Extreme

MAKEOVER
Larynx edition
Diagnosis and Treatment of
Muscle Tension Dysphonia
Starr Cookman, M.A., CCC-SLP

A rose by any other name .

..

Functional Dysphonia
Vocal disruption without organic cause
Also called:

Hyperfunctional Dysphonia
Psychogenic Dysphonia (Aphonia)
Non Organic Dysphonia
Vocal Hyperfunction
Muscular Tension Dysphonia
Hyperkinetic Dysphonia
Laryngeal Tension-Fatigue Syndrome
Laryngeal Isometric Dysphonia

Classification System,
Koufman & Blalock 1991
Functional

Term)

Dysphonia (Umbrella

6 Subtypes
Conversion
Habituated Hoarseness
Inappropriate Falsetto
Vocal Abuse Syndromes
Post Operative Dysphonia
Relapsing Aphonia

Vocal Abuse Syndromes

Tension

Fatigue Syndrome
Bogart-Bacall Syndrome
Nodules
Reinkes Edema
Vocal Process Ulcer/Granuloma

Muscular Tension Dysphonia

(MTD)
Morrison

Inability of the arytenoids to come

together
Posterior Glottal Gap

Over-specificity

later corrected

MTD separated into 4 types

Type 1 = PGG
Type 2 = Ventricular Compression
Type 3 = Anterior-Posterior Compression
Type 4 = Spincteric Larynx

Challenges

Functional Dysphonia
Implies voluntary misuse of the larynx
Not descriptive

Subtypes

are numerous

Over classification
No evidence of generalization into voice
clinics

Proposed Classification
System
Umbrella

Term: Muscle Tension

Dysphonia (Aphonia)
Vocal disruption resulting from an
imbalance of laryngeal musculature
Advantages
Descriptive
Does not imply etiology
Easier for patient

4 Subtypes of MTD
Psychogenic
Habituated
Compensatory
Contributory

Psychogenic MTD
Onset

Sudden
Can be linked to psychologically
disruptive event
No concomitant URIs
Progression

Usually little to no change over time

Psychogenic MTD (cont.)

Voice

quality

aphonic, whispery, monotone, constant,

severe dysphonia, glottal fry, vegetative
tasks are normal
Acoustic

Studies

Yanigahara hoarseness rating 3-4

Elevated perturbation measures
Abnormal fundamental frequency

Psychogenic MTD (cont.)

Laryngeal

Presentation

Structure = normal
Function = Arytenoids held open, arytenoids
pressed, ventricular compression,
sphincteric supraglottis, arytenoids mobile
EMG

Normal
Response

Excellent

to speech therapy

Habituated MTD
Etiology

Associated with laryngeal disturbance

Chemical exposure
Upper respiratory infection
Laryngeal Trauma
Reflux
Laryngeal Surgery

Habituated MTD (cont.)

Progression

Extended course
Consistent voice quality across
time/settings
Patient complains of laryngeal pain/
fatigue
Secondary gain may be present

Habituated MTD (cont.)

Voice

Quality

glottal fry, breathiness, roughness,

diplophonia, sustained phonation worse
than conversation, abnormal pitch/register
(falsetto), vegetative tasks are normal
Acoustics
Yanigahara 2 - 3
Elevated perturbation
Range restrictions

Habituated MTD (cont.)

Laryngeal

Presentation

Structure = normal
Function = poor vibratory coordination, poor
vocal fold closure, ventricular compression,
anterior - posterior compression
EMG

normal
Response

Excellent

to speech therapy

Compensatory MTD
Onset

Laryngeal event (URI/Trauma/Surgery),

aging process, compromised pulmonary
status
Progression

Consistent dysphonia including veg tasks

Some change over time is possible
Patient complains of increased effort and
fatigue

Compensatory MTD (cont.)

Voice

Quality

Breathy, diplophonia, glottal fry

Acoustic

Findings

Abnormal fundamental frequency

Yanigahara 1-4
Variety of perturbation measures

Compensatory MTD (cont.)

