ARTICLE IN PRESS

Detection of Muscle Tension Dysphonia Using Eulerian Video

Magnification: A Pilot Study
*Jason Adleberg, †Ashley P. O’Connell Ferster, ‡Daniel A. Benito, and §Robert T. Sataloff, *xPhiladelphia, and
yHershey, Pennsylvania, and zWashington, District of Columbia

Summary: Objective. To determine whether Eulerian Video Magnification software is useful in diagnosis of
muscle tension dysphonia (MTD).
Study Design. Prospective.
Methods. Adult patients scheduled in a tertiary care laryngology practice for evaluation of dysphonia were
recruited between November 2016 and March 2017. Demographic and clinical data were extracted from patient
charts. Diagnosis of MTD was confirmed with videostroboscopic and physical exam and by a speech-language
pathologist. Eighteen MTD patients were video recorded while at rest and with phonation. Five patients without
MTD also were analyzed as controls. Videos were analyzed using Eulerian Video Magnification software (Mas-
sachusetts Institute of Technology) to assess change in blood flow at the forehead, infrahyoid muscles, and ster-
nocleidomastoid muscles, while using the values of the background wall as a control value.
Results. Patients with MTD demonstrated little change in perfusion to the infrahyoid muscles of the neck while
phonating (+1% § 55%). Control subjects demonstrated an increase in perfusion to the infrahyoid muscles while
phonating (+102% § 164%), with this change being significant when comparing the two groups (P = 0.04,
t = 2.189, df = 21). A change in perfusion of 0% or less to infrahyoid muscles was 75% sensitive and 70% specific
for diagnosis of MTD. No differences in perfusion were found between other regions assessed. Patient age and
gender did not correlate with any change in perfusion between rest and phonation.
Conclusion. Our data suggest that Eulerian Video Magnification can be used in the diagnosis of MTD by
focusing on the difference in perfusion to the infrahyoid muscles between rest and phonation.

Key Words: Muscle tension dysphonia−Eulerian Video Magnification−Invisible motion−Laryngology−Dys-

phonia.

