Muscle tension dysphonia

Last updated
Muscle Tension Dysphonia
Specialty Otolaryngology, Speech Language Pathology [1]
Symptoms changes in voice, hoarse voice, breathy voice [1] [2]
Usual onsetMiddle Age [2]

Muscle tension dysphonia (MTD) was originally coined in 1983 by Morrison [2] and describes a dysphonia caused by increased muscle tension of the muscles surrounding the voice box: the laryngeal and paralaryngeal muscles. [3] MTD is a unifying diagnosis for a previously poorly categorized disease process. It allows for the diagnosis of dysphonia caused by many different etiologies and can be confirmed by history, physical exam, laryngoscopy and videostroboscopy, a technique that allows for the direct visualization of the larynx, vocal cords, and vocal cord motion. [4]

Contents

MTD has been known by other names including muscle misuse dysphonia, hyperfunctional dysphonia, and hyperkinetic dysphonia among others. [1] MTD can be broken in two groups: primary and secondary. Primary MTD occurs without an underlying organic cause while secondary MTD occur due to an underlying organic source. [3]

MTD is more commonly diagnosed in women, [5] [3] the middle aged, [2] and individuals who have high levels of stress. [1] It is also more often seen in those who use their voice often such as singers and teachers. [2]

Etiology

Pathophysiology

The pathophysiology of MTD is multifactorial. [3] [6] Voice production requires the coordination of multiple muscles and other structures in the larynx. [7] Multiple factors cause the muscles of the larynx to become tense. This changes the position of the larynx and affects the cartilaginous structures within the larynx leading to abnormal phonation. [3] There is increased muscle activity in MTD due to personal temperament, increased vocal use, and underlying medical or physical causes. [3]

Primary MTD

Primary MTD has no underlying medical or physical cause and no known psychogenic or neurologic cause. [8] It is caused by increased tension of the laryngeal muscles secondary to personality traits such as anxiety or life factors such as increased stress. [3] Individual with high vocal use like teachers, singers, and others professions with high vocal expectations can also develop MTD. [3] Additionally incorrect use of the voice can cause increased tension and lead to MTD. [3] Primary MTD makes up a significant proportion (as high as 40%) of patients seen for voice complaints. [9]

Secondary MTD

Secondary MTD is caused by an underlying medical or physical reason. [3] Vocal fold lesions such as a vocal fold nodule or other changes in the vocal fold mucosa can lead to increased tension in the larynx and cause dysphonia. [2] Larynogopharyngeal reflux, a process that is similar to GERD, can bring stomach acid into the larynx. This can provoke the larynx to tense to prevent the aspiration of the acid. [3] It also has been found that MTD can occur in postmenopausal women due to decreased hormone levels which lead to swelling of the laryngeal tissues and eventual atrophy. [3] Older men can also develop MTD as their vocal cords thin as they age. [3] Post infectious MTD is also possible. For example during an episode of laryngitis, the muscles of the larynx tense secondary to the inflammation and residual tension can remain following the resolution of the illness. [3]

Signs and Symptoms

The voice quality in MTD can be described as breathy and can also sound harsh. [2] Patients may complain that their voice sounds abnormal as well as needing to strain to produce sound, and having increased dysphonia with increased vocalization. [1]

Diagnosis

A multidisciplinary team including otolaryngologists and speech language pathologists is useful for the evaluation and diagnosis of MTD. [1] It is important to consider other dysphonias in the differential diagnosis.

Physical Exam

Palpation is a key exam maneuver when evaluating MTD. Because of the increased muscle tension of the paralaryngeal and laryngeal muscles, the larynx will be elevated on palpation. [6] To make the exam more objective, various scales have developed to help standardize the process. [10] [11]

Voice Quality

The voice in MTD has been described as hoarse and breathy. [2] MTD can be distinguished for another similar dysphonia, adductor spasmodic dysphonia, by differences in voice characteristics. [12] In MTD, all vocal tasks (vowels, singing, etc) are difficult for the patient while in adductor spasmodic dysphonia, some vocal tasks are difficult while others are unaffected. [12] There are objective parameters that help characterize the degree of dysphonia such as the Dysphonia Severity Index. [13] This index is made up of many measurements of the voice include voice frequency measurements (high and low), maximum phonation time (MPT), and jitter (frequency instability). [13] [14]

Vocal Fold Visualization

Videostroboscopy is the use of a camera to see the larynx and vocal cords. [15] Stroboscopy allows the visualization of vocal cord movement, which vibrate too quickly for human eye to perceive. [15] When assessing the vocal cords, the most common finding in MTD is a posterior glottic gap. [2] Other findings include increased movement of the vocal folds towards one another, and changes in the angles of the vocal fold openings. [15]

