Muscular Tension Dysphonia Research Articles

Relative Fundamental Frequency: Only for Hyperfunctional Voices? A Pilot Study.

(1) Background: Assessing phonatory disorders due to laryngeal biomechanical alterations requires aerodynamic analysis, assessing subglottic pressure, transglottic flow, and laryngeal resistance. This study explores whether the acoustic parameter, the relative fundamental frequency (RFF), can be studied using the current acoustic analysis protocol at the University of Navarra's voice laboratory and its association with pathologies linked to laryngeal biomechanical alterations. (2) Methods: A retrospective cohort study included patients diagnosed with muscular tension dysphonia, organic lesions of the vocal fold, and vocal fold paralysis (VFP) at the Clínica Universidad de Navarra from 2019 to 2021. Each patient underwent endoscopic laryngeal exploration, followed by acoustic study, RFF calculation, and an aerodynamic study. Additionally, a control group was recruited. (3) Results: 79 patients and 22 controls were studied. Two-way ANOVA showed significant effects for groups and cycles in offset and onset cycles. Statistically significant differences were observed in cycle 1 onset among all groups and in cycles 1 and 2 between the control group and non-healthy groups. (4) Conclusions: RFF is a valuable indicator of phonatory biomechanics, distinguishing healthy and pathological voices and different disorders. RFF in onset cycles offers a cost-effective, accurate method for assessing biomechanical disorders without complex aerodynamic analyses. This study describes RFF values in VFP for the first time, revealing differences regardless of aerodynamic patterns.

Acupuncture Combined with Voice Training Improved Voice Function in Patients with Primary Muscular Tension Dysphonia (MTD): A Randomized, Three‐Armed, Open‐Label Clinical Trial

Objective. This randomized controlled trial aimed to evaluate the clinical efficacy of acupuncture combined with voice training for treating patients with primary muscular tension dysphonia (MTD) (Qi stagnation and blood stasis type in traditional Chinese medicine). Methods. A total of 108 patients with primary MTD (Qi stagnation and blood stasis type) were recruited in this study. The participants were randomly divided into 3 equal groups: a test group and two control groups (control groups 1 and 2). An additional 38 participants without primary MTD were recruited as the healthy group. Control group 1 received acupuncture sessions 3 times per week on alternate days on the Hegu (LI 4), Taichong (LR 3), Open Voice No. 1 point, and Open Voice No. 2 points. Control group 2 received a 40‐minute voice training session once weekly. The test group received both treatments. The total treatment course for all groups was 30 days. The healthy participants did not receive any interventions. The physiological and functional voice improvements after treatment were compared between all 3 MTD groups and healthy participants. The Voice Handicap Index (VHI‐10), the VHI‐10 emotional score, the Chinese Medicine Symptom Score Scale (TCM), and the Grade Roughness Breathiness Asthenia Strain (GRBAS) were used to evaluate the changes in the voice after treatment. A laryngeal muscle blood oxygen monitoring was used to measure the blood oxygen saturation (SO2) of the suprahyoid and infrahyoid muscles, and a stroboscopic laryngoscopy was used to measure the dysphonia severity index (DSI). Acoustic voice analysis was used to measure the maximum phonation time (MPT), the jitter, and the shimmer. Result. The SO2 levels of the laryngeal muscle were significantly higher in the healthy subjects than in pretreatment MTD patients and were correlated with the VHI‐10 and DSI scores. A significant improvement in the physiological and functional scores, the total VHI‐10, the GRBAS score, the voice acoustic analysis indices, MPT, jitter, shimmer, and DSI, was noted after treatment in all 3 MTD groups (P < 0.05). However, the posttreatment scores in the test group were significantly higher compared to control group 2, whose score were superior than that in control group 1 (P < 0.05). Both the test group and control group 1 showed a significant increase in the SO2 levels of the laryngeal muscles after treatment, where the test group had a higher elevation than control group 1. No significant difference was noted in the posttreatment SO2 of the laryngeal muscles in control group 2 (P > 0.05). Conclusion. Acupuncture monotherapy or in combination with voice training can reduce the anxiety emotion, relieve MTD‐associated systemic symptoms, and increase the SO2 levels of the laryngeal muscle. This combination is a promising approach for the treatment of MTD. This trial is registered with ChiCTR2200061469.