INTRODUCTION thinking about MTD has suggested the condition as a dis-

Muscle tension dysphonia (MTD) is a term used to describe
difficulty with phonation due to contraction of the paralar-
yngeal musculature.1,2 Features of MTD may include pal-
pably increased muscle tension in the paralaryngeal and
suprahyoid muscles with phonation, elevation of the larynx
in the neck on increasing vocal pitch, an open posterior glot-
tic chink between the arytenoid cartilages on phonation,
and variable degrees of mucosal changes, such as vocal nod-
ules or chronic laryngitis.3 Increased tension of extralaryng-
eal muscles may shift the larynx superiorly or inferiorly,
disturbing alignment of cartilaginous structures of the lar-
ynx, and may be associated with dysphonia.1 More recent
Accepted for publication February 13, 2019.
Meeting Information: Accepted for poster presentation at the 2018 Annual Meeting
of The American Laryngological Association, National Harbor, MD, April 18−20,
2018.
Level of Evidence: 4.
Competing Interests: The authors declare that they have no competing interests.
From the *Drexel University College of Medicine, Philadelphia, Pennsylvania;
yDepartment of Surgery, Division of Otolaryngology − Head & Neck Surgery, Penn
State Health: Milton S. Hershey Medical Center, Hershey, Pennsylvania; zDepart-
ment of Surgery, Division of Otolaryngology − Head & Neck Surgery, The George
Washington University School of Medicine and Health Sciences, Washington, Dis-
trict of Columbia; and the xDepartment of Otolaryngology − Head & Neck Surgery,
Drexel University College of Medicine, Philadelphia, Pennsylvania.
Address correspondence and reprint requests to Robert T. Sataloff, Otolaryngology
− Head & Neck Surgery, Drexel University College of Medicine, 219 N. Broad Street,
10th Floor, Philadelphia, PA 19107. E-mail: RTSataloff@phillyent.com
Journal of Voice, Vol. &&, No. &&, pp. &&−&&
0892-1997
© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2019.02.006
ease with multifactorial etiology as opposed to a stand-
alone entity.4−9
Diagnosis of MTD is difficult, and it can be confused with
other disorders such as spasmodic dysphonia.10,11 Moreover,
many commonly used clinical diagnostic methods, such as
history taking and musculoskeletal assessments via palpation,
are prone to variability.12 While laryngeal elevation is a com-
mon finding in MTD, assessment scales for its measurement
have low reliability and validity.13−15 Radiography and sur-
face electromyography (sEMG) have been proposed as more
objective measurements of MTD. A study of radiographs by
Lowell et al reported elevated hyoid and larynx positions dur-
ing phonation in MTD patients compared with normal sub-
jects.16 Several studies have used sEMG to record muscle
activation using surface electrodes.12,15,17−23 These studies
have demonstrated that paralaryngeal muscles are activated
during phonation. However, problems with reproducibility
of these sEMG experiments have led to inconclusive and
mixed results with this approach.12
In an effort to improve objective detection of MTD, we
assessed the utility of Eulerian Video Magnification (EVM).
EVM is an open-source software program developed at the
Massachusetts Institute of Technology which can be used to
measure muscle activation.24,25 This technology measures
muscle activation in a manner different from sEMG. This
software is used on digital video recordings of patients. It
focuses on an anatomical region of interest and tracks the
 ARTICLE IN PRESS
2 Journal of Voice, Vol. &&, No. &&, 2019
change in pixel redness over a given amount of time. This
slight change in pixel redness, which may not be visible to
the human eye, signifies a change in blood perfusion. This
subtle change in blood perfusion can then extrapolated to
measure muscle activation.26−29
In medicine, EVM has been used to monitor vital signs,30−32
fasciculations in patients with Amyotrophic Lateral
Sclerosis,33 and microvascular blood perfusion.34−36 In one
study within the Otolaryngology-Head and Neck Surgery
literature, EVM was used for noninvasive monitoring of
perfusion in free flaps.37 Using EVM, the degree in color
change allowed for intraoperative assessment of perfusion,
with the hope of using this technology to monitor perfusion
in the postoperative setting following anastomosis and inset
of free flaps. To the author’s knowledge, EVM has not been
used otherwise within the Laryngology or Otolaryngology-
Head and Neck Surgery literature.
Our study investigated whether EVM may have diagnos-
tic utility for the assessment of MTD. To the knowledge of
the authors, correlations between extralaryngeal muscle
blood perfusion and a diagnosis of MTD have not been
studied. It is known that, with skeletal muscle contraction,
both arterial and venous blood flow are increased due to a
phenomenon known as exercise hyperemia.26−29 Therefore,
we hypothesized that in patients with baseline muscle con-
traction as noted in MTD, there would be less potential for
muscle contraction during phonation. In turn, there would
not be a large change in blood flow to extralaryngeal
muscles in patients with MTD. Using EVM, we aimed to
examine differences in extralaryngeal muscle perfusion dur-
ing rest and phonation in patients with and without MTD.
With this knowledge, EVM has the potential to alter our
understanding of the complex body motions involved in
phonation. To our knowledge, this is the first study to use
EVM within the field of Laryngology.
MATERIALS AND METHODS
Participants
The study was approved by the Institutional Review Board at
Drexel University College of Medicine in Philadelphia, Penn-
sylvania. Adult patients in a tertiary care laryngology practice
were recruited for the study between November 2016 and
March 2017. All patients were already scheduled for assess-
ment of dysphonia and underwent standard evaluation in the
laryngology office, including videostroboscopy and voice
team evaluation. Patients with MTD were deemed candidates
for inclusion if they demonstrated supraglottic compression,
pressed phonation, excessive strap muscle tension, and other
signs, such as laryngeal elevation during phonation. The
selected patients were those only with findings of MTD and
presented with findings typical of MTD. This diagnosis was
confirmed independently by a laryngologist and a speech-lan-
guage pathologist. Patients were excluded from the study if
