Muscle Tension Dysphonia in Vietnamese Female

Teachers
*,Duong Duy Nguyen, Dianna T. Kenny, Ninh Duy Tran, and kJonathan R. Livesey, *xThai Nguyen city, Vietnam, and
yzkSydney, Australia

Summary: There has been no published research on muscle tension dysphonia (MTD) in speakers who use a tonal
language. Using a sample of 47 Northern Vietnamese female primary school teachers with MTD, we aimed to discover
whether professional voice users of tonal languages presented with the same symptoms of MTD as speakers of nontonal
languages and whether they presented with additional symptoms as a result of speaking a tonal language. The vocal
characteristics were assessed by use of a questionnaire and expert perceptual evaluation. Laryngeal features were assessed by photolaryngoscopy. The results showed that MTD was associated with a larger number of vocal symptoms
than previously reported. However, the participants did not have the same vocal symptoms reported in English speakers,
for example, hard glottal attack, pitch breaks, unusual speech rate, and glottal fry. Factor analysis of the vocal symptoms
revealed three factors: vocal fatigue/hyperfunction, physical discomfort, and voice quality, all of which demonstrated high reliability. The major laryngeal characteristic was a glottal gap. The glottal shapes observed included:
44.7% had an incomplete closure, 29.8% a posterior gap, 12.8% an hourglass-shaped gap, 8.5% a spindle-shaped
gap, and 4.3% had complete glottal closure. The findings implied a potential contribution of linguistic-specific factors
and teaching-related factors to the presentation of this voice disorder in this group of teachers.
Key Words: Muscle tension dysphoniaTeaching voiceGlottal gap.
INTRODUCTION
Muscle tension dysphonia (MTD) is a voice disorder in the absence of current organic laryngeal pathology, without obvious
psychogenic and neurologic etiology.1 It is characterized by
a generalized increase in muscle tension in the larynx and paralaryngeal areas associated with vocal abuse.2,3 The syndrome is
seen commonly in young and middle-aged people with extensive voice use in stressful situations.4 The laryngeal features
of MTD include a posterior glottal gap4 and supraglottic hyperfunctional activities, that is, anteroposterior (AP) contraction
and lateral ventricular fold adduction.3 Voice therapy is the major method of treatment because the disorder results from functional problems related to improper use of the laryngeal muscles
in phonation rather than a structural change in the larynx.3
The etiology of the increased laryngeal muscle tension is
multifactorial.5 However, the above definition excludes some
voice disorders of other etiologies that share clinical features
with MTD. The first is dysphonia in relation to psychological
phenomena, which also has considerable supraglottic activities6
and in many situations it is difficult to differentiate it from MTD
without referring to its etiology. Morrison and Rammage2
maintain that a diagnosis of psychogenic dysphonia should
only be given to muscle misuse disorders that have a clear priAccepted for publication September 6, 2007.
Presented at the Voice Foundations 36th Annual Symposium: Care of the Professional
Voice, May 29June 3, 2007, The Westin Philadelphia, Philadelphia, Pennsylvania, USA.
From the *Department of Otolaryngology, Thai Nguyen General Central Hospital, Thai
Nguyen city, Vietnam; yFaculty of Health Sciences, The University of Sydney, Sydney,
Australia; zFaculty of Health Sciences and the Australian Centre for Research in Music
Performance, The University of Sydney, Sydney, Australia; xDepartment of Otolaryngology, Thai Nguyen Medical College, Thai Nguyen University, Thai Nguyen city, Vietnam;
and the kVoice Connection at the North Shore Medical Centre and the Voice Clinics at the
St. Vincents Hospital, Sydney, Australia.
Address correspondence and reprint requests to Duong Duy Nguyen, Department of
Otolaryngology, Thai Nguyen General Central Hospital, Luong Ngoc Quyen Street,
Thai Nguyen city, Vietnam. E-mail: duongtmh@gmail.com
Journal of Voice, Vol. 23, No. 2, pp. 195-208
0892-1997/$36.00
2009 The Voice Foundation
doi:10.1016/j.jvoice.2007.09.003

mary psychoemotional etiology defined using standard psychiatric evaluations. Sapir7 suggests that psychogenic dysphonia
should be suspected when three criteria are satisfied: symptom
incongruity (ie, the dysphonia is physiologically incongruent
with the existing disease, internally inconsistent, and incongruent with other speech and language findings); symptom reversibility (ie, the voice completely returns to normal state with
short-term voice therapy or psychotherapy); and symptom psychogenicity (ie, the dysphonia occurs in logical linkage at the
time of onset, course, and severity to an identifiable psychological stimulus).7 The second is laryngeal focal dystonia, that is,
adductor spasmodic dysphonia, which is characterized by action-induced, task-specific hyperadduction of the vocal folds.1
Various techniques have been suggested to differentiate this
neurogenic condition from MTD, for example, acoustic voice
analyses.8 Additionally, there is also an increased muscle tension known as secondary MTD as an attempt to compensate
for a glottal incompetence in an organic voice disorder such as
vocal fold paralysis. In this condition, the characteristics of the
dysphonia and the choice of treatment methods are substantially influenced by the primary organic pathology rather than
the disordered muscle tension and the diagnosis of MTD is normally not given even in mucosal pathologies occurring as a consequence of vocal hyperfunction as in the case of vocal nodules.
Despite its wide recognition and description, no published
study has investigated clinical characteristics of MTD in a population of tonal language speakers, for example, Vietnamese. It
is possible that phonation differences between tonal and nontonal languages are related to the different uses of the larynx
in languages, which may affect the characteristics of this voice
disorder in each type of language. In tonal languages, there are
specific phonological features that are not usually present or are
not linguistically significant in nontonal languages. This typically results from the cross-linguistic use of the glottis associated with the various states of the vocal folds.9 In tonal
languages, the glottis is configured for different phonation types

