Extreme
MAKEOVER
Larynx edition
Diagnosis and Treatment of Muscle
Tension Dysphonia
Starr Cookman, M.A., CCC-SLP
“A rose by any other name . . . ”

Functional Dysphonia
– Vocal disruption without organic cause
– Also called:








Hyperfunctional Dysphonia
Psychogenic Dysphonia (Aphonia)
Non Organic Dysphonia
Vocal Hyperfunction
Muscular Tension Dysphonia
Hyperkinetic Dysphonia
Laryngeal Tension-Fatigue Syndrome
Laryngeal Isometric Dysphonia
Classification System,
Koufman & Blalock 1991

Functional Dysphonia (Umbrella Term)
– 6 Subtypes
 Conversion
 Habituated Hoarseness
 Inappropriate Falsetto
 Vocal Abuse Syndromes
 Post Operative Dysphonia
 Relapsing Aphonia
Vocal Abuse Syndromes
Tension Fatigue Syndrome
 Bogart-Bacall Syndrome
 Nodules
 Reinke’s Edema
 Vocal Process Ulcer/Granuloma

Muscular Tension Dysphonia
(MTD)

Morrison
– “Inability of the arytenoids to come together”
 Posterior Glottal Gap

Over-specificity later corrected
– MTD separated into 4 types
 Type
 Type
 Type
 Type
1
2
3
4
=
=
=
=
PGG
Ventricular Compression
Anterior-Posterior Compression
Spincteric Larynx
Challenges

“Functional Dysphonia”
– Implies voluntary “misuse” of the larynx
– Not descriptive

Subtypes are numerous
– Over classification
– No evidence of generalization into voice clinics
Proposed Classification System

Umbrella Term: Muscle Tension
Dysphonia (Aphonia)
– Vocal disruption resulting from an imbalance
of laryngeal musculature
– Advantages
 Descriptive
 Does not imply etiology
 Easier for patient
4 Subtypes of MTD
Psychogenic
 Habituated
 Compensatory
 Contributory

Psychogenic MTD

Onset
– Sudden
– Can be linked to psychologically disruptive
event
– No concomitant URIs

Progression
– Usually little to no change over time
Psychogenic MTD (cont.)

Voice quality
– aphonic, whispery, monotone, constant,
severe dysphonia, glottal fry, vegetative tasks
are normal

Acoustic Studies
– Yanigahara hoarseness rating 3-4
– Elevated perturbation measures
– Abnormal fundamental frequency
Psychogenic MTD (cont.)

Laryngeal Presentation
– Structure = normal
– Function = Arytenoids held open, arytenoids
pressed, ventricular compression, sphincteric
supraglottis, arytenoids mobile

EMG
– Normal

Response to speech therapy
– Excellent
Habituated MTD

Etiology
– Associated with laryngeal disturbance
 Chemical exposure
 Upper respiratory infection
 Laryngeal Trauma
 Reflux
 Laryngeal Surgery
Habituated MTD (cont.)

Progression
– Extended course
– Consistent voice quality across
time/settings
– Patient complains of laryngeal pain/ fatigue
– Secondary gain may be present
Habituated MTD (cont.)

Voice Quality
– glottal fry, breathiness, roughness,
diplophonia, sustained phonation worse than
conversation, abnormal pitch/register
(falsetto), vegetative tasks are normal
– Acoustics
– Yanigahara 2 - 3
– Elevated perturbation
– Range restrictions
Habituated MTD (cont.)

Laryngeal Presentation
– Structure = normal
– Function = poor vibratory coordination, poor
vocal fold closure, ventricular compression,
anterior - posterior compression

EMG
– normal

Response to speech therapy
– Excellent
Compensatory MTD

Onset
– Laryngeal event (URI/Trauma/Surgery), aging
process, compromised pulmonary status

Progression
– Consistent dysphonia including veg tasks
– Some change over time is possible
– Patient complains of increased effort and
fatigue
Compensatory MTD (cont.)

Voice Quality
– Breathy, diplophonia, glottal fry

Acoustic Findings
– Abnormal fundamental frequency
– Yanigahara 1-4
– Variety of perturbation measures
Compensatory MTD (cont.)