Perceived Causes and Background of Onset in Patients with Muscular Tension Dysphonia

Perceived Causes and Background of Onset in Patients with Muscular Tension Dysphonia

Consensus-Based Attributes for Identifying Patients With Spasmodic Dysphonia and Other Voice Disorders

A roadblock for research on adductor spasmodic dysphonia (ADSD), abductor SD (ABSD), voice tremor (VT), and muscular tension dysphonia (MTD) is the lack of criteria for selecting patients with these disorders. To determine the agreement among experts not using standard guidelines to classify patients with ABSD, ADSD, VT, and MTD, and develop expert consensus attributes for classifying patients for research. From 2011 to 2016, a multicenter observational study examined agreement among blinded experts when classifying patients with ADSD, ABSD, VT or MTD (first study). Subsequently, a 4-stage Delphi method study used reiterative stages of review by an expert panel and 46 community experts to develop consensus on attributes to be used for classifying patients with the 4 disorders (second study). The study used a convenience sample of 178 patients clinically diagnosed with ADSD, ABSD, VT MTD, vocal fold paresis/paralysis, psychogenic voice disorders, or hypophonia secondary to Parkinson disease. Participants were aged 18 years or older, without laryngeal structural disease or surgery for ADSD and underwent speech and nasolaryngoscopy video recordings following a standard protocol. Speech and nasolaryngoscopy video recordings following a standard protocol. Specialists at 4 sites classified 178 patients into 11 categories. Four international experts independently classified 75 patients using the same categories without guidelines after viewing speech and nasolaryngoscopy video recordings. Each member from the 4 sites also classified 50 patients from other sites after viewing video clips of voice/laryngeal tasks. Interrater κ less than 0.40 indicated poor classification agreement among rater pairs and across recruiting sites. Consequently, a Delphi panel of 13 experts identified and ranked speech and laryngeal movement attributes for classifying ADSD, ABSD, VT, and MTD, which were reviewed by 46 community specialists. Based on the median attribute rankings, a final attribute list was created for each disorder. When classifying patients without guidelines, raters differed in their classification distributions (likelihood ratio, χ2 = 107.66), had poor interrater agreement, and poor agreement with site categories. For 11 categories, the highest agreement was 34%, with no κ values greater than 0.26. In external rater pairs, the highest κ was 0.23 and the highest agreement was 38.5%. Using 6 categories, the highest percent agreement was 73.3% and the highest κ was 0.40. The Delphi method yielded 18 attributes for classifying disorders from speech and nasolaryngoscopic examinations. Specialists without guidelines had poor agreement when classifying patients for research, leading to a Delphi-based development of the Spasmodic Dysphonia Attributes Inventory for classifying patients with ADSD, ABSD, VT, and MTD for research.

Laryngeal Reflexes: Physiology, Technique, and Clinical Use.

This review examines the current level of knowledge and techniques available for the study of laryngeal reflexes. Overall, the larynx is under constant control of several systems (including respiration, swallowing and cough) as well as sensory motor reflex responses involving glossopharyngeal, pharyngeal, laryngeal, and tracheobronchial sensory receptors. Techniques for the clinical assessment of these reflexes are emerging and need to be examined for sensitivity and specificity in identifying laryngeal sensory disorders. Quantitative assessment methods for the diagnosis of sensory reductions and sensory hypersensitivity may account for laryngeal disorders, such as chronic cough, paradoxical vocal fold disorder, and muscular tension dysphonia. The development of accurate assessment techniques could improve our understanding of the mechanisms involved in these disorders.