196
such as laryngealization and breathiness.9 In Vietnamese, for
example, laryngealization is produced in the broken tone and
the dropped tone as a contrastive cue and breathiness is associated with the falling tone as a tonal enhancement feature.10
Tonal languages also use pitch variation to convey lexical information. In Vietnamese, pitch variation creates six tonal distinctions, including one level tone, two falling tones, one rising
tone, and two concave tones. Additionally, there may also be
supraglottic involvement in lexical tone production, which
has not been well understood. It is not yet known whether there
is a relationship between phonological characteristics in a tonal
language and the probability of acquiring a functional voice disorder and if so, whether its clinical manifestations differ between tonal and nontonal language speakers. Examining
characteristics of MTD in tonal language speakers would help
clarify this problem and give insight into whether linguisticspecific factors play any role in this voice disorder, which
would form the basis for understanding the interaction between
linguistic-specific and pathology-specific factors.
Because the physiological basis for lexical tones are the laryngeal muscles,11 functional problems associated with MTD
may affect tone production, causing tone misperception. This
can be reflected by two aspects. Firstly, linguistic phonation
types may not be properly produced in speakers with MTD.
For example, laryngealization is produced with a tightly adducted posterior glottis so that the vocal folds only vibrate in
the anterior parts.9 Meanwhile, MTD is believed to have
a posterior glottal gap due to the excessive contraction of the
posterior cricoarytenoid muscle during phonation.12 This phenomenon clearly interferes with laryngealization. In Vietnamese, the broken tone phonated without laryngealization will
be heard as the rising tone. Secondly, abnormal laryngeal muscle tension may restrict pitch variation, which affects the realization of lexical contrasts in tonal languages. This is possible
because previous studies on both nontonal and tonal language
speakers have found evidence of pitch problems in MTD subjects. For example, Morrison et al reported pitch breaks and inappropriate pitch.13 Koufman and Blalock3 found reduction in
vocal range and pitch lock. In Vietnamese speakers, Nguyen
and Kenny14 found that tone height was decreased in high tones,
and pitch movement were affected in the falling tone and rising
tone in those who had MTD. Understanding the characteristics
of MTD in tonal language speakers would help explain mechanisms of tone production in this disorder.
MTD is often seen in professional voice users, such as teachers
because of their high vocal demands. Teachers are at high risk of
developing voice disorders in general15 and MTD in particular.16
However, to date no study has investigated MTD in school
teachers. This voice disorder can negatively affect their job performance, threaten their career, and result in financial difficulties
due to job absence and medical care. Furthermore, teachers who
use a tonal language may have difficulties in tone phonation if
they suffer from MTD. This may affect tone perception by listeners, impairing the intelligibility of speech conveyed to students. Therefore, data on the characteristics of this voice
disorder in teachers would be useful for early diagnosis and management of voice disorders in this population, given that MTD

Journal of Voice, Vol. 23, No. 2, 2009

may be an antecedent of vocal fold lesions,13 which require

more complicated protocols and longer treatment time.
The aims of the present study were to (1) assess vocal symptoms of MTD in Northern Vietnamese primary school teachers
and compare them with those reported previously in nontonal
language speakers and (2) examine laryngeal symptoms of
MTD in Northern Vietnamese primary school teachers.

METHODS
Participants
Participants were recruited from 14 primary schools in the city
of Thai Nguyen (Thai Nguyen province, Northern Vietnam,
76 km North of Hanoi) using school-based survey and screening examination with the permission of the head of the Department of Education and Training. In total, 500 teachers were
surveyed and 416 returned survey questionnaires. Based on
the results of school-based surveys, teachers who reported voice
symptoms were invited to undertake a laryngeal examination.
Teachers with voice problems were reluctant to go to hospital
to attend voice and laryngeal examination, citing the complex
administrative procedures in hospitals and reluctance to leave
their students as disincentives to hospital attendance. Therefore,
schools arranged a time in the working day where examinations
could be conducted in the medical room in the school. Examinations were carried out in the first hour of the teaching day
(89 AM) to obtain data before potential changes in the vocal apparatus related to teaching during the day. On the day of the examination, an otolaryngologist performed a perceptual voice
assessment and laryngeal examination on all teachers with
voice problems. Those who were diagnosed with MTD completed a data collection questionnaire (described below) about
their vocal symptoms and other details related to MTD as relevant to the aims of this study. Those diagnosed with other voice
disorders were consulted about further examination and treatment but were not included in the present study.
Forty-seven primary school teachers were diagnosed with
MTD during the period from September 2005 to July 2006.
The mean age of the participants was 42.8 years (SD 8.6),
ranging from 22 to 54 years. All participants were female.
Mean duration of occupation of the participants was 22.5 years
(SD 8.7), ranging from 1 to 33 years. On average, participants
taught 5.98 hours per day (ranging from 3 to 8 hours per day), 5
days per week.
Diagnostic criteria included a problem with the voice, for example, hoarseness; no organic lesions on the vocal folds; signs
of vocal hyperfunction, for example, supraglottic constriction
and increased external laryngeal muscle tonicity; normal hearing; and nonsmoker.
Teachers with organic lesions of the vocal folds, for example,
laryngitis, vocal nodules, polyps, and Reinkes edema were excluded. The study also excluded teachers who had a history of
psychological problems preceding the onset of dysphonia, signs
of psychological problems at the time of study, spasmodic
dysphonia, acute respiratory tract infection, rheumatoid arthritis,
history of neck or chest trauma, and history of laryngeal surgery.

