Primary Muscle Tension Dysphonia Research Articles

Adductor Laryngeal Dystonia Versus Muscle Tension Dysphonia: Examining the Utility of Automated Acoustic Analysis to Detect Task Dependency as a Distinguishing Feature.

Differentiating adductor laryngeal dystonia (ADLD) and primary muscle tension dysphonia (pMTD) can be challenging. Unlike pMTD, ADLD is described as "task-dependent" with voiced phonemes purportedly provoking greater sign expression than voiceless phonemes. We evaluated the ability of two automated acoustic measures, the Cepstral Spectral Index of Dysphonia (CSID) and creak, to detect task dependency and to discriminate ADLD and pMTD. CSID, % creak, and listener ratings of dysphonia severity were obtained from audio recordings of patients with ADLD (n = 29) or pMTD (n = 33) reading two sentences loaded with either voiced or voiceless phonemes. Group × Sentence Type interaction effects confirmed that both "normalized" CSID and % creak detected task-dependent sign expression in ADLD (i.e., worse symptoms on the voiced- vs. voiceless-loaded sentence). However, a stepwise binary logistic regression analysis with group (ADLD vs. pMTD) as the dependent variable and % creak and normalized CSID variables (voiced, voiceless, and voiced vs. voiceless difference) as covariates revealed that the normalized CSID voiceless-laden sentence z score was the only significant predictor of group membership. Estimates of diagnostic precision from the normalized CSID voiceless sentence z scores were superior to % creak or listener ratings. Finally, the CSID possessed the strongest correlations with listener severity ratings regardless of group or sentence type. Although both normalized CSID and % creak detected task-dependent performance as a distinguishing feature of ADLD, a CSID profile wherein (a) the voiceless sentence z score was less severe than the voiced sentence and (b) the normalized voiceless sentence z score was within approximately 2 SDs (or less) of typical expectations provided the best estimates of diagnostic precision. Automated acoustic measures such as the CSID and creak provide useful information to objectively discriminate ADLD and pMTD.

The Risk of Obstructive Sleep Apnea in Patients with Primary Muscle Tension Dysphonia.

To explore the risk of obstructive sleep apnea (OSA) in patients with primary muscle tension dysphonia (MTD). The medical records of patients diagnosed with primary MTD between November 2021 and March 2023, were reviewed. The risk of having OSA was assessed by looking at the scores of two validated questionnaires, namely the STOP-BANG questionnaire and the Berlin questionnaire. A total of 40 patients with primary MTD were enrolled in this study, including 16 females (40%) and 24 males (60%). The mean total STOP-BANG score was 3.57 ± 1.67. Seventeen of the study group had intermediate risk of OSA, and 14 had high risk, accounting for 77.5% of patients with primary MTD. When using the Berlin questionnaire, the mean total score was 1.65 ± 0.95, and 67.5% of the study group had a score > 2 and were at high risk of having OSA. The results of this study indicate that patients with primary MTD are at moderate to severe risk of having OSA.

A Conceptual Framework and Treatment Taxonomy for Respiratory Lung Volume Training (RLVT)

ObjectivesThe purpose of this study was to describe the theoretical and procedural framework of a novel intervention, Respiratory Lung Volume Training (RLVT), and to implement a standardized treatment taxonomy to operationalize the RLVT treatment paradigm. Study DesignThis study involved a prospective design with a consensus treatment classification process. MethodsThe Respiratory Lung Volume Training (RLVT) paradigm was developed based on biomechanical constructs governing the interactions of the respiratory and phonatory systems in voice production and principles of motor learning theory. In RLVT, higher levels of lung volume during speech are trained using multiple speech breathing targets while providing real-time visual biofeedback with superimposed guidelines for desired lung volume initiation and termination levels. For people with primary muscle tension dysphonia, RLVT can capitalize on non-muscular respiratory forces to increase efficiency of voice production with reduced speaking effort. To define and operationalize the treatment components of RLVT, six investigators with training in RLVT used the Rehabilitation Treatment Specification System (RTSS) to delineate the treatment targets, mechanisms of action, ingredients and dosing through a multi-stage, consensus decision-making process. ResultsThe finalized taxonomy for RLVT included four treatment targets, with three addressing the area of Respiratory Function and one addressing Somatosensory Function. For each treatment target, three categories of ingredients were defined: 1) Provide opportunities to practice breathing during voicing/speech, 2) Provide feedback, and 3) Provide volition ingredients. Within each ingredient category, three to seven specific ingredients were ultimately defined to further operationalize RLVT. ConclusionsThe RLVT paradigm is a theoretically driven approach for optimizing speech breathing patterns to increase efficient voice production in people with primary muscle tension dysphonia. By applying a standardized, systematic treatment taxonomy system to specify the components of RLVT, future researchers and clinicians can implement RLVT with improved fidelity and consistency to optimize treatment outcomes.

