Functional

MUSCLE TENSION DYSPHONIA:

Overview:

Muscle tension dysphonia is a functional disorder, or one in where there is nothing structurally wrong with the voice. People with muscle tension dysphonia have muscles that do not function properly, causing poor sound, discomfort, or a sensation of increased effort when speaking. Muscle tension dysphonia may affect the way that the voice sounds, however it may also cause pain, discomfort, and fatigue in the absence of an audible vocal problem. 

People with muscle tension dysphonia will be required to use muscles outside of the larynx, which are usually not directly used in speech, to compensate for the dysfunctional muscles of the larynx. This can result in a stronger voice, but one that requires more and more effort. This cycle of increased effort can often continue for months before someone is aware that their voice is abnormal. In these cases, the onset of muscle tension dysphonia is very subtle.

The muscle tension can present in a variety of ways. Some of the common patterns are the following:

• Anterior-Posterior Constriction
• Hyper-Abduction
• Hyper-Adduction
• Pharyngeal Constriction
• Ventricular Phonation
• Vocal Fold Bowing

See Types of Muscle Tension Dysphonia for more information on these patterns of tension.

Cause:

A vocal fold hemorrhage is caused from phonotrauma, or the physical stresses caused by using the voice, often inappropriately. Phonotrauma can result from the following:

• Prolonged illness
• Continually using the voice while one has laryngitis, upper respiratory infections, etc.
• This causes one to adapt maladaptive compensatory techniques
• Prolonged overuse
• Prolonged underuse, e.g., after surgery
• Trauma
• Injury
• Chemical exposure
• Emotionally traumatic event
• Poor vocal technique
• Reflux disease
• Psychological factors
• Personality factors

These may lead to an abnormal vocal response. Often, the individual will therefore compensate by using extra effort while speaking.

Symptoms:

Individuals with muscle tension dysphonia will experience a variety of symptoms, and they can vary dramatically from one patient to another. They will depend on the pattern of muscular tension that is present. See Types of Muscle Tension Dysphonia for information regarding the symptoms associated with each pattern of muscle tension. Symptoms include vocal characteristics and sensations. Possible vocal characteristics of muscle tension dysphonia can include the following:

• A rough, hoarse, gravely, raspy, or coarse voice
• A weak, breathy, airy, leaky, backward, or hollow voice
• A strained, pressed, squeezed, tight, tense, choked, or effortful voice
• Vocal fatigue
• Suddenly cutting out, squeezing shut, breaking off, changing pitch, or fading away
• A voice that gives out gradually, or becomes weaker or more tense with continued voice use
• Inability to project your voice
• Reduced range of pitch
• Reduced volume

Possible sensations of muscle tension dysphonia can include the following:

• Pain or discomfort anywhere in the throat area associated with voice use
• A tight choking sensation associated with voice use
• A sensation of fatigue or effort that increases with voice use
• Some area of the neck is tender to the touch
• A feeling of the need to clear the throat frequently
• A feeling of a lump in the throat

Types of Muscle Dysphonia:

Anterior-Posterior Constriction:

Muscle Tension Pattern:

Two abnormal movements may be present in the anterior-posterior pattern of muscle tension dysphonia: the arytenoid cartilages bend forward toward vocal use and/or the epiglottis bends backward. This causes the larynx to squeeze from front to back, or anterior to posterior. This squeezing puts pressure on the vocal folds and causes them to bow and causing poor vibration. See Vocal Fold Bowing for more information on bowing. In extreme cases, the arytenoids may vibrate against the epiglottis. This is especially prevalent in children. 

Sound of Voice:

The voice will range from sounding normal to extremely tight and squeezed sounding. If this squeezing of the larynx causes irregular vibration of the vocal folds, the voice may have a rough quality to it. If the arytenoids vibrate against the epiglottis, the voice will sound "froggy."

