Journal of Voice

Vol. 11, No. 1. pp. 108--114

1997Lippincott-RavenPublishers,Philadelphia

Pattern Recognition in Muscle Misuse Voice Disorders:

How I Do It
Murray Morrison
Division of Otolaryngology, University of British Columbia, Vancouver Hospital and Health Sciences Centre,
Vancouver, B.C., Canada

Summary: The diagnosis of the patient with a muscle misuse voice disorder
can be a complex process. The dysphonia is usually caused by problems stemming from a number of interacting factors that may include habitual vocal
technique and postural use, vocal behavior, emotion, manifestations of gastroesophageal reflux, neuromuscular abnormalities, and associated organic
mucosal disease. Sorting out the relative importance of the various factors is
the first step towards planning an effective treatment program. This article
addresses the difficulties caused by trying to classify dysphonia too rigidly, and
presents a strategy for collecting the necessary information in a manner that
facilitates the development of effective tools for clinical decision making. For
each dysphonic patient, a pattern of causation will emerge in a way that
helps the clinician to disentangle the interrelated factors. Key Words: Dysphonia--Functionai--Spasmodic--Muscle tension--Etiology patterns.

Physicians like to classify things. This is reasonable since classification systems are a great aid to
diagnosis and treatment in most clinical situations.
The treatment plan for a particular cancer is directed by the histologic class or by the classification
of depth of invasion. Hoarseness, in a similar way,
can be etiologically classified into broad groups
such as those due to tumors, infection, vocal fold
paralysis, and so on, but many voice-disordered patients do not fit into a single diagnosis format very
well. F o r example, if a patient is given the diagnosis
of vocal nodules then much of the therapeutic energy is naturally directed at the nodules, possibly to
the extent o f early excision. Less time may be spent
on treating the muscle misuse aspects, behavioral,
and emotional factors or associated gastric reflux.
In a similar way, these same factors may aggravate
the spasmodic voice of the patient with laryngeal

dystonia, and attending to them may lessen the

need for dependence on botulinum toxin.

BACKGROUND
In the early 1980s, our voice clinic group at the
University of British Columbia studied clinical relationships in patients with mucosal abnormalities
of the vocal folds, such as vocal nodules, and found
that many had demonstrable muscle misuses and
postural abnormalities, including suprahyoid muscle tension, jaw restrictions, and an open posterior
glottis with voicing. The open posterior chink was
attributed to retained abductor tension in the posterior c r i c o a r y t e n o i d muscles during phonation,
part of a global hypertonicity of muscle systems in
the phonatory apparatus. We felt that vocal nodules
developed because extra glottic tension was used
for voice production in a manner that added to the
shearing forces on the vocal folds. We termed the
process " m u s c l e tension d y s p h o n i a " and became
interested in developing a classification system for
this and related vocal dysfunction (1,2).

Accepted January 3, 1996.

Address correspondence and reprint requests to Dr. Murray
Morrison, Division of Otolaryngology, University of British Columbia, Vancouver Hospital and Health Sciences Centre, 805 W.
12th Ave., Vancouver, B.C., V5Z IM9, Canada.
108

MUSCLE MISUSE VOICE DISORDERS

We initially "classified" types of muscle tension
dysphonia (MTD) as being present without mucosal
change (type 1) or with mucosal abnormalities, including nodules (type 2a), chronic laryngitis (type
2b), and polypoidal degeneration (type 2c). But
there were other patients in the clinic who clearly
had voice problems related to muscular tension but
did not have the MTD pattern. These were then
"classified" as having a "functional" dysphonia
without using the muscle tension dysphonia title.
Thus, we had functional dysphonia with ventricular
band phonation (FDVB), with bowing (FDB), with
hypoadducting states (FDHA), or a miscellaneous
assortment of misuses that we called nonspecific
(FDNS). We thus created classification confusion
(3). This classification system of 1983 and the reworked classification system of 1993 are summarized on Table 1.
Koufman's (4) work brought to our attention that
supraglottic anteroposterior contraction states
should also be brought into the relationship. So we
reclassified the ways in which a laryngologist could
group misuse of the laryngeal structures based on
visual inspection during indirect or fiberoptic laryngoscopy. Now all the patterns were included, with
the original MTD being type 1, also called the "laryngeal isometric." Type 2 included lateral contraction states at either a glottic or supraglottic location.
Type 3 indicated varying severities of anteroposterior supraglottic contraction, type 4 hypoadducting
or hysterical conversion aphonia, type 5 psychologically based vocal fold bowing, and type 6 adolescent transitional dysphonia. We thus augmented
our level of classification confusion (5).
We dropped the word "functional" from usage in