they did not speak English or were under the age of 18 years.
Twenty-four patients were recruited for the study. Due to
excess movement in videos, six patients were excluded from
the statistical analysis. A total of 18 patients were thus
included. Additionally, five patients with no history of or
exam findings consistent with a voice disorder, such as
MTD, were included in the control population. Demo-
graphic and clinical data were extracted from the charts on
each patient and control subject. Patients included in the
study gave written consent obtained by the authors. Chi-
squared tests were used to test for the prevalence of different
comorbidities in both groups.
Recording of Videos
Each patient underwent video recording with a Canon
Powershot SD1400IS camera, with a 28-mm wide lens and
14.1-megapixel resolution. In order to ensure stability
throughout the recordings, a tripod was used. Autofocus
was not used to ensure consistent image quality. Videos of a
frontal view were recorded using standard studio lighting
with a white backdrop in a quiet room. Videos were
recorded with the patient at rest and during phonation while
saying /i/. Each video was recorded for 10 seconds, and a
consistent, stable video segment of exactly 4 seconds was
spliced out to ensure a homogenous number and quality of
frames in each video for analysis. All videos were de-identi-
fied and stored on a secure computer.
Eulerian Video Magnification
Analysis of video data was conducted following a protocol
similar to the original publication describing the process of
EVM.24 Change in pixel redness over time was extracted
and amplified from the captured video recordings; these
changes resembled sine waves in each subject, correspond-
ing to their heart rate (Figure 1). From each sine wave, a
Fourier Transform was used to compute the subject’s heart
rate and the intensity of perfusion. Four specific regions of
interest were selected for each video to focus on change in
blood flow: (1) medial forehead, (2) the body of sternoclei-
domastoid, (3) infrahyoid muscles, and (4) the wall next to
the patient (Figure 2). The medial forehead was included as
a control, as the forehead musculature is not involved in
phonation. The body of the sternocleidomastoid muscle
was included due to its proximity to the extralaryngeal mus-
culature in an effort to ensure no perfusion changes in other
muscles of the neck during phonation. The wall served as a
control to ensure that the software was not confounded by
lighting or video recording. The infrahyoid muscles were
the most visible muscles involved with phonation that could
be recorded while the patient was at rest and phonating.
The suprahyoid region was not adequately captured on
video with the patient in a seated position. Therefore, it was
not included in our analysis.
In order to extract perfusion data from a patient video, this
technology requires the selection and calibration of several
parameters. The amplified frequency range was set from
0.8 Hz to 1.4 Hz, representing a resting heart rate range
of 48−84 beats per minute. The alpha level, a magnification
parameter, was set to 25. The sampling rate was set to 30
 ARTICLE IN PRESS
Jason Adleberg, et al MTD Detection Using Video Magnification
FIGURE 1. Analysis of blood perfusion using Eulerian Video Magnification technology.
frames per second, chromatic attenuation was set to 4, and
the magnification type was set to color magnification instead
of motion magnification. These values were chosen from orig-
inal studies of the software by its authors and kept constant
for all participants in the study. As the sampling rate far
exceeded the heart rate in each captured video, no concern
was warranted that the sampling rate could confound results.
Calibration for Control Subjects
To ensure the accuracy of our approach, videos from sub-
jects without MTD were collected during three sessions
over a 2-week period. Values for each patient were com-
pared over multiple dates to ensure consistency. Paired
t tests were used to determine whether there was significant
variation with values recorded for control subjects. Videos
FIGURE 2. *Sites of perfusion measurement for patients with
muscle tension dysphonia (MTD) and control subjects; sites
include (1) forehead; (2) infrahyoid muscles; (3) sternocleidomas-
toid; 4) wall (not pictured).
*Image modified from "Elementary Anatomy and Physiology: for
Colleges, Academies, and Other Schools", by Edward Hitchcock, p
115. Published date 1860.
3
from each subject with MTD were recorded at one sitting,
due to uncertain patient follow-up. Volunteer control sub-
jects were available for repeat testing to ensure accuracy
and reliability of the calibration methodology.
Analysis of Perfusion Intensity Data
Once EVM was applied to the four areas of interest in each
video, perfusion frequencies and intensities were extracted
and recorded. For each patient, percent change in perfusion
was calculated between values at rest versus during phona-
tion. Unpaired t tests were used to measure differences in
percent change in perfusion between control and MTD
patients.
Influence of Age and Gender on Perfusion Intensity
and Ratios
The influence of age and gender was investigated evaluating
percent change in perfusion for all patients. Pearson’s corre-
lation coefficients and unpaired t tests were calculated.
Microsoft Excel was used to make all calculations.
RESULTS
Characteristics of MTD Patients and Normal
Speakers
Eighteen patients with MTD were included (12 women, 6
men; mean age 44 years, age range 22−87 years). Five con-
trol subjects without a history of MTD were recruited (three
women, two men; mean age 32 years, age range 29−38
years). Patients from both groups exhibited various comor-
bidities, although there were no significant differences in
prevalence between the two groups (Table 1).
Influence of Age and Gender on Perfusion Ratios
The effects of age and gender were studied to determine
whether they influenced perfusion ratios in patients. Age
(Table 2) and gender (Table 3) were not correlated with a
change in perfusion during phonation. The average ages of
the control and MTD groups were 32 and 44 years old,
respectively. The percent genders of the control and MTD
groups were 40% and 33% male, respectively.
 ARTICLE IN PRESS
4 Journal of Voice, Vol. &&, No. &&, 2019