The Vocal Aerodynamic Change in Female Patients With Muscular Tension Dysphonia After Voice Training

To investigate the changes of vocal aerodynamics indicators after voice training in female patients with muscular tension dysphonia (MTD). Twenty-one female MTD patients (before voice training and 12 weeks after voice training) and 20 female volunteers with normal voices (the control group) received vocal aerodynamic analysis. Parameters included subglottal pressure (SGP), aerodynamic power (AP), mean expiratory airflow (MEA), and maximum phonation time (MPT) were recorded and analyzed by phonatory aerodynamic system. Before voice training, the median SGP and mean AP were higher than control group, whereas median MPT was shorter, and these differences were statistically significant. After 12 weeks of voice training, the median SGP and mean AP were decreased and the median MPT was increased compared with the measurements obtained before training, and these differences were statistically significant. The differences of median SGP, mean AP, mean MEA, and median MPT between MTD after 12 weeks of training and control group were not statistically significant. Voice training is an effective treatment for MTD patients. Aerodynamic analysis can effectively evaluate the vocal functional status of MTD patients before and after training, which is beneficial for the treatment efficacy evaluation.

Collaboration and Conquest: MTD as Viewed by Voice Teacher (Singing Voice Specialist) and Speech-Language Pathologist

This study was designed as a qualitative case study to demonstrate the process of diagnosis and treatment between a voice team to manage a singer diagnosed with muscular tension dysphonia (MTD). Traditionally, literature suggests that MTD is challenging to treat and little in the literature directly addresses singers with MTD. Data collected included initial medical screening with laryngologist, referral to speech-language pathologist (SLP) specializing in voice disorders among singers, and adjunctive voice training with voice teacher trained in vocology (singing voice specialist or SVS). Initial target goals with SLP included reducing extrinsic laryngeal tension, using a relaxed laryngeal posture, and effective abdominal-diaphragmatic support for all phonation events. Balance of respiratory forces, laryngeal coordination, and use of optimum filtering of the source signal through resonance and articulatory awareness was emphasized. Further work with SVS included three main goals including a lowered breathing pattern to aid in decreasing subglottic air pressure, vertical laryngeal position to lower to allow for a relaxed laryngeal position, and a top-down singing approach to encourage an easier, more balanced registration, and better resonance. Initial results also emphasize the retraining of subject toward a sensory rather than auditory mode of monitoring. Other areas of consideration include singers' training and vocal use, the psychological effects of MTD, the personalities potentially associated with it, and its relationship with stress. Finally, the results emphasize that a positive rapport with the subject and collaboration between all professionals involved in a singer's care are essential for recovery.

The Assessment Methods of Laryngeal Muscle Activity in Muscle Tension Dysphonia: A Review

The purpose of this paper is to review the methods used for the assessment of muscular tension dysphonia (MTD). The MTD is a functional voice disorder associated with abnormal laryngeal muscle activity. Various assessment methods are available in the literature to evaluate the laryngeal hyperfunction. The case history, laryngoscopy, and palpation are clinical methods for the assessment of patients with MTD. Radiography and surface electromyography (EMG) are objective methods to provide physiological information about MTD. Recent studies show that surface EMG can be an effective tool for assessing muscular tension in MTD.

Laryngeal Aerodynamic Analysis in Assisting With the Diagnosis of Muscle Tension Dysphonia