TABLE 1. Early muscle misuse

dysphonia classifications

First (1983)

Second (1993)

MTD 1
MTD2a (nodules)
MTD2b (chronic laryngitis)
MTD2c (polyp degeneration)

mml laryngeal isometric

mml plus vocal nodules
mml plus chronic laryngitis
mml plus polypoidal
degeneration
mm2 glottic
mm2 supraglottic
mm3 (anteroposterior
contraction)
mm4 (conversion aphonia)
mm5 (psychogenic bowing)
mm6 (adolescent transitional)

FDNS (nonspecific)
FDVB (ventricular)
FDHA (hypoadducting)
FDB (bowing)
FMD (mutational)

MTD, muscle tension dysphonia; mm, muscle misuse; FD,

functional dysphonia.

109

describing the clinical features in muscle misuse

voice disorders. The word can imply either a voice
problem due to psychological factors or a simple
disorder of physiological function; we found the
term added confusion.
The detailed description and criteria for the use of
each class in the second system still seems too artificial and restrictive when one considers the complex clinical pattern usually present in any one patient. We still use the system in our database to
assist in organizing clinical detail, but prefer now to
view each patient as presenting a pattern of clinical
features beyond laryngeal postures and visible features of laryngoscopy.

CLINICAL PATTERN RECOGNITION IN

MUSCLE MISUSE VOICE DISORDERS
Classification systems are more useful when
there is a single disease state that accounts for the
full range of clinical features observed. In voice disorders, we have found that impairment can be due
to a collection of causative factors, including (a)
habitual technical and postural misusage, (b) psychologically based muscular hypertonicity, (c) increased pharyngolaryngeal tone due to the reflux
reflex, (d) neuromuscular abnormalities such as
dystonia or tremor, and (e) organic processes, including nodules, polyps, cysts, or tumors.
Any classification that points a finger at one
cause tends to ignore or undervalue the contribution of others. We have found that successful treatment programs address each abnormal process involved. Each of the above factors plays a role in the
production of dysphonia in a patient with a muscle
misuse voice disorder, and the way in which these
facts interact and interrelate presents a problemsolving challenge. Each of these patients has a pattern of causative factors, and many of these "patterns" are typical. For example, the person with
long-standing poor postural habits and marginal vocal technical skill and who also has subclinical gastroesophageal reflux disease often responds to emotional stressors with depression, vocal effort, fatigue, and voice loss. Another example may be the
outgoing ebulent and vocally active teacher who is
losing time at work. In order to sort out which of the
etiological factors are most important to treat, the
clinician must examine all aspects of the case. A
clinical pattern will emerge for each.
Journal of Voice, Vol. 11, No. I, 1997

110

M. MORR1SON

IDENTIFICATION OF VARIOUS ASPECTS OF

VOCAL MUSCLE MISUSE
Visual inputs
Before getting into the details of pattern recognition, it will be helpful to review the ways in which
we collect data from a voice-disordered patient.
The classifications listed above have focused on
laryngological appearance, which is only one part of
the visual examination of the patient. Other visual
observations that we make include the following:

1. General movement and posture: Patients

with muscle misuse voice disorders (MMVD)
tend to hold themselves rather rigidly and
" s l o u c h . " Posture also is an expression
about how one feels about oneself.
2. Mental state and personality: Many voice
disorders are the result of the repression of
negative emotion. Depression may be related
to a suppressed cry or anger; jaw tension, to
overactive neural activity with anxiety; and
severe anxiety may convert to total voice
loss. Persons with a hypochondriacal personality may anticipate the poor voice and
find it.
3. Shoulder and neck motion, and alignment:
Free and easy voice use is difficult if the neck
and shoulders are held tightly. The tension is
often asymmetrical, and one shoulder may be
at a higher level than the other. Cervical lordosis may be increased. Neck torsion injury,
or " w h i p l a s h , " may trigger or cause a
MMVD.
4. Head position and movement: With extra
cervical lordosis, the head is extended at the
atlantooccipital joint and the jaw juts forward. Spontaneous head movements are reduced in MMVD.
5. Jaw excursion and freedom: In a person with
a MMVD, the jaw does not move very much
during phonation.
6. Scalloped tongue edges: Pressure against the
teeth from a tense tongue creates a series of
ridges that reflect the overall " h e l d " nature
of the voice and speech system.
7. Laryngeal movement with speech: In the normal state, the larynx can be observed to
move up and down freely during speech at
various pitches, especially in untrained voice
users. In trained professionals, decreased
vertical variation with pitch is not necessarily
a bad sign.
Journal of Voice, Vol. I1, No. I, 1997