TABLE 1.
Prevalence of Comorbidities and Surgical History of Patients With Muscle Tension Dysphonia (MTD) and Control Subjects
MTD Prevalence Control Prevalence
Condition (n = 18) (n = 5) P Value* Chi-Squared
Pulmonary disease 6 (33%) 3 (60%) 0.28 1.148
Neck surgery 4 (22%) 0 (0%) 0.25 1.271
Chest/lung surgery 1 (6%) 0 (0%) 0.58 0.301
Phonosurgery 2 (11%) 0 (0%) 0.44 0.576
Neurologic disorders 2 (11%) 0 (0%) 0.44 0.576
Musculoskeletal disorders 3 (17%) 0 (0%) 0.33 0.938
Cervical spine surgery 1 (6%) 0 (0%) 0.58 0.301
* Significant P value <0.05.

demonstrated significantly different patterns in perfusion.

TABLE 2.
Correlation Coefficients (r) of Percent Change in Perfu-
sion Versus Patient Age
Site of Perfusion
Ratio Measurement
Forehead
Sternocleidomastoid
muscle
Infrahyoid muscles
wall
* Significant P value <0.05.
During phonation, perfusion increased by 102% § 164% in
control subjects, and increased by 1% § 55% in MTD
patients (P = 0.04, t = 2.29, df = 21). Analysis at this site
Correlation Coefficient yielded several options for cut-off values which can be used
(r) with Age P Value* to rule-in or rule-out MTD in our patient set. A change in
¡0.053 0.77 perfusion of 0% or less was 75% sensitive and 70% specific
¡0.007 0.96 for diagnosis of MTD. The area under the Receiver Operat-
ing Curve was 0.77. No significant differences in percent
¡0.091 0.62 change in perfusion were seen between phonation and rest
¡0.298 0.10 at the three other sites observed (Table 5).

