Dyshphonia

Muscle Tension Dysphonia

Lifetime risk of developing a voice disorder is 30% with an estimated point prevalence of 3–9% in the U.S. population. Voice disorders negatively impact quality of life, job performance, and job attendance, costing approximately $2.67 billion dollars in lost wages, physicians’ visits, and treatment expenses. Muscle tension dysphonia (MTD) is a functional voice disorder that comprises approximately 10–40% of clinical caseloads in voice centers. It is characterized by increased laryngeal musculoskeletal tension with excessive muscular recruitment in the larynx and pharynx with concomitant disruption of efficient vibratory parameters. MTD is further classified as primary or secondary. Primary occurs in the absence of identifiable fixed laryngeal pathology (e.g. vocal fold lesions, paralysis), while secondary refers to MTD that occurs concomitantly with such pathologies. Clinically, both types present with variable symptomology including hoarseness, vocal fatigue, effortful voice production, change in habitual pitch, reduced vocal range, pain with voice use, muscular cramping and neck stiffness.

 There is growing recognition that voice production requires whole-body muscular engagement. For example, posture related to the spine, shoulders, and hip position can impact voice. During speaking tasks, expiratory muscles and passive recoil of the thorax act to maintain adequate subglottic pressure for voicing. The sternocleidomastoid, scalene, and trapezius muscles are recruited to allow greater control of thoracic contraction during singing and complex speech tasks in which loudness and pitch are varied. This permits greater regulation of the subglottic pressures required to complete these demanding tasks. Resonance also necessitates intricate coordination of muscles that alter tongue position, larynx height, and mouth opening. Therefore, muscle imbalances can disrupt any and all aspects of the mechanism – respiration, phonation, and articulation/resonance –and produce symptoms of MTD.

 Treatment of MTD focuses on the rebalancing of subsystems involved in voice production, including respiration, phonation, and articulation, ultimately resulting in restoration of proper vibratory parameters and improved efficiency of voice production. A systematic review from the Cochrane Collaboration found behavioral voice therapy – a combination of direct and indirect methods – to be an effective treatment for MTD. Indirect methods include vocal hygiene and voice conservation education. Direct methods use vocal exercises, facilitating vocal techniques, and often circumlaryngeal massage to increase efficiency of voice production and reduction of extra-laryngeal muscle tension. Manual circumlaryngeal massage is used to regulate and restore the balance of intrinsic and extrinsic laryngeal musculature during phonation. Some have attributed a portion of voice therapy failures to insufficient reduction of musculoskeletal tension, thereby underscoring the importance of manual treatment in this patient population.

Current treatment for MTD addresses extrinsic laryngeal area muscle tension, despite growing recognition implicating both laryngeal and “extralaryngeal musculature” as therapeutic targets. To treat the entire mechanism requires collaboration with practitioners adept at treating neck, back, shoulder, and diaphragmatic/abdominal muscular tension. In this study, we introduced a manual physical therapy treatment program as an adjunct to traditional voice therapy. The aim of this study was to determine patient perceived improvement in voice handicap using the Voice Handicap Index (VHI) when treated with voice therapy alone, combined voice and physical therapy, physical therapy alone, or incomplete or no treatment.

Craig J, Tomlinson C, Stevens K, et al. Combining voice therapy and physical therapy: A novel approach to treating muscle tension dysphonia. J Commun Disord. 2015;58:169-178. doi:10.1016/j.jcomdis.2015.05.001