Risk of Fibromyalgia in Patients with Primary Muscle Tension Dysphonia: A Prospective Pilot Study

Risk of Fibromyalgia in Patients with Primary Muscle Tension Dysphonia: A Prospective Pilot Study

The Patient Experience: The Relationship Between Vocal Handicap, Congruency, Perceived Present Control, and Mood Across Four Voice Disorders.

The potential for negative sequalae in psychosocial well-being presents clinical importance to the assessment of voice disorders. Despite the impairment voice disorders cause in the psychosocial domain, the clinical assessment of these disorders relies heavily on visual perceptual judgments of the larynx, audio-perceptual, as well as acoustic and aerodynamic measures. While these measures aid in accurate diagnosis and are necessary for standard of care, they present little insight into the patient experience of having a voice disorder. Retrospective between-subject, non-experimental design. Data from 335 patients from the University of Pittsburgh Voice Center were collected from scores of the Voice Handicap Index-10 (VHI-10) and two recent questionnaires, the Voice Present Perceived Control scale (VPPC), and the Vocal Congruency Scale (VCS). Examining how these voice-specific scales related to three mental health screeners for stress (Perceived Stress Scale-4), anxiety (Generalized Anxiety Disorder-7) and depression (Patient Health Questionnaire-9) were also examined. Patient diagnoses included primary muscle tension dysphonia (pMTD), unilateral vocal fold paralysis (UVFP), vocal fold atrophy, and mid membranous vocal fold lesions. There were significant differences in scores from the voice-specific scales between diagnostic groups with UVFP being the highest (worst) in VHI-10 and UVFP being the lowest (worst) in VCS compared to healthy controls. There was no significant difference in VPPC scores between diagnostic groups. Results showed statistically significant inverse relationships between the VHI-10 and the VPPC and between the VHI-10 and VCS for all diagnostic groups. A significant direct relationship was found between the VPPC and the VCS for patients diagnosed with MTD, UVFP and Lesions. In sum, patients with UVFP presented with the most frequent and sometimes strongest relationships between voice and mental health measures. This study marks an initial investigation into the nuanced patient experience of having a voice disorder. Three theoretically unrelated voice constructs: handicap, perceived control, and sense of self, were measured via self-report. Results from this study describe the patient experience correlating to these constructs with weak correlations to stress, anxiety, and depression. Findings also clearly suggest that patient experience varies among diagnostic groups, as well as varying constructs. Measures of multiple constructs of patient perception provide valuable insight into a patient's experience of their voice disorder, guidance on the direction of voice treatment, and justification for such treatments.

Relationships Between Vocal Fold Adduction Patterns, Vocal Acoustic Quality, and Vocal Effort in Individuals With and Without Hyperfunctional Voice Disorders

Increased vocal effort and aberrant vocal quality are often attributed to vocal fold hyperadduction in hyperfunctional voice disorders. However, there are currently no established methods to quantify vocal fold adduction beyond subjective descriptors in this clinical population. Furthermore, relationships between vocal fold adduction patterns, vocal effort severity, and vocal quality are not well characterized. Therefore, the objectives of this study were to (1) quantify vocal fold adduction, applying a previously validated method developed for patients with vocal fold paralysis, and (2) correlate these measures with acoustic vocal quality and self-perceived measures of vocal effort severity. A deep learning program, Automated Glottic Action Tracking using artificial Intelligence, was used to track glottic angle configurations and vocal fold adduction velocities on laryngoscopic videos across 60 laryngoscopies (20 primary muscle tension dysphonia [pMTD], 20 phonotraumatic lesions, and 20 healthy controls). Voice samples were also acquired, and cepstral peak prominence (CPP) and H1-H2 acoustic measures were used to quantify vocal quality. Participants were also asked to rate their vocal effort on a 100mm visual analog scale. There were no significant group differences in glottic angle configurations or vocal fold adduction velocities, although there were trends toward increased peak vocal fold adduction velocities in patients with hyperfunctional voice disorders compared to controls. Vocal effort was significantly higher in the two hyperfunctional groups compared to controls. CPP was significantly lower in the pMTD group, but there were no group differences in acoustic parameters between any of the other groups or for H1-H2 values. Despite significantly more vocal effort reported in patients with hyperfunctional voice disorders, there were no significant group differences in vocal fold adduction patterns. These findings suggest other physiologic mechanisms may also be responsible for the symptoms and genesis of pMTD and benign vocal fold lesions.

