal
  tension
• Laryngeal tenderness, soreness, pain, tightness,
  swellings which intensify with extended voice
  use
• Pain radiates to one or both ears
• Unilateral symptoms are more common
• Vocal fatigue, increased effort
• Restricted dynamic range

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Patient History

• Voice Use History
• may not reveal patterns of excessive voice use
• Psychosocial History
• may reveal elevated stress
• Stress may be coincident with history of vocal
  symptoms

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Auditory Perceptual Features

• Generally
• Severity of voice quality disturbance typically
  consistent across a range of speech tasks
• Signs are usually continuous and rarely
  intermittent (no islands of normal speech)
• Typically shows no improvement with falsetto or
  singing

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Auditory Perceptual Features

• The most disordered voices produced with normal
  larynges
• Wide range variety of voice qualities
• Possible existence of 5 auditory-perceptual
  clusters
• qualitatively distinct
• within a cluster, voices vary from mild-severe

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Auditory-perceptual Clusters

• Cluster 1
• Persistent glottal fry
• Cluster 2
• Sustained harsh, strained (tension)
• Cluster 3
• Diplophonia, intermittent pitch voice breaks
• Cluster 4
• Aphonia (continuous)
• Cluster 5
• Elevated pitch (falsetto) with without
  strain, aphonia

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THOUGHT QUESTION

• Why dont persons with MTD develop laryngeal
  pathologies?

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Laryngoscopic Features

• Dysregulated muscle activity myriad of
  glottic/supraglottic contraction patterns
• Rammage Morrison (2001) suggest a distinct set
  of laryngoscopic patterns
• Controversial

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MTD Type 1 Laryngeal Isometric(/- benign
mucosal disease)

• Principle feature posterior glottic chink
• Presumed due to ? PCA activity
• Suggested association with benign mucosal lesions

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MTD Type 2a Glottic Lateral Compression

• Lateral compression principally at the glottis
• May be some ventricular compression
• ? closed phase
• ? vibratory amplitude

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MTD Type 2b Supraglottic Lateral Compression

• Ventricular folds are approximated

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MTD Type 3 Anterior-posterior supraglottic
compression

• ? distance between anterior and posterior glottis
• Arytenoids pull toward epiglottis
• Associated with Bogart-Bacall syndrome

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MTD Type 4 Non-adducted hyperfunction(-
supraglottic compression)

• Incomplete glottal closure with normal mobility

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MTD Type 4 Non-adducted hyperfunction(
supraglottic compression)

• Incomplete glottal closure with normal mobility
• Concomitant compression of the ventricular folds

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MTD Type 5 Bowed vocal folds

• Spindle-shape glottis
• Also associated with
• aging (presbylaryngis or presbyphonia)
• Neurologic conditions (Parkinsons Disease)

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Note

• Relation between auditory-perceptual judgments
  and laryngoscopic findings are not straightforward

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Direct Clinical Assessment

• Focal palpation of circumlaryngeal area to
  determine
• Presence of tenderness and/or pain
• Laryngeal Stiffness
• Presence of nodularity or taut bands
• Reduced mobility of the larynx
• Extent of laryngeal elevation

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Manual Assessment of Laryngeal Musculoskeletal
Tension

• All patients with voice disorders, regardless
  of etiology should be tested for excess
  musculoskeletal tension, either as a primary or
  secondary cause of dysphonia (Aronson, 1990)

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Manual Assessment of Laryngeal Musculoskeletal
Tension

• Pressure is directed over the
• Major horns of the hyoid bone
• Superior border of the thyroid cartilage
• Anterior border of sternocleidomastoid and into
  the suprahyoid muscles
• Determine size of the thyrohyoid space
• Digital pressure should be just enough to
• blanche (lighten in color) your nail bed

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From Aronson (1990)
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From Roy et al. (1996)
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Treatment Options