Laryngeal Findings
– Structure = normal
– Function = poor vocal fold closure, posterior
glottal gap, sluggish arytenoid movement,
asymmetry VF vibratory characteristics

EMG
– Abnormal (Haglund, et. al. 10 of 18
“functional dysphonia” patients = abnormal
EMG of CT and/or TA)
Compensatory MTD (cont.)

Response to speech therapy
– Variable
 “unloading” tension may help diagnostic clarity
and surgical result
 Usually underlying pathology (usually glottic
insufficiency) needs to be addressed as well
Contributory MTD

Onset
– gradual, after extensive vocal use, yelling,
screaming, poor vocal hygiene

Progression
– No fluctuations
– Worsens if not treated
– Worsens with use
– Patient complains of pain/fatigue/increased
effort
Contributory MTD (cont.)

Vocal Quality
– raspy, rough, breathy, normal prosody,
increased rate, dysphonia consistent across
task and environment, loud speech, hard
glottal attacks, sustained phonation similar to
speech

Acoustic Findings
– Normal to low Fo, restricted range (usually
high restrictions), Yanigahara type 1-2,
elevated perturbation
Contributory MTD (cont.)

Laryngeal Presentation
– Structure = Pathology
 nodules, edema, posterior contact
ulcers/granuloma, polyps
– Function = vibratory restrictions, arytenoid
movement well coordinated, posterior
glottal gap, mild ventricular compression
and/or mild anterior-posterior compression
Contributory MTD (cont.)

EMG
– normal

Response to speech therapy
– variable
Contributory MTD (cont.)

Jiang and colleagues, 1998 Ann Otol
Rhinol & Laryngol (107)
– Computer modeling of laryngeal vibration
 Normal
 Tense (tension in TA)
 Nodule
– Findings
 Intraepithelial mechanical stress increases at the
midpoint of the membranous vocal folds under
condition of muscular tension
Describing Laryngeal
Configuration
Formerly MTD types 1-4
 Use descriptive terms

– PGG
– Ventricular Compression
– Anterior-Posterior Supraglottic Compression
– Sphincteric Glottis

Additional type: Thyroarytenoid Tension?
Posterior Glottal Gap
Considered a normal
finding for many
females
 Problematic when
seen in conjunction
with nodules or poor
vibratory
characteristics
 Describe extent of
gap

Ventricular Compression
Mild - Severe
 Usually symmetrical
 Can be primary
source of phonation

Anterior-Posterior Supraglottic
Compression
Mild - Severe
 Normal finding at
extremes of range
for singers
 Best diagnosed with
flexible endoscopy
 Normal for some
vowels

Sphincteric Glottis
Both ventricular and
AP compression
 View of vocal folds
obscured
 Rare
 Usually
Compensatory MTD
or conversion MTD

Clinical Application of
Classification System
Replace “Functional Dysphonia” with
“Muscle Tension Dysphonia”
 Describe type of MTD as one of 4 types
 Describe glottic/supraglottic configuration
 Example

– “Patient presents with habituated muscle
tension dysphonia s/p URI as characterized by
moderate ventricular compression”
Diagnostic Considerations for
MTD
Intake Interview
 Perceptual Evaluation
 Acoustic Evaluation
 Aerodynamic Evaluation
 Medical Evaluation
 Videolaryngostroboscopy
 Laryngeal and cervical neck palpation
 Diagnostic Probes

Intake Interview

Special attention to . . .
–
–
–
–

Onset
Progression – previous treatment modalities
Anxiety/stress factors and management
Vocal load
Tools
– VHI (Jacobson)
– Vocal Tract Discomfort (VTD) scale (Mathieson, et.al.,
2009, J of Voice)

Build rapport through unconditional positive
regard; reflecting; listening; non-judgmental
affect
Vocal Tract Discomfort Scale (VTD)
Mathieson, et.al., 2009 J of Vx
Frequency
of sensation/sympt.
Burning
1 2 3 4 5 6
1 2 3 4 5 6
2.
Tight
1
2
3
4
5
6
1 2
3
4
5
6
3.
Dry
1
2
3
4
5
6
1 2
3
4
5
6
4.
Aching
1 2 3 4 5 6
1 2 3 4 5 6
5.
Tickling
1
2
3
4
5
6
1 2
3
4
5
6
6.
Sore
1
2
3
4
5
6
1 2
3
4
5
6
7.
Irritable
1 2 3 4 5 6
1 2 3 4 5 6
8.
Lump in the Throat
1
1 2
1.
0 = never
2 = sometimes
4 = often
6 = always
Severity
of sensation/sympt
2
3
4
5
6
3
4
5
6
Intake Interview