The Effect of Adding Cricothyroid Visor Maneuver to Voice Facilitating Techniques on Improving Voice in Individuals With Primary Muscle Tension Dysphonia: A Pilot Randomized Clinical Trial

The purpose of the present study was to examine the effect of adding a cricothyroid visor maneuver to conventional voice-facilitating techniques on voice quality and reported symptoms in patients with primary muscle tension dysphonia. This was a double-blind two parallel-group clinical trial in which 20 adult patients participated through convenience sampling. Participants were allocated to intervention (combined treatment) and control (conventional treatment) groups. The intervention was performed for both groups for five sessions, twice a week. The two groups were compared after the intervention for primary outcome measures including maximum phonation time, jitter, shimmer, harmonic-to-noise ratio, and consensus auditory-perceptual evaluation of voice, and for secondary outcome measures including the voice handicap index, the voice activity and participation profile, the voice-related pain scale, and the vocal tract discomfort scale. Within-group primary outcome comparison showed that both groups showed significant improvement in maximum phonation time and consensus auditory-perceptual evaluation of voice indices after treatment. the between-group comparison showed that the maximum phonation time increased significantly in the intervention group after the treatment (P=0.03) and the effect size was large (es=1.05). within-group secondary outcome comparison showed that all indices improved significantly in both groups except for the voice-related pain scale frequency. The between-group comparison showed that except for voice-related pain scale frequency, the intervention group reported significantly more improvement in all other self-reporting indices with a large effect size. The study showed that adding cricothyroid visor maneuver to conventional voice-facilitating techniques, compared to conventional treatment alone, resulted in a significant increase in maximum phonation time, reduction in pain and vocal tract discomfort, increase in activity and participation, and improvement in voice-handicapped index in primary muscle tension dysphonia patients. Therefore adding cricothyroid visor maneuver to other treatments can be an effective method in improving primary muscle tension dysphonia which needs more studies in the future.

Comparative Investigation of Laryngeal Palpation Scale Between Primary and Secondary Muscle Tension Dysphonia

Comparative Investigation of Laryngeal Palpation Scale Between Primary and Secondary Muscle Tension Dysphonia

Acoustic and Physiologic Correlates of Vocal Effort in Individuals With and Without Primary Muscle Tension Dysphonia.

The aims of this study were to determine relationships between vocal effort and (a) acoustic correlates of vocal output and (b) supraglottic compression in individuals with primary muscle tension dysphonia (pMTD) and without voice disorders (controls) in the context of a vocal load challenge. Twenty-six individuals with pMTD and 35 vocally healthy controls participated in a 30-min vocal load challenge. The pre- and postload relationships among self-ratings of vocal effort, various acoustic voice measures, and supraglottic compression (mediolateral and anteroposterior) were tested with multiple regression models and post hoc Pearson's correlations. Acoustic measures included cepstral peak prominence (CPP), low-to-high spectral ratio, difference in intensity between the first two harmonics, fundamental frequency, and sound pressure level (dB SPL). Regression models for CPP and mediolateral compression were statistically significant. Vocal effort, diagnosis of pMTD, and vocal demand were each significant variables influencing CPP measures. CPP was lower in the pMTD group across stages. There was no statistical change in CPP following the vocal load challenge within either group, but both groups had an increase in vocal effort postload. Vocal effort and diagnosis influenced the mediolateral compression model. Mediolateral compression was higher in the pMTD group across stages and had a negative relationship with vocal effort, but it did not differ after vocal loading. CPP and mediolateral supraglottic compression were influenced by vocal effort and diagnosis of pMTD. Increased vocal effort was associated with lower CPP, particularly after vocal load, and decreased mediolateral supraglottic compression in the pMTD group.