• Facilitating techniques designed to elicit easy,
  relaxed phonation, phonation at optimal pitch,
  etc
• General and focal relaxation
• Broad spectrum treatments that focus on
  increasing support and efficiency of phonatory
  behavior
• Manual Circumlaryngeal Techniques
• Pharmacologic Intervention (topical lidocaine)

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Manual circumlaryngeal techniques

• Goals
• Determine contribution of laryngeal/extralaryngeal
  hypertonicity
• Assure proper diagnosis and selection of
  appropriate treatment
• Avoid unnecessary medical or surgical management
• Show Pre-Post Samples

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Manual circumlaryngeal techniques

• A group of techniques
• a hands on approach
• Clinician manually repositions, repostures or
  massages the laryngeal structure while
  eliciting voice
• Use voice task with a hierarchy of difficulty
• Exploit facilitating techniques

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Manual circumlaryngeal techniques

• May be used as
• primary treatment technique for musculoskeletal
  tension dysphonia (MTD)
• diagnostic therapy to evaluate degree of
  contribution of musculoskeletal tension to voice
  disorder

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MCT Reposturing techniques

• Compression in the A-P direction (push-back)
• Impede laryngeal elevation (Pull down)
• Medial compression and downward traction
  (Reposturing)
• Goal Perturb the abnormal laryngeal posture and
  evaluate change in voice quality

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Technique 1 Push Back Maneuver

• Digital compression in the posterior direction
  within the region of the larynx
• Vary height and pressure
• Suprahyoid
• Hyoid
• Infrahyoid
• T-H space
• Thyroid notch

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Technique 2 Pull Down Maneuver

• Impede laryngeal elevation by applying downward
  traction over the superior border of the thyroid

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Technique 3 Laryngeal Reposturing

• Medial compression and downward traction
• pressure directed over posterior aspect of
  thyroid cartilage (and within T-H space)
• Often helpful with non-adducted hyperfunction

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Circumlaryngeal massage (manual laryngeal
tension reduction)

• What is it?
• Circular motion over
• Tips of major horns of the hyoid bone
• Thyrohyoid space
• Posterior border of the thyroid cartilage
• Medial and lateral suprahyoid muscles

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Circumlaryngeal massage (manual laryngeal
tension reduction)

• What is it?
• Locate sites of focal tenderness, nodularity and
  tautness
• Progress from superficial to deep pressure
• Vary pressure according to patient tolerance
• Patient must vocalize concurrently
• Progressively increase complexity of voice stimuli

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Indications for improvement (single session)

• Improved voice quality
• Pain reduction/relief
• Normalized laryngeal height and mobility
• Reduced muscle nodularity

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Factors affecting management of MTD using MCT

• Patient based factors
• Motivation
• Duration and severity of dysphonia
• Persisting psychological issues
• Primary and secondary gain, litigation etc

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Clinician based factors

• Technical skill
• Clinician-patient dynamic
• Communicate expectations and confidence in
  procedure
• Pt learns by doing (avoid discussion)
• Brisk therapeutic pace
• Engage pt in process
• Confront pt when effort ?
• Reinforce improvement

• Expect successive approximations to a normal
  voice
• Variety of facilitating techniques
• Know when to abandon a technique or stick with it
• Establish that patient is responsible for change
• May employ negative practice

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Manual Circumlaryngeal Techniques

• Evidence for clinical utility of MCT in
• Functional dysphonia (muscle tension dysphonia)
• Roy et al. (1997) J Voice

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Short and long term effects of MCT

• N25
• Some improvement following Tx (96)
• Normal or only mildly dysphonic following Tx (64
  )
• Deterioration of voice at follow up (25 )
• Improvement of voice at follow up (17 )

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Short and long term effects of MCT

• What about relapse?
• 68 report some evidence of recurrence of some
  dysphonic symptoms
• Recurrence is partial rather than complete
• Occurs within 3 mos. following initial treatment
• Less than 4 days in duration, self limiting (i.e.
  resolves spontaneously)

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Concomitant MTD Organic/Neurogenic Dysphonia

• Elevated laryngeal musculoskeletal tension may
  co-occur in patients with documented laryngeal
  pathology
• Why? Cause, Effect, Complication
• MCT have diagnostic treatment utility with
  these populations

