MSD: Lec- 5 Muscle Tension Dysphonia

• Muscle tension dysphonia (MTD) is a voice change caused by muscle tension. Around 40-70% of
people with a voice disorder have MTD.
• MTD is known by many other names, including hyper functional dysphonia, spastic dysphonia, and
psychogenic dysphonia.
Types Of Muscle Tension Dysphonia
There are 2 main types of muscle tension dysphonia:
• Primary muscle tension dysphonia is when there is a voice disorder or dysphonia without the
presence of a neurologic or structural abnormality.
• Secondary muscle tension dysphonia is when MTD co-occurs with another laryngeal disorder or
abnormality for example, a patient may have vocal nodules and then develop MTD as a result.
Vocal Characteristics Of Muscle Tension Dysphonia
• Patients with MTD may exhibit a variety of vocal characteristics, including:
• Weak voice
• Decreased vocal range when speaking
• Lower pitch when speaking
• Harsh or constricted voice
• Tension of the voice
• Glottal fry or hard glottal attacks
• Breathiness
• Monopitch
• Pitch breaks
• A double voice (“diplophonia”)
• Periods of no voice (“aphonia”;
• Excessive force of the voice, such as yelling, whispering frequently, straining, and too much vocal cord
tension
• Lifestyle habits such as smoking. Or speaking excessively, too loudly, or in too low or too high of a
pitch.
• Stress, including anxiety and depression, can cause tension in breathing, the neck, shoulders, and/or the
larynx
• Health issues such as acid reflux, allergies, or respiratory infections
Muscle Tension Dysphonia Exercises and Treatment
Voice therapy works for many patients with muscle tension dysphonia! Here are 9 evidence-based exercises and
treatment strategies.
1. Manual Therapy
2. Circum-laryngeal Massage
3. Vocal Function Exercises
4. Stretch And Flow Phonation
5. Semi-Occluded Vocal Tract (SOVT) Exercises.
6. Resonant Voice Therapy Exercises
7. Conversation Training Therapy
8. Vocal Hygiene Education
9. Reduce Postural Tension
 1. Manual Therapy
• Manual therapy can help patients with laryngeal tension reposition and relax the larynx and surrounding
structures (Stemple et al., 2018). There are 3 primary maneuvers:
• Push-back maneuver. Gently apply the pointer finger on the thyroid cartilage. Gently push back on the
thyroid cartilage to change the shape of the glottis.
• Pull-down maneuver. Find the space between the thyroid notch (Adam’s apple) and the hyoid bone.
Gently place your thumb and pointer finger and pull the larynx down.
• Medial compression and downward traction. Place your thumb and pointer finger gently on the space
between the thyroid notch (Adam’s apple) and hyoid bone. Gently pull the larynx down while also
squeezing to apply medial compression.
2. Circum-laryngeal Massage
Circum-laryngeal massage is a form of manual therapy that can stretch and relax muscle tissue and fascia,
increase circulation, and reduce pain and discomfort. It’s been shown to improve symptoms of muscle
tension dysphonia long-term (Dehqan & Scherer, 2019).
• Have your patient hum
▫ Ask your patient to hum while you perform the massage.
▫ You’ll listen for changes in pitch, loudness, and vocal quality as feedback.
• Massage the hyoid bone:
▫ Place your thumb and pointer finger on either side of the hyoid bone.
▫ Apply gentle, circular pressure and gently move the hyoid bone side to side.
▫ Your patient will continue to hum as you massage.
• Find the thyroid notch:
▫ Next, find and apply gentle circular pressure on either side of the thyroid notch. Your patient will
continue humming.
▫ Repeat, starting on each posterior (back) border of the thyroid cartilage as the patient hums.
▫ Repeat and apply pressure down toward the inferior border as your patient hums. Move the
thyroid cartilage laterally as your patient hums. Note the placement and amount of pressure that
improves your patient’s voice (vocal quality, effort, and range).
3. Vocal Function Exercises
• Vocal function exercises are a set of four exercises designed by Joseph Stemple to help people regain
healthy vocal function.
• Before teaching the exercises, remind your patient to take big breaths and use good posture with a
forward focus.
• A forward focus means using a voice that resonates forward, toward the front of the face. Teach patients