Relationships Between Laryngoscopic Analysis Metrics of Supraglottic Compression and Vocal Effort in Primary Muscle Tension Dysphonia

Supraglottic compression is thought to underlie vocal effort in patients with primary muscle tension dysphonia (pMTD). However, the relationship between supraglottic compression and vocal effort in this clinical population remains unclear. Gold standard laryngoscopic assessment metrics for supraglottic compression are also lacking. The goals of this study were to identify metrics proposed in the literature that could distinguish patients diagnosed with pMTD from typical voice users and determine their relationships to the vocal effort. Flexible laryngeal endoscopy was performed on 50 participants (25 pMTD, 25 controls). The presence of supraglottic compression was characterized using a categorical (nominal) scale and severity was quantified on ordinal and continuous scales. The three laryngoscopic metrics were correlated with self-perceived ratings of vocal effort on a 100mm visual analog scale. Inter-rater reliability was strongest for the continuous scale (P's<0.0001) compared to categorical (P's<0.001) and ordinal (P's<0.001) scales. The presence of different supraglottic compression patterns varied in both groups, and there were no significant group differences on categorical (P's>0.05) scales. Mediolateral (M-L) supraglottic compression was significantly greater in the pMTD group (P<0.0001), and anteroposterior(A-P) compression was significantly greater in the control group (P=0.001) using continuous scales. There were no significant relationships between any of the three laryngoscopic metric types and vocal effort ratings (P's>0.05), except for a significantly positive relationship between anterior-posterior compression on the ordinal scale and vocal effort in the control group (P=0.047). Continuous scales are reliable and valid for distinguishing individuals with pMTD from those without voice disorders, especially occupational voice users. M-L supraglottic compression may be a better indicator of pMTD than A-P compression. However, the poor correlation between supraglottic compression and vocal effort suggests that one may not influence the other. Future studies should focus on other mechanisms underlying vocal effort in patients with pMTD.

Normalization of speech kinematic data for characterizing primary muscle tension dysphonia

Primary muscle tension dysphonia (pMTD) is a voice disorder of unknown etiology in which people have reduced volume and become easily fatigued. The tongue has biomechanical linkage to the laryngeal motor system that affects the voice, suggesting that tongue movement variability might be a marker for this disorder. Previous studies of healthy/disordered speech have reduced individual talker differences in physical vocal tract characteristics via normalization procedures. Here, we obtained tongue movement data for diadochokinetic sequences produced by healthy adult talkers and people with pMTD. We used an electromagnetic articulography system to test three healthy adult talkers and a participant with pMTD. We recorded vertical displacement of the tongue dorsum for sustained /a/ and 30 sec of rapidly repeated /pataka/. Displacement (mm) was scaled relative to each talker’s sustained vowel production, while movement time (msec) was normalized by dividing each /ka/ portion by the corresponding /pataka/ utterance length. The results suggest (1) normalization effectively reduced talker variability in tongue movement displacement and timing, and (2) the talker with pMTD showed markedly higher temporal variability, compared to the control talkers. We are currently testing this putative group difference using additional participants.

Optical Flow Analysis of Paralaryngeal Muscle Movement.

The paralaryngeal muscles are thought to be hyperfunctional with phonation in patients with primary muscle tension dysphonia (pMTD). However, objective, quantitative tools to assess paralaryngeal movement patterns lack. The objectives of this study were to (1) validate the use of optical flow to characterize paralaryngeal movement patterns with phonation, (2) characterize phonatory optical flow velocities and variability of the paralaryngeal muscles before and after a vocal load challenge, and (3) compare phonatory optical flow measures to standard laryngoscopic, acoustic, and self-perceptual assessments. Phonatory movement velocities and variability of the paralaryngeal muscles at vocal onsets and offsets were quantified from ultrasound videos and optical flow methods across 42 subjects with and without a diagnosis of pMTD, before and after a vocal load challenge. Severity of laryngoscopic mediolateral supraglottic compression, acoustic perturbation, and ratings of vocal effort and discomfort were also obtained at both time points. There were no significant differences in optical flow measures of the paralaryngeal muscles with phonation between patients with pMTD and controls. Patients with pMTD had significantly more supraglottic compression, higher acoustic perturbations, and higher vocal effort and vocal tract discomfort ratings. Vocal load had a significant effect on vocal effort and discomfort but not on supraglottic compression, acoustics, or optical flow measures of the paralaryngeal muscles. Optical flow methods can be used to study paralaryngeal muscle movement velocity and variability patterns during vocal productions, although the role of the paralaryngeal in pMTD diagnostics (e.g., vocal hyperfunction) remains suspect. 2 Laryngoscope, 134:1792-1801, 2024.

