SPPA 6400 Voice Disorders Tasko Functional Dysphonia/ Muscle Tension Dysphonia (MTD)
-
Upload
bertha-mathews -
Category
Documents
-
view
223 -
download
7
Transcript of SPPA 6400 Voice Disorders Tasko Functional Dysphonia/ Muscle Tension Dysphonia (MTD)
SPPA 6400 Voice Disorders Tasko
Functional Dysphonia/Muscle Tension Dysphonia (MTD)
SPPA 6400 Voice Disorders Tasko
Muscle Tension Dysphonia: A Functional Voice Disorder
What is a functional voice disorder? Voice disorder in the absence of
structural/neurological pathology Pathology insufficient to explain the degree
of dysphonia Voice disorder based on abuse/misuse
causally linked to anatomical abnormalities
SPPA 6400 Voice Disorders Tasko
Functional dysphonia vs. muscle tension dysphonia
SPPA 6400 Voice Disorders Tasko
Muscle Tension Dysphonia (MTD)Presumed Etiology Excess or dysregulated activity of the intrinsic and extrinsic
laryngeal muscles
Possible Sources Technical misuse of the vocal mechanism Learned adaptations following upper respiratory infection Compensation for underlying vocal fold pathology ↑ laryngeal tone 2° to laryngopharyngeal reflux Psychological/personality factors
SPPA 6400 Voice Disorders Tasko
Muscle Tension Dysphonia (MTD)Key Features Laryngeal/paralaryngeal hypertonicity
“stiff” larynx Larynx in unnatural position high in neck
Laryngeal muscle “cramping” No unique voice quality/glottic configuration
Pre-treatment MTD samples
SPPA 6400 Voice Disorders Tasko
Muscle Tension Dysphonia (MTD)Some Trends Occurs predominantly in women (90 %)* May account for > 10 % of cases referred to
multidisciplinary voice clinics Often the most severely affected voices encountered Commonly follows URI symptoms* Past history of voice problems (80%)* Varies in response to treatment
*Roy et al. (1997)
SPPA 6400 Voice Disorders Tasko
Recognizing Muscle Tension Dysphonia
Patient history Auditory-perceptual Features Laryngoscopic Features Direct clinical examination:
Manual assessment of laryngeal musculoskeletal tension
Primary or Diagnostic therapy
SPPA 6400 Voice Disorders Tasko
Patient History Vocal symptoms…
Can have a sudden onset May have had periods of resolution May have developed along with a URI
Symptoms suggestive of excess musculoskeletal tension Laryngeal tenderness, soreness, pain, tightness, “swellings” which
intensify with extended voice use Pain radiates to one or both ears Unilateral symptoms are more common Vocal fatigue, increased effort Restricted dynamic range
SPPA 6400 Voice Disorders Tasko
Patient History Voice Use History…
may not reveal patterns of excessive voice use Psychosocial History…
may reveal elevated stress Stress may be coincident with history of vocal
symptoms
SPPA 6400 Voice Disorders Tasko
Auditory Perceptual FeaturesGenerally… Severity of voice quality disturbance typically
consistent across a range of speech tasks Signs are usually continuous and rarely
intermittent (no islands of normal speech) Typically shows no improvement with
falsetto or singing
SPPA 6400 Voice Disorders Tasko
Auditory Perceptual Features The most disordered voices produced
with normal larynges Wide range & variety of voice qualities Possible existence of 5 auditory-
perceptual clusters qualitatively distinct within a cluster, voices vary from mild-severe
SPPA 6400 Voice Disorders Tasko
Auditory-perceptual Clusters Cluster 1
Persistent glottal fry Cluster 2
Sustained harsh, strained (tension) Cluster 3
Diplophonia, intermittent pitch & voice breaks Cluster 4
Aphonia (continuous) Cluster 5
Elevated pitch (falsetto) – with & without strain, aphonia
SPPA 6400 Voice Disorders Tasko
THOUGHT QUESTION
Why don’t persons with MTD develop laryngeal pathologies?