Duong Duy Nguyen, et al

MTD in Teacher

Data collection
Questionnaire. The questionnaire contained 37 short answer
and multiple-choice questions on personal and occupational details, voice usage, voice care, history of voice problems, and current voice problems (Appendix 1). Participants indicated whether
or not they encountered voice problems and other uncomfortable
signs in the throat, neck, chest, and breathing associated with phonation. Participants also gave an overall self-rating of their voice
using a five-point equal-appearing interval (EAI) scale: 1 very
good, 2 good, 3 fair, 4 bad, and 5 very bad. They
were also asked to rate each of the symptoms they had: 1 slight,
2 mild, 3 moderate, and 4 severe. Participants were offered support to complete the questionnaire if needed.
Voice assessment and laryngeal examination. The
voice and laryngeal examinations for the MTD participants
were parts of the screening examination mentioned above and
the results were recorded on an assessment form (Appendix
2). The examiner evaluated the voices of the participants for
symptoms in pitch, intensity, voice quality, and tone phonation.
He also gave an overall rating score for the severity of dysphonia in each participant using a six-point EAI scale with 0 being
normal and 5 severe.
Participants then underwent a laryngoscopy and neck examination. Instruments included a 90 rigid telescope (Hawk Optical Electronic Instruments Co., Ltd., Zhejiang, China) with
a light fountain (OLYMPUS CLV-S30, Shirakawa Olympus
Co., Ltd. Fukushima, Japan). A digital video camera (OLYMPUS OTV-S6) was connected to the telescope. The output of
the camera was connected to a video capture board that was input to a laptop computer, which was used to take digital images
of the larynx during examination. These instruments were considered suitable for examination at schools, where more complicated procedures such as transnasal flexible strobolaryngoscopy
was not suitable. During the procedure, participants were seated
in a comfortable posture to avoid overall muscle tension that
may cause involuntary tension or gag reflex. Two sprays of Xylocaine 10% solution were applied into the posterior mouth cavity. The use of local anesthetic was considered necessary to
avoid excessive gag reflex. This was not expected to affect hyperfunctional behaviors of participants because previous research has found no significant interference of local anesthetic
with laryngeal movement during laryngoscopy.17 The examiner
used a small strip of gauze to hold the participants protruded
tongue and inserted the telescope to the intended position in
the posterior mouth cavity. The participant was required to produce a stably sustained /i/ sound for at least 5 seconds. An assistant helped the examiner with taking the photographs.
After the procedure, the examiner made ratings of the laryngeal findings using the assessment form. The larynx was assessed at the glottic and supraglottic levels. At the glottic
level, glottal shape, vocal folds, and the arytenoid cartilages
were assessed. The vocal fold was examined for smoothness
and straightness of the vibrating edge and mucosa (color, edema,
and mucus); the arytenoids were evaluated for symmetry, mobility, and mucosa. At the supraglottic level, the degree of AP contraction and ventricular fold adduction (lateral contraction) were

197
assessed. The AP contraction was rated from absence to vocal fold obscured. The lateral contraction was also rated from
absence to vocal fold obscured. Tonicity of the external laryngeal muscles and the vertical position of the larynx during
phonation were also evaluated.
Statistical methods
Data were managed with Microsoft Access and transferred to the
statistics software SPSS version 12.0 for Windows for analyses.
The observed phenomena were described in terms of frequency
of occurrences. Pearsons correlation coefficient was used for correlation analyses. Chi-square tests were used to examine the association between categorical variables. Exploratory factor analysis
(principal component analysis) was performed on the selfreported vocal symptoms in the questionnaire data. The aim
was to extract the most significant clusters of symptoms that represented possible underlying pathophysiological phenomena.
The appropriateness of factor analysis to the data was checked using the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and the Bartletts test of sphericity. KMO values below
0.5 were considered unacceptable. Values between 0.5 and 0.7
are acceptable, and measures >0.70.8 are excellent.1820 The
KMO measure was calculated for the whole sample and separately for individual variables. The extracted factors were examined with regard to their eigenvalue and percentage of variance
explained. Based on Kaisers criterion,21 only factors with an eigenvalue greater than 1 were retained. Variables in the factors
with high eigenvalues (1) were examined for their implications
with respect to the characteristic clusters of symptoms that the
factors represented. Both orthogonal (varimax method) and oblique rotations (direct oblimin method) were run and the results of
the oblique rotation were checked for correlation between factors.18 The results of the oblique rotation showed correlations between a number of extracted factors, therefore, the orthogonal
rotation was discarded and the oblique rotation was used. Using
the direct oblimin method, the recommended delta value of
zero was set to avoid too high or too low correlations between factors.18 The postrotation extracted factors were used to explain the
data. Only variables with a factor loading greater than 0.3 were
retained. The reliability of the factors extracted from the factor
analysis was assessed using Cronbachs alpha. In all statistical
calculations, the significance level selected was 0.05.
RESULTS
Demographic and vocal use characteristics
All 47 teachers with MTD returned the data collection questionnaire. However, questionnaires from six participants were not
used because they did not provide required information, for example, occupational details or current voice symptoms. Therefore, questionnaire data were available for 41 participants.
Among these, 37 were general primary school teachers, three
were music teachers, and one was an art teacher.
Sixteen (39%) very frequently used a loud voice in teaching
and 25 (61%) used a loud voice sometimes during teaching.
None replied never used loud voice in teaching. Most of the
participants (85.4%) shouted or screamed occasionally, three

198

Journal of Voice, Vol. 23, No. 2, 2009

Subjective vocal symptoms

Table 1 presents subjective vocal complaints in the 41 participants. There were a large number of vocal symptoms associated
with this voice disorder and most of them occurred at a relatively high frequency. Although hoarseness was predominant,
there were also symptoms of various negative changes in the
voice, for example, changes in vocal pitch, signs of an uncomfortable phonation (eg, voice gets tired quickly), and symptoms
of physical discomfort, for example, throat pain in talking, increased throat mucus, neck and chest discomfort, neck tension,
and throat constriction. Symptoms were seen at different severity levels but the higher frequency of symptoms fell into the
mild and moderate levels. This is further reflected by the
mean scores of the symptoms in which the highest was only
2.07 for hoarseness. All but one participant had two or more
symptoms.
The duration of symptoms varied, with a mean of 40.36
months (SD 36.8). The shortest duration of constantly present dysphonia in these participants was 3 months and the longest was almost 10 years. Intermittent symptoms were not
included in the duration of voice problem.

(7.3%) frequently shouted or screamed, and three reported that

they never shouted. Most of the participants also reported having
to speak over background noise (73.2%); eight (19.5%) frequently talked over noise; only three (7.3%) never talked over
noise. In singing and speaking, 33 participants (80.5%) sometimes used the wrong register and only eight (19.5%) reported
never using the wrong register. The use of the wrong register in
these participants was related to their intention to increase the attractiveness and authority of their voices. Most (87.8%) claimed
that they did not have any knowledge about how to use their voices properly. None had received formal voice training.
Teachers were asked whether they rested their voices after
teaching and during upper respiratory tract infections. After
teaching, 70.7% of the participants never rested their voices,
24.4% had voice rest only occasionally, and only 4.9% frequently had voice rest. During upper respiratory tract infection
(eg, rhinopharyngitis), 51.2% of the participants still used their
voices extensively; 48.8% sometimes rested their voices; and
none rested their voices completely during upper respiratory
tract infection. Likewise, no participant rested her voice when
she had a voice problem. Most participants (75.6%) reported
a normal or comfortable psychological state during teaching.
Negative psychological states were reported in 24.4%, including worried (14.6%) and tense (9.8%). None ever had required
treatment or consultation for a psychological problem.
Most of the participants were aware of the conditions that
triggered their vocal difficulties. These included extensive
voice use (n 17, 41.5%), rhinopharyngitis (n 13, 31.7%),
and shouting (n 2, 4.9%). Six participants (14.6%) could
not identify a precedent and three participants (7.3%) did not
respond to this question.