To estimate the aerodynamic multiparameters for patients with muscular tension dysphonia (MTD) and evaluate voice aerodynamic analysis for assisting the diagnosis of this disorder. A prospective study. Voice aerodynamic parameters, including subglottal pressure (SGP) level, glottal resistance (GR), mean airflow rate (MFR), and maximum phonation time (MPT), for 26 MTD patients and 27 normal adults were analyzed using receiver operating characteristics (ROC) analysis and multivariate logistic regression. For male samples, MTD patients had higher SGP (P=0.001), higher GR (P=0.012), lower MFR (P=0.042), and shorter MPT (P=0.027), whereas for female samples, the difference between cases and controls was statistically significant only in SGP (P<0.001) and MPT (P<0.001). ROC analysis showed that the threshold of 8.175 cm H(2)O for SGP achieved a good classification for MTD, with an adequate sensitivity (76.9%) and the perfect specificity (100%). Finally, multivariate logistic regression established a credible model (with SGP and MPT as the predictors) for classifying MTD, with a 92.5% percentage correct. This analysis indicates that aerodynamics evaluation could help the diagnosis of MTD patients, jointly with medical history scrutiny, physical examination, fibrolaryngoscopy, and/or videoendostroboscopy.

Functional Analysis of Voice Using Simultaneous High-Speed Imaging and Acoustic Recordings

We present a comprehensive, functional analysis of clinical voice data derived from both high-speed digital imaging (HSDI) of the larynx and simultaneously acquired acoustic recordings. The goals of this study are to: (1) correlate dynamic characteristics of the vocal folds derived from direct laryngeal imaging with indirectly acquired acoustic measurements; (2) define the advantages of using a combined imaging/acoustic approach for the analysis of voice condition; and (3) identify new quantitative measures to evaluate the regularity of the vocal fold vibration and the complexity of the vocal output -- these measures will be key to successful diagnosis of vocal abnormalities. Image- and acoustic-based analyses are performed using an analytic phase plot approach previously introduced by our group (referred to as 'Nyquist' plot). Fast Fourier Transform (FFT) spectral analyses are performed on the same data for a comparison. Clinical HSDI and acoustic recordings from subjects having normal and specific voice pathologies, including muscular tension dysphonia (MTD) and recurrent respiratory papillomatosis (RRP) were analyzed using the Nyquist plot approach. The results of these analyses show that a combined imaging/acoustic analysis approach provides better characterization of the vibratory behavior of the vocal folds as it correlates with vocal output and pathology.

The Characteristic Features of Muscle Tension Dysphonia before and after Surgery in Benign Lesions of the Vocal Fold

Muscular tension dysphonia (MTD) is often concomitant in patients with underlying glottic insufficiency. It remains unclear, however, whether the characteristic features of MTD appear independently or as a consequence of dysphonia. We report here on a retrospective study of the prevalence of the four prominent characteristic features of MTD, as described by the Morrison-Rammage classification, in patients with benign lesions of the vocal fold. Two otorhinolaryngologists, independent of one another, rated the preoperative and postoperative videolaryngostroboscopic results of 260 patients to assess the presence or absence of MTD. Of the 260, 185 had vocal nodules, 49 had vocal polyp, and 26 had vocal cyst. Postoperative follow-up examinations were conducted for a period ranging from 4.5 to 35 months (mean = 18.5 months). Patient ages ranged from 18 to 76 years (mean = 47.3 years). Nearly 90% of the preoperative patients in our study cohort exhibited at least one of the MTD characteristic features. Approximately 74% of postoperative ‘asymptomatic’ patients in our study cohort exhibited at least one characteristic feature. As the characteristic features of MTD were found in both preoperative dysphonic patients and those patients who were successfully treated, MTD etiology may be causal (type I), concomitant (type IIa, IIb, III) or psychogenic (type IIa, IIb). Therefore characteristic features of MTD cannot be adequately resolved through surgery, and treatment should be supplemented by speech therapy to achieve the greatest effect in causal type I MTD.

