Current and Emerging Concepts in Muscle Tension

Dysphonia: A 30-Month Review

*Kenneth W. Altman, Cory Atkinson, and Cathy Lazarus
*,Chicago, Illinois, and New York, New York
Summary: The modern theory of hoarseness is that there are multifactorial
etiologies contributing to the voice problem. The hypothesis of this study
is that muscle tension dysphonia is multifactorial with various contributing
etiologies. Methods: This project is a retrospective chart review of all patients
seen in the Voice Speech and Language Service and Swallowing Center at
our institution with a diagnosis of muscle tension (functional hypertensive)
dysphonia over a 30-month period. A literature search and review is also
performed regarding current and emerging concepts of muscle tension dys-
phonia. Results: One hundred fty subjects were identied (60% female, 40%
male, with a mean age of 42.3 years). Signicant factors in patient history
believed to contribute to abnormal voice production were gastroesophageal
reux in 49%, high stress levels in 18%, excessive amounts of voice use in
63%, and excessive loudness demands on voice use in 23%. Otolaryngologic
evaluation was performed in 82% of patients, in whom lesions, signicant
vocal fold edema, or paralysis/paresis was identied in 52.3%. Speech pathol-
ogy assessment revealed poor breath support, inappropriately low pitch, and
visible cervical neck tension in the majority of patients. Inappropritate intensity
was observed in 23.3% of patients. This set of multiple contributing factors
is discussed in the context of current and emerging understanding of muscle
tension dysphonia. Conclusions: Results conrm mutifactorial etiologies con-
tributing to hoarseness in the patients identied with muscle tension dysphonia.
An interdisciplinary approach to treating all contributing factors portends the
best prognosis.
Key Words: DysphoniaMuscle tension dysphoniaFunctional hyperten-
sive dysphoniaVoiceAerodigestive tract.
Accepted for publication March 30, 2004.
From the *Department of OtolaryngologyHead & Neck
Surgery, Northwestern University Feinberg School of Medicine,
Chicago, Illinois; The Department of Communication Sci-
ences & Disorders, Voice Speech and Language Service and
Swallowing Center, Northwestern University, Chicago, Illinois;
Department of Otolaryngology, New York University School
of Medicine, New York, New York.
Presented at the Annual Meeting of the Voice Foundation,
Philadelphia, PA, June 6, 2003.
Address correspondence and reprint requests to Kenneth W.
Altman, Department of OtolaryngologyHead & Neck Sur-
gery, Northwestern University Feinberg School of Medicine,
303 E. Chicago Ave., Searle 12-561, Chicago, IL 60611. E-mail:
k-altman@northwestern.edu
Journal of Voice, Vol. 19, No. 2, pp. 261267
0892-1997/$30.00
2005 The Voice Foundation
doi:10.1016/j.jvoice.2004.03.007
261
KENNETH W. ALTMAN ET AL 262
INTRODUCTION
Voice literature has long recognized functional
dysphonia as an umbrella diagnosis for impairment
of voice production in the absence of structural
change or neurogenic disease of the larynx. Muscle
tension dysphonia (MTD) semantically lies within
the bounds of functional dysphonia, although it has
only occasionally been investigated as a distinct
entity in the spectrum of functional voice disorders,
despite its widely accepted clinical presence. Early
mention is made of voice disorders stemming from
apparent increased laryngeal tension and poor habits
of phonation,
1
and terms such as myasthenia lar-
yngis
2
and psychophonasthenia
3
have been sug-
gested. Several authors have more recently proposed
categorization schemes for the range of underlying
behaviors in functional dysphonia, which include an
MTD classication.
46
Delineation of MTD from functional dysphonia
has been suggested based on history, laryngoscopic,
perceptual-acoustic, musculoskeletal, and psycho-
logical features.
7
These data suggested that key
features of MTD include posterior glottal chink,
mucosal vocal cord changes, larynx rise, suprahyoid
muscle tension, breathiness, glottal fry, glottal
attack, and stridency.
7,8
Along with classication
schemes, authors have suggested myriad titles for
MTD in the literature (Table 1), suggesting various
underlying etiologies and characteristics. This is
curiously analogous to the modern theory of
hoarseness, where there are multifactorial etiologies
contributing to the voice problem. The hypothesis of
this study is that muscle tension dysphonia is multi-
factorial with various contributing etiologies. Re-
sults of this retrospective chart review are put into
the context of the present understanding of MTD
with a thorough review of the literature.
