2. SPPA 6400 Voice Disorders Tasko Functional Dysphonia/ Muscle Tension Dysphonia (MTD)

3. SPPA 6400 Voice Disorders Tasko Muscle Tension Dysphonia: A Functional Voice Disorder What is a functional voice disorder?  Voice disorder in the absence of structural/neurological pathology  Pathology insufficient to explain the degree of dysphonia  Voice disorder based on abuse/misuse causally linked to anatomical abnormalities

4. SPPA 6400 Voice Disorders Tasko Functional dysphonia vs. muscle tension dysphonia

5. SPPA 6400 Voice Disorders Tasko Muscle Tension Dysphonia (MTD) Presumed Etiology  Excess or dysregulated activity of the intrinsic and extrinsic laryngeal muscles Possible Sources  Technical misuse of the vocal mechanism  Learned adaptations following upper respiratory infection  Compensation for underlying vocal fold pathology  ↑ laryngeal tone 2° to laryngopharyngeal reflux  Psychological/personality factors

6. SPPA 6400 Voice Disorders Tasko Muscle Tension Dysphonia (MTD) Key Features  Laryngeal/paralaryngeal hypertonicity “stiff” larynx Larynx in unnatural position high in neck  Laryngeal muscle “cramping”  No unique voice quality/glottic configuration Pre-treatment MTD samples

7. SPPA 6400 Voice Disorders Tasko Muscle Tension Dysphonia (MTD) Some Trends  Occurs predominantly in women (90 %)*  May account for > 10 % of cases referred to multidisciplinary voice clinics  Often the most severely affected voices encountered  Commonly follows URI symptoms*  Past history of voice problems (80%)*  Varies in response to treatment *Roy et al. (1997)

8. SPPA 6400 Voice Disorders Tasko Recognizing Muscle Tension Dysphonia  Patient history  Auditory-perceptual Features  Laryngoscopic Features  Direct clinical examination: Manual assessment of laryngeal musculoskeletal tension  Primary or Diagnostic therapy

9. SPPA 6400 Voice Disorders Tasko Patient History  Vocal symptoms… Can have a sudden onset May have had periods of resolution May have developed along with a URI  Symptoms suggestive of excess musculoskeletal tension Laryngeal tenderness, soreness, pain, tightness, “swellings” which intensify with extended voice use Pain radiates to one or both ears Unilateral symptoms are more common Vocal fatigue, increased effort Restricted dynamic range

10. SPPA 6400 Voice Disorders Tasko Patient History  Voice Use History… may not reveal patterns of excessive voice use  Psychosocial History… may reveal elevated stress Stress may be coincident with history of vocal symptoms

11. SPPA 6400 Voice Disorders Tasko Auditory Perceptual Features Generally…  Severity of voice quality disturbance typically consistent across a range of speech tasks  Signs are usually continuous and rarely intermittent (no islands of normal speech)  Typically shows no improvement with falsetto or singing

12. SPPA 6400 Voice Disorders Tasko Auditory Perceptual Features  The most disordered voices produced with normal larynges  Wide range & variety of voice qualities  Possible existence of 5 auditory- perceptual clusters qualitatively distinct within a cluster, voices vary from mild-severe

13. SPPA 6400 Voice Disorders Tasko Auditory-perceptual Clusters  Cluster 1 Persistent glottal fry  Cluster 2 Sustained harsh, strained (tension)  Cluster 3 Diplophonia, intermittent pitch & voice breaks  Cluster 4 Aphonia (continuous)  Cluster 5 Elevated pitch (falsetto) – with & without strain, aphonia

14. SPPA 6400 Voice Disorders Tasko THOUGHT QUESTION Why don’t persons with MTD develop laryngeal pathologies?

15. SPPA 6400 Voice Disorders Tasko Laryngoscopic Features  Dysregulated muscle activity = myriad of glottic/supraglottic contraction patterns  Rammage & Morrison (2001) suggest a distinct set of laryngoscopic patterns  Controversial