Complaints:

Typical complains of individuals with anterior-posterior constriction may include the following:

• Poor voice quality
• Discomfort 
• Pain that increases with vocal use, but may be consistently present even during vocal rest
• Vocal fatigue with prolonged use
• Declining vocal quality with prolonged use

Cause:

Causes of anterior-posterior constriction may include the following:

• Prolonged vocal overuse
• Continuously using the voice when the vocal mechanism is impaired
• Prolonged use of a tense style of speaking
• Emotional stress

Treatment:

Treatment of anterior-posterior constriction can include the following:

• Functional therapy
• Indirect therapy
• Vocal hygiene education
• Direct therapy
• Voice therapy to change maladaptive vocal behaviors
• Circumlaryngeal manual therapy

Hyper-Abduction:

Muscle Tension Pattern:

In hyper-abduction, the vocal folds do not come together, which is a requirement to successfully phonate. When viewing the vocal folds, they may appear to be pulled apart while the person phonates.

Sound of Voice:

The voice may have the following characteristics:

• Weak
• Breathy or airy
• Very reduced volume
• Breaks in voicing

Complaints:

Typical complains of individuals with hyper-adbuction may include the following:

• Increased effort with vocal use
• Increased fatigue with vocal use
• Ineffective voice

Cause:

Causes of hyper-abduction may include the following:

• Abnormality in the vocal mechanism which causes pain may lead to avoidance of voicing for protection
• Emotional trauma or problems
• Stress

Treatment:

Treatment of anterior-posterior constriction can include the following:

• Functional therapy, which is often combined with psychotherapy to combat emotional issues
• Functional therapy:
• Indirect therapy
• Vocal hygiene education
• Direct therapy
• Voice therapy to change maladaptive vocal behaviors
• Circumlaryngeal manual therapy
• Injections of a substance to add bulk to the vocal folds to assist in closure
• This is an effective, but temporary, treatment

Hyper-Adduction:

Muscle Tension Pattern:

In hyper-adduction, the vocal folds come together very tightly, which produces a valve-like seal which restricts airflow through the vocal folds. The larynx may look normal when it is examined, but the sound and sensation will not be. 

Sound of Voice:

The voice may range from normal to extremely tight, pressed, squeezed, strangled or forced sounding. In addition, speech may be effortful. 

Tension may be irregular, which causes a shaking effect or a pattern of stopping and starting when speaking.

Complaints:

Typical complains of individuals with hyper-adduction may include the following:

• Poor vocal quality
• Increased effort with vocal use
• Increased fatigue with vocal use
• Pain
• Discomfort

Cause:

Causes of hyper-adduction may include the following:

• Prolonged overuse
• Continuously using the voice when the vocal mechanism is impaired
• Emotional trauma or problems
• Tense vocal style, which can cause hyper-adduction to become habitual over time

Treatment:

Treatment of anterior-posterior constriction can include the following:

• Functional therapy
• Indirect therapy
• Vocal hygiene education
• Direct therapy
• Voice therapy to change maladaptive vocal behaviors
• Circumlaryngeal manual therapy
• Botox injections to weaken the muscles

Pharyngeal Constriction:

Muscle Tension Pattern:

In pharyngeal constriction, the muscles of the larynx contract excessively while speaking, which leaves the throat feeling extremely constricted. 

Sound of Voice:

The voice may range from sounding normal to very tight or squeezed. It may also include the following characteristics:

• Tremulous sounding
• Backward or "throaty" sounding 

Complaints:

Typical complains of individuals with pharyngeal constriction may include the following:

• Poor vocal quality
• Decline of vocal quality with vocal use
• Increased fatigue with vocal use
• Pain that increases with vocal use, may be consistently present during vocal rest
• Discomfort

Cause:

Causes of pharyngeal constriction may include the following:

• Prolonged overuse
• Continuously using the voice when the vocal mechanism is impaired
• Prolonged use of a tense speaking style
• Emotional stress

Treatment:

Treatment of anterior-posterior constriction can include the following:

• Functional therapy
• Indirect therapy
• Vocal hygiene education
• Direct therapy
• Voice therapy to change maladaptive vocal behaviors
• Circumlaryngeal manual therapy

Ventricular Phonation:

Muscle Tension Pattern:

In ventricular phonation, the ventricular folds come together and vibrate instead of--or in addition to--the vocal folds. The ventricular folds are also known as the false vocal folds, and they are mounds of tissue (which are not muscular) that are located above the vocal folds. Because they are not muscular, they are not meant to vibrate. Therefore they can not vibrate very fast or strong, which is needed for high pitches and loud volume respectively. The pressure that comes from the ventricular folds are they try to vibrate can be strong enough to interfere with the vocal folds and keep them from vibrating.