METHODS
This project was approved by the Northwestern
University Institutional Review Board Human Sub-
jects Committee and preceded the need for Health
Insurance Portability and Accountability Act
(HIPAA) compliance. A retrospective chart review
was performed of all patients seen in the Voice
Speech and Language Service and Swallowing
Center at Northwestern Memorial Hospital with a
Journal of Voice, Vol. 19, No. 2, 2005
TABLE 1. Synonymous Terms for Muscle
Tension Dysphonia
Hyperfunctional dysphonia
Muscle misuse dysphonia
Hyperkinetic dysphonia
Musculoskeletal tension dysphonia
Mechanical voice disorder
Functional hypertensive dysphonia
Laryngeal tension-fatigue syndrome
Laryngeal isometric dysphonia
diagnosis of muscle tension (functional hyperten-
sive) dysphonia over a 30-month period from Janu-
ary 1, 2000 through June 30, 2002. The Center for
Voice at Northwestern maintained integrated otola-
ryngologic and speech pathology care of patients,
which facilitated retrieval of pertinent medical infor-
mation. Data were collected on demographics, voice
complaints, voice use demands, as well as pertinent
medical history, lifestyle/social history, otolaryn-
gologic assessment and laryngoscopic ndings,
dysphonia characteristics, and initial prognosis for
improvement on therapy. Tobacco use history was
categorized as mild (10 pack/year history), moder-
ate (1130 pack/year) and extreme (30 pack/year).
Alcohol use was categorized as mild (16 per week
presently), moderate (12 per day), and extreme
(2 per day). Caffeine use was categorized as mild
(12 per day), moderate (24 per day), and ex-
treme (4 per day). As this information was not
standardized in the medical record at the time of
initial documentation, some judgments were made
to t this categorization scheme at the time of formal
chart review. Formal statistical analysis of the data
was not performed as the data were deemed to be
dealing with observation (judgments) rather than
true measured quantities. The reliability of these
judgments was considered to be very good based
on the experience, qualications, and consistency
of those performing otolaryngologic (K.W.A.) and
speech pathology (C.L.) evaluations.
RESULTS
One hundred fty subjects were identied, 94
female (63%) and 56 male (37%). The median age
was 42.3 years, with a female median age of 41.7
MUSCLE TENSION DYSPHONIA 263
and a male median age of 44.7. Pertinent voice
complaints on initial presentation are summarized
in Table 2. The most common complaints were
hoarseness 83%, vocal fatigue 26%, vocal strain
23%, and pain related to phonation 17%. Pertinent
medical history of these subjects is summarized in
Table 3. Notably, a prior history of gastroesophageal
(or laryngopharyngeal) reux was present in 49%
and a history of seasonal/perennial allergy symp-
toms in 37%. Lifestyle/social issues are listed in
Table 4, including the distribution of tobacco, alco-
hol, and caffeine use. Twenty-seven subjects (19%)
reported signicant stress in their daily life. Ninety-
four subjects (63%) reported excessive amounts of
voice use in their professions, and 34 subjects (23%)
reported that their voice use demands required ex-
cessive loudness to successfully perform their
professions.
Otolaryngologic evaluation with laryngoscopic
ndings were available in 123 subjects and summa-
rized in Table 5. Gastroesophageal (laryngopharyn-
geal) reux and/or chronic laryngitis was observed
in 52 subjects (35%). Thirty-four subjects had a
vocal fold polyp (23%), with a sex distribution of
21 female to 13 male. Twenty subjects had nodules
(13%), with a sex distribution of 16 female to 4
male. Twelve subjects had vocal fold cysts (8%),
with a sex distribution of 7 female to 5 male. Other
pertinent ndings include bowing (n 2), scar
(n 2), hemorrhage (n 1), granuloma (n 1),
leukoplakia (n 1), and papilloma and unspecied
lesion (n 2). Vocal fold paralysis was observed in
5 subjects (3%).
Speech pathology evaluation and assessment is
listed in Table 6, with predominant ndings of poor
breath support in 98% of subjects, inappropriate
pitch in 82%, and obvious cervical neck tension
visible in 70%. Inappropriate intensity, fast rate of
speech, glottal fry, jaw tension, and hard glottal
attacks were also observed. Initial prognosis for im-
provement on speech therapy was excellent in 13
subjects (9%), good in 114 (76%), fair in 7 (5%),
and poor in 5 (3%). Speech therapy was not recom-
mended or the patient declined therapy in 6 cases
(4%).
DISCUSSION
It is clear that muscle tension dysphonia in these
patients was multifactorial in nature with respect to
Journal of Voice, Vol. 19, No. 2, 2005
TABLE 2. Patient Complaints in MTD
n %
Hoarseness 125 83%
Vocal fatigue 39 26
Vocal strain 35 23
Pain on or after phonation 26 17
Tightness in throat 17 11
Voice loss 13 9
Unable to project voice 7 5
Globus 7 5
Loss of pitch range 3 2
underlying etiology and contributing factors. Com-
mon clinical features of MTD in our series was
consistent with well-known qualities of this dis-
order, including poor control of the breath stream,
an abnormally low-pitched speaking voice,
9
and
increased frequency of hard glottal attacks,
10
and
possible increased prevalence in female patients.