Factor analysis and reliability analysis of the self-reported vocal symptoms. From the initial 19 items, the
item complete voice loss was discarded as no participant reported this symptom; 18 items were subjected to factor and reliability analysis. Cronbachs alpha for the total scale of 18
items was 0.909. Item-total correlations (0.4080.733) and alpha if item deleted statistics indicated that all items contributed
equally to the scale, hence none was deleted. Although the sample size was relatively small for factor analysis, KMO measure
of sampling adequacy for the sample was 0.79. The KMO range

TABLE 1.
Self-Reported Vocal Symptoms (Multiple-Response Data)
Severity Self-Rating Score
Symptoms

Mean Score SD

Hoarseness
Voice gets tired quickly
Out of breath in talking
Throat clearing
High notes difficulties
Increased vocal effort
Weak voice
Pitch change
Throat pain in talking
Voice deteriorates at end of day
Increased throat mucus
Neck-chest discomfort
Throat constriction
Neck tension
Decreased pitch range
Low notes difficulties
Loss of voice at times
Tone phonation difficulties
Complete voice loss

35
29
29
27
26
26
26
24
23
23
19
19
17
15
13
10
7
4
0

85.4
70.7
70.7
65.9
63.4
63.4
63.4
58.5
56.1
56.1
46.3
46.3
41.5
36.6
31.7
24.4
17.1
9.8
0

6
2
4
7
1
4
4
6
4
1
7
10
8
2
1
1
1
0
0

12
9
12
11
7
6
7
9
5
7
5
4
4
7
7
2
3
0
0

13
15
10
4
14
14
13
7
12
11
4
4
3
5
5
7
3
4
0

4
3
3
5
4
2
2
2
2
4
3
1
2
1
0
0
0
0
0

2.07 1.21
1.88 1.38
1.71 1.33
1.49 1.38
1.78 1.49
1.61 1.41
1.59 1.40
1.29 1.31
1.41 1.43
1.56 1.52
1.00 1.32
0.83 1.12
0.80 1.19
0.85 1.24
0.73 1.14
0.63 1.18
0.39 0.92
0.29 0.90
0

Duong Duy Nguyen, et al

199

MTD in Teacher

for all variables (0.720.88) indicated adequate sample size for

all the variables. Bartletts test of sphericity was highly significant, also confirming that the data were suitable for factor analysis (c2 384.65, df 153, P < 0.001).
Using factor analysis with oblique rotation (direct oblimin),
three factors explaining the largest amount of variance were extracted (Table 2). The three factors, labeled to describe the clustering of variables, were as follows:
(1) Factor 1: Vocal fatigue/hyperfunction explained the
largest amount of variance (39.8%) and also contained
the highest number of variables. Cronbachs alpha for
this factor was 0.894. Item-total correlations ranged
from 0.437 to 0.761.
(2) Factor 2: Physical discomfort contained three items
and explained 9.8% of the variance. Cronbachs alpha
for this factor was 0.839. Item-total correlations ranged
from 0.64 to 0.763.
(3) Factor 3: Voice quality explained 9.3% of the variance. Cronbachs alpha was 0.84. Item-total correlations
ranged from 0.472 to 0.723.
Factors 1 and 2 (r 0.31) and factors 1 and 3 (r 0.423) were
correlated, confirming the need for oblique rotation.
Examiner-reported vocal symptoms. In 47 participants
with MTD, the examiner reported strained voice in 45 participants (95.7%), breathiness in 43 (91.5%), and roughness in
23 (48.9%). Symptoms such as pitch breaks, glottal fry, hard
glottal attack, and voice loss were not reported.

Laryngoscopic findings
Glottal shapes. Table 3 shows the glottal shape patterns observed. The posterior glottal gap was defined as a triangle-shaped
gap in the posterior glottis between the two arytenoid cartilages
and posterior membranous vocal folds (Figure 1). This definition
excluded the cases in which there was a gap between the two arytenoids but no gap between the posterior vocal folds. The incomplete glottal closure indicated the cases in which the two
vocal folds did not completely close the glottis during the closed
phase (Figure 2). The spindle-shaped gap was a special case of
the incomplete closure in which the two vocal folds did not completely approach, leaving a glottal gap in the shape of a spindle
(Figure 3). An hourglass gap was defined as a glottal gap in
which there were both anterior and posterior glottal chinks,
with a small contact at approximately the middle of the membranous vocal folds in the absence of mucosal lesions (Figure 4).
Supraglottic findings. Thirty-five participants had an AP
contraction: 20 had a score of 1, 10 had a score of 2, four had
a score of 3, and one had a score of 4. None had a full AP contraction. Eleven participants had a lateral contraction among
whom nine had a score of 1 and two had a score of 2.
Vocal fold and arytenoid mucosa. The status of mucosa
was assessed for each vocal fold. The degree of visible mucosal
changes was minor and comparable between the two vocal
folds. The rating scores for the vocal fold smoothness ranged
from 1 to 3 on the six-point EAI rating scale. For both vocal
folds, the smoothness score was 1 for most of the rated vocal
folds. Only one participant had a score of 3 for vocal fold

TABLE 2.
Characteristics of the Three Factors in Vocal Symptoms (a Cronbachs Alpha)
Factor 1
Vocal Symptoms

Loading

a if item deleted

Voice deteriorates at end of day

Increased vocal effort
Voice gets tired quickly
Weak voice
Out of breath in talking
High notes difficulties
Neck tension
Loss of voice at times
Throat pain in talking
Increased throat mucus
Throat constriction
Tone phonation difficulties
Neck-chest discomfort
Low notes difficulties
Decreased pitch range
Pitch change
Throat clearing
Hoarseness