Laryngeal Findings

Structure = normal
Function = poor vocal fold closure,
posterior glottal gap, sluggish arytenoid
movement, asymmetry VF vibratory
characteristics

EMG
Abnormal (Haglund, et. al. 10 of 18
functional dysphonia patients =
abnormal EMG of CT and/or TA)

Compensatory MTD (cont.)

Response

to speech therapy

Variable
unloading tension may help diagnostic
clarity and surgical result
Usually underlying pathology (usually
glottic insufficiency) needs to be
addressed as well

Contributory MTD
Onset

gradual, after extensive vocal use,

yelling, screaming, poor vocal hygiene
Progression

No fluctuations
Worsens if not treated
Worsens with use
Patient complains of
pain/fatigue/increased effort

Contributory MTD (cont.)

Vocal

Quality

raspy, rough, breathy, normal prosody,

increased rate, dysphonia consistent
across task and environment, loud speech,
hard glottal attacks, sustained phonation
similar to speech
Acoustic

Findings

Normal to low Fo, restricted range (usually

high restrictions), Yanigahara type 1-2,
elevated perturbation

Contributory MTD (cont.)

Laryngeal

Presentation

Structure = Pathology
nodules, edema, posterior contact
ulcers/granuloma, polyps

Function = vibratory restrictions,

arytenoid movement well
coordinated, posterior glottal gap,
mild ventricular compression and/or
mild anterior-posterior compression

Contributory MTD (cont.)

EMG

normal
Response

variable

to speech therapy

Contributory MTD (cont.)

Jiang

and colleagues, 1998 Ann Otol

Rhinol & Laryngol (107)
Computer modeling of laryngeal vibration
Normal
Tense (tension in TA)
Nodule

Findings
Intraepithelial mechanical stress increases at
the midpoint of the membranous vocal folds
under condition of muscular tension

Describing Laryngeal
Configuration
Formerly

MTD types 1-4

Use descriptive terms

PGG
Ventricular Compression
Anterior-Posterior Supraglottic
Compression
Sphincteric Glottis
Additional

Tension?

type: Thyroarytenoid

Posterior Glottal Gap

Considered a
normal finding for
many females
Problematic when
seen in
conjunction with
nodules or poor
vibratory
characteristics
Describe extent of
gap

Ventricular Compression

Mild - Severe
Usually
symmetrical
Can be primary
source of
phonation

Anterior-Posterior
Supraglottic Compression

Mild - Severe
Normal finding at
extremes of range
for singers
Best diagnosed
with flexible
endoscopy
Normal for some
vowels

Sphincteric Glottis

Both ventricular
and AP
compression
View of vocal
folds obscured
Rare
Usually
Compensatory
MTD or
conversion MTD

Clinical Application of
Classification System
Replace

Functional Dysphonia with

Muscle Tension Dysphonia
Describe type of MTD as one of 4 types
Describe glottic/supraglottic configuration
Example
Patient presents with habituated muscle
tension dysphonia s/p URI as characterized by
moderate ventricular compression

Diagnostic Considerations
for MTD
Intake

Interview
Perceptual Evaluation
Acoustic Evaluation
Aerodynamic Evaluation
Medical Evaluation
Videolaryngostroboscopy
Laryngeal and cervical neck palpation
Diagnostic Probes

Intake Interview

Special attention to . . .

Onset
Progression previous treatment modalities
Anxiety/stress factors and management
Vocal load

Tools

VHI (Jacobson)
Vocal Tract Discomfort (VTD) scale (Mathieson,
et.al., 2009, J of Voice)

Build rapport through unconditional

positive regard; reflecting; listening; nonjudgmental affect

Vocal Tract Discomfort Scale (VTD)

Mathieson, et.al., 2009 J of Vx
Frequency
of sensation/sympt.

Burning

1 2 3 4 5 6

1 2 3 4 5 6

2.

Tight

1 2 3 4 5 6

1 2 3 4 5 6

3.

Dry

1 2 3 4 5 6

1 2 3 4 5 6

4.

Aching

1 2 3 4 5 6

1 2 3 4 5 6

5.