Risk of fibromyalgia in patients with primary muscle tension dysphonia: a possible local manifestation of a musculoskeletal systemic disorder.

To investigate the risk of fibromyalgia in patients with primary muscle tension dysphonia. A retrospective review was conducted of patients with primary muscle tension dysphonia, diagnosed based on history of dysphonia with evidence of laryngeal muscle tension on examination. Fibromyalgia was assessed using the Fibromyalgia Rapid Screening Tool ('FiRST'). Fifty patients were enrolled: 25 with primary muscle tension dysphonia (study group) and 25 matched controls. The mean age of the study group was 50.7 ± 15.2 years versus 49.5 ± 18.6 years for the controls, with a male to female ratio of 3:2 for both groups. Fifty-six per cent tested positive for fibromyalgia in the study group versus 4 per cent in the controls (p < 0.001). The mean Voice Handicap Index 10 score in the study group was significantly higher for those who screened positive for fibromyalgia compared to those who screened negative. There was a positive, strong point-biserial correlation between Fibromyalgia Rapid Screening Tool and Voice Handicap Index 10 scores (r = 0.39; p = 0.09). These results suggest that fibromyalgia is a significant co-morbid condition in primary muscle tension dysphonia.

Extrinsic Laryngeal Muscle Tension in Primary Muscle Tension Dysphonia with Shear Wave Elastography.

It has been assumed that patients with primary muscle tension dysphonia (pMTD) have more extrinsic laryngeal muscle (ELM) tension, but tools to study this phenomenon lack. Shear wave elastography (SWE) is a potential method to address these shortcomings. The objectives of this study were to apply SWE to the ELMs, compare SWE measures to standard clinical metrics, and determine group differences in pMTD and typical voice users before and after vocal load. SWE measurements of the ELMs from ultrasound examinations of the anterior neck, supraglottic compression severities from laryngoscopic images, cepstral peak prominences (CPP) from voice recordings, and self-perceptual ratings of vocal effort and discomfort were obtained in voice users with (N = 30) and without (N = 35) pMTD, before and after a vocal load challenge. ELM tension significantly increased from rest-to-voiced conditions in both groups. However, the groups were similar in their ELM stiffness levels at SWE at baseline, during vocalization, and post-vocal load. Levels of vocal effort and discomfort and supraglottic compression were significantly higher and CPP was significantly lower in the pMTD group. Vocal load had a significant effect on vocal effort and discomfort but not on laryngeal or acoustic patterns. SWE can be used to quantify ELM tension with voicing. Although the pMTD group reported significantly higher levels of vocal effort and vocal tract discomfort and, on average, exhibited significantly more severe supraglottic compression and lower CPP values, there were no group differences in levels of ELM tension using SWE. 2 Laryngoscope, 133:3482-3491, 2023.

Use of Motion Capture Technology to Study Extrinsic Laryngeal Muscle Tension and Hyperfunction.

Patients with primary muscle tension dysphonia (pMTD) commonly report paralaryngeal pain and discomfort, and extrinsic laryngeal muscle (ELM) tension and hyperfunction are commonly implicated. However, quantitative physiological metrics to study ELM movement patterns for the characterization of pMTD diagnosis and monitoring of treatment progress are lacking. The objectives of this study were to validate motion capture (MoCap) technology to study ELM kinematics, determine whether MoCap could distinguish ELM tension and hyperfunction between individuals with and without pMTD, and investigate relationships between common clinical voice metrics and ELM kinematics. Thirty subjects (15 with pMTD and 15 controls) were recruited for the study. Sixteen markers were placed on different anatomical landmarks on the chin and anterior neck. Movements across these regions were tracked during four voice and speech tasks using two three-dimensional cameras. Movement displacement and variability were determined based on 16 key-points and 53 edges. Intraclass correlation coefficients demonstrated high intra- and inter-rater reliability (p's < 0.001). Other than greater movement displacements around the thyrohyoid space during longer phrasing (reading passage, 30-s diadochokinetics) and more movement variability in patients with pMTD, kinematic patterns between groups were similar across the 53 edges for the four voice and speech tasks. There were also no significant correlations between ELM kinematics and standard voice metrics. Results demonstrate the feasibility and reliability of MoCap for the study of ELM kinematics. 3 Laryngoscope, 133:3472-3481, 2023.