Calibration for Control Subjects
Data from five control subjects were collected during three
sessions over a 2-week period. Using one-sample t tests, val-
ues were not found to vary significantly over the 2 week
time period (Table 4), except for the wall measurement (P =
0.04, t = 4.84, df = 2) for Patient #3.
EVM Values
Percent change in perfusion values was calculated for con-
trol and MTD patients. Only the infrahyoid muscles
DISCUSSION
This study compared blood perfusion levels of four regions
in 18 patients with MTD and five patients, each recorded
three times, without MTD. In this pilot study, our data sug-
gest that EVM can be used in the diagnosis of MTD by
focusing on the difference in perfusion to the infrahyoid
muscles between rest and phonation.
Patients with MTD experienced little change in infra-
hyoid muscle perfusion during phonation, whereas con-
trol subjects experienced a two-fold increase in perfusion.
We hypothesize that since patients with MTD have a
higher baseline state of muscle tension, there is less

TABLE 3.
Difference in Percent Change in Perfusion (%) Versus Male and Female Gender
Percent Change in
Percent Change in Perfusion in
Site of Perfusion Perfusion in Men (%) Women (%)
Measurement (n = 11) (n = 21) P Value* t Value†
Forehead 2.2 § 55.3 36.6 § 103.0 0.31 1.032
Sternocleidomastoid muscle 106.6 § 177.7 66.4 § 110.1 0.43 0.800
Infrahyoid muscles 100.1 § 174.2 20.2 § 86.9 0.09 1.751
Wall 27.6 § 76.4 11.2 § 39.7 0.42 0.817
* Significant P value <0.05.
†
Degrees of freedom (df) for all cases was 30.
 ARTICLE IN PRESS
Jason Adleberg, et al MTD Detection Using Video Magnification 5

change in muscle contraction during phonation in MTD

P Value t Value
0.67
1.08
4.84
1.42
0.95
patients. Since there is less change in muscle contraction,
this results in less change in perfusion. This decreased
change of perfusion was demonstrated with EVM tech-

0.57
0.39
0.04
0.29
0.44
nology. A change in perfusion of 0% or less was 75% sen-
sitive and 70% specific for diagnosis of MTD. Percent
change in perfusion was smaller in MTD patients than in

75 § 108.9
11.9 § 33.7
¡32.4 § 57.8
38.1 § 22.9

44.4 § 91.7
control patients, with this difference being statistically
significant (P = 0.04). Due to the small number of
Wall

patients in this pilot study, it is possible that this statisti-

cal significance was due to chance. However, our findings
are supported by what would be expected based on our
understanding of skeletal muscle physiology.26−29
Percent (%) Change in Perfusion (average percent over three sessions)

P Value t Value Mastoid Muscle P Value t Value

3.57
1.46
1.03
1.00
1.51

Given that EVM is a new technology, best practices have

yet to be established for its clinical use. Successful use of the
technology requires both consistent technique for capture of
0.07
0.28
0.41
0.42
0.27

video subjects and appropriate analysis of results obtained. A

relatively strict, controlled environment with consistent light-
ing and steady filming is necessary. Any excess movement of
116.6 § 162.5

107.7 § 211.8
210.7 § 290.1
Sternocleido-

the video recording is detected by the sensitive EVM software,

92.8 § 68.1

¡16.6 § 31.8

making the use of a stabilizing unit such as a camera tripod

essential. Slight patient movement also can distort results, as
Percent Change in Perfusion (%) for Control Subjects at Three Sessions Over a 2-Week Time Period

we found in our study. Appropriate selection of patients is

also critical, as recordings from several of our patients had to
be discarded due to resting tremor. Tremor distorted elements
of the video and rendered EVM analysis invalid. As EVM
3.89
1.08
1.08
1.55
1.46

analyzes the change in pixel redness of a subject, variable

lighting and filming conditions can introduce noisy data.
We believe that while our control subjects did not
0.06
0.39
0.39
0.26
0.28

show significant variation in blood perfusion over multi-

ple recording sessions, the variation found could be
reduced further with an even more rigorous recording
141.6 § 191.0
224.2 § 317.4
89.6 § 62.3

