MUSCLE TENSION

DYSPHONIA
Muscle tension dysphonia (MTD)
Muscle tension dysphonia (MTD)
Voice disturbance without structural or neurologic
laryngeal pathology.
Excessive tension in intrinsic and/or extrinsic laryngeal
muscles.
Primary MTD
vocalizing or speaking in which the muscles in the neck are
tense and when no other lesion or paralysis is seen.
Secondary MTD
a compensatory method of vocalizing due either to a paralysis,
paresis or muscular weakness causing the person to squeeze
other parts of the larynx to help produce sound.
Muscle tension dysphonia (MTD)
10 to 40%, female, professional voice users.

(1) Technical misuses of vocal mechanism in the context

of extraordinary voice demands,
(2) Learned adaptations after URI,
(3) Increased pharyngolaryngeal tone secondary to LPR,
(4) Extreme compensation for minor glottic insufficiency
and/or underlying mucosal disease,
(5) Psychologic and/or personality factors that tend to
induce elevated tension in the laryngeal region.
In response to stress, conflict, anxiety, depression, or inhibited
emotional expression,
Conversion reaction, hysteria, hypochondriasis, and various
situational conflicts or personality dispositions
However, research evidence to support these various psychologic
mechanisms has seldom been provided.
Muscle tension dysphonia (MTD)
Muscle tension dysphonia (MTD)
Breathy or harsh with use through the day and recovers
with rest.
severe vocal restrictions or complete loss of voice by Thursday
or Friday, with a weekend barely providing sufficient recovery
time.
Fine control in the middle vocal frequencies is lost first
and whispering or shouting later.
Organic changes in vocal cords may occur secondary to
such faulty use or overloading.
Causes of laryngeal irritation
Post nasal drip, sinus disease, etc.. tobacco smoke.
Laryngo-pharyngeal reflux (LPR)
10% of general population, 46% of professional voice users.
heartburn, acid tastes in mouth, nocturnal coughing, halitosis.
swelling of laryngeal mucosa frequent throat clearing and
coughing.
reflex increase in muscle tension in the pharynx and larynx.
Causes of laryngeal irritation

Globus -- a lump in the throat.

spasm of muscles of lower pharynx
sore throat, vague rawness or dry feeling localized to
the area of the larynx or below.
the neck muscles can become tender with the ache
extending up the neck muscles to behind the ear.
the symptoms resolve during eating because swallowing
allows the muscles to relax.
intermittent hoarseness or voice fatigue, returns to
normal at certain times of the day.
globus can be precipitated by a post nasal drip or LPR.
History
The amount / type of voice use at home, socially, at work.
Daily behavior.
Recent URI.
Medications.
Neurologic disorders
generalized dystonia or myasthenia gravis.
Laryngeal trauma or neural injury.
Prior neck surgery or trauma.
TMJ disorders, cervical myalgia, or muscular fatigue.
GERD and LPR.
Endocrinopathies.
Hypothyroidism.
Any psychiatric history.
Exposure to irritants
tobacco smoke, alcohol, caffeine, dairy products, chocolate, mints
and occupational irritants.
 History
Sufferers belong to a particular group.
their career and lifestyle have not altered, their voice has deteriorated.

Teachers
Speak above background noise in rooms with poor acoustics and
dust.
Teaching is a stressful job
Teachers rarely have received any education about voice care or use.
Singers and actors
Lifestyle with many adverse effects upon voice and health.
People talking on the telephone all day
often use an inappropriate pitch, have few rests or appropriate drinks
and limited vocal recovery time.
office atmosphere may be dry due to air-conditioning.
Aerobics instructors
Shout above the music level to be heard and to motivate.
 Examination

Thorough clinical examination to exclude organic laryngeal

pathology.
Body posture may be poor, raised overall body tension
(including the neck and laryngeal muscles) with MTD.
Elevation of the larynx and hyoid bone due to increased tone
in the thyrohyoid and tongue base muscles.
Tense and tenderness of the thyrohyoid / cricothyroid muscle.
Difficult to move the larynx up and down and from side to side.
Laryngeal elevation may occur on phonation.
Gentle downward traction on the larynx after massage of the tender
areas reduction of the hoarseness.
Examination
Indirect laryngoscopy (mirror examination)
to confirm the vocal folds at the same level.
mucosal colour and inflammation.
interarytenoid area alone LPR
petiole (back of the epiglottis) excessive coughing
supraglottic post nasal drip
generalized inflammation smoking, alcohol and gross reflux.
Videostroboscopic laryngoscopy
detailed assessment of the vocal fold symmetry and regularity of
vibration, glottal closure, amplitude of vocal fold excursion,
mucosal wave and non-vibrating portions of the vocal folds.
Fibreoptic laryngoscopy
the nasal cavities and post nasal space
the vocal range and limits, the changing shape of the larynx.
The clinical features
The clinical features
Management
1. Posture and muscle usage
The compensatory laryngeal hyperfunction and the
causes need to be identified and removed by re-
education.
The voice needs to be sustained by correct breath
support in a relaxed and unstrained manner.
Less laryngeal effort:
a thorough explanation of anatomy and physiology of vocal tract.
reassurance with patients own laryngeal video that there is no
serious pathology.
laryngeal deconstriction exercises in addition to altering the
focus of resonance and tongue and mouth placement.
improvement in overall body posture and muscle relaxation
particularly in the head, neck, back and shoulders.
Management
2. Behavioural
An understanding of the environmental and
behavioural aspects of voice use.
Environment:
poor acoustics/amplification, dry air, dust or smoke,
background or competing noise (bars, sporting
arenas, large family gatherings, airplanes and buses),
inadequate rest.
Personal behavior:
smoking/alcohol/caffeine, whispering, shouting or
screaming (ie. sporting events or night clubs), poor
timing or types of eating, throat clearing or coughing,
dehydration, voice use at a lower or higher pitch than
is comfortable.
Management
3. Laryngo-pharyngeal reflux
Acid reducing drug (ie. Zantac or Losec)
doubled dose + gastric emptying drug
pH monitoring
surgery of G-E junction
Lifestyle advice chart.

4. Post-nasal drip
Allergic rhinitis
CPS
Management
5. Psychological platform
A normal stress response
to speak to a group of people
Heavier psychological load
increased muscle tension.
benefit from counselling
to know how to identify and understand past
behavioral patterning and learn new behavior.
release of emotional blocks and negativity.

relaxed, self-confident and more outgoing

voice is one of the major beneficiaries.
Voice therapy
Symptomatic voice therapy
identification and elimination of vocally abusive behaviors.
auditory feedback, head positioning, laryngeal massage,
relaxation.
Psychogenic voice therapy
emotional and psychosocial issues.
Etiological voice therapy
recognition and elimination of the cause of the voice disorder,
may be multifaceted.
Physiologic voice therapy
biofeedback, use of acoustic and aerodynamic analysis.
Eclectic voice therapy
combination of therapeutic approaches.
speech therapy + botulinum injection,
voice therapy + psychotherapy.
Multimodal approach is frequently essential, since many
of these voice disorders have psychogenic overlay.
Voice therapy