0.832
0.783
0.743
0.681
0.644
0.608
0.593
0.575
0.447
0.323

0.886
0.876
0.883
0.879
0.883
0.880
0.884
0.894
0.885
0.893

Variance explained (%)

a

Factor 2
Loading

0.885
0.790
0.780

0.426
39.8
0.894

0.886
9.8
0.839

a if item deleted

Factor 3
Loading

a if item deleted

0.324

0.811

0.387

0.820

0.849
0.842
0.724
0.564
0.530

0.800
0.813
0.834
0.808
0.835

0.718
0.842
0.744

9.3
0.840

200

Journal of Voice, Vol. 23, No. 2, 2009

TABLE 3.
Glottal Shape Findings
n by Age
Categories

2229 3039 4049 5054

%
44.7
29.8
12.8
8.5
4.3

Incomplete
Posterior gap
Hourglass
Spindle
Complete

2
2
1
0
0

3
4
1
0
0

14
7
3
3
1

2
1
1
1
1

21
14
6
4
2

Total

28

47 100

smoothness bilaterally. Similarly, the straightness scores also

ranged from 1 to 3 and most of the participants had a score of
1. Pearsons correlation coefficients between smoothness and
straightness scores for the left and right vocal folds were 0.72
and 0.74, respectively (P < 0.01). This finding indicated that
the straightness of the vocal fold medial edge depended largely
on the status of the vocal fold mucosa.
Table 4 shows the findings on the vocal fold mucosa. Increased mucus secretion was found in 34% and 36.2% of the
participants for the left and right vocal folds, respectively. Mucus was often present either on the superior surface of the vocal
folds or at the middle of the medial vibrating edge where it
could be mistaken as vocal nodule. By having the participant
do a slight throat clearing, the mucus was removed but returned
shortly afterward. Additionally, mild to moderate thickness,
edema, and erythema of the vocal folds were also observed.
The arytenoid mucosa was also examined including the interarytenoid space. Signs of inflammation, including edema and
erythema, were noted in 30 participants (63.8%). The interarytenoid space showed erythema lesion in 19 participants
(40.4%). The main characteristic of arytenoid mucosal inflammation was uneven distribution; the lesions did not diffuse all
over the surface of the arytenoids but concentrated in clusters,
mostly in the areas near the upper esophageal sphincter and
the aryepiglottic fold.

FIGURE 1. Posterior glottal gap.

FIGURE 2. Incomplete glottal closure.

Neck. The suprahyoid muscles increased tonicity in 31 participants (66%) and laryngeal vertical position was found to rise in
29 participants (61.7%). There was a strong correlation between
increased suprahyoid muscle tension and elevated larynx height
during phonation (c2 39.1, P < 0.001).
DISCUSSION
Vocal characteristics of MTD in Vietnamese teachers
This study found that the Vietnamese teachers with MTD had
more vocal symptoms than previously reported in nontonal language speakers.3,13 The symptoms covered various aspects of
dysfunction in the phonation system, for example, problems in
the larynx (eg, hoarseness), lack of effective coordination between phonation and breathing support (eg, out of breath in
talking), disorders in the related musculoskeletal system (eg,
neck chest discomfort), functional sensorimotor problems of
the vocal tract (eg, throat constriction and throat pain in talking), and the possible coexistence of cofactors (eg, increased
throat mucus). Symptoms reliably fitted three factors: vocal fatigue/hyperfunction, physical discomfort, and voice quality, representing three major areas of dysfunction in this voice disorder.
However, a number of vocal symptoms of MTD reported in

FIGURE 3. Spindle-shaped glottal gap.

Duong Duy Nguyen, et al

201

MTD in Teacher

FIGURE 4. Hourglass glottal gap.

previous studies were not observed in this study, for example,
hard glottal attack, stridency, pitch breaks, and glottal fry (except
for the creaky voice associated with the linguistic laryngealization in the broken tone and the dropped tone).
Differences in linguistic characteristics between Vietnamese
and nontonal languages may have contributed to the findings.
This possibility might explain for the absence of some symptoms of MTD reported in previous studies. It is not known
how linguistic features affect vocal quality in voice disorders because the cross-linguistic manifestation of voice disorders has
not been well investigated. However, the different uses of the larynx by tonal and nontonal languages suggest that there may be
an association between the linguistic background and the vocal
output in a voice disorder. When the larynx is used for creating
tonal contrasts, the laryngeal features pertinent to the phonolog-

TABLE 4.
Mucosal Findings
Findings and
Rating Scores
Mucus
1
2
Total
Thickness
1
2
Total
Edema
1
2
3
Total
Erythema
1
3
Total

n
Left Vocal Fold

Right Vocal Fold

14
2

15
2

16/47

17/47
9
1

10/47

9
1
10/47

7
3
1
11/47

7
3
1
11/47

6
1
7/47

5
1
6/47

ical characteristics of the tonal language may interact with those

generated by the voice disorder. The actual mechanism of interaction is not yet understood and should be studied in future research. In Vietnamese, such an interaction may exist given
that the larynx performs two linguistically significant phenomena, that is, pitch variation at word level and nonmodal phonation types (ie, laryngealization and breathiness). These are
distinctive features of the language, which may result in certain
differences in the symptomatology of MTD as compared with
nontonal language speakers. In nontonal languages, pitch variation and phonation types are not lexically significant. Therefore,
the pattern of interaction between linguistic factors and voice
disorders, if any, may be different from that in tonal languages.
For example, interaction may exist between vocal tract activities
and voice disorders rather than between linguistically relevant
laryngeal features and voice disorders. The interaction pattern
may even be different between nontonal languages because of
differences in articulatory characteristics. This leads to the
fact that differences in dysphonic symptoms because of linguistic differences may occur not only between tonal and nontonal
language speakers but also between nontonal language
speakers. For example, Lorch and Whurr22 investigated the perceptual characteristics of spasmodic dysphonia in a number of
French participants. They applied the same diagnostic criteria
for this voice disorder as those used in studies on English participants. They did not find pitch breaks, a symptom normally
found in English spasmodic dysphonia patients. In contrast,
some symptoms not considered important in English speakers
were found to be prominent, for example, harshness and breathiness. Clearly, the linguistic-specific effects of laryngeal and vocal tract features on voice disorders need to be taken into account
and should be investigated further.
The higher number of MTD symptoms in this study than previously reported might be attributed to a well-recognized problem in the teaching voice in general, that is, voice problems in
teachers often involve a high number of symptoms23 regardless
of the underlying diagnosis. This perhaps results from the impact of various factors on their voices such as vocal skills, posture, physical and psychological conditions, and teaching
environment24,25. However, the effect of factors related to seasons and the stage of the school year are not well understood. In
the first authors experience, teachers suffer from more voice
problems in the transitional periods between autumn and winter
and between winter and spring, probably due to low humidity
and episodes of viral infection in the upper respiratory tract.
Additionally, teachers tend to have more problems with their
voices toward the end of a school year, particularly those related
to vocal fatigue. Because this study spanned a period from September 2005 (autumn and commencement of school year in
Vietnam) to July 2006 (summer, two months after the school
year), these factors may have played some role in adding
more vocal symptoms into the vocal profile of MTD in these
Vietnamese teachers. Future research designed to assess the
effect of these factors on the teaching voice is needed.
The findings may have been compromised by testing errors
due to the use of subjective measures (questionnaires and examiners perceptual voice assessment) that obscured actual