16. SPPA 6400 Voice Disorders Tasko MTD Type 1: Laryngeal Isometric (+/- benign mucosal disease)  Principle feature: posterior glottic chink  Presumed due to ↑ PCA activity  Suggested association with benign mucosal lesions

17. SPPA 6400 Voice Disorders Tasko MTD Type 2a – Glottic Lateral Compression  Lateral compression principally at the glottis  May be some ventricular compression  ↑ closed phase  ↓ vibratory amplitude

18. SPPA 6400 Voice Disorders Tasko MTD Type 2b – Supraglottic Lateral Compression  Ventricular folds are approximated

19. SPPA 6400 Voice Disorders Tasko MTD Type 3: Anterior-posterior supraglottic compression  ↓ distance between anterior and posterior glottis  Arytenoids “pull” toward epiglottis  Associated with “Bogart- Bacall” syndrome

20. SPPA 6400 Voice Disorders Tasko MTD Type 4 – Non-adducted hyperfunction (- supraglottic compression)  Incomplete glottal closure with normal mobility

21. SPPA 6400 Voice Disorders Tasko MTD Type 4 – Non-adducted hyperfunction (+ supraglottic compression)  Incomplete glottal closure with normal mobility  Concomitant compression of the ventricular folds

22. SPPA 6400 Voice Disorders Tasko MTD Type 5 – Bowed vocal folds  “Spindle”-shape glottis  Also associated with aging (presbylaryngis or presbyphonia) Neurologic conditions (Parkinson’s Disease)

23. SPPA 6400 Voice Disorders Tasko Note Relation between auditory-perceptual judgments and laryngoscopic findings are not straightforward

24. SPPA 6400 Voice Disorders Tasko Direct Clinical Assessment Focal palpation of circumlaryngeal area to determine… Presence of tenderness and/or pain Laryngeal Stiffness  Presence of nodularity or taut bands  Reduced mobility of the larynx Extent of laryngeal elevation

25. SPPA 6400 Voice Disorders Tasko Manual Assessment of Laryngeal Musculoskeletal Tension “All patients with voice disorders, regardless of etiology should be tested for excess musculoskeletal tension, either as a primary or secondary cause of dysphonia” (Aronson, 1990)

26. SPPA 6400 Voice Disorders Tasko Manual Assessment of Laryngeal Musculoskeletal Tension  Pressure is directed over the Major horns of the hyoid bone Superior border of the thyroid cartilage Anterior border of sternocleidomastoid and into the suprahyoid muscles  Determine size of the thyrohyoid space Digital pressure should be just enough to blanche (lighten in color) your nail bed

27. SPPA 6400 Voice Disorders Tasko From Aronson (1990)

28. SPPA 6400 Voice Disorders Tasko From Roy et al. (1996)

29. SPPA 6400 Voice Disorders Tasko Treatment Options  Facilitating techniques designed to elicit easy, relaxed phonation, phonation at optimal pitch, etc  General and focal relaxation  “Broad spectrum” treatments that focus on increasing support and efficiency of phonatory behavior  Manual Circumlaryngeal Techniques*  Pharmacologic Intervention (topical lidocaine)

30. SPPA 6400 Voice Disorders Tasko Manual circumlaryngeal techniques Goals  Determine contribution of laryngeal/extralaryngeal hypertonicity  Assure proper diagnosis and selection of appropriate treatment  Avoid unnecessary medical or surgical management  Show Pre-Post Samples

31. SPPA 6400 Voice Disorders Tasko Manual circumlaryngeal techniques  A group of techniques  a “hands on” approach  Clinician manually repositions, repostures or “massages” the laryngeal structure while eliciting voice  Use voice task with a hierarchy of difficulty  Exploit facilitating techniques

32. SPPA 6400 Voice Disorders Tasko Manual circumlaryngeal techniques May be used as  primary treatment technique for musculoskeletal tension dysphonia (MTD)  diagnostic therapy to evaluate degree of contribution of musculoskeletal tension to voice disorder