SPPA 6400 Voice Disorders Tasko
Laryngoscopic Features Dysregulated muscle activity = myriad of
glottic/supraglottic contraction patterns Rammage & Morrison (2001) suggest a
distinct set of laryngoscopic patterns Controversial
SPPA 6400 Voice Disorders Tasko
MTD Type 1: Laryngeal Isometric(+/- benign mucosal disease)
Principle feature: posterior glottic chink
Presumed due to ↑ PCA activity
Suggested association with benign mucosal lesions
SPPA 6400 Voice Disorders Tasko
MTD Type 2a – Glottic Lateral Compression
Lateral compression principally at the glottis
May be some ventricular compression
↑ closed phase ↓ vibratory amplitude
SPPA 6400 Voice Disorders Tasko
MTD Type 2b – Supraglottic Lateral Compression
Ventricular folds are approximated
SPPA 6400 Voice Disorders Tasko
MTD Type 3: Anterior-posterior supraglottic compression
↓ distance between anterior and posterior glottis
Arytenoids “pull” toward epiglottis
Associated with “Bogart-Bacall” syndrome
SPPA 6400 Voice Disorders Tasko
MTD Type 4 – Non-adducted hyperfunction(- supraglottic compression)
Incomplete glottal closure with normal mobility
SPPA 6400 Voice Disorders Tasko
MTD Type 4 – Non-adducted hyperfunction(+ supraglottic compression)
Incomplete glottal closure with normal mobility
Concomitant compression of the ventricular folds
SPPA 6400 Voice Disorders Tasko
MTD Type 5 – Bowed vocal folds
“Spindle”-shape glottis Also associated with
aging (presbylaryngis or presbyphonia)
Neurologic conditions (Parkinson’s Disease)
SPPA 6400 Voice Disorders Tasko
NoteRelation between auditory-perceptual judgments and laryngoscopic findings are not straightforward
SPPA 6400 Voice Disorders Tasko
Direct Clinical AssessmentFocal palpation of circumlaryngeal area to
determine… Presence of tenderness and/or pain Laryngeal Stiffness
Presence of nodularity or taut bands Reduced mobility of the larynx
Extent of laryngeal elevation
SPPA 6400 Voice Disorders Tasko
Manual Assessment of Laryngeal Musculoskeletal Tension
“All patients with voice disorders, regardless of etiology should be tested for excess musculoskeletal tension, either as a primary or secondary cause of dysphonia” (Aronson, 1990)
SPPA 6400 Voice Disorders Tasko
Manual Assessment of Laryngeal Musculoskeletal Tension Pressure is directed over the
Major horns of the hyoid bone Superior border of the thyroid cartilage Anterior border of sternocleidomastoid and into the
suprahyoid muscles Determine size of the thyrohyoid space
Digital pressure should be just enough to
blanche (lighten in color) your nail bed
SPPA 6400 Voice Disorders TaskoFrom Aronson (1990)
SPPA 6400 Voice Disorders Tasko
From Roy et al. (1996)
SPPA 6400 Voice Disorders Tasko
Treatment Options Facilitating techniques designed to elicit easy,
relaxed phonation, phonation at optimal pitch, etc General and focal relaxation “Broad spectrum” treatments that focus on
increasing support and efficiency of phonatory behavior
Manual Circumlaryngeal Techniques* Pharmacologic Intervention (topical lidocaine)
SPPA 6400 Voice Disorders Tasko
Manual circumlaryngeal techniquesGoals Determine contribution of laryngeal/extralaryngeal
hypertonicity Assure proper diagnosis and selection of appropriate
treatment Avoid unnecessary medical or surgical management
Show Pre-Post Samples
SPPA 6400 Voice Disorders Tasko
Manual circumlaryngeal techniques A group of techniques a “hands on” approach Clinician manually repositions, repostures or
“massages” the laryngeal structure while eliciting voice