Other Diagnosis Modalities

Surface electromyography (sEMG) has been considered as a diagnosis tool for MTD. [16] sEMG can measure the muscle units of the muscles of the larynx to deduce if there is increased activity which means they are more tense. [16] The results of studies using sEMG in MTD is currently mixed. Some studies demonstrate increased EMG levels in MTD [17] [18] while others do not demonstrate a difference in EMG between individuals with MTD and individuals without MTD. [16]

Treatment

Medical Treatment

In secondary MTD, the underlying medical cause should be addressed. Residual infections should be treated. [3] Laryngopharyngeal reflux is treated similarly to GERD with diet and lifestyle adjustments and consideration for a proton pump inhibitor. [3]

Voice Therapy

Voice therapy is commonly used in the treatment of MTD. [7] The goal of voice therapy is to encourage proper vocal used and decrease the tension of the laryngeal muscles. [15] Examples of voice therapy include voice exercises to help increase glottic closure, vocal hygiene, manual laryngeal therapy, respiratory exercises, nasal exercises and frequency modulation amongst other techniques. [15]

Surgery

Surgery may be used as a treatment when there is a vocal lesion such as nodule or polyp that is causing the MTD. [3] There is little utility to surgery in primary MTD. [3]

Related Research Articles

The term phonation has slightly different meanings depending on the subfield of phonetics. Among some phoneticians, phonation is the process by which the vocal folds produce certain sounds through quasi-periodic vibration. This is the definition used among those who study laryngeal anatomy and physiology and speech production in general. Phoneticians in other subfields, such as linguistic phonetics, call this process voicing, and use the term phonation to refer to any oscillatory state of any part of the larynx that modifies the airstream, of which voicing is just one example. Voiceless and supra-glottal phonations are included under this definition.

<span class="mw-page-title-main">Larynx</span> Voice box, an organ in the neck of amphibians, reptiles, and mammals

The larynx, commonly called the voice box, is an organ in the top of the neck involved in breathing, producing sound and protecting the trachea against food aspiration. The opening of larynx into pharynx known as the laryngeal inlet is about 4–5 centimeters in diameter. The larynx houses the vocal cords, and manipulates pitch and volume, which is essential for phonation. It is situated just below where the tract of the pharynx splits into the trachea and the esophagus. The word 'larynx' comes from the Ancient Greek word lárunx ʻlarynx, gullet, throat.ʼ

Vocal cord nodules are bilaterally symmetrical benign white masses that form at the midpoint of the vocal folds. Although diagnosis involves a physical examination of the head and neck, as well as perceptual voice measures, visualization of the vocal nodules via laryngeal endoscopy remains the primary diagnostic method. Vocal fold nodules interfere with the vibratory characteristics of the vocal folds by increasing the mass of the vocal folds and changing the configuration of the vocal fold closure pattern. Due to these changes, the quality of the voice may be affected. As such, the major perceptual signs of vocal fold nodules include vocal hoarseness and breathiness. Other common symptoms include vocal fatigue, soreness or pain lateral to the larynx, and reduced frequency and intensity range. Airflow levels during speech may also be increased. Vocal fold nodules are thought to be the result of vocal fold tissue trauma caused by excessive mechanical stress, including repeated or chronic vocal overuse, abuse, or misuse. Predisposing factors include profession, gender, dehydration, respiratory infection, and other inflammatory factors.

Vocal fold cysts are benign masses of the membranous vocal folds. These cysts are enclosed, sac-like structures that are typically of a yellow or white colour. They occur unilaterally on the midpoint of the medial edge of the vocal folds. They can also form on the upper/superior, surface of the vocal folds. There are two types of vocal fold cysts:

  1. Sub-epithelial vocal fold cysts- located in the superficial lamina propria of the vocal folds.
  2. Ligament vocal fold cysts- located within the deeper layers of the lamina propria or on the vocal ligament.
<span class="mw-page-title-main">Reinke's edema</span> Medical condition

Reinke's edema is the swelling of the vocal cords due to fluid (edema) collected within the Reinke's space. First identified by the German anatomist Friedrich B. Reinke in 1895, the Reinke's space is a gelatinous layer of the vocal cord located underneath the outer cells of the vocal cord. When a person speaks, the Reinke's space vibrates to allow for sound to be produced (phonation). The Reinke's space is sometimes referred to as the superficial lamina propria.