Quantification of False Vocal Fold Hyperfunction During Quiet Breathing in Muscle Tension Dysphonia.

False vocal fold (FVF) hyperfunction during phonation is thought to be a diagnostic sign of primary muscle tension dysphonia (pMTD). However, hyperfunctional patterns with phonation are also observed in typical speakers. This study tested the hypothesis that FVF posturing during quiet breathing, as measured by the curvature of FVF, could differentiate patients with pMTD from typical speakers. Laryngoscopic images were collected prospectively in 30 subjects with pMTD and 33 typical speakers. Images were acquired at the end of expiration and maximal inspiration during quiet breathing, during sustained /i/, and during loud phonation before and after a 30-min vocal loading task. The FVF curvature (degree of concavity/convexity) was quantified using a novel curvature index (CI, >0 for hyperfunctional/convex, <0 for "relaxed"/concave) and compared between the two groups. At end-expiration, the pMTD group adopted a convex FVF contour, whereas the control group adopted a concave FVF contour (mean CI 0.123 [SEM 0.046] vs. -0.093 [SEM 0.030], p = 0.0002) before vocal loading. At maximal inspiration, the pMTD group had a neutral/straight FVF contour, whereas the control group had a concave FVF contour (mean CI 0.012 [SEM 0.038] vs. -0.155 [SEM 0.018], p = 0.0002). There were no statistically significant differences in FVF curvature between groups in either the sustained voiced or loud conditions. Vocal loading did not change any of these relationships. A hyperfunctional posture of the FVFs during quiet breathing especially at end-expiration may be more indicative of a hyperfunctional voice disorder than supraglottic constriction during voicing. 3 Laryngoscope, 133:3449-3454, 2023.

Interoception, Voice Symptom Reporting, and Voice Disorders

Interoception may play a role in how individuals perceive their voice disorder. The first objective of this study was to investigate relationships between interoception and voice disorder class (functional, structural, neurological). The second objective was to determine relationships between interoception and voice-related outcome measures between patients with functional voice and upper airway disorders and typical voice users. The third objective was to determine whether patients with primary muscle tension dysphonia (a type of functional voice disorder) had different levels of interoceptive awareness than typical voice users. Prospective cohort study. One hundred subjects with voice disorders completed the multidimensional assessment of interoceptive awareness-2 (MAIA-2). Voice diagnosis and singing experience were also acquired from each patient's medical chart. Voice handicap (VHI-10) and Part 1 of the vocal fatigue index (VFI-Part1) scores were obtained from patients diagnosed with functional voice and upper airway disorders. MAIA-2, VHI-10, VFI-Part1, and singing experience were also obtained from 25 typical voice users. Multivariable linear regression models were used to assess the association between response variables and voice disorder class, adjusting for singing experience, gender, and age. There were no significant group differences between voice disorder class (functional, structural, neurological) after adjusting for multiple comparisons. Participants with functional voice and upper airway disorders who scored significantly higher on the VHI-10 and VFI-Part1 had lower Attention Regulation sub-scores on the MAIA-2 (P's<0.05). Patients with primary muscle tension dysphonia scored significantly lower on the Emotional Awareness MAIA-2 subscale than typical voice users (P=0.005). Patients with functional voice disorders with lower capabilities to attend to body sensations may score higher on voice-related patient-reported outcome measures, like the VHI-10 and VFI-Part1. Patients with primary muscle tension dysphonia may also have lower capabilities in processing their body sensations than typical voice users.

Assessing Candidacy for Conversation Training Therapy: The Role of Patient Perception