33. SPPA 6400 Voice Disorders Tasko MCT: Reposturing techniques 1. Compression in the A-P direction (push-back) 2. Impede laryngeal elevation (Pull down) 3. Medial compression and downward traction (Reposturing) Goal: Perturb the abnormal laryngeal posture and evaluate change in voice quality

34. SPPA 6400 Voice Disorders Tasko Technique 1: Push Back Maneuver  Digital compression in the posterior direction within the region of the larynx  Vary height and pressure Suprahyoid Hyoid Infrahyoid T-H space Thyroid notch

35. SPPA 6400 Voice Disorders Tasko Technique 2: Pull Down Maneuver  Impede laryngeal elevation by applying downward traction over the superior border of the thyroid

36. SPPA 6400 Voice Disorders Tasko Technique 3: Laryngeal Reposturing  Medial compression and downward traction  pressure directed over posterior aspect of thyroid cartilage (and within T-H space)  Often helpful with non-adducted hyperfunction

37. SPPA 6400 Voice Disorders Tasko Circumlaryngeal massage (manual laryngeal tension reduction) What is it?  Circular motion over Tips of major horns of the hyoid bone Thyrohyoid space Posterior border of the thyroid cartilage Medial and lateral suprahyoid muscles

38. SPPA 6400 Voice Disorders Tasko Circumlaryngeal massage (manual laryngeal tension reduction) What is it?  Locate sites of focal tenderness, nodularity and tautness  Progress from superficial to deep pressure  Vary pressure according to patient tolerance  Patient must vocalize concurrently  Progressively increase complexity of voice stimuli

39. SPPA 6400 Voice Disorders Tasko Indications for improvement (single session)  Improved voice quality  Pain reduction/relief  Normalized laryngeal height and mobility  Reduced muscle nodularity

40. SPPA 6400 Voice Disorders Tasko Factors affecting management of MTD using MCT Patient based factors  Motivation  Duration and severity of dysphonia  Persisting psychological issues  Primary and secondary gain, litigation etc…

41. SPPA 6400 Voice Disorders Tasko Clinician based factors  Technical skill  Clinician-patient dynamic  Communicate expectations and confidence in procedure  Pt learns by doing (avoid discussion)  Brisk therapeutic “pace”  Engage pt in process  Confront pt when effort ↓  Reinforce improvement  Expect successive approximations to a normal voice  Variety of facilitating techniques  Know when to abandon a technique or stick with it  Establish that patient is responsible for change  May employ ‘negative’ practice

42. SPPA 6400 Voice Disorders Tasko Manual Circumlaryngeal Techniques Evidence for clinical utility of MCT in  Functional dysphonia (muscle tension dysphonia) Roy et al. (1997) J Voice

43. SPPA 6400 Voice Disorders Tasko Short and long term effects of MCT  N=25  Some improvement following Tx (96%)  Normal or only mildly dysphonic following Tx (64 %)  Deterioration of voice at follow up (25 %)  Improvement of voice at follow up (17 %)

44. SPPA 6400 Voice Disorders Tasko Short and long term effects of MCT What about relapse?  68 % report some evidence of recurrence of some dysphonic symptoms Recurrence is partial rather than complete Occurs within 3 mos. following initial treatment Less than 4 days in duration, self limiting (i.e. resolves spontaneously)

45. SPPA 6400 Voice Disorders Tasko Concomitant MTD & Organic/Neurogenic Dysphonia  Elevated laryngeal musculoskeletal tension may co-occur in patients with documented laryngeal pathology  Why? Cause, Effect, Complication  MCT have diagnostic & treatment utility with these populations

46. SPPA 6400 Voice Disorders Tasko Manual Assessment of Laryngeal Musculoskeletal Tension “All patients with voice disorders, regardless of etiology should be tested for excess musculoskeletal tension, either as a primary or secondary cause of dysphonia” (Aronson, 1990)