32.3 § 59.4
Infrahyoid

105.1 § 193

setup. Moreover, analysis of blood perfusion is sensitive

Muscles

to differences in skin tone between patients.34 This factor

does not occur with Doppler Ultrasound, which has also
been used previously with skeletal muscle perfusion for
diagnosis of disease states.38−40
P Value* t Value†

This study is subject to a few additional limitations. First,

1.24
0.95
1.06
0.17
0.12

there was a small sample of control subjects used in our

analysis. This small size likely led to larger degrees of vari-
ability in data obtained within the control patients’ group.
0.34
0.44
0.40
0.88
0.91

Accordingly, a larger sample of control patients would

allow for higher reliability of results. Recruitment of control
patients (ie, patients without voice disorders) was limited, as
Degrees of freedom (df) for all cases was 2.
77.5 § 123.5

patients were recruited from a tertiary care laryngology

18.4 § 37.7
¡25.0 § 46.5
¡5.4 § 59.1
4.4 § 67.5
Forehead

clinic with a vast majority of referred patients presenting

with a voice disorder. Future studies would benefit from
recruitment of patients from nonlaryngology clinics in order
to increase the number of control patients.
* Significant P value <0.05.

In addition, our analysis did not examine perfusion to the

Control patient No.

suprahyoid musculature. Since our camera faced seated

subjects at a perpendicular angle, we were unable to ade-
quately capture the muscles of the suprahyoid region on
Control 1
Control 2
Control 3
Control 4
Control 5
TABLE 4.

video. In order to obtain video of this region, it would

require the patient to be in an uncomfortable and unnatural
position with extreme neck extension. This position would
†

not be reasonably applied in a clinical setting due to patient

 ARTICLE IN PRESS
6 Journal of Voice, Vol. &&, No. &&, 2019
TABLE 5.
Percent Change in Perfusion (%) for Control and Muscle Tension Dysphonia (MTD) Patients
Percent Change in
Perfusion, Control (%)
Region of interest (n = 5)
Forehead 14 § 69
Sternocleidomastoid 119 § 168
Infrahyoid 102 § 164
Wall 28 § 68
* Significant P value <0.05.
†
Degrees of freedom (df) for all cases was 21.
discomfort. This position may have also caused other neck
musculature to become contracted during phonation and
at rest, which could have been a confounder to our analysis
if this was applied. Finally, our approach was unable to
separate the individual contributions of the omohyoid, ster-
nohyoid, sternothyroid, and thyrohyoid muscles. We
believe that higher video resolution capture may facilitate
the ability to do so.
Further study of EVM is warranted for patients with
MTD, not only preceding but also following voice therapy.
Clinicians could potentially use this software to aid in nar-
rowing their differential diagnosis as well as to track patient
progress during voice therapy. Depending on patient progress
as detected by perfusion via EVM, clinicians could alter treat-
ment regimens in order to improve patient outcomes. Future
studies may also include the use of this technology to help dif-
ferentiate patients with MTD due to muscle-based hyper-
function from those patients with emotional-based
hyperfunction, which could also help to direct therapy.
CONCLUSION
This study investigated the utility of EVM in detecting
differences in perfusion to the extralaryngeal and, specifi-
cally, infrahyoid muscles. Patients with MTD demon-
strated little change in perfusion to the infrahyoid muscles
while phonating, but there was an increase in perfusion to
the same location in control subjects. This difference in
percent change in perfusion between control and MTD
patients makes EVM a potential tool for diagnosing
MTD and for monitoring efficacy of treatment, however,
the utility of EVM for these purposes certainly warrants
additional study.
Acknowledgments
We would like to thank Drexel University for their support
of this research.
SUPPLEMENTARY MATERIALS
Supplementary material associated with this article can be
found in the online version at https://doi.org/10.1016/j.
jvoice.2019.02.006.
Percent Change in
Perfusion, MTD (%)
(n = 18) P Value* t Value†
31 § 103 0.58 0.562
59 § 103 0.26 1.157
1 § 55 0.04* 2.189
6 § 39 0.30 1.062
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