Multifactorial contributions leading to functional
dysphonia and MTD have long been recognized and
indicate that clinical evaluationof the voice shouldbe
comprehensive for accurate diagnosis.
1115
Otolaryngologic evaluation of the larynx in our
study and others similarly reveals multiple etiologies
in patients with muscle tension voice disorders. Vid-
eostroboscopic evaluation of patients with MTDreg-
ularly shows abnormal ndings such as uneven
mucous layer, vessel dilation, abnormal glottal clo-
sure, and bilateral vibratory asymmetry.
16,17
Addi-
tionally, laryngopharyngeal reux, identiable by
laryngeal edema and/or erythema, was conrmed
by pH probe testing in 70% of patients found to
have vocal abuse/misuse/overuse syndromes, and in
78% of an MTD subgroup.
18
Laryngoscopy ndings
alone, however, may not distinguish patients with
functional dysphonia from normal subjects and are
only part of a diagnostic evaluation.
19
Our study conrms this high prevalence of gastro-
esophageal/laryngopharyngeal reux in the MTD
population. As shown in Tables 3 and 5, a history
or laryngoscopic ndings suggestive of reux was
present in 49%and 46%of our patients, respectively.
Including the overlap, 86 subjects (57%) had past
or present reux, having the potential to signi-
cantly affect optimal laryngeal function and voice
production.
KENNETH W. ALTMAN ET AL 264
TABLE 3. Pertinent Medical History
n %
Gastroesophageal reux 74 49
Allergy 56 37
Depression/anxiety medications 10 7
Asthma 12 8
Dysphagia 7 5
Hypertension 5 3
Sinusitis 4 3
H/o tracheostomy 1 0.6
In this review, approximately one fth of the pa-
tients (19%) reported high levels of stress in their
lives. Also, 86% of the patients in our study reported
that they require excessive voice use or the use of a
loud voice in daily activity. Mood disorders, anxiety,
and tension have been recognized to contribute
to functional dysphonia and have been identied
in as many as one third of a total group of func-
tion dysphonia patients reported by House and
Andrews.
11
Roughly half of another functionally
dysphonic group had experienced a difculty with
speaking out, as compared with 16% of a control
group.
20
It has been suggested, however, that other
types of functional dysphonia, such as that associ-
ated with ventricular phonation, bowed vocal cords,
or conversion aphonia have a much stronger psychi-
atric relationship as compared with MTD.
8
Aaron-
son
21
classies musculoskeletal tension disorders
under the category of psychogenic voice disor-
ders, stating that the extrinsic and intrinsic laryn-
geal muscles are exquisitely sensitive to emotional
stress, and their hyperconstriction is the common
denominator behind the dysphonia and aphonia in
virtually all psychogenic voice disorders. Personal-
ity investigation classied individuals with func-
tional dysphonia versus vocal nodules as introverts
and extroverts, respectively, and suggested that per-
sonality variables and their behavioral consequences
may contribute to these vocal conditions.
22,23
It is widely accepted that prolonged phonation
under increased laryngeal muscle tension levels
in MTD may lead to mucosal changes, including
vocal nodules, polypoidal degeneration, or chronic
laryngitis.
21,24
Studies of mechanical stress in phona-
tion suggest excessive collision, and acceleration
Journal of Voice, Vol. 19, No. 2, 2005
TABLE 4. Pertinent Lifestyle/Social History
n %
Stress 27 19
Tobacco
None 106 71
Mild 15 10
Moderate 11 7
Extreme 9 6
Alcohol
None 42 28
Mild 64 43
Moderate 29 19
Extreme 9 6
Caffeine
None 46 31
Mild 49 33
Moderate 42 28
Extreme 9 6
forces may be responsible for the greatest vocal fold
tissue damage.
25
Indeed, computer modeling of the
vibratory dynamics of vocal folds indicates the pres-
ence of high mechanical stress within the vocal
fold epithelium at their midpoint, when vibrating in
a mode other than normal phonation.
26
Abnormal muscle tension patterns have been doc-
umented as a compensatory gesture in individuals
with glottal insufciency as in presbylaryngis or
vocal fold paresis.
27
Our study reinforces the concept
of muscle tension dysphonia serving as a compensa-
tory adaptation to glottal insufciency. As shown in
Table 5, a total of 88 subjects (59%) had the presence
of vocal polyps, nodules, cysts, lesions, bowing, or
paralysis that contributed to glottal insufciency on
intended phonation. In addition, this gure is ex-
pected to be an underestimate because of an emerg-
ing understanding of the presence of subtle vocal
fold paresis.
