Muscle Tension Dysphonia

Muscle tension dysphonia.

What is it?

What are the causes of muscle tension dysphonia?

How can you tell if you have it?

And how do you treat MTD?

You will find answers to these questions and more, right here on this page. Let's start with the first question: what is muscle tension dysphonia?

Muscle tension dysphonia or MTD for short. You may know MTD under other names, such as hyperfunctional voice disorder, spastic dysphonia or functional dysphonia, or even muscle misuse or abuse disorder.

Muscle tension dysphonia is a voice disorder in the absence of other structural or neurological disorders. This simply means that there are no other findings or abnormalities of vocal folds (for example there are no vocal nodules.)

When there are no other structural changes present, we talk about primary MTD.

However, people can develop muscle tension dysphonia as a result of having vocal fold abnormalities and we would recognize this as a secondary MTD.

As a result, you can have muscle tension dysphonia and vocal nodules at the same time.

In this case, muscles tension develops as a compensatory strategy.

And you may be surprised to know that according to current understanding of this disorder, this tension may be located not only in the laryngeal area. Other areas of tension may include the chest or abdominal areas, or in several areas at the same time.

MTD is quite a common voice problem. As a result, 50% of voice clinic clients suffer from this condition. In spite of that, we really don’t quite understand the causes of MTD.

However, there are many causes of MTD and they include psychological factors as well as physiological factors:

• stress,
• anxiety,
• significant emotional trauma,
• acid reflux,
• glottal insufficiency,
• viral infections,
• muscular discoordination,
• allergies,
• environmental irritants,
• increased vocal demand,
• and others.

Common Complaints of MTD

Here is a list of common complaints of people suffering from muscle tension dysphonia:

• Vocal fatigue is a common complaint.
• Pain when speaking.
• Hoarseness is another common complaint.
• Reduced vocal range, or inability to sing in either high or low ranges.
• A feeling of a lump in the throat, so called globus sensation.
• Shortness of breath when speaking.

As you can see, the symptoms of MTD can be really varied and every person with MTD sounds differently.

Also, it is also interesting to know that some people with MTD have different breathing patterns than people without this disorder. When a healthy person speaks, he or she starts speaking at about 60% of their lung capacity and takes another breath at about 40%. However, some people with MTD usually start talking at 40% of their lung capacity and talk down to 10% of their lung volume.

Link to the video: https://www.youtube.com/watch?v=qab7zGHnKDc

Laryngeal Position in MTD

Another sign of MTD that is quite common is a high laryngeal position. This is caused by tension in the superficial neck muscles that move the larynx upward. These would be muscles that are above the hyoid bone or above the thyroid cartilage.

Similarly, some people with MTD may have habitual forward head position, which impacts voice production and breathing too.

Diagnostic Process of MTD

Symptoms and signs are really wide-ranging.

So, how do you know if you have MTD?

In summary, there are three important components in the process of making the diagnosis of MTD.

Symptoms cannot be the only measure to determine if you have or have not muscle tension dysphonia. So, don’t try to self-diagnose based on your signs and symptoms.

This diagnosis requires a team of voice professionals, including a physician, speech-language pathologist and potentially other medical professionals.

• The first component is very detailed history of the voice problem.

• Perceptual voice evaluation, palpation to assess muscular tension, and careful observations is another important part of the diagnostic process.

• Finally, laryngoscopy, and more specifically videostroboscopy, is absolutely crucial in confirming the diagnosis of MTD. A laryngologist has to see and evaluate the structures and function of the vocal folds and other laryngeal structures.

If you experience voice changes or hoarseness for more than two weeks without the presence of an acute infection, speak to your doctor and see a specialist.

The sooner, the better.

Muscle Tension Dysphonia Treatment

The good news is that primary MTD responds really well to voice therapy, which should be the gold standard for treating this condition. The length of therapy depends on several factors and can last from a few weeks to several months or longer.

Naturally, the goal of therapy is to decrease or eliminate tension so that the laryngeal muscles can work efficiently again.

Link to the video: https://www.youtube.com/watch?v=L5yk4CA0IXQ

In addition, it may be necessary to treat underlying or contributing factors as well as the voice itself. For example, if MTD developed secondary to vocal fold lesions, the ENT specialist may suggest other treatment options, such as medication or surgery.

Or if acid reflux or emotional stress is a contributing factor to MTD, then these conditions should be treated appropriately.

Voice Therapy for Muscle Tension Dysphonia

The role of a speech-language pathologist is important in the therapy process.

Personally, I like to use the ALERT framework. Each letter of this word stands for an area addressed in voice therapy. Let’s go through the letters together:

A STANDS FOR ANATOMY

During the diagnostic process of MTD, the voice specialist should get a very clear picture about the anatomy and function of the vocal instrument.

This is done through a videostroboscopic examination. Based on the findings, it may be necessary to consider medication or surgery in some cases.

L STANDS FOR LIFESTYLE

In this area, you need to identify behaviours and lifestyle factors that contribute or are responsible for MTD.

This may include:

• adjusting your daily schedule to decrease vocal use,
• get enough sleep,
• eat healthy diet including sufficient hydration,
• improve overall vocal health,
• or identify and eliminate harmful vocal behaviours.

The most dangerous vocal behaviours are those that we don’t know we are using in our every day lives.

E STANDS FOR EMOTIONS

Emotional stress and anxiety are well recognized causes of MTD in many people.

The speech-language pathologist may help you identify these factors. She or he may offer some relaxation, breathing and mindfulness techniques to deal with some of them.

Sometimes, it may be necessary to work with other professionals to treat them.

R STANDS FOR REFLUX

Reflux can be a triggering factor of MTD.

LPR or laryngo-pharyngeal reflux is very common in people with voice disorders. Therefore, it has its own special letter in this voice treatment framework.

So, in order to eliminate tension, you need to start managing acid reflux with the help of your doctor.

AND FINALLY T STANDS FOR TECHNIQUE.

This is the core of voice therapy.

The speech-language pathologist may use different approaches and techniques to eliminate tension from the vocal mechanism and establish and promote more efficient ways of sound production.

Here are three examples:

• Establishing optimal body and head and neck alignment.
• Improving breathing patterns and coordination of breathing with the phonatory system.
• Vocal exercises to establish and strengthen healthy voice use.

Even though, these techniques may be very different, they have many things in common. The goal is to take away pressure from the vocal folds and re-distribute vocal effort to all participating structures.

These techniques use vocal exercises like humming, buzzing, phonating on the vowels /i/ or /o/, on fricatives Z or V or phonating on NG like in the word sing.

Moreover, they start in the most comfortable range and slowly progress to include a wider vocal range through stretching vocal exercises such as slides or glides.

Many of these techniques work directly with breath management in coordination with laryngeal muscle use.