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Manual Assessment of Laryngeal Musculoskeletal
Tension

• All patients with voice disorders, regardless
  of etiology should be tested for excess
  musculoskeletal tension, either as a primary or
  secondary cause of dysphonia (Aronson, 1990)

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Examples
Post-MCT
Pre-MCT

• Polyp
• CVA
• Reinkes edema

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MCT with BMD Patients

• N18
• Gender
• 83 female
• 17 male
• Age
• Mean 44.1 years
• SD 13 years
• Dysphonia Duration
• Mean 2.27 years
• SD 3.64 years

• 4/18 bilateral nodules
• 2/18 unilateral nodule
• 2/18 unilateral polyp
• 2/18 Reinkes edema
• 5/18 TVF irregularities/edema/erythema
• 1/18 ventricular cyst
• 1/18 interarytenoid lesion
• 1/18 post-intubation granuloma

(Tasko, et al. 1994)
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(No Transcript)
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Topical Lidocaine (J Voice (2000))

• Use of topical lidocaine in the treatment of
  muscle tension dysphonia.Dworkin JP, Meleca RJ,
  Simpson ML, Garfield I.Department of
  Otolaryngology, Head and Neck Surgery, Wayne
  State University School of Medicine, Detroit,
  Michigan 48201, USA. aa1544_at_wayne.eduThis
  investigation explored the potential usefulness
  of topical lidocaine in the treatment of muscle
  tension dysphonia. Three patients with this
  disorder, who were previously unresponsive to
  standard voice therapy, were treated with
  lidocaine. In each case, the outcome was prompt,
  clinically significant, and sustained.
  Persistently high-pitched and shrill vocal
  quality was converted to near normal voice
  patterns within 15 minutes after
  transcricothyroid membrane lidocaine injection.
  We suggest that this temporary and simple
  laryngeal and tracheal anesthetic technique may
  have helped to break the perverse cycle of
  hyperactive glottal and supraglottal muscle
  contractions evident in each of these patients
  during phonation efforts. We discuss the possible
  sensorimotor mechanism of action of this
  therapeutic technique.

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Atypical Presentation (video)
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Psychological/Personality factors MTD

• Issues
• State vs. Trait Factors
• Psychological Factors in Disease
• Cause, Effect or Catalyst

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Psychological/Personality factors MTD

• Empirical findings in a group with MTD
• Neuroticism - ? emotional stability and ?
  reactivity
• ? scores
• Extraversion-sociability, dominance, energy and
  enthusiasm
• ? scores
• Psychoticism impulsivity/aggressiveness (high)
  vs. agreeable/conscientiousness (low)
• Similar to normal controls

Roy et al. (2000)
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Psychological/Personality factors associated with
MTD

• Additionally,
• Anxious
• Somatization physical complaints
• Stress reactive
• Alienated
• Unhappy

Roy et al. (1997)
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MTD compared to Vocal Nodule Patients

• Empirical findings in a group with vocal nodules
• Neuroticism - ? emotional stability and ?
  reactivity
• Mildly ? scores
• Extraversion-sociability, dominance, energy and
  enthusiasm
• ? scores
• Psychoticism impulsivity/aggressiveness (high)
  vs. agreeable/conscientiousness (low)
• ? scores

Roy et al. (2000)
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Functional Dysphonia

• When no structural abnormality exists,
  descriptive terms are often used which imply a
  psychological etiology. For example,
• Psychogenic dysphonia
• Conversion dysphonia
• Hysterical dysphonia

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What is hysterical conversion?

• conversion of psychological stress into
  physical complaints
• Psychiatric literature suggests it arises from
• Bland emotional unconcern/affect
• Numerous physical complaints
• Denial of anxieties and fears

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Is MTD a hysterical conversion?

• This triad of features was not observed with
  patients with broad diagnosis of FD (MTD)
• Patients are typically quite anxious and
  concerned about problem
• Short answer No