27
Although it is well known that inap-
propriate voice use behavior may in fact lead to
the development of vocal lesions (ie, nodules), the
presence of such a lesion is not amenable to vocal
conservation efforts with continued voice use de-
mands. An attempt to compensate for glottal insuf-
ciency because of the mass effect of the lesion
would be expected to heighten the shearing forces
at the site of a lesion, enhancing its maturity
26
and
subsequently requiring increased vocal compensa-
tion for worsening glottal insufciency. We recog-
nize, however, that the underlying development of
MUSCLE TENSION DYSPHONIA 265
TABLE 5. Otolaryngologic Assessment
n %
Gastroesophageal reux/chronic laryngitis 52 35
Polyps 34 23
Nodules 20 13
Cyst 12 8
Other 9 6
TVC edema 8 6
Paralysis/paresis 5 3
the lesion may have contributions from psychologi-
cal, physiological, and behavioral components.
Signicant vocal demand may correlate with
MTD. Teaching has been identied as a highly vo-
cally demanding profession
28
with increased risk for
vocal disability,
2931
in females more than males.
32
Other research investigates internal central monitor-
ing and feedback systems in relation to vocal activ-
ity. An unexpected change in the perception of ones
own voice output results in a compensatory vocal
response and modied vocal output.
3338
The rela-
tion between inappropriate use of auditory feedback
and specic types of voice disorders is yet to be
determined. Additionally, it has been suggested that
acquired plastic change to central brainstem nuclei
may lead to certain types of vocal hyperfunction.
39
The complaint of vocal fatigue was reported in 39
(26%) of the patients in our study. Various acoustic
measures have been documented in relation to MTD
and vocal fatigue, a common complaint of patients
with MTD.
24
Vocal fatigue frequently results in a
signicant increase in speaking fundamental fre-
quency and the presence of an anterior glottal chink
as well as reduced maximum phonation time and
abnormally high airow rate.
4042
However, no dif-
ference in phonatory air ow has been shown in
an MTD population versus normal phonators.
43
An
increase in EMG in the perioral and supralaryngeal
muscles before and during phonation was found
inmost of apatient samplewithMTD.
44
Furthermore,
a relationship between MTD and palpable thyrohy-
oid muscle tension has been shown.
45
In addition,
computer-aided phonetograms may provide classi-
catory information for the types of functional
dysphonia.
46
As determined during the voice diagnostic evalua-
tion, prognosis for improvement in voice quality
Journal of Voice, Vol. 19, No. 2, 2005
TABLE 6. Clinical Findings in Speech
Pathology Assessment
n %
Poor breath support 147 98%
Inappropriate pitch 123 82
Low 118 79
High 5 3
Cervical tension visible 105 70
Inappropriate intensity 35 23
Low 21 14
High 14 9
Fast rate of speech 31 21
Glottal fry 30 20
Jaw tension 20 13
Hard glottal attacks 10 7
was judged to be excellent or good in 85% of the
patients reviewed. Various protocols have been in-
vestigated in the treatment of functional voice disor-
ders and MTD. Successful treatment outcomes were
reported using EMG biofeedback training and relax-
ation training,
4749
behavioral treatment using the
Accent Method of voice therapy,
50
Manual Laryn-
geal Musculoskeletal Tension Reduction Tech-
nique,
5153
and topical lidocaine.
54
Vocal hygiene
training and voice amplication have both been
shown to improve acoustic measures in teachers
with voice disorders, with voice amplication yield-
ing greater subjective improvement per subjects.
55
However, we believe it is important to respect multi-
factorial contributions to MTD, which requires
taking a good history of possible contributing etiolo-
gies as well as formal laryngoscopic and otolaryn-
gologic evaluations.
Personality factors and physiology predominate
current theory on the etiology of muscle tension
dysphonia. However, it appears from this study that
a signicant portion of subjects are also compen-
sating for increased vocal limitations because of
suboptimal voice production and/or inability to meet
voice use demands. The emerging concept of com-
pensation for chronic laryngeal irritation
18
or glottal
insufciency
27
in the MTD population is also rein-
forced by our data.
CONCLUSIONS
There are many contributing factors leading to
MTD, with multifactorial etiologies in many patients.
KENNETH W. ALTMAN ET AL 266
Our results and review of the literature indicate
that MTD is not a solitary disease or dysfunction
and that it is interrelated with comorbid conditions,
such as medical/neoplastic/movement issues affecting
the larynx, voice use demands, and personality/
behavior issues. A signicant portion of MTD ap-
pears to be an unconscious attempt to compensate
for conditions that result in suboptimal laryngeal
function.
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