8. Strap muscle contraction: In MMVD, the

strap muscles are tense and prominent during
speech. This generally reflects the intensity
of the "tug-of-war" that is going on in the
neck, between the tongue and jaw muscles
above and the infrahyoid straps below. Observing the inferior bellys of the omohyoid
muscles as they cross the supraclavicular fossae is often the easiest way to note this effect.
It is helpful to ask the patient to change into
a surgical scrub shirt during the interview if
his/her attire makes it difficult to see the front
of the neck.
9. Voice-related chest pressure: Chest and subglottic air pressure during speech are increased in patients with MMVD, due to the
hypervalving effect of the tight laryngeal closure. Jugular vein distension and overfilling
of the supraclavicular fossae during voicing
suggest the presence of this increased pressure.
I0. Breathing pattern: Optimal breathing for
speech is present when a controlled flow of
low pressure air passes up through a loosely
adducted glottis. This control requires a
push-pull interaction of some sort between
the diaphragm and the other thoracic and abdominal muscles. For example, it can be
achieved when abdominal muscles push air
up against a degree of retained inspiratory
force maintained by the diaphragm and intercostals. Patients with MMVD may exhibit a
lot of respiratory effort in the upper chest and
shoulder areas, giving evidence to their
breath control problem.
I 1. Level of vocal effort: People with a muscle
misuse voice problem generally have to work
harder at talking than normal, and this effort
is reflected in their complaints of fatigue and
voice loss with use. This extra effort can also
be observed by the clinician during the evaluation.
Auditory inputs
Listening to the voice is important in the evaluation of a patient with a voice disorder. The following are a number of questions that the laryngologist
may find useful in sorting out patterns of muscle
misuse.

1. How "tight" & the voice? Just thinking this

question will help the clinician, since much of
the focus in muscle misuse voice disorders is

M U S C L E MISUSE VOICE DISORDERS

on the degree and causation of tension.
2. Is the tightness "fry" or "spasm"? Effortful
pushing out of the voice in a low-pitched vocal fry register can sound to the uninitiated
listener much the same as the spasmodic
voice associated with focal dystonia or a psychologically based spasm.
3. H o w steady is the voice? The presence of
tremor helps to confirm the neurological
component of a voice misuse pattern. Tremor
can be part of a spasmodic voice or be the
central component in benign essential familial tremor. Tremor is part of the core muscle
function status upon which other factors act
to shift the symptom severity up or down.
Voice breaks are another form of unsteadiness and can be a component of almost any
form of MMVD.
4. In what way is it "hoarse" or "clear"? This
quality assessment refers to the amount of
noise in the acoustic spectrum. Many descriptive terms are used, including harsh,
strident, raspy, breathy, or rough. Other
acoustic features such as diplophonia, which
usually represents an asymmetry of the vocal
fold mass or tension, have diagnostic value.
5. Are pitch and loudness appropriate? One
way to get an idea of what the normal vocal
pitch would be in the absence of the muscular
misuse is to have the patient utter an abdominally supported " h u m p h " repeatedly. This
act tends to release the tightness rather well
in many cases. Because laryngologists now
regularly use a laryngeal stroboscope, they
have easy access to a pitch-measuring device. Even without a stroboscope, pitch can
be estimated with an inexpensive keyboard
or pitch pipe.
6. Where does the voice resonate? Effective
voice production tends to sound somewhat
nasal due to the "proper" use of the upper
vocal tract resonators for amplification. In
patients with MMVD, the voice may sound
as if it is resonating further back in the throat.
7. Are modal and falsetto registers present?
How well is the transition between registers
achieved? A vocal register is a range of
pitches that have a similar tonal quality and
are produced by roughly similar phonatory
dynamics and postures. In the pitch range
where these registers are adjacent or overlapping, the vocalist needs greater technical skill

111

to maintain a smooth transition of sound. As

the voice tightens, the initial difficulty noted
is often a problem with smooth transition between modal (chest) register and the higher
head (falsetto) register. When the MMVD is
more advanced, the ability to sing in the upper register may be lost, and the patient is
restricted to modal voice usage. High notes
must then be achieved by force, which is
both injurious and aesthetically unpleasant.
Does the voice fatigue? Sustaining constant
vocal effort when the production forces are
excessive leads to loss of quality, power, and
projection, and it may be painful.
. How does the voice change with a hum,
glide, or with movement o f the tongue, jaw,
or head? These are some typical tools used in
voice therapy for MMVD, and incorporating
them into the evaluation will give the clinician insight into the nature of the disorder
and may help estimate the likelihood of success in treatment.
10. How does the voice change with emotion or
with the topic o f conversation? The voice
may become tight or dissonant when the
topic of conversation moves into some specific sphere and stay clear when the patient is
distracted or more relaxed.
.