Tickling

1 2 3 4 5 6

1 2 3 4 5 6

6.

Sore

1 2 3 4 5 6

1 2 3 4 5 6

7.

Irritable

1 2 3 4 5 6

1 2 3 4 5 6

8.

Lump in the Throat

1 2 3 4 5 6

1 2 3 4 5 6

1.

0 = never
2 = sometimes
4 = often
6 = always

Severity
of sensation/sympt

Intake Interview

Common PT. complaints

Hoarseness
Vocal fatigue
Vocal strain
Pain on or after phonation
Tightness in throat
Voice loss
Unable to project
Globus
Loss of pitch range

Perceptual Evaluation
Visual

tensions jaw; forehead; SCM;

larynx
GRBAS scale
Breath behaviors
Glottal attacks, rate of speech, throat
clearing, inappropriate intensity, fry
tone, low pitch,
Look for task specificity

Perceptual Evaluation
Perceptual

worsening of dysphonia
for SD for voiced vs. voiceless
consonants; no change for MTD
Perceptual worsening in SD from
sustained /a/ to connected speech;
MTD no change
Roy, el.al., (2007) Folia Phoniatric Logo and
(2005) Laryngoscope

Acoustic Evaluation

Fo; MTD; Fo range; MDVP (jitter, shimmer

and variation; degree of unvoiced signal)
S:Z
Spectrograph
ADSD vs MTD (Roy, et.al., Laryngoscope, 2008;
Sapienza, et.al., 2000 J of Voice)
Phonatory breaks (complete interruption of
phonation within a word) ADSD > MTD
SD increase dysphonia with increase in task
complexity

MTD vs. SD (cont.)

Spectrograms

from ADSD vs MTD

differenciated with 94% and 98%
accuracy by SLP raters
Rees, et. al., (2007) Oto. HN Surgery

Spectrograph: Diagnostic
Tool
ADSD

MTD

Aerodynamic Evaluation
PAS

Subglottal pressure
cmH2O
Above NL

Glottal airflow
mL/s
Below NL

Estimated Laryngeal Resistance

cm/H2O/L/s
Above NL

Medical Evaluation
Contributions

to MTD

Tissue sensitivity
Neurological abnormality
Pulmonary abnormality
Glottic insufficiency

Common

medical findings

GERD 49%
Allergies 37%
Altman, et.al. 2005, J of Vx. N = 150 MTD

Stroboscopy
Glottic

Configuration

Ventricular Compression
A-P supraglottic compression
Sphincteric glottis
PGG
Glottic constriction on inspiration (n=15
MTD; 15 controls) Vertigan, et.al., 2006,
Laryngoscope

Stability

Stroboscopy (cont.)
Other

findings

Paresis or paralysis
VF atrophy
Secondary lesions (location)
Primary lesions

Diagnostic

Probes

Stroboscopy (cont.)
Pattern

of Muscular Tension

Few aberrant laryngeal behaviors appeared

unique for spasmodic dysphonia versus
muscle tension dysphonia
Patterns of laryngeal tension did seem to
differentiate
SD = intermittent; associated with phonetic
variability
MTD = consistent from task to task

Tremor only found with SD

Leonard & Kendall, 1999. Laryngoscope

Palpatory Evaluation

Determine sites and levels of muscle

tenderness, tension and resistance
Hyoid and Larynx elevated
Some cases larynx is forcibly depressed
Larynx resists lateral displacement
TH space constricted and painful to the
touch (less so with ADSD)
Submandible bulging/tight
SCMs tight and tender

Diagnostic Probes
Laryngeal Relaxation Humming Vegetative
Manip
Tasks

Psychogenic
MTD
Habituated
MTD
Compensatory
MTD
Contributory
MTD

Treatment for MTD

Efficacious
Differentiates

SD from MTD
1 to 25 sessions of trp
More severe cases tend to need fewer
sessions

Treatment Protocol
Medical

management of irritation

Few cases of PPI curing MTD (Mesuda,

et.al., 2007, Japanese journal with a big
long name, n=3)
Education/Counseling
Direct

therapy

Education/Counseling
Listen

Cue to relatable aspects of Pt.