Voice therapy is the primary treatment modality for voice rehabilitation. Specific patient-ability factors beyond patient-characteristic factors (eg, disorder diagnosis, age, etc.), that influence individual patient responses to voice treatment remain largely unknown. The goal of the current study was to determine the relationship between patient-perceived improvements in both the sound and feel of voice during stimulability assessment and voice therapy outcomes. Prospective Cohort study. This study was a single-arm, single-center, prospective study. Fifty patients with primary muscle tension dysphonia and benign vocal fold lesions were enrolled. Patients read the first four sentences of the Rainbow Passage and were asked if they experienced a change in the feel or sound of their voice following the stimulability prompt. Patients then completed four sessions of conversation training therapy (CTT) voice therapy and followed up one-week and three-months after their last therapy session, for a total of six time-points. Demographic data were collected at baseline, and voice handicap index 10 (VHI-10) scores were collected at each follow-up time-point. The primary exposure variables were CTT intervention and patient perception of voice change to stimulability probes. The primary outcome was change in VHI-10 score. On average, VHI-10 scores improved for all participants following CTT treatment. All participants heard a change in the sound of voice with stimulability prompts. Descriptively, patients who reported a positive change in the feel of their voice after stimulability testing recovered faster (ie, experienced a sharper decline in VHI-10) compared to those who did not note a change in feel of voice during stimulability testing. However, the rate of change over time was not significantly different between groups. Patient self-perception of a change in the sound and feel of voice in response to stimulability probes during initial evaluation is an important factor in treatment outcomes. Patients who perceive an improved feel of their voice production after stimulability probes may respond to voice therapy more quickly.

A randomized controlled trial of the effects of flow phonation voice treatment for primary muscle tension dysphonia

ObjectiveThe purpose of the study was to investigate the effects of flow phonation voice therapy on laryngeal physiology and vocal quality in persons with primary Muscle Tension Dysphonia (MTD1). MethodsSeventeen participants with a diagnosis of MTD1 completed the study. Participants were randomized to two groups. Group 1 (9 participants) received flow phonation treatment and individualized vocal hygiene education for 12 sessions over six weeks. Group 2 (8 participants) received vocal hygiene education only for three weeks (6 sessions), followed by another three weeks (6 sessions) of both vocal hygiene instruction and flow phonation therapy. Treatment consisted of cup-bubble blowing, gargling, and stretch and flow exercises. Visual-perceptual. auditory-perceptual, acoustic, aerodynamic and voice-related quality-of-life measures were obtained at three time points: before treatment, three weeks after initiation of treatment and after completion of treatment. ResultsVoice quality was perceived to be significantly improved in both groups. Voice related quality-of-life trended toward improvement for both groups across time points. Changes in aerodynamic and acoustic measures did not reach statistical significance compared to baseline for both groups. Visual comparisons of laryngeal closure patterns demonstrated comparably better outcomes for Group 1. ConclusionsResults of this study indicate flow phonation exercises can potentially be favorably employed for individuals with MTD1. In particular, it appears that the exercises aid in alleviating vocal hyperfunction, as evidenced by visual perceptual stroboscopic analysis, and clinically improved auditory-perceptual measures.

Clinical Characteristics and Effects of Vocal Demands in Occupational Voice Users With and Without Primary Muscle Tension Dysphonia

The objectives of this study were to (1) compare laryngeal configuration patterns in occupational voice users with and without primary muscle tension dysphonia (pMTD), (2) characterize laryngeal configurations in relation to other clinical metrics (acoustic, perceptual), and (3) determine the effects of vocal demands (load) on these clinical parameters. Thirty subjects (15 pMTD, 15 control) were recruited for the study. Laryngoscopic examinations and voice samples for sustained /i/ were obtained before and after a half hour vocal load task. Subjects rated their vocal effort and discomfort before and after the vocal load. Laryngeal configurations were analyzed subjectively with dichotomous and categorical rating scales and hyper function severity quantified (endolaryngeal area outlets). Overall dysphonia severity and vocal instability of each voice sample was rated on 100mm visual analog scales and cepstral peak prominence (CPP) extracted from each voice sample. Laryngeal configurations between groups or vocal load condition were not distinguishable with any of the dichotomous, categorical, or quantitative laryngeal metrics. Vocal effort and discomfort ratings were significantly higher in the pMTD group compared to the control group. Vocal load also had significant effects across groups on vocal effort and vocal tract discomfort ratings. Although CPP values fell within the normal range in both groups, CPP was significantly lower in the pMTD group at both pre-load and post-load time points. Auditory-perceptual ratings were also significantly worse in the pMTD group. Vocal load did not have a significant effect on acoustic or auditory-perceptual measures. Similar laryngeal configurations between groups at both pre- and post-vocal load suggests classic patterns of laryngeal "hyperadduction" may occur variably in occupational voice users and may not be indicative of pMTD pathophysiology. Greater vocal effort, discomfort, instability, and perturbation within the vocal system may better define pMTD than laryngeal configuration in occupational voice users with pMTD.