Sound of Voice:

The voice may have the following characteristics:

• Rough sounding
• Strained sounding
• Limited range in pitch
• Limited range in volume
• Sometimes does not sound "human"

Complaints:

Typical complains of individuals with ventricular phonation may include the following:

• Poor vocal quality
• Fatigue with vocal use, especially when attempting to increase volume
• Pain or dryness with vocal use
• Discomfort, however this may not always be present

Cause:

Causes of ventricular phonation may include the following:

• Using the voice while the true vocal folds are impaired
• Extreme strain in response to trauma

Treatment:

Treatment of ventricular phonation can include the following:

• Functional therapy
• Indirect therapy
• Vocal hygiene education
• Direct therapy
• Voice therapy to change maladaptive vocal behaviors
• Circumlaryngeal manual therapy
• Medical treatment if functional therapy is ineffective
• Surgical treatment if functional therapy is ineffetive

Vocal Fold Bowing:

Muscle Tension Pattern:

In vocal fold bowing, the vocal folds do not come together to vibrate. They leave a gap which allows air to leak through.

Sound of Voice:

The voice may have the following characteristics:

• Weak sounding
• Breathy sounding
• Rough or scratchy quality

Complaints:

Typical complains of individuals with vocal fold bowing may include the following:

• Fatigue from vocal use
• Undependable voice
• Increased effort while speaking
• Reduced volume
• Voice weakens with vocal use

Cause:

Causes of vocal fold bowing may include the following:

• Over-exertion of the voice, sometimes when the individual is in poor condition
• Old age sometimes causes atrophy of the vocal folds
• Compensatory muscle tension in the anterior-posterior direction which squeezes the vocal folds apart

Treatment:

Treatment of anterior-posterior constriction can include the following:

• Functional therapy
• Indirect therapy
• Vocal hygiene education
• Direct therapy
• Voice therapy to change maladaptive vocal behaviors
• Circumlaryngeal manual therapy

Diagnosis:

Diagnosis of muscle tension dysphonia is best accomplished by using a fibreoptic laryngoscopy, which is used via the nose. Through this technology, the vocal range, vocal limits, and the changing shape of the larynx can be examined. The following characteristics will be evident and will aid in the diagnosis of the particular type of muscle tension dysphonia:

• Hyper-Abduction

• Vocal folds do not come together

• Patient will not be able to successfully phonate. 

• Vocal folds may appear to be pulled apart during phonation

• Hyper-Adduction

• Vocal folds will be together very tightly

• A valve-like seal is created at the vocal folds which restricts airflow 

• The larynx may look normal when it is examined, 

• Sound and sensation should be examined for abnormalities

• Pharyngeal Constriction

• The muscles of the larynx will contract excessively while speaking

• Ventricular Phonation

• Vocal folds may vibrate normally

• False vocal folds (or ventricular folds) vibrate in addition to or instead of the vocal folds

• Reduced pitch and volume

• Vocal Fold Bowing

• Vocal folds will not vibrate during phonation

• Visible gap between vocal folds

• Air leakage through vocal folds

Treatment:

Treatment of muscle tension dysphonia depends on the pattern of muscle tension that the individual possesses. Please see the Types of Muscle Tension Dysphonia section for more information regarding various treatment options for each pattern of muscle tension.

References:

http://www.voiceconnection.com.au/pdf/muscletension.pdf

http://www.dukehealth.org/services/voice_care_center/care_guides/voice_conditions/muscle_tension_dysphonia

http://www.hopkinsmedicine.org/otolaryngology/specialty_areas/voice_center/conditions/muscle_tension_dysphonia.html

http://www.nyee.edu/cfv-larynx-disorders.html

http://emedicine.medscape.com/article/865191-overview#a1