to feel vibrations at the front of their face (lips, nose). Model good posture, breathing, and airflow when
speaking.
• Instruct your patient to complete the following.
• Warm up. “Say the sound /i/ as long as possible (on a comfortable note).” Repeat 2 times.
• Stretch. “Glide from your lowest to highest comfortable sound on the sound /o/ as in the word ‘knoll’.”
Repeat 2 times.
• Contract. “Go from a comfortably highest sound to your lowest sound on the sound /o/ as in the word
‘knoll’.” Repeat 2 times.
• Power. “You will sustain 5 different musical notes (middle C, D, E, F, G) for as long as you can on the
sound /o/ as in the word ‘knoll’.” Repeat two times.
 4. Stretch And Flow Phonation
• Stretch and Flow is a hierarchical therapy first developed by Stone and Casteel that targets increased
airflow, easier phonation, and forward oral resonance. It is intended for patients with laryngeal tension
who hold back airflow.
• Instruct your patient to complete the following steps in order. Hold a tissue in front of a patient’s mouth
for helpful biofeedback about airflow!
• Airflow. Have your patient first work on releasing a slow breath with the vowel sound /u/ with only
airflow (no voicing). Watch the tissue to assess airflow.
• Voiceless sounds/speech with airflow. In this step, your patient will articulate speech with no voicing.
Have your patient breathe, “Who is Sue?” The focus is on the flow of the breath while articulating.
• Add voiced sounds/speech. Have your patient add in voicing while easily sighing, “Who is Sue?” while
still focusing on the forward movement of airflow.
• Stretch with pitch change. Have your patient say, “Who is Sue?” while stretching the sounds with
more pitch variations, still focusing on airflow.
• Reduce stretch. Have your patient say, “Who is Sue?” using more natural pitch variation, yet still
focusing on airflow.
• Reduce flow. Finally, have your patient produce, “Who is Sue?” in a more functional voice. The sound
of their voice should still have a forward focus with good airflow.
5. Semi-Occluded Vocal Tract (SOVT) Exercises
• Semi-occluded vocal tract exercises aim to improve vocal quality by decreasing vocal fold stress. They
do this by partially occluding (rounding) at the lips to improve supraglottal pressure (Gillepsie, n.d.).
• Imagine a reverse megaphone with an open throat and a small, rounded mouth. Have patients focus on
feeling the vibrations at the lips and keeping an open throat.
• SOVT exercises may be best used as a vocal warm-up rather than for carryover into everyday speech.
• Straw phonation. Put a straw in your mouth. Close your lips gently around the straw and puff air into
the cheeks, making an /u/ or ‘ooo’ sound, feeling the vibration in the face.
• Straw singing. Sing through a straw with your lips end at the edge of the straw.
• Straw bubbles. Use the straw to blow bubbles in a cup of water. Continue by blowing bubbles while
making an “oo” or voicing sound (Gillepsie, n.d.).
• Lip and tongue trill.
• Small card or Post-it® note. Hold up the card perpendicular to the lips (but not touching the lips) and
ask the patient to glide up and down in a comfortable range. The card will ‘buzz’ as auditory
biofeedback that they are doing the exercise correctly. This can be helpful for patient who can’t sustain a
lip or tongue trill (Rosenberg, 2014).
6. Resonant Voice Therapy Exercises
• A resonant voice feels like vibrations at the front of the face (lips, nose, cheeks) with a focus on easy
phonation. Easy phonation is voicing and articulation that feels minimally effortful and free of tension.
• Some common resonant voice therapy exercises include:
• Chanting
• Humming
• Lip trills
• Forward/oral focus
• Nasal consonant exercises /m/, /n/, /ng/
 7. Conversation Training Therapy
• It aims to generalize the gains of voice therapy into patients’ everyday lives. CTT does this by keeping
treatment short and functional and by following the principles of motor learning.
• During CTT, the clinician focuses on:
• Clear speech
• Increasing the patient’s sensory awareness of their voice
• Negative practice (switching between their “old” and “new” voice to compare)
• Basic training gestures
• Prosody
8. Vocal Hygiene Education
Key Principles of Vocal Hygiene:

9. Hydration: Drinking plenty of water helps keep the vocal cords lubricated and prevents them from becoming dry and
strained.
10. Vocal Rest: Allowing your voice to rest, especially when tired or strained, is crucial for recovery.
11. Avoid Vocal Abuse: Refrain from yelling, screaming, or using your voice excessively, especially when you are sick or have a
cold.
12. Proper Breathing: Practice good breathing techniques to support vocal production and reduce strain.
13. Avoid Throat Clearing: Instead of clearing your throat forcefully, try to sip water or gently cough.
14. Limit Caffeine and Alcohol: These can dehydrate the body and negatively impact vocal cords.
15. Stay Away from Irritants: Avoid smoking, exposure to smoke, and other irritants that can damage the vocal cords.
16. Warm-Up and Cool-Down: Perform vocal warm-ups before speaking or singing and cool-downs afterward to prepare and
protect your vocal cords.
17. Seek Professional Help: If you experience persistent vocal problems, consult a speech-language pathologist or a doctor
specializing in voice disorders.
18. Be Mindful of Your Body: Pay attention to how your voice feels and take breaks when needed.
19. Use Your Voice Wisely: Avoid using the extremes of your vocal range, such as screaming or whispering.
20. Consider Using Amplification: When necessary, use a microphone or other amplification systems to project your voice
without straining your vocal cords.
21. Take Breaks Between Speaking: If you have a job that requires a lot of talking, take regular breaks to allow your voice to
rest.
22. Practice Proper Breathing Techniques: When singing or talking, practice good breathing techniques to support vocal
production and reduce strain.
23. Avoid Cradling the Phone: This can put pressure on the vocal cords.

9. Reduce Postural Tension

• Shoulder Rolls: Roll your shoulders forward and backward.
• Neck Stretches: Gently turn your head from side to side, and tilt your head towards your shoulders.
• Chest Stretches: Reach your arms behind your back and gently pull them towards each other.

Breathing disorders are cause of voice disorders

• Respiratory diseases can be broadly divided into obstructive and restrictive. However, but most patient
have components of both.
• Obstructive diseases include conditions in which there is a resistance to airflow either through
reversible factors or through irreversible factors.
• Restrictive diseases are characterized by reduced lung compliance leading to the loss of lung volume.
Introduction About Respiratory Tract
• Respiration means breathing. In this you will learn about the respiratory tract, also called the
respiratory system.
 • This is the passage that air goes through as we breathe in and out.
• The respiratory tract contains these important parts:
The Upper Respiratory Tract
• Nose—warms the air breathed and filters out bacteria and debris. Nasal breathing is important for best
lung function.
• Sinuses—cavities (holes) in the skull. They connect to the nasal passage and are lined with nasal tissue.
• Pharynx—passageway that conducts air from the nose to the voice box. The pharynx also conducts food
from the mouth to the esophagus, the tube that leads to the stomach.
• Epiglottis—flap that covers the entrance to the voice box when we swallow. It prevents food and liquids
from getting into the lungs.
• Larynx—the voice box, located between the pharynx and the windpipe (trachea).
• Trachea—windpipe. This is the airway connecting the larynx to the tubes leading to the lungs (bronchi).
The Lower Respiratory Tract
• Bronchi—two tubes that lead from the trachea to the lungs. The bronchi divide into many smaller
airways, called bronchioles.
• Lungs—pair of large spongy organs that take oxygen out of the air we breathe and exchange it for
carbon dioxide in our blood.
• Alveoli—millions of tiny air sacs in the lungs, surrounded by tiny blood vessels called capillaries. This
is where the exchange of oxygen and carbon dioxide takes place. These sacs look like bunches of grapes.
• Pleura—a membrane that covers the lungs and helps them move freely.