202
physiological differences in the symptoms of MTD between
this and previous reports. Higher frequency of self-reported
symptoms might have resulted from the possibility that some
participants included intermittent symptoms. Other factors affecting subjective self-report include possible misunderstanding of the description of some of the vocal symptoms in the
questionnaire and variability in teachers awareness of and sensitivity to their vocal symptoms. Although the result of factor
analysis in the present study was encouraging, the sample
size was small and replication with a larger group is needed.

Laryngeal characteristics of MTD in Vietnamese

teachers
We did not find any differences in laryngeal characteristics of
MTD compared with previous studies, suggesting that, the laryngeal symptoms observed were not specific to this tonal language.
The major symptoms found were glottal gaps and supraglottic
constriction, which have been documented in nontonal language
speakers.2,3 These findings appeared not to support the involvement of the phonological characteristics of Vietnamese in the
manifestation of MTD. Probably, linguistic factors in this tonal
language, for example, phonation types, may contribute to
some differences in vocal symptoms but they might not necessarily result in a distinctive laryngeal feature in this voice disorder.
This might stem from two possibilities. Firstly, the tonal language
speakers who have MTD might voluntarily reduce the magnitude
of lexically significant phenomena in an attempt to adapt to the
changed laryngeal muscle tension or vocal tract discomfort associated with MTD. For example, they might reduce pitch movement or laryngealization to avoid vocal fatigue. As a result,
those linguistic phenomena could not affect the laryngeal features
in this voice disorder. However, the linguistic content in the restricted tones might not be sufficiently contrastive and would result in tone misperception.
Secondly, the differences in vocal symptoms without any difference in laryngeal findings compared with previous studies
might also result from the fact that MTD is an unexplained voice
disorder in which the laryngeal appearance may not precisely reflect the underlying vocal function and control mechanism. It has
been known that MTD is characterized by an incongruity between vocal symptoms and laryngeal findings,3 which is related
to the fact that many of its symptoms are behaviorally induced
and behaviorally modifiable.1 Furthermore, the laryngeal findings in MTD are not specific: they may also be seen in some people whose voice is not dysphonic. For example, Linville26 found
that both young and elderly female speakers showed a high incidence of glottal gaps. The patterns of glottal gaps seen in young
women were posterior gap and incomplete closure. In elderly
women, the common patterns were anterior gap and spindleshaped gap. Sama et al27 found that vocally healthy people
also possessed many features of MTD, for example, incomplete
vocal fold adduction, AP contraction, and ventricular fold contraction. The incongruity between vocal and laryngeal symptoms
of MTD, and the nonspecificity of its laryngeal symptoms suggest that, regardless of the language used, laryngeal findings
alone may not constitute a diagnosis of MTD.

Journal of Voice, Vol. 23, No. 2, 2009

A number of methodological limitations should be noted.

First, the laryngoscopic findings in this study were collected using a fiberoptic right-angled rigid laryngoscope at a school setting. Whether the findings can be generalized to a larger MTD
population or whether they are comparable with previous reports on MTD using transnasal flexible fiberoptic laryngoscopy
needs to be validated. Sodersten and Lindestad28 reported that
the estimated degree of incomplete glottal closure was significantly higher during rigid telescopy than during flexible laryngoscopy especially in soft phonation. Their results might have
resulted from the fact that a rigid telescope tends to better magnify the details in the observed field than the flexible laryngoscope. Second, although the purpose of the study was to
examine how MTD presented in tonal language speakers, the
study did not use tone-specific speech samples for examination
because it only used rigid laryngoscopy, which precluded the
use of connected speech samples. Additionally, the setting of
the study did not allow more complex laryngeal examination
to be performed. Although the use of the /i/ sound facilitated laryngeal examination, it was not a suitable stimulus to find the
potential glottal configuration specific to this tonal language.
As a result, the findings did not allow a conclusive statement
to be made on the potential role of linguistic-specific factors
in the manifestation of this voice disorder. Laryngeal movement
during various vocal tasks should be examined in future studies
of MTD in tonal language speakers. Acoustic and physiological
investigation of tone production in normal and dysphonic voices should also be conducted and laryngeal findings should
be interpreted based on data from those measurements. Findings from such studies might reveal useful information for understanding the laryngeal function during lexical tone
phonation in normal and pathological states of the larynx.
CONCLUSION
Our study provided preliminary data about MTD in primary
school teachers who used a tone language and identified a range
of vocal symptoms in teachers with a specified voice disorder.
The vocal symptoms of MTD identified in this study may represent a wide range of disorders in the phonatory system. The
major groups of symptoms included hyperfunction, vocal fatigue, impaired voice quality, and physical dysfunction. Because of the multidimensional nature of MTD, in diagnosis of
this voice disorder particularly in teachers, it is necessary to
look for all voice symptoms rather than focus on voice quality.
The higher number of vocal symptoms overall and the absence
of particular vocal symptoms found in previous MTD studies in
nontonal language speakers suggest that symptom presentation
of MTD may be influenced by linguistic factors. Nevertheless,
the symptom configuration of MTD of the tonal language per se
needs to be separated from effects on the voice of teaching.
Abnormal glottal closure in the absence of structural lesions
of the vocal folds was the major laryngeal characteristic in these
participants. Five types of glottal closure were observed. However, the design of the study did not allow confirmation of an
association between the use of a tonal language and the specific
pattern of glottal shape and other laryngeal features in this voice
disorder. This issue should be examined in future research.