<span class="mw-page-title-main">Laryngitis</span> Medical condition

Laryngitis is inflammation of the larynx. Symptoms often include a hoarse voice and may include fever, cough, pain in the front of the neck, and trouble swallowing. Typically, these last under two weeks.

<span class="mw-page-title-main">Arytenoid cartilage</span> Part of the larynx, to which the vocal folds (vocal cords) are attached

The arytenoid cartilages are a pair of small three-sided pyramids which form part of the larynx. They are the site of attachment of the vocal cords. Each is pyramidal or ladle-shaped and has three surfaces, a base, and an apex. The arytenoid cartilages allow for movement of the vocal cords by articulating with the cricoid cartilage. They may be affected by arthritis, dislocations, or sclerosis.

<span class="mw-page-title-main">Bogart–Bacall syndrome</span> Voice disorder caused by abuse or overuse of the vocal cords

Bogart–Bacall syndrome (BBS) is a voice disorder that is caused by abuse or overuse of the vocal cords.

A hoarse voice, also known as dysphonia or hoarseness, is when the voice involuntarily sounds breathy, raspy, or strained, or is softer in volume or lower in pitch. A hoarse voice can be associated with a feeling of unease or scratchiness in the throat. Hoarseness is often a symptom of problems in the vocal folds of the larynx. It may be caused by laryngitis, which in turn may be caused by an upper respiratory infection, a cold, or allergies. Cheering at sporting events, speaking loudly in noisy situations, talking for too long without resting one's voice, singing loudly, or speaking with a voice that is too high or too low can also cause temporary hoarseness. A number of other causes for losing one's voice exist, and treatment is generally by resting the voice and treating the underlying cause. If the cause is misuse or overuse of the voice, drinking plenty of water may alleviate the problems.

"Voice therapy" or "voice training" refers to any non-surgical technique used to improve or modify the human voice. Because voice is a social cue to a person's sex and gender, transgender people may frequently undertake voice training or therapy as a part of gender transitioning in order to make their voices sound more typical of their gender, and therefore increase their likelihood of being perceived as that gender. Having voice and speech characteristics align with one's gender identity is often important to transgender individuals, whether their goal be feminization, neutralization or masculinization. Voice therapy can be seen as an act of gender- and identity-affirming care, in order to reduce gender dysphoria and gender incongruence, improve the self-reported wellbeing and health of transgender people, and alleviate concerns over an individual being recognized as transgender.

<span class="mw-page-title-main">Contact granuloma</span> Medical condition

Contact granuloma is a condition that develops due to persistent tissue irritation in the posterior larynx. Benign granulomas, not to be confused with other types of granulomas, occur on the vocal process of the vocal folds, where the vocal ligament attaches. Signs and symptoms may include hoarseness of the voice, or a sensation of having a lump in the throat, but contact granulomas may also be without symptoms. There are two common causes associated with contact granulomas; the first common cause is sustained periods of increased pressure on the vocal folds, and is commonly seen in people who use their voice excessively, such as singers. Treatment typically includes voice therapy and changes to lifestyle factors. The second common cause of granulomas is gastroesophageal reflux and is controlled primarily through the use of anti-reflux medication. Other associated causes are discussed below.

Vocal cord paresis, also known as recurrent laryngeal nerve paralysis or vocal fold paralysis, is an injury to one or both recurrent laryngeal nerves (RLNs), which control all intrinsic muscles of the larynx except for the cricothyroid muscle. The RLN is important for speaking, breathing and swallowing.

Spasmodic dysphonia, also known as laryngeal dystonia, is a disorder in which the muscles that generate a person's voice go into periods of spasm. This results in breaks or interruptions in the voice, often every few sentences, which can make a person difficult to understand. The person's voice may also sound strained or they may be nearly unable to speak. Onset is often gradual and the condition is lifelong.

Puberphonia is a functional voice disorder that is characterized by the habitual use of a high-pitched voice after puberty, hence why many refer to the disorder as resulting in a 'falsetto' voice. The voice may also be heard as breathy, rough, and lacking in power. The onset of puberphonia usually occurs in adolescence, between the ages of 11 and 15 years, at the same time as changes related to puberty are occurring. This disorder usually occurs in the absence of other communication disorders.

<span class="mw-page-title-main">Laryngopharyngeal reflux</span> Medical condition

Laryngopharyngeal reflux (LPR) is the retrograde flow of gastric contents into the larynx, oropharynx and/or the nasopharynx. LPR causes respiratory symptoms such as cough and wheezing and is often associated with head and neck complaints such as dysphonia, globus pharyngis, and dysphagia. LPR may play a role in other diseases, such as sinusitis, otitis media, and rhinitis, and can be a comorbidity of asthma. While LPR is commonly used interchangeably with gastroesophageal reflux disease (GERD), it presents with a different pathophysiology.