47. SPPA 6400 Voice Disorders Tasko Examples  Polyp  CVA  Reinke’s edema Pre-MCT Post-MCT

48. SPPA 6400 Voice Disorders Tasko MCT with BMD Patients  N=18  Gender 83% female 17% male  Age Mean: 44.1 years SD: 13 years  Dysphonia Duration Mean: 2.27 years SD: 3.64 years  4/18 bilateral nodules  2/18 unilateral nodule  2/18 unilateral polyp  2/18 Reinke’s edema  5/18 TVF irregularities/edema/erythe ma  1/18 ventricular cyst  1/18 interarytenoid lesion  1/18 post-intubation granuloma (Tasko, et al. 1994)

49. SPPA 6400 Voice Disorders Tasko

50. Topical Lidocaine (J Voice (2000)) Use of topical lidocaine in the treatment of muscle tension dysphonia. Dworkin JP, Meleca RJ, Simpson ML, Garfield I. Department of Otolaryngology, Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan 48201, USA. aa1544@wayne.edu This investigation explored the potential usefulness of topical lidocaine in the treatment of muscle tension dysphonia. Three patients with this disorder, who were previously unresponsive to standard voice therapy, were treated with lidocaine. In each case, the outcome was prompt, clinically significant, and sustained. Persistently high-pitched and shrill vocal quality was converted to near normal voice patterns within 15 minutes after transcricothyroid membrane lidocaine injection. We suggest that this temporary and simple laryngeal and tracheal anesthetic technique may have helped to break the perverse cycle of hyperactive glottal and supraglottal muscle contractions evident in each of these patients during phonation efforts. We discuss the possible sensorimotor mechanism of action of this therapeutic technique. Dworkin JPMeleca RJSimpson MLGarfield I

51. SPPA 6400 Voice Disorders Tasko Atypical Presentation (video)

52. SPPA 6400 Voice Disorders Tasko Psychological/Personality factors & MTD Issues  State vs. Trait Factors  Psychological Factors in Disease: Cause, Effect or Catalyst

53. SPPA 6400 Voice Disorders Tasko Psychological/Personality factors & MTD Empirical findings in a group with MTD  Neuroticism - ↓ emotional stability and ↑ reactivity ↑ scores  Extraversion-sociability, dominance, energy and enthusiasm ↓ scores  Psychoticism – impulsivity/aggressiveness (high) vs. agreeable/conscientiousness (low) Similar to normal controls Roy et al. (2000)

54. SPPA 6400 Voice Disorders Tasko Psychological/Personality factors associated with MTD Additionally,  Anxious  Somatization – physical complaints  Stress reactive  Alienated  Unhappy Roy et al. (1997)

55. SPPA 6400 Voice Disorders Tasko MTD compared to Vocal Nodule Patients Empirical findings in a group with vocal nodules  Neuroticism - ↓ emotional stability and ↑ reactivity Mildly ↑ scores  Extraversion-sociability, dominance, energy and enthusiasm ↑ scores  Psychoticism – impulsivity/aggressiveness (high) vs. agreeable/conscientiousness (low) ↑ scores Roy et al. (2000)

56. SPPA 6400 Voice Disorders Tasko Functional Dysphonia  When no structural abnormality exists, descriptive terms are often used which imply a psychological etiology. For example,  Psychogenic dysphonia  Conversion dysphonia  Hysterical dysphonia

57. SPPA 6400 Voice Disorders Tasko What is “hysterical conversion”?  “conversion” of psychological stress into physical complaints Psychiatric literature suggests it arises from  Bland emotional unconcern/affect  Numerous physical complaints  Denial of anxieties and fears

58. SPPA 6400 Voice Disorders Tasko Is MTD a “hysterical conversion”?  This triad of features was not observed with patients with broad diagnosis of FD (MTD)  Patients are typically quite anxious and concerned about problem  Short answer: No