Duong Duy Nguyen, et al

MTD in Teacher

Acknowledgment
The authors thank the school teachers who participated in this
study and the Education and Training Department of Thai
Nguyen City, Vietnam for supporting this study. We also thank
the two anonymous reviewers for their helpful comments on the
manuscript.
REFERENCES
1. Verdolini K, Rosen C, Branski R. Classification Manual for Voice DisordersI. Mahwah, NJ: Lawrence Erlbaum Associates; 2006.
2. Morrison MD, Rammage LA. Muscle misuse voice disorders: description
and classification. Acta Otolaryngol. 1993;113:428-434.
3. Koufman JA, Blalock PD. Functional voice disorders. Otolaryngol Clin
North Am. 1991;24:1059-1073.
4. Morrison MD, Rammage LA, Belisle GM, Pullan CB, Nichol H. Muscular
tension dysphonia. J Otolaryngol. 1983;12:302-306.
5. Altman KW, Atkinson C, Lazarus C. Current and emerging concepts in
muscle tension dysphonia: a 30-month review. J Voice. 2005;19:261-267.
6. Rammage L, Morrison M, Nichol H. Management of the Voice and Its Disorders. San Diego, CA: Singular-Thomson Learning; 2001.
7. Sapir S. Psychogenic spasmodic dysphonia: a case study with expert opinions. J Voice. 1995;9:270-281.
8. Sapienza CM, Walton S, Murry T. Adductor spasmodic dysphonia and muscular tension dysphonia: acoustic analysis of sustained phonation and reading. J Voice. 2000;14:502-520.
9. Ladefoged P. The features of the larynx. J Phonetics. 1973;1:73-83.
10. Nguyen LV, Edmondson JA. Tones and voice quality in modern Northern
Vietnamese: instrumental case studies. Mon-Khmer Stud. 1998;28:1-18.
11. Ohala J. Production of tone. In: Fromkin V, ed. Tone: A Linguistic Survey.
New York, NY: Academic Press; 1978:5-39.
12. Belisle GM, Morrison MD. Anatomic correlation for muscle tension
dysphonia. J Otolaryngol. 1983;12:319-321.
13. Morrison M, Nichol H, Rammage L. Diagnostic criteria in functional
dysphonia. Laryngoscope. 1986;94:1-8.

203
14. Nguyen DD, Kenny DT. Impact of muscle tension dysphonia on tone
height, contour and fundamental frequency movements in Vietnamese
tones. Presented at: The 5th Asia-Pacific Conference on Speech, Language
and Hearing; July 913, 2007; Brisbane, Australia.
15. Smith E, Lemke J, Taylor M, Kirchner HL, Hoffman H. Frequency of voice
problems among teachers and other occupations. J Voice. 1998;12:480-488.
16. Mathieson L. The Voice and Its Disorders. London: Whurr Publishers;
2001.
17. Peppard RC, Bless DM. The use of topical anesthetic in videostroboscopic
examination of the larynx. J Voice. 1991;5:57-63.
18. Field A. Discovering Statistics Using SPSS. London: Sage Publications;
2005.
19. Kaiser HF. An index of factorial simplicity. Psychometrika. 1974;39:31-36.
20. Hutcheson GD, Sofroniou N. The Multivariate Social Scientist: Introductory Statistics Using Generalized Linear Models. London: Sage Publications; 1999.
21. Kaiser HF. The application of electronic computers to factor analysis. Educ
Psychol Meas. 1960;20:141-151.
22. Lorch M, Whurr R. Cross-linguistic study of vocal pathology: perceptual
features of spasmodic dysphonia in French-speaking subjects. J Multiling
Commun Disord. 2003;1:35-52.
23. Smith E, Gray SD, Dove H, Kirchner L, Heras H. Frequency and effects of
teachers voice problems. J Voice. 1997;11:81-87.
24. Kooijman PG, de Jong FI, Oudes MJ, Huinck W, van Acht H, Graamans K.
Muscular tension and body posture in relation to voice handicap and voice
quality in teachers with persistent voice complaints. Folia Phoniatr Logop.
2005;57:134-147.
25. Kooijman PGC, de Jong FICRS, Thomas G, Huinck W, Donders R,
Graamans K, Schutte HK. Risk factors for voice problems in teachers. Folia
Phoniatr Logop. 2006;58:159-174.
26. Linville SE. Glottal gap configurations in two age groups of women.
J Speech Hear Res. 1992;35:1209-1215.
27. Sama A, Carding PN, Price S, Kelly P, Wilson JA. The clinical features of
functional dysphonia. Laryngoscope. 2001;111:458-463.
28. Sodersten M, Lindestad PA. A comparison of vocal fold closure in rigid
telescopic and flexible fiberoptic laryngostroboscopy. Acta Otolaryngol.
1992;112:144-150.

204

Journal of Voice, Vol. 23, No. 2, 2009

Appendix 1

QUESTIONNAIRE
Evaluation and management of voice disorders
Please fill in this questionnaire with your best knowledge. Information you provide in this questionnaire will be kept
confidential and will be used only for the purpose of this study.
PART 1: PERSONAL DETAILS
1. Full name (Print):.....................................................................Sex (circle): Male/Female
2. Date of birth:............................. Ethnic group:...........................Contact number:........................................................
3. Name of school: ...........................................................................................................................................................
PART 2: OCCUPATIONAL DETAILS
4. What type of school are you teaching (e.g. primary or secondary)? ............................................................................
5. How long have you been teaching (years and months)? ..............................................................................................
6. What subjects are you teaching? ..................................................................................................................................
7. How many days per week are you teaching?................................................................................................................
8. On average, how many hours do you teach per day? ...................................................................................................
9. Are you involved in any other vocal activities and what are they? ..............................................................................
10. Your current psychological state in teaching:
Comfortable

Stressed

Worried

Sometimes

Frequent

Sometimes

Frequent

PART 3: YOUR VOCAL USE

11. Do you speak loudly in teaching?
Never
12. Do you speak over background noise?
Never

13. Do you ever shout or scream during teaching?

Never

Sometimes

Frequent

14. Have you ever spoken or sung in your wrong register?

Never

Sometimes

Frequent

Sometimes

Frequent

Sometimes

Frequent

15. Do you often clear your throat?

Never
16. Do you plan any voice rest after teaching?
Never

17. Do you seek voice rest during flu/pharyngitis/upper respiratory tract infections?
Never

Sometimes

Frequent

18. You think that when you are teaching, you should speak:
With normal voice

Louder

As loud as you can

19. Do you know how to use your voice efficiently?.........................................................................................................

20. When you have a voice problem, do you stay at home or still go to work? .................................................................
PART 4: VOCAL HISTORY
21. Have you ever had any voice problem in the past? ......................................................................................................
If yes, list the symptoms you have had:......................................................................................................................................
....................................................................................................................................................................................................