Determine vocal intelligence
Establish open body language
Be prepared for tears

Reassure

We do not think this is in your head

Show

Treatment Modalities
Direct

Therapy

Manual Circumlaryngeal Therapy (MCT)

LMRVT
Breath and Alignment Retraining
Auditory Masking
Biofeedback
Shaping from Vegetative Tasks
Estill Voice Training System

MCT

Goal: Relax excessively tense perilaryngeal and laryngeal musculature

inhibiting norm. phon.
Massage = relax & reduce discomfort
Based on Aaronson laryngeal
musculoskeletal reduction approach (1990)
circular movements made with thumb/finger applied to
TH space from ant. to post. as well as over thyroid
cart.
Larynx coaxed side-to-side and down
Vocalizations are coached and shaped to speech

MCT
Benefits

shown in literature

Dcrs perceptual severity ratings

Dcrs perturbation values
Dcrs first three formants
Improved maximum phonation time

Roy and colleagues (1993, 1997 & 2001)

MCT
Dysphonia

Severity Index reduced

DSI = weighted MPT, highest Fo, Lowest

dB and jitter

Van Lierde, et.al., in press, J of Voice. n=10 MTD.

No change in Ab brthg tx grp. Also, Van Lierde,
et.al., 2004, J of Vx. N = 4)

MCT
111

female MTD pt. demo improved

speech continuity (changes in VT)

diphthong 2nd formant slope increased

Vowel Space Area incrsd
Vowel Artic Index incrsd
Global speech rate incrsd
Dromey, et.al., 2008, JSLHR
Roy, et.al., 2009, J of Comm Dis.

Laryngeal Massage Therapy

Differs from CMT:

T-H space not directly addressed

Patient silent
Patients rate VTD before and after
Primarily bimanual

Goal: reducing laryngeal height and hyperengaged supralaryngeal musculature

Reduction of RAP and VTD severity and

frequency

(Mathieson, et.al., 2009, J of Voice. N = 10 MTD)

Lessac-Madson Resonant Vx Tx
(LMRVT)
Cranial/facial

sympathetic

vibration
MTD seems to prevent
Works directly with filter
Works indirectly with source

Breath/Alignment Retraining
Reduce

cervical/neck tension

Abdominal, rather than cervical

displacement during inhalation
Adjust alignment to head/neck (ears
over shoulders)
Stretches
Self massage jaw/larynx/SCMs
Improve breath flow

Auditory Masking
Disrupts

auditory feedback loop

Encourages return to normal
muscular coordination
Facilitator by Kay Elemetrics,
SoundPro by Resound, audiometer.

Biofeedback
Surface

EMG

Elevated peri-oral and peri-laryngeal EMG

activity before and during phonation in MTD
population (Hocevar - Boltezar, et. al. 1998)
Evidence that patients can reduce this
activity using EMG biofeedback (Stemple, et.
al. 1980)
Phonatory

Aerodynamic System
Endoscopy
Improved vocal intelligence for some

Vegetative Tasks

Yawn
Throat Clearing
Coughing
Gargle
Grunt
Giggle
Sigh

Cry
Laughter
Animal Sounds
Hum

Estill Voice Training System

Jo

Estill, Singer/Speech Pathologist

Laryngeal and vocal tract positioning
for different singing styles
11 manipulations

4 source
6 filter (pharynx, tongue, soft palate,
aryepiglottic space)
False Fold Retraction

Intervention Strategies
by MTD Type

Compensatory
Un-loading (LMT; RVT; Education;
breath/alignment)

Contributory
Un-loading (LMT; RVT; Education;
breath/alignment)

Psychogenic
MCT/LMT combo

Habituated
MCT/LMT combo

If Therapy Fails

Reconsider Diagnosis
Experimental techniques

Botox injection to ventricular folds

Lidocaine bath

Referrals

Otolaryngology
Psychology
Neurology
Pulmonology
Allergy
Gastroenterology