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.. Å 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 Æ 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 Laryngeal trauma or neural injury. Prior neck surgery or trauma. TMJ disorders, cervical myalgia, or muscular fatigue. GERD and LPR. Endocrinopathies. generalized dystonia or myasthenia gravis. 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 Æ reduction of the hoarseness. Examination Indirect laryngoscopy (mirror examination) to confirm the vocal folds at the same level. mucosal colour and inflammation. Videostroboscopic laryngoscopy interarytenoid area alone Æ LPR petiole (back of the epiglottis) Æ excessive coughing supraglottic Æ post nasal drip generalized inflammation Æ smoking, alcohol and gross reflux. 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 reeducation. 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 patient’s 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. Æ relaxed, self-confident and more outgoing Æ voice is one of the major beneficiaries. Voice therapy Symptomatic voice therapy Psychogenic voice therapy recognition and elimination of the cause of the voice disorder, may be multifaceted. Physiologic voice therapy emotional and psychosocial issues. Etiological voice therapy identification and elimination of vocally abusive behaviors. auditory feedback, head positioning, laryngeal massage, relaxation. 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