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