Common PT. complaints
–
–
–
–
–
–
–
–
–
Hoarseness
Vocal fatigue
Vocal strain
Pain on or after phonation
“Tightness” in throat
Voice loss
Unable to project
Globus
Loss of pitch range
Perceptual Evaluation
Visual tensions – jaw; forehead; SCM;
larynx
 GRBAS scale
 Breath behaviors
 Glottal attacks, rate of speech, throat
clearing, inappropriate intensity, fry tone,
low pitch,
 Look for task specificity

Perceptual Evaluation
Perceptual worsening of dysphonia for SD
for voiced vs. voiceless consonants; no
change for MTD
 Perceptual worsening in SD from sustained
/a/ to connected speech; MTD no change

– Roy, el.al., (2007) Folia Phoniatric Logo and (2005)
Laryngoscope
Acoustic Evaluation
Fo; MTD; Fo range; MDVP (jitter, shimmer and
variation; degree of unvoiced signal)
 S:Z
 Spectrograph

– ADSD vs MTD (Roy, et.al., Laryngoscope, 2008;
Sapienza, et.al., 2000 J of Voice)
– Phonatory breaks (complete interruption of phonation
within a word) ADSD > MTD
– SD – increase dysphonia with increase in task
complexity
MTD vs. SD (cont.)

Spectrograms from ADSD vs MTD
differenciated with 94% and 98%
accuracy by SLP raters
– Rees, et. al., (2007) Oto. HN Surgery
Spectrograph: Diagnostic Tool
ADSD
MTD
Aerodynamic Evaluation

PAS
– Subglottal pressure
 cmH2O
 Above NL
– Glottal airflow
 mL/s
 Below NL
– Estimated Laryngeal Resistance
 cm/H2O/L/s
 Above NL
Medical Evaluation

Contributions to MTD
– Tissue sensitivity
– Neurological abnormality
– Pulmonary abnormality
– Glottic insufficiency

Common medical findings
– GERD 49%
– Allergies 37%
Altman, et.al. 2005, J of Vx. N = 150 MTD
Stroboscopy

Glottic Configuration
– Ventricular Compression
– A-P supraglottic compression
– Sphincteric glottis
– PGG
– Glottic constriction on inspiration (n=15 MTD;
15 controls) Vertigan, et.al., 2006, Laryngoscope
 Stability
Stroboscopy (cont.)

Other findings
 Paresis or paralysis
 VF atrophy
 Secondary lesions (location)
 Primary lesions

Diagnostic Probes
Stroboscopy (cont.)

Pattern of Muscular Tension
– Few aberrant laryngeal behaviors appeared
unique for spasmodic dysphonia versus
muscle tension dysphonia
– Patterns of laryngeal tension did seem to
differentiate
– SD = intermittent; associated with phonetic variability
– MTD = consistent from task to task
 Tremor only found with SD
Leonard & Kendall, 1999. Laryngoscope
Palpatory Evaluation







Determine sites and levels of muscle tenderness,
tension and resistance
Hyoid and Larynx elevated
Some cases larynx is forcibly depressed
Larynx resists lateral displacement
TH space constricted and painful to the touch
(less so with ADSD)
Submandible bulging/tight
SCMs tight and tender
Diagnostic Probes
Laryngeal Relaxation Humming Vegetative
Manip
Tasks
Psychogenic
MTD
Habituated
MTD
Compensatory
MTD
Contributory
MTD
Y
N
N
Y
Y
Y
Y
Y
Y
N
N
N
Y
Y
Y
N
Treatment for MTD
Efficacious
 Differentiates SD from MTD
 1 to 25 sessions of trp

– More severe cases tend to need fewer
sessions
Treatment Protocol

Medical management of irritation
– Few cases of PPI curing MTD (Mesuda, et.al.,
2007, Japanese journal with a big long name,
n=3)
Education/Counseling
 Direct therapy