Duong Duy Nguyen, et al

205

MTD in Teacher

22. Did you seek treatment for those problems?

Yes
Methods of treatment:..................................................................................................
Normal
Improved
The same
Your voice after treatment
No

PART 5: YOUR CURRENT VOICE

23. In your opinion, your current voice is (circle the most appropriate):
1. Very good
2. Good
3. Fair
4. Bad
24. Do you have any problem with your voice currently?
No

Worsened

5. Very bad

Yes
Which symptoms of the following do you currently have?
(Mark x in the appropriate boxes to indicate the symptoms you have, and give your rating for the severity of each
of those symptoms: 1 = Slight; 2 = Mild; 3 = Moderate; 4 = Severe. For the symptom you do not have, please leave
the box blank):

Symptoms

Severity
1

Hoarseness
Complete voice loss
Loss of voice at times
Pitch change
Reduced pitch range
Difficulties with high notes
Difficulties with low notes
Weak voice
Voice gets tired quickly
Voice deteriorates at the end of a teaching day
Difficulties in tone phonation
Running out of breath in talking
Increased vocal effort
Neck tension
Throat pain in talking
Feel like a lump in the throat
Increased mucus in throat
Throat-clearing
Discomfort in neck/chest
25. If you have other symptoms not mentioned above, please list them here ....................................................................
....................................................................................................................................................................................................
26. How long have you had the current voice problem? ....................................................................................................
27. In what situation did you have the current voice problem:
After rhinopharyngitis

After a period of intensive voice use

After loud speaking

Not sure

Other:...........................................................................................................................................................
28. Which of the following are the causes of your voice problem (check the appropriate boxes):
Intensive voice use
Loud speaking
No vocal training
Frequent shouting
Pharyngitis
Other respiratory tract infections
Speaking over noise
Not sure
Other causes:.....................................
29. Have you had treatment for the current voice problems?
Yes
No

Methods of treatment:............................................................................................................
Normal
Improved
The same
Worsened
Your voice after treatment

206

Journal of Voice, Vol. 23, No. 2, 2009

PART 6: IMPACT OF VOICE PROBLEMS

30. With your current voice problem, what tone is the most difficult for you to phonate:.................................................
31. With your current voice problem, do you phonate one tone to be another?
0. No
1. Rarely
2. Sometimes
3. Frequently
4. Constantly
What tone to be what tone:
32. The degree of difficulties the listeners have when listening to your voice:
0. No 1. Very little
2. Moderate
3. Much
4. Very much
33. Do you have to repeat what you have just said to the audience?
0. No 1. Very little
2. Moderate
3. Much
4. Very much
34. How does your voice problem affect your job performance?
0. No 1. Very little
2. Moderate
3. Much
4. Very much
35. When you have voice problem, you think that teaching is:
0. The same
1. Slightly difficult
2. Rather difficult
3. Difficult
4. Very difficult
36. How does your voice problem affect your daily conversation?
0. No 1. Very little
2. Moderate
3. Much
4. Very much
37. In general, how does your voice problem affect your life?
0. No 1. Very little
2. Moderate
3. Much
4. Very much
Date..............
Signature:.

END OF QUESTIONNAIRE

Duong Duy Nguyen, et al

207

MTD in Teacher

Appendix 2

LARYNGOSCOPIC FORM
I. Personal details
- Full name:..................................................................D.O.B.:.....................M/F. Ethnic group:....................................
- Occupation:.......................... Address: ..........................................................................................................................
- Contact number:....................................Hospital code:.................................Study code:..............................................
II. History
ENT:
Voice problems:
Allergy

Smoking

Alcohol

Reflux

Other

III. Larynx and voice assessment

1. Perceptual assessment
Pitch:

Average

High

Low

Intensity:

Average

Loud

Soft

Voice quality:

Normal

Rough

Breathy

Strained

Pitch breaks

Phonation breaks

Tone phonation:

Phonation type:

Voice rating:

2.

Creaky
Diplophonia
Tremor
Other qualities:.........................................................................................
Normal
Difficulties in (circle):
T1 T2 T3 T4 T5 T5s T6 T6s
Remarks:.......................................................................................................................
Breathiness (T2, T4):
Yes
No Tones:.................................
Laryngealization (T3, T6):
0
1
Normal

Yes
2

No
3

Tones:.................................
5
Severe dysphonia

Glottal shape (circle the most appropriate one)

Remarks:..........................................................................................................................................................................
3. Supraglottic activities (circle the best number)
A-P contraction
0
1
2
3
Absence
Slight
Lateral contraction
0
1
2
3
Absence
Slight

5
Vocal fold obscured

5
Vocal fold obscured

208
4.
Left

Journal of Voice, Vol. 23, No. 2, 2009

Vocal fold medial edge smoothness

0
1
2
3
Smooth

5
Rough

Right

0
1
2
3
4
5
Smooth
Rough
Remarks:..........................................................................................................................................................................
5.
Left

Vocal fold medial edge straightness

0
1
2
Straight

5
Irregular

0
1
2
3
4
5
Straight
Irregular
Remarks:..........................................................................................................................................................................
Right

6.

Vocal fold mucosa (circle the best number)

Findings
Edema
Erythema
Thickening
Mucus
Dilation
Sulcus
Contact ulcers
Plaque
Nodules
Polyps
Other

7.

Left vocal fold

No
0
0
0
0
0
0
0
0

Arytenoids
Mucosa:

1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4

Right vocal fold

Severe
5
5
5
5
5
5
5
5

No
0
0
0
0
0
0
0
0

1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2

Normal

Edema

Erythema

Symmetry:

Yes

No

Palsy

Vocal processes:

Normal

Thickened

Ulcer

Interarytenoid space:

Normal

Erythema

Ulcer

3
3
3
3
3
3
3
3

4
4
4
4
4
4
4
4

Severe
5
5
5
5
5
5
5
5

Ulcer

(circle) Left -- Right

Remarks: .........................................................................................................................................................................
8.

Lower pharynx and piriform sinuses

Normal
Edema
Erythema
Mucus
Remarks:..........................................................................................................................................................................
IV. Neck
1.

Larynx height in phonation

Elevated

2.

Unchanged

Supra- and infra-hyoid muscular tone

High

Date:
Examiner:

Average

Low