Vocal cord dysfunction (VCD) is a pathology affecting the vocal folds characterized by full or partial vocal fold closure causing difficulty and distress during respiration, especially during inhalation.

<span class="mw-page-title-main">Voice therapy</span> Used to aid voice disorders or altering quality of voice

Voice therapy consists of techniques and procedures that target vocal parameters, such as vocal fold closure, pitch, volume, and quality. This therapy is provided by speech-language pathologists and is primarily used to aid in the management of voice disorders, or for altering the overall quality of voice, as in the case of transgender voice therapy. Vocal pedagogy is a related field to alter voice for the purpose of singing. Voice therapy may also serve to teach preventive measures such as vocal hygiene and other safe speaking or singing practices.

Thyroplasty is a phonosurgical technique designed to improve the voice by altering the thyroid cartilage of the larynx, which houses the vocal cords in order to change the position or the length of the vocal cords.

Arytenoid adduction is a surgical procedure used to treat vocal cord paralysis. A suture is used to emulate the action of the lateral cricoarytenoid muscle and position the paralyzed vocal cord closer to the midline. This allows the two vocal cords to meet and can improve speaking and swallowing ability for affected patients. Arytenoid adduction is often performed in conjunction with medialization thyroplasty.

<span class="mw-page-title-main">Feminization laryngoplasty</span>

Feminization laryngoplasty is a reconstructive surgery surgical procedure that results in the increase of the pitch of a patient, making the voice sound higher and more feminine. It is a form of Open Laryngoplasty and effectively reaches its goals via a Partial Laryngectomy of the anterior portion of the larynx, thereby diminishing the size of the larynx to cisgender female proportions. It also changes the vocal weight or resonance quality of the voice by diminishing the size of the larynx. It is a type of voice feminization surgery (VFS) and an alternative to vocal therapy. Feminization laryngoplasty is performed as a treatment for both transgender women and non-binary people as part of their gender transition, and women with androphonia. The surgery can be categorized into two main steps: Incision and vocal fold modification followed by thyrohyoid elevation. Risks and complications include granuloma, dysphonia and tracheostomy. Patients are recommended to follow perioperative management such as voice rest to hasten recovery.