Education/Counseling

Listen
– Cue to relatable aspects of Pt.
– Determine vocal intelligence
– Establish open body language
– Be prepared for tears

Reassure
– We do not think this is “in your head”

Show
Treatment Modalities

Direct Therapy
– Manual Circumlaryngeal Therapy (MCT)
– LMRVT
– Breath and Alignment Retraining
– Auditory Masking
– Biofeedback
– Shaping from Vegetative Tasks
– Estill Voice Training System
MCT
Goal: Relax excessively tense peri-laryngeal and
laryngeal musculature inhibiting norm. phon.
 Massage = relax & reduce discomfort
 Based on Aaronson laryngeal musculoskeletal
reduction approach (1990)

 circular movements made with thumb/finger applied to TH
space from ant. to post. as well as over thyroid cart.
 Larynx coaxed side-to-side and down
 Vocalizations are coached and shaped to speech
MCT

Benefits shown in literature
– Dcrs perceptual severity ratings
– Dcrs perturbation values
– Dcrs first three formants
– Improved maximum phonation time
– Roy and colleagues (1993, 1997 & 2001)
MCT

Dysphonia Severity Index reduced
– DSI = weighted MPT, highest Fo, Lowest dB
and jitter
Van Lierde, et.al., in press, J of Voice. n=10 MTD. No
change in Ab brthg tx grp. Also, Van Lierde, et.al.,
2004, J of Vx. N = 4)
MCT

111 female MTD pt. demo improved
speech continuity (changes in VT)
– diphthong 2nd formant slope increased
– Vowel Space Area incrsd
– Vowel Artic Index incrsd
– Global speech rate incrsd
– Dromey, et.al., 2008, JSLHR
– Roy, et.al., 2009, J of Comm Dis.
Laryngeal Massage Therapy

Differs from CMT:
–
–
–
–
T-H space not directly addressed
Patient silent
Patient’s rate VTD before and after
Primarily bimanual

Goal: reducing laryngeal height and hyperengaged supralaryngeal musculature

Reduction of RAP and VTD severity and
frequency
 (Mathieson, et.al., 2009, J of Voice. N = 10 MTD)
Lessac-Madson Resonant Vx Tx
(LMRVT)
Cranial/facial sympathetic vibration
 MTD seems to prevent
 Works directly with filter
 Works indirectly with source

Breath/Alignment Retraining

Reduce cervical/neck tension
– Abdominal, rather than cervical displacement
during inhalation
– Adjust alignment to head/neck (ears over
shoulders)
– Stretches
– Self massage – jaw/larynx/SCMs
– Improve breath flow
Auditory Masking
Disrupts auditory feedback loop
 Encourages return to normal muscular
coordination
 Facilitator by Kay Elemetrics, SoundPro
by Resound, audiometer.

Biofeedback

Surface EMG
– Elevated peri-oral and peri-laryngeal EMG
activity before and during phonation in MTD
population (Hocevar - Boltezar, et. al. 1998)
– Evidence that patients can reduce this activity
using EMG biofeedback (Stemple, et. al.
1980)
Phonatory Aerodynamic System
 Endoscopy

– Improved “vocal intelligence” for some
Vegetative Tasks







Yawn
Throat Clearing
Coughing
Gargle
Grunt
Giggle
Sigh
Cry
 Laughter
 Animal Sounds
 Hum

Estill Voice Training System
Jo Estill, Singer/Speech Pathologist
 Laryngeal and vocal tract positioning for
different singing styles
 11 manipulations

– 4 source
– 6 filter (pharynx, tongue, soft palate,
aryepiglottic space)
– False Fold Retraction
Intervention Strategies
by MTD Type

Compensatory
– Un-loading (LMT; RVT; Education; breath/alignment)

Contributory
– Un-loading (LMT; RVT; Education; breath/alignment)

Psychogenic
– MCT/LMT combo

Habituated
– MCT/LMT combo
If Therapy Fails
Reconsider Diagnosis
 Experimental techniques

– Botox injection to ventricular folds
– Lidocaine bath

Referrals
–
–
–
–
–
–
Otolaryngology
Psychology
Neurology
Pulmonology
Allergy
Gastroenterology