Respiratory System and Voice Production

• The respiratory system provides the airflow (breath) that powers voice production. When there are
issues with breathing, it can disrupt the airflow and affect the way the vocal cords vibrate, leading to
voice problems
Examples of Breathing Disorders that can Affect Voice
• Asthma: Asthma can cause inflammation and narrowing of the airways, making it difficult to breathe
and potentially leading to a strained or hoarse voice.
• Vocal Cord Dysfunction (VCD): VCD is a condition where the vocal cords close abnormally during
breathing, causing difficulty breathing and potentially leading to a breathy or weak voice.
• Vocal Fold Paralysis: Paralysis of the vocal folds (vocal cords) can result in a breathy, hoarse, or weak
voice, and may also cause breathing difficulties.
• Laryngitis: Inflammation of the larynx (voice box) can cause hoarseness or loss of voice, often due to
viral infections or other irritants.
• Laryngopharyngeal Reflux (LPR): Acid reflux into the larynx can irritate the vocal cords, leading to
hoarseness, throat clearing, and other voice problems.
• Both asthma and vocal cord dysfunction can make breathing difficult. Signs and symptoms of either
condition can include coughing, wheezing, throat tightness and hoarseness, but they're two separate
disorders.
• Vocal cord dysfunction is the abnormal closing of the vocal cords when you breathe in or out. It's also
called laryngeal dysfunction, paradoxical vocal cord movement disorder or paradoxical vocal fold
motion. Like asthma, vocal cord dysfunction can be triggered by breathing in lung irritants, having an
upper respiratory infection or exercising. However, unlike asthma, vocal cord dysfunction isn't an
immune system reaction and doesn't involve the lower airways. Commonly
• Voice therapy, specifically respiratory retraining, is a crucial part of managing Vocal Cord Dysfunction
(VCD), also known as Paradoxical Vocal Fold Movement (PVFM), helping individuals regain control
over breathing and vocal fold function.
• Respiratory retraining: Learning to breathe using abdominal muscles and maintaining a relaxed throat
during breathing.
• Identifying and controlling triggers:
• Understanding what situations or activities trigger VCD episodes and developing strategies to manage
them.
• Relaxation techniques: Learning to relax the throat muscles and reduce tension, which can worsen
VCD symptoms.
• Breathing exercises: Practicing specific breathing exercises to improve airflow and vocal cord
function.
• Quick-release techniques: Learning techniques to rapidly release the vocal folds from the paradoxical
movement during an episode.
• Sniff-breath: Inhaling quickly through the nose, followed by a slow, controlled exhalation through
pursed lips.
• Pursed-lip breathing: Exhaling slowly through pursed lips, which helps to create a gentle pressure in
the airway.
• Abdominal breathing: Focusing on breathing from the lower abdomen to improve lung capacity and
reduce tension in the upper chest and throat.
• Nasal inspiration with pursed-lip exhalation:
• Breathing in through the nose and exhaling through pursed lips.
• Breathing through a large-diameter straw or cut endotracheal tube:
• These techniques can help to improve airflow and vocal cord function.
• Panting: A quick, shallow breathing pattern that can help to relieve tension and improve airflow.
• Beyond Breathing Exercises:
• Identifying and managing triggers:
• Working with the SLP to identify and avoid or manage triggers that can worsen VCD symptoms.
• Upper body stretches and relaxation:
• Addressing any upper body tension that may be contributing to breathing difficulties.
• Psychological support:
• In some cases, psychological counseling may be beneficial for individuals with VCD, especially if
there's an underlying psychological component.
• Laryngeal control therapy:
• This therapy focuses on retraining the larynx to function correctly during breathing and speaking.
 MSD- LEC 6 Neurogenic Voice Disorders
Review of the Nervous System
◼ Review your motor speech and anatomy/physiology notes.
◼ Neurotransmitter issues in the CNS can cause hypo- and hyperkinetic dysarthria.
◼ Spasticity of vocal folds results from UMN lesions
◼ Flaccidity of VFs and VF paralysis result from LMN lesions
◼ The PNS cranial nerves can have an effect on the voice if they are damaged:
 IX (Glossopharyngeal)—taste, sensation, innervation of pharynx
 X (Vagus)—SLN and RLN branches affect sensory and motor systems related to the pharynx,
larynx, and respiratory structures
 XI (Spinal Accessory)—resonance/respiration
 XII (Hypoglossal)—resonance and quality of the voice; positioning of the larynx and tongue
SLN and RLN
◼ SLN innervates the cricothyroid muscles. Recall that CT
contraction lengthens the VFs and increases pitch and contribute
to VF adduction.
◼ RLN innervates the thyroarytenoid, lateral cricoarytenoid,
transverse/oblique arytenoids, and the posterior cricoarytenoid muscles.
INTRODUCTION
organic voice disorders that result from problems with the central
