sppa 6400 voice disorders tasko functional dysphonia/ muscle tension dysphonia (mtd)

SPPA 6400 Voice Disorders Tasko

Functional Dysphonia/Muscle Tension Dysphonia (MTD)


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


Functional dysphonia vs. muscle tension dysphonia


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


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


Muscle Tension Dysphonia (MTD)Some Trends Occurs predominantly in women (90 %)* May account for > 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)


Recognizing Muscle Tension Dysphonia

Patient history Auditory-perceptual Features Laryngoscopic Features Direct clinical examination:

Manual assessment of laryngeal musculoskeletal tension

Primary or Diagnostic therapy


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


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


Auditory Perceptual FeaturesGenerally… 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


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


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


THOUGHT QUESTION

Why don’t persons with MTD develop laryngeal pathologies?


Laryngoscopic Features Dysregulated muscle activity = myriad of

glottic/supraglottic contraction patterns Rammage & Morrison (2001) suggest a

distinct set of laryngoscopic patterns Controversial


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

Principle feature: posterior glottic chink

Presumed due to ↑ PCA activity

Suggested association with benign mucosal lesions


MTD Type 2a – Glottic Lateral Compression

Lateral compression principally at the glottis

May be some ventricular compression

↑ closed phase ↓ vibratory amplitude


MTD Type 2b – Supraglottic Lateral Compression

Ventricular folds are approximated


MTD Type 3: Anterior-posterior supraglottic compression

↓ distance between anterior and posterior glottis

Arytenoids “pull” toward epiglottis

Associated with “Bogart-Bacall” syndrome


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

Incomplete glottal closure with normal mobility


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

Incomplete glottal closure with normal mobility

Concomitant compression of the ventricular folds


MTD Type 5 – Bowed vocal folds

“Spindle”-shape glottis Also associated with

aging (presbylaryngis or presbyphonia)

Neurologic conditions (Parkinson’s Disease)


NoteRelation between auditory-perceptual judgments and laryngoscopic findings are not straightforward


Direct Clinical AssessmentFocal 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


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)


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

SPPA 6400 Voice Disorders TaskoFrom Aronson (1990)


From Roy et al. (1996)


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)


Manual circumlaryngeal techniquesGoals Determine contribution of laryngeal/extralaryngeal

hypertonicity Assure proper diagnosis and selection of appropriate

treatment Avoid unnecessary medical or surgical management

Show Pre-Post Samples


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


Manual circumlaryngeal techniquesMay be used as primary treatment technique for

musculoskeletal tension dysphonia (MTD) diagnostic therapy to evaluate degree of

contribution of musculoskeletal tension to voice disorder


MCT: Reposturing techniques

1. Compression in the A-P direction (push-back)

2. Impede laryngeal elevation (Pull down)

3. Medial compression and downward traction (Reposturing)

Goal: Perturb the abnormal laryngeal posture and evaluate change in voice quality


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


Technique 2: Pull Down Maneuver

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


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


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


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


Indications for improvement (single session)

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


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…


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


Manual Circumlaryngeal Techniques

Evidence for clinical utility of MCT in Functional dysphonia (muscle tension

dysphonia) Roy et al. (1997) J Voice


Short and long term effects of MCT

N=25 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 %)


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)


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


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)


Examples

Polyp

CVA

Reinke’s edema

Pre-MCT Post-MCT


MCT with BMD Patients

N=18 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 Reinke’s edema 5/18 TVF

irregularities/edema/erythema

1/18 ventricular cyst 1/18 interarytenoid lesion 1/18 post-intubation

granuloma

(Tasko, et al. 1994)


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. [email protected]

This 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.


Atypical Presentation (video)


Psychological/Personality factors & MTD

Issues State vs. Trait Factors Psychological Factors in Disease:

Cause, Effect or Catalyst


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)


Psychological/Personality factors associated with MTD

Additionally, Anxious Somatization – physical complaints Stress reactive Alienated Unhappy

Roy et al. (1997)


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)


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


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


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

sppa 6400 voice disorders tasko functional dysphonia/ muscle tension dysphonia (mtd)

Documents

voice disorders taskosppa

functional voice disorderwhat

extended voice usepain

past history of voice

muscle tension dysphoniasppa

history of vocal symptomssppa

disordered voices

uri symptoms