Tactile inputs: laryngeal palpation

Palpation of the larynx at rest and during voice
gives useful information about its function and the
degree of tension. In some patients, the larynx contracts to an abnormal degree and in an unphysiologic way during voicing but returns to normal during rest. In others, the larynx is held tightly at all
times, as if the person has forgotten to let go. There
is also a difference between the "tight" larynx, in
which most of the tension is within the larynx itself,
and the " h e l d " larynx, where the larynx is splinted
by the straps or, more importantly, held against the
vertebral column by a tense inferior constrictor
muscle.
Specifically, the laryngologist can assess these
functional areas by palpating the following, at rest
and with voicing:

1. Suprahyoid tension: The examiner should,

from the patient's right side, lightly support
the occiput in a neutral position while palpating upward into the muscle region extending from the body of the hyoid forward toward
Journal of Voice, Vol. 11, No. 1, 1997

112

2.

3.

4.

5.

6.

M. MORRISON
the submental area. At rest this will be soft
unless the tongue is being forced against the
lower teeth. The intensity of contraction of
muscles in this area with voice production is
assessed.
Thyrohyoid space tension and tenderness:
Still from the side, the examiner palpates the
thyrohyoid membrane areas with the tip of the
index finger on the left and thumb on the right.
Is it open and relaxed? Are the thyrohyoid
muscles tender to touch? Is pushing the hyoid
bone to one side and the thyroid cartilage to
the other easy? When the patient is asked to
speak or p h o n a t e lightly on a vowel or
"humph," does the thyrohyoid space disappear? Is there any relationship between tension here and the degree of anteroposterior
contraction of the supraglottis on laryngoscopy?
Cricothyroid space and mobility: The cricothyroid space should be palpated with the index fingertip. Is it open at rest? Does it open
further when the voice glides down to the bottom of the range? Does it close with high
pitches? The space that is held tightly closed
at all times is particularly significant and undesirable.
Cricoid displacement: Harris and Lieberman
(6) have suggested that in MMVD the cricothyroid muscles will eventually fatigue and let
go, allowing the cricoid cartilage to slip forward and partly sublux the cricothyroid joint.
This can be felt by relating the inferior midline
edge of the thyroid cartilage to the cricoid
arch.
Laryngeal excursion: The degree of up and
down mobility of the larynx throughout the
pitch range may be palpated or visualized.
Inferior constrictor tightness and freedom of
the lateral laryngeal gutters: If the inferior
constrictors are not holding the larynx tightly
against the vertebral column, the larynx can
be rotated and the fingertips insinuated behind
the posterior edge of the thyroid lamina. If the
area is very relaxed, then the movement of the
arytenoid cartilage can be felt, and posterior
cricoarytenoid muscle contraction can be palpated during an inspiratory sniff. If the larynx
is tightly held, then the lateral gutters are not
accessible at all. Great care must be taken to
avoid carotid artery compression during this
maneuver.

Journal of Voice, Vol. 11, No. 1, 1997

FIG. 1. The major causative factor fields in muscle misuse voice

disorders.

IDENTIFYING CLINICAL PATTERNS:

A MANAGEMENT STRATEGY
It has been pointed out that voice disorders are
frequently due to misuse of a muscle system, which
is the common final pathway to the impairment.
Dysphonia is caused by component factors from
each of a number of areas, including poor technical
and postural habits, psychologically based muscular h y p e r t o n i c i t y , p e r s o n a l i t y , reflux-related
pharyngolaryngeal tone, neuromuscular abnormalities, and organic processes such as nodules, polyps,
cysts, or tumors. It is helpful to estimate what proportion of any one patient's symptoms is due to
dysfunction in each area.
The four broad fields to be considered by the clinician when beginning the process of establishing
the clinical pattern of muscle misuse are illustrated
in Fig. 1.
The first field addresses general posture and muscle use, and encompasses an assessment of vocal

FIG. 2. An example of interaction in an individual patient: a

preponderance of emotional and behavioral factors.