or peripheral nervous system innervation to the larynx that affect
functioning of the vocal mechanism, such as. vocal tremor, spasmodic
dysphonia, or. vocal fold paralysis
Etiology
◼ Neurogenic voice disorders are caused by brain/nervous system damage or malfunction as it
interacts with the larynx. Sometimes your nerves can become damaged during common surgeries and
cause a lack of movement or weakness in the vocal fold.
Neurogenic Voice Disorders
1. Vocal Fold Paralysis
▪ Unilateral vocal fold paralysis
▪ Bilateral Vocal fold paralysis
Spasmodic Dysphonia
3. Essential voice tremor
4. Differential disorder’s
▪ CVA/ stroke
▪ TBI
▪ MG
▪ ALS
▪ Parkinson’s disease
Vocal Fold Paralysis
◼ Vocal cord paralysis is a condition in which you can't control the movement of the muscles that
control your voice. It happens when the nerve impulses to your voice box (larynx) are disrupted. This
results in paralysis of the vocal cord muscles. Vocal cord paralysis can make it hard to speak and even
breathe.
Unilateral vocal fold paralysis (one-sided)
Unilateral vocal fold paralysis is when only one-fold will not move or only moves a little bit. It is more
common than bilateral paralysis. The paralyzed vocal fold does not vibrate with the other fold. The person’s
voice will not sound clear or loud. They may run out of air when speaking.
Bilateral vocal fold paralysis (both sides)
Bilateral vocal fold paralysis means that both vocal folds will not move. People with this condition may need a
tracheotomy if the vocal folds are close to a closed position which interferes with breathing. A tracheotomy is
an opening made in the neck. They breathe through this opening.
Signs of Vocal Fold Paralysis
Vocal fold paralysis can cause problems that are mild or severe. Some signs include:
◼ Hoarseness
◼ Breathy voice
◼ Being unable to speak loudly
◼ Limited pitch and loudness
◼ Being able to produce voice for a very short time
◼ Choking or coughing while eating
◼ Possible pneumonia if food and liquid get into the lungs. This may happen if the vocal folds cannot
close to protect the airway while swallowing.
Causes
◼ In vocal cord paralysis, the nerve impulses to your voice box (larynx) are disrupted, causing paralysis of
the muscle. Health care providers often can't determine the exact cause of vocal cord paralysis. But some
known causes may include:
◼ Injury to the vocal cord during surgery. Surgery on or near the neck or upper chest can result in
damage to the nerves that serve the voice box. Surgeries that carry a risk of damage include surgeries to
the thyroid or parathyroid glands, esophagus, neck, and chest.
◼ Neck or chest injury. Trauma to the neck or chest may injure the nerves that serve the vocal cords or
the voice box itself.
◼ Stroke. A stroke interrupts blood flow in the brain and may damage the part of the brain that sends
messages to the voice box.
◼ Tumors. Tumors, both cancerous and noncancerous, can grow in or around the muscles, cartilage or
nerves controlling the function of the voice box and can cause vocal cord paralysis.
◼ Infections
Some infections, such as lyme disease, viral infections can cause inflammation and directly damage the nerves
in the voice box.
COVID-19 may cause vocal cord paralysis.
◼ Neurological conditions
Certain neurological conditions, such as multiple sclerosis or Parkinson's disease, can lead to vocal cord
paralysis.
Spasmodic Dysphonia
◼ Spasmodic dysphonia, also known as laryngeal dystonia, is a neurologic disorder that can affect the
voice and speech.
◼ It is a lifelong condition that causes the muscles that generate a person’s voice to go into periods of
spasm. In some cases, the disorder is temporary or can be improved through treatment. Spasmodic
dysphonia most commonly begins when an adult reaches middle age. Women are affected more often
than men.
 Causes of Spasmodic Dysphonia?
◼ Surgery
◼ Virus
◼ Inflammatory Illness
◼ Lesions
◼ Neurologic conditions such as
◼ multiple sclerosis or
◼ Parkinson’s disease
Symptoms of Spasmodic Dysphonia
◼ A person with dysphonia may experience:
◼ Breaks or interruptions in speech, often every few sentences
◼ A hoarse, grating voice that can also sound strained or strangled or hoarse and breathy.
◼ Odd sounding speech that is difficult to understand
◼ Gradual or sudden difficulty speaking
◼ The problem may go away when the person laughs, whispers, speaks in a high-pitched voice, sings, or
shouts
Essential Tremor of the Voice
◼ vocal tremor is a neurologic voice condition characterized by involuntary rhythmic movements of the
vocal folds during speech, resulting in a "shaky" voice quality.
Causes of EVT
◼ There is no known underlying condition that triggers the onset of this neurologic voice condition. Vocal
tremor can affect patients of any age, but most commonly affects people beginning in their 50s or 60s.
Dysarthria [AP2(R)]
◼ Flaccid
◼ Unilateral upper motor neuron
◼ Spastic
◼ Ataxic
◼ Hypokinetic
◼ Hyperkinetic
◼ Mixed
Flaccid Dysarthria
Disorder Cause Effects Treatment