Adductor spasmodic dysphonia and muscular tension dysphonia: Acoustic analysis of sustained phonation and reading

Acoustic phonatory events were identified in 10 women diagnosed with adductor spasmodic dysphonia (ADSD) and compared to 5 women and 5 men diagnosed with muscle tension dysphonia (MTD). The three acoustic parameters examined during sustained vowel production and reading included phonatory breaks, aperiodicity, and frequency shifts. Intra- and intermeasurer correlations showed high reliability for the measures. Findings indicated that those with ADSD produced a greater number of aberrant acoustic events than those with MTD. The results suggested that: (1) only those with ADSD show evidence of phonatory breaks during vocalization, albeit a sustained vowel or voicing during reading; (2) those with ADSD demonstrate greater variation in the type of aberrant acoustic events produced as a function of speech task. The latter point suggests that control of the larynx varies as a function of task demand, a finding not evident in the functionally based disorder of MTD. MTD is a disorder that often presents itself in a similar clinical manner to ADSD because of its perceptual commonalties and resembling laryngoscopic characteristics. The acoustic analysis presented in this study could be used as a method to assist in distinguishing between the two disorder types.

The irritable larynx syndrome.

Muscular tension dysphonia, episodic laryngospasm, globus, and cough may be considered to be hyperfunctional laryngeal symptoms. Suggested etiological factors for these symptoms include gastroesophageal reflux, psychological problems, and/or dystonia. We propose a unifying hypothesis that involves neural plastic change to brainstem laryngeal control networks through which each of the above etiologies, plus central nervous system viral illness, can play a role. We suggest that controlling neurons are held in a "spasm-ready" state and that symptoms may be triggered by various stimuli. Inclusion criteria for the irritable larynx syndrome are episodic laryngospasm and/or dysphonia with or without globus or chronic cough; visible or palpable evidence of tension or tenderness in laryngeal muscles; and a definite symptom-triggering stimulus. thirty-nine patients with irritable larynx syndrome were studied. Gastroesophageal reflux was felt or proven to play a major role in a large number of the group (>90%), and about one third were deemed to have psychological causative factors. Viral illness seemed quite prevalent, with one third of patients able to relate the onset of symptoms to a viral illness that we feel might lead to central nervous system changes. Our proposed hypothesis includes a mechanism whereby acquired plastic change to central brainstem nuclei may lead to this form of hyperkinetic laryngeal dysfunction. It gives structure and reason to an array of therapy measures and suggests direction for basic research.

Muscle misuse voice disorders: description and classification.

It is apparent that voice disorders frequently labelled "functional" are associated with laryngeal muscle misuse. This use of the word "functional" is, however, intrinsically ambiguous, and so we propose an alternative term based on descriptive features of dysfunction: "muscle misuse voice disorders". Persistent phonation with an abnormal laryngeal posture can lead to organic changes such as nodules or polyps, particularly in females with posterior glottic chink. We hypothesized that the chink was related to an overall increase in laryngeal muscle tension, and more directly due to inadequate relaxation of the posterior crico-arytenoid muscle during phonation. We employed the term "muscular tension dysphonia" (MTD) to note this condition, but it may be that the term "laryngeal isometric" is superior since there are other misuses of the larynx that obviously are manifestations of abnormalities of muscular tension. With this in mind we have evolved a new classification based on the laryngeal isometric, glottic and supraglottic lateral contraction states, antero-posterior contraction states, conversion aphonia, psychogenic bowing, and adolescent transitional dysphonia.

Diagnostic criteria in functional dysphonia.

One thousand consecutive patients seen in a multidisciplinary voice clinic are reviewed. The incidence and relative severity of diagnostic features in each of five assessment areas are calculated and compared. The five areas include: 1. history, 2. laryngoscopic examination, 3. perceptual-acoustic assessment, 4. voice related musculoskeletal, and 5. psychological evaluations. Feature prevalence is presented for patients we have classified as having muscular tension dysphonia, which can be primary, or associated with vocal nodules, chronic laryngitis, or polypoidal degeneration; or as having a psychogenic "functional" dysphonia. Following review of the data, we present a suggested list of diagnostic criteria that should be present before using a specific diagnostic label. These criteria have been further broken down into those that will be present to make a diagnosis, and those that may be present.