M U S C L E M I S U S E VOICE DISORDERS

FIG. 3. Factor interaction in a dysphonic patient with a major

reflux problem.

technical skill as well as muscular posture and tension in the shoulder, neck, jaw, larynx, and paralaryngeal areas.
The second field considers the personality of the
patient. A person who talks or sings excessively
may affectionately be considered to be "vocaholic." Is the voice regularly abused? Does the patient smoke?
The third addresses emotion. Voice problems are
often the result of repression of negative emotion,
and the main ones to consider are depression, anger, and chronic anxiety.
Fourth, chronic gastroesophageal reflux may produce an increase in pharyngolaryngeal muscle tone
through a vagal reflex. Singers who reflux regularly
report an easing of the voice when the reflux of acid
is controlled. Muscle misuse voice disorders are
more resistant to voice therapy techniques in the

q/
8

FIG. 5. Dystonia will generally cause a spasmodic voice disorder in the presence of predisposing, precipitating, or perpetuating factors.

113

FIG. 4. Another individual example of muscle misuse etiologic

factors in dysphonia,

presence of reflux esophagitis. There may also be

active inflammation in the larynx that is reflux
based, producing edema, erythema, or granuloma
formation.
Figure 2 demonstrates how the four fields may
interact in a particular patient. In this example, the
patient has major problems in the emotional and
behavioral areas more than in the other two. Figures 3 and 4 could reflect the relative importance of
reflux and posture in two other patients. Each patient will have his/her own profile, which of course
will change with time and circumstance.
Overlying these background fields come organic
mucosal disease and neurological processes as illustrated in Figs. 5 and 6. The figures particularly
make the point that dystonia and mucosal disease
seldom occur in isolation, and treating background
problems facilitates resolution of the other processes.

FIG. 6. Mucosal disease should be evaluated together with the

contributing effects of the muscle misuse pattern.
Journal of Voice, Vol. 11, No. 1, 1997

114

M. M O R R I S O N

Figure 5 considers dystonia and tremor, the abnormal baseline tone upon which background factors exert their impact. Therapy directed at the alterable factors can facilitate symptom resolution.
Figure 6 considers mucosal changes. These may
result from misuse and abuse, or can activate and
trigger the misuses themselves. It is easy to lay all
blame for the symptom on a poor nodule, when it
may be just a trigger, an effect, or an innocent bystander.
In conclusion, this article presents my approach
to the disentanglement of the complex factors that
can cause a muscle misuse voice disorder in a way
that may help the clinician treat patients more effectively. It is hoped that this account will generate
as many questions as solutions and encourage the
research that is needed to better our understanding
of this intriguing muscle use system.
More information on clinical recognition of features related to psychological, postural, reflux, or
behavioral manifestations of voice disorders has
been presented elsewhere, and the reader is encouraged to explore further (7-10).

Journal of Voice, Vol. I1, No. 1, 1997

REFERENCES
1. Morrison MD, Rammage LA, Belisle GM, Nichol H, Pullan
B. Muscular tension dysphonia. J Otolaryngol 1983;12:
302--6.
2. Belisle G, Morrison MD. Anatomic correlation for muscle
tension dysphonia. J Otolaryngol 1983;12:319-21.
3. Morrison MD, Nichol H, Rammage LA. Diagnostic criteria
in functional dysphonia. Laryngoscope 1986;96: I-8.
4. Koufman JA, Blalock PD. Classification and approach to
patients with functional voice disorders. Ann Otol Rhinol
Laryngol 1982;91:372-7.
5. Morrison MD, Rammage LA. Muscle misuse voice disorders: description and classification. Acta Otolaryngo!
(Stockh) 1993;113:428-34.
6. Harris T, Lieberman J. The cricothyroid mechanism, its relation to vocal fatigue and vocal dysfunction. Voice Forum
1993 ;2:89-96.
7. Morrison MD, Rammage LA. The management of voice disorders. London: Chapman and Hall, 1994.
8. Rubin JS, Sataloff RT, Korovin GS, Gould WJ. Diagnosis
and treatment of voice disorders. New York: Igaku-Shoin,
1995.
9. Colton RH, Casper JK. Understanding voice problems. Baltimore: Williams & Wilkins, 1990.
10. Sataloff RT. Professional voice: the science and art of clinical care. New York: Raven Press, 1991.