Functional Dysphonia Jason Y K Chan M.B.B.S. January 13, 2012
Functional Dysphonia Jason Y K Chan M.B.B.S. January 13, 2012 1 Acknowledgements • Lee Akst MD • Barbara Messing MA, CCC-SLP, BRS-S January 13, 2012 2 Disclosures • None January 13, 2012 3 Objectives • Define functional dysphonia • Appreciate the diagnostic challenges of functional dysphonia • Management of functional dysphonia January 13, 2012 4 Definition • Abnormal quality of voice in the absence of an identifiable lesion • However there is debate and ambiguity with minor tissue changes and its relation to a primary functional disorder January 13, 2012 5 Definition • Common terms used include: – Muscle tension dysphonia – Psychogenic dysphonia – Hyperfunctional dysphonia – Ventricular disorder • Bogart-Bacall syndrome January 13, 2012 6 Definition • Secondary functional dysphonia/ muscle tension dysphonia (MTD) – Organic pathologies leading to MTD e.g. vocal cord paralysis January 13, 2012 7 Epidemiology • Prevalence of voice disorders in the US 3%-9% • UK 40,000 patients a year referred to voice therapy • Herrington-Hall et al. 1988 found in 1262 voice patients, 57.6% had functional dysphonia January 13, 2012 8 Etiology • Psychological and personality factors – Anxiety – Depression – Neuroticism – History of sexual or physical abuse – Life events January 13, 2012 9 Etiology • Social factors – Vocal misuse/ abuse – Professional voice users January 13, 2012 10 Pathophysiology • Inappropriate muscle tension – Increased extrinsic musculature tension – Laryngeal rise – Reduced thyrohyoid space • Affects intrinsic musculature – Tension of vocal folds January 13, 2012 11 Diagnosis • Clinical exam: – Tightness of extrinsic laryngeal musculature – Decreased thyrohyoid space – Focal tenderness January 13, 2012 12 Diagnosis • Videostroboscopy – Adduction of ventricular folds to midline – Anterior posterior contraction – Extreme supraglottic squeeze January 13, 2012 13 Management • Indirect therapy: – Vocal hygeine: • Environmental advice • Vocal use • Personal behavious January 13, 2012 14 Management • Direct therapy: – Circumlaryngeal manual therapy – Working on posture, breathing, phonation and articulation January 13, 2012 15 Management • Cognitive Behavioral Therapy • Medical therapy: Botulinum Toxin • Treatment of organic pathology if present January 13, 2012 16 Functional Dysphonia Van Houtte et al. 25 (2) 2011. Pathophysiology and treatment of muscle tension dysphonia January 13, 2012 17 Examples: GK January 13, 2012 18 Examples: GK • Functional dysphonia: – Psychogenic – Emotional stress causes supraglottic strain – Periods of normal voice – Can present as MTD or conversion disorders e.g. mutational falsetto January 13, 2012 19 Examples: EF January 13, 2012 20 Examples: EF • Functional dysphonia – Minimal arytenoid edema – Supraglottic strain with apposition of FVC on phonation – Plica ventricularis • Chronic laryngitis likely secondary to smoking and reflux January 13, 2012 21 Examples: KB January 13, 2012 22 Examples: KB • Functional dysphonia – False cord tension particularly noticeable on the right false cord January 13, 2012 23 Examples: PB January 13, 2012 24 Examples: PB • Functional dysphonia – Likely MTD see supraglottic strain AP and also false cord – Possible SD given history – Trial of voice therapy followed – TA botox no improvement January 13, 2012 25 Examples: TK January 13, 2012 26 Examples: TK • Secondary MTD – Right TVC paralysis – Supraglottic strain to compensate January 13, 2012 27 Examples: CH January 13, 2012 28 Examples: CH • Functional dysphonia – MTD with AP shortening and false cord tension January 13, 2012 29 Selected References • • • • Van Houtte E et al. (2009) Pathophysiology and treatment of muscle tension dysphonia: a review of the current knowledge. J Voice 25(2): 202-207 Ruotsalainen J et al. (2008). Systematic review of the treatment of functional dysphonia and prevention of voice disorders. Oto Head Neck Surg 138: 557-565 Deary V et al. (2011) Reconsidering the role of psychosocial factors in functional dysphonia. Curr Opin Otolaryngol Head Neck Surg 19: 150154 Bos-Clark et al. (2011) Effectiveness of voice therapy in functional dysphonia: where are we now? Curr Opin Otolaryngol Head Neck Surg 19:160-164 January 13, 2012 30
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