Bilateral vocal fold Lesions to Vagus nerve VFs paralyzed in Medical and/or surgical
paralysis adducted or abducted
position

Unilateral vocal fold Surgical trauma to left Aphonia, monotone, Voice therapy; perhaps surgery
paralysis RLN, also viral hoarse/breathy voice,
infections, smoking pitch breaks, vocal
hyperfunction

Cricothyroid Viral infection of SLN Difficulty with pitch Resolves in time; voice therapy helps
paralysis change; breathiness
 Myasthenia Gravis Antibodies block Dysphonia and voice Medical. SLP may recognize symptoms
acetylcholine from fatigue; weakness and refer; could monitor symptoms
binding to muscles increases with use

Guillain-Barre Body’s immune Possibly dysarthric Focus on clear speech and safe
Syndrome system attacks nerves speech and weak voice swallowing

Unilateral Upper Motor Neuron Dysarthria

◼ Often due to unilateral lesions in the CNS, caused by CVAs, tumors, or trauma.
◼ Symptoms include a harsh, strained voice that may be accompanied by reduced loudness.
◼ Good breath support is an essential form of voice therapy for these patients.
Hypokinetic Dysarthria
◼ Occurs when there is not enough dopamine to regulate basal ganglia functioning = Parkinson’s disease.
◼ Physical manifestations include rigidity, bradykinesia, limited range of motion, and tremor.
◼ Voice symptoms include decreased loudness, breathy voice, monotone, rapid rushes of speech, and
soft/imprecise consonants.
◼ Bowed vocal folds accompanied by respiration difficulties may accompany voice symptoms.
◼ Treatments include the Lee Silverman Voice Treatment program for increased loudness, quality, and
intelligibility. The Pitch Limiting Voice Treatment also has good results.
Hyperkinetic Dysarthria
Disorder Cause Effects Treatment

Huntington’s Overabundance of Jerky, irregular bursts of loud voice; Behavioral voice therapy in
Disease dopamine strained/strangled voice; early stages (slower speech
Monopitch; poor breath control. and easier voice production)

Adductor Spasmodic Generally Strained, tight voice produced when Vocal hygiene therapy,
Dysphonia neurogenic VFs (true and sometimes false) including easy voice
adduct during phonation production); Botox injections

Abductor Spasmodic Generally Intermittent aphonia Botox, possible voice therapy

Dysphonia neurogenic
Essential tremor Neurogenic Alternating changes in pitch; shaky Behavioral voice therapy-talk
voice quality less loudly with a higher pitch
and shortened vowel duration
Mixed Dysarthria
❑ Amyotrophic Lateral Sclerosis (ALS) and Multiple Sclerosis (MS) are examples.
❑ A hoarse voice due to hyper function is typical of both of these disorders. Breath support and easy onset
of voice is recommended.
❑ Voice symptoms associated with