References

  1. 1 2 3 4 5 6 Altman, Kenneth W.; Atkinson, Cory; Lazarus, Cathy (June 2005). "Current and Emerging Concepts in Muscle Tension Dysphonia: A 30-Month Review". Journal of Voice. 19 (2): 261–267. doi:10.1016/j.jvoice.2004.03.007. ISSN   0892-1997. PMID   15907440.
  2. 1 2 3 4 5 6 7 8 9 Morrison, M. D.; Rammage, L. A.; Belisle, G. M.; Pullan, C. B.; Nichol, H. (October 1983). "Muscular tension dysphonia". The Journal of Otolaryngology. 12 (5): 302–306. ISSN   0381-6605. PMID   6644858.
  3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Van Houtte, Evelyne; Van Lierde, Kristiane; Claeys, Sofie (March 2011). "Pathophysiology and Treatment of Muscle Tension Dysphonia: A Review of the Current Knowledge". Journal of Voice. 25 (2): 202–207. doi:10.1016/j.jvoice.2009.10.009. ISSN   0892-1997. PMID   20400263.
  4. ↑ Sercarz, Joel A.; Berke, Gerald S.; Gerratt, Bruce R.; Ming, Ye; Natividad, Manuel (July 1992). "Videostroboscopy of Human Vocal Fold Paralysis". Annals of Otology, Rhinology & Laryngology. 101 (7): 567–577. doi:10.1177/000348949210100705. ISSN   0003-4894. PMID   1626902. S2CID   22044354.
  5. ↑ Roy, Nelson (June 2003). "Functional dysphonia". Current Opinion in Otolaryngology & Head and Neck Surgery. 11 (3): 144–148. doi:10.1097/00020840-200306000-00002. ISSN   1068-9508. PMID   12923352. S2CID   18595200.
  6. 1 2 Khoddami, Seyyedeh Maryam; Nakhostin Ansari, Noureddin; Izadi, Farzad; Talebian Moghadam, Saeed (2013). "The Assessment Methods of Laryngeal Muscle Activity in Muscle Tension Dysphonia: A Review". The Scientific World Journal. 2013: 507397. doi: 10.1155/2013/507397 . ISSN   1537-744X. PMC   3834625 . PMID   24319372.
  7. 1 2 da Cunha Pereira, Gabriela; de Oliveira Lemos, Isadora; Dalbosco Gadenz, Camila; Cassol, Mauriceia (September 2018). "Effects of Voice Therapy on Muscle Tension Dysphonia: A Systematic Literature Review". Journal of Voice. 32 (5): 546–552. doi:10.1016/j.jvoice.2017.06.015. ISSN   0892-1997. PMID   28739332. S2CID   44364291.
  8. ↑ Verdolini, Katherine (2014-04-08). Verdolini, Katherine; Rosen, Clark A.; Branski, Ryan C. (eds.). Classification Manual for Voice Disorders-I. doi:10.4324/9781410617293. ISBN   9781410617293.
  9. ↑ Lowell, Soren Y.; Kelley, Richard T.; Colton, Raymond H.; Smith, Patrick B.; Portnoy, Joel E. (2012-01-17). "Position of the hyoid and larynx in people with muscle tension dysphonia". The Laryngoscope. 122 (2): 370–377. doi:10.1002/lary.22482. ISSN   0023-852X. PMID   22252849. S2CID   28727823.
  10. ↑ Angsuwarangsee, Thana; Morrison, Murray (September 2002). "Extrinsic Laryngeal Muscular Tension in Patients with Voice Disorders". Journal of Voice. 16 (3): 333–343. doi:10.1016/s0892-1997(02)00105-4. ISSN   0892-1997. PMID   12395986.
  11. ↑ Kooijman, P.G.C.; de Jong, F.I.C.R.S.; Oudes, M.J.; Huinck, W.; van Acht, H.; Graamans, K. (2005). "Muscular Tension and Body Posture in Relation to Voice Handicap and Voice Quality in Teachers with Persistent Voice Complaints". Folia Phoniatrica et Logopaedica. 57 (3): 134–147. doi:10.1159/000084134. ISSN   1021-7762. PMID   15914997. S2CID   30712211.
  12. 1 2 Roy, Nelson (June 2010). "Differential diagnosis of muscle tension dysphonia and spasmodic dysphonia". Current Opinion in Otolaryngology & Head and Neck Surgery. 18 (3): 165–170. doi:10.1097/MOO.0b013e328339376c. ISSN   1068-9508. PMID   20389245. S2CID   5483819.
  13. 1 2 Wuyts, Floris L.; Bodt, Marc S. De; Molenberghs, Geert; Remacle, Marc; Heylen, Louis; Millet, Benoite; Lierde, Kristiane Van; Raes, Jan; Heyning, Paul H. Van de (June 2000). "The Dysphonia Severity Index". Journal of Speech, Language, and Hearing Research. 43 (3): 796–809. doi:10.1044/jslhr.4303.796. ISSN   1092-4388. PMID   10877446.
  14. ↑ Teixeira, João Paulo; Oliveira, Carla; Lopes, Carla (2013). "Vocal Acoustic Analysis – Jitter, Shimmer and HNR Parameters". Procedia Technology. 9: 1112–1122. doi: 10.1016/j.protcy.2013.12.124 . hdl: 10198/11033 . ISSN   2212-0173.
  15. 1 2 3 4 5 Casiano, Roy R.; Zaveri, Vijaykumar; Lundy, Donna S. (July 1992). "Efficacy of Videostroboscopy in the Diagnosis of Voice Disorders". Otolaryngology–Head and Neck Surgery. 107 (1): 95–100. doi: 10.1177/019459989210700115 . ISSN   0194-5998. PMID   1528610. S2CID   9792644.
  16. 1 2 3 Van Houtte, Evelyne; Claeys, Sofie; D'haeseleer, Evelien; Wuyts, Floris; Van Lierde, Kristiane (March 2013). "An examination of surface EMG for the assessment of muscle tension dysphonia". Journal of Voice. 27 (2): 177–186. doi:10.1016/j.jvoice.2011.06.006. ISSN   1873-4588. PMID   21889301.
  17. ↑ Redenbaugh, Margaret A.; Reich, Alan R. (Feb 1989). "Surface EMG and Related Measures in Normal and Vocally Hyperfunctional Speakers". Journal of Speech and Hearing Disorders. 54 (1): 68–73. doi:10.1044/jshd.5401.68. ISSN   0022-4677. PMID   2915528.
  18. ↑ HOCEVAR-BOLTEZAR, I.; JANKO, M.; ZARGI, M. (Jan 1998). "Role of Surface EMG in Diagnostics and Treatment of Muscle Tension Dysphonia". Acta Oto-Laryngologica. 118 (5): 739–743. doi:10.1080/00016489850183287. ISSN   0001-6489. PMID   9840515.
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