Use voice task with a hierarchy of difficulty Exploit facilitating techniques
SPPA 6400 Voice Disorders Tasko
Manual circumlaryngeal techniquesMay be used as primary treatment technique for
musculoskeletal tension dysphonia (MTD) diagnostic therapy to evaluate degree of
contribution of musculoskeletal tension to voice disorder
SPPA 6400 Voice Disorders Tasko
MCT: Reposturing techniques
1. Compression in the A-P direction (push-back)
2. Impede laryngeal elevation (Pull down)
3. Medial compression and downward traction (Reposturing)
Goal: Perturb the abnormal laryngeal posture and evaluate change in voice quality
SPPA 6400 Voice Disorders Tasko
Technique 1: Push Back Maneuver
Digital compression in the posterior direction within the region of the larynx
Vary height and pressure Suprahyoid Hyoid Infrahyoid T-H space Thyroid notch
SPPA 6400 Voice Disorders Tasko
Technique 2: Pull Down Maneuver
Impede laryngeal elevation by applying downward traction over the superior border of the thyroid
SPPA 6400 Voice Disorders Tasko
Technique 3: Laryngeal Reposturing
Medial compression and downward traction pressure directed over posterior aspect of thyroid
cartilage (and within T-H space) Often helpful with non-adducted hyperfunction
SPPA 6400 Voice Disorders Tasko
Circumlaryngeal massage (manual laryngeal tension reduction)
What is it? Circular motion over
Tips of major horns of the hyoid bone Thyrohyoid space Posterior border of the thyroid cartilage Medial and lateral suprahyoid muscles
SPPA 6400 Voice Disorders Tasko
Circumlaryngeal massage (manual laryngeal tension reduction)
What is it? Locate sites of focal tenderness, nodularity and tautness Progress from superficial to deep pressure Vary pressure according to patient tolerance Patient must vocalize concurrently Progressively increase complexity of voice stimuli
SPPA 6400 Voice Disorders Tasko
Indications for improvement (single session)
Improved voice quality Pain reduction/relief Normalized laryngeal height and mobility Reduced muscle nodularity
SPPA 6400 Voice Disorders Tasko
Factors affecting management of MTD using
MCT Patient based factors Motivation Duration and severity of dysphonia Persisting psychological issues Primary and secondary gain, litigation etc…
SPPA 6400 Voice Disorders Tasko
Clinician based factors Technical skill Clinician-patient dynamic Communicate expectations
and confidence in procedure Pt learns by doing (avoid
discussion) Brisk therapeutic “pace” Engage pt in process Confront pt when effort ↓ Reinforce improvement
Expect successive approximations to a normal voice
Variety of facilitating techniques
Know when to abandon a technique or stick with it
Establish that patient is responsible for change
May employ ‘negative’ practice
SPPA 6400 Voice Disorders Tasko
Manual Circumlaryngeal Techniques
Evidence for clinical utility of MCT in Functional dysphonia (muscle tension
dysphonia) Roy et al. (1997) J Voice
SPPA 6400 Voice Disorders Tasko
Short and long term effects of MCT
N=25 Some improvement following Tx (96%) Normal or only mildly dysphonic following Tx
(64 %) Deterioration of voice at follow up (25 %) Improvement of voice at follow up (17 %)
SPPA 6400 Voice Disorders Tasko
Short and long term effects of MCT
What about relapse? 68 % report some evidence of recurrence of some
dysphonic symptoms Recurrence is partial rather than complete Occurs within 3 mos. following initial treatment Less than 4 days in duration, self limiting (i.e.
resolves spontaneously)
SPPA 6400 Voice Disorders Tasko
Concomitant MTD & Organic/Neurogenic Dysphonia
Elevated laryngeal musculoskeletal tension may co-occur in patients with documented laryngeal pathology
Why? Cause, Effect, Complication MCT have diagnostic & treatment utility with
these populations
SPPA 6400 Voice Disorders Tasko
Manual Assessment of Laryngeal Musculoskeletal Tension
“All patients with voice disorders, regardless of etiology should be tested for excess musculoskeletal tension, either as a primary or secondary cause of dysphonia” (Aronson, 1990)
SPPA 6400 Voice Disorders Tasko
Examples
Polyp
CVA
Reinke’s edema
Pre-MCT Post-MCT
SPPA 6400 Voice Disorders Tasko
MCT with BMD Patients
N=18 Gender
83% female 17% male
Age Mean: 44.1 years SD: 13 years
Dysphonia Duration Mean: 2.27 years SD: 3.64 years
4/18 bilateral nodules 2/18 unilateral nodule 2/18 unilateral polyp 2/18 Reinke’s edema 5/18 TVF
irregularities/edema/erythema
1/18 ventricular cyst 1/18 interarytenoid lesion 1/18 post-intubation
granuloma
(Tasko, et al. 1994)
SPPA 6400 Voice Disorders Tasko
SPPA 6400 Voice Disorders Tasko
Topical Lidocaine (J Voice (2000))Use of topical lidocaine in the treatment of muscle tension dysphonia.
Dworkin JP, Meleca RJ, Simpson ML, Garfield I.
Department of Otolaryngology, Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan 48201, USA. [email protected]
This investigation explored the potential usefulness of topical lidocaine in the treatment of muscle tension dysphonia. Three patients with this disorder, who were previously unresponsive to standard voice therapy, were treated with lidocaine. In each case, the outcome was prompt, clinically significant, and sustained. Persistently high-pitched and shrill vocal quality was converted to near normal voice patterns within 15 minutes after transcricothyroid membrane lidocaine injection. We suggest that this temporary and simple laryngeal and tracheal anesthetic technique may have helped to break the perverse cycle of hyperactive glottal and supraglottal muscle contractions evident in each of these patients during phonation efforts. We discuss the possible sensorimotor mechanism of action of this therapeutic technique.
SPPA 6400 Voice Disorders Tasko
Atypical Presentation (video)
SPPA 6400 Voice Disorders Tasko
Psychological/Personality factors & MTD
Issues State vs. Trait Factors Psychological Factors in Disease:
Cause, Effect or Catalyst
SPPA 6400 Voice Disorders Tasko
Psychological/Personality factors & MTD
Empirical findings in a group with MTD Neuroticism - ↓ emotional stability and ↑ reactivity
↑ scores Extraversion-sociability, dominance, energy and
enthusiasm ↓ scores
Psychoticism – impulsivity/aggressiveness (high) vs. agreeable/conscientiousness (low) Similar to normal controls
Roy et al. (2000)
SPPA 6400 Voice Disorders Tasko
Psychological/Personality factors associated with MTD
Additionally, Anxious Somatization – physical complaints Stress reactive Alienated Unhappy
Roy et al. (1997)
SPPA 6400 Voice Disorders Tasko
MTD compared to Vocal Nodule Patients
Empirical findings in a group with vocal nodules Neuroticism - ↓ emotional stability and ↑ reactivity
Mildly ↑ scores Extraversion-sociability, dominance, energy and
enthusiasm ↑ scores
Psychoticism – impulsivity/aggressiveness (high) vs. agreeable/conscientiousness (low) ↑ scores
Roy et al. (2000)
SPPA 6400 Voice Disorders Tasko
Functional Dysphonia
When no structural abnormality exists, descriptive terms are often used which imply a psychological etiology. For example,
Psychogenic dysphonia Conversion dysphonia Hysterical dysphonia
SPPA 6400 Voice Disorders Tasko
What is “hysterical conversion”? “conversion” of psychological stress into physical
complaints
Psychiatric literature suggests it arises from Bland emotional unconcern/affect Numerous physical complaints Denial of anxieties and fears
SPPA 6400 Voice Disorders Tasko
Is MTD a “hysterical conversion”? This triad of features was not observed with
patients with broad diagnosis of FD (MTD) Patients are typically quite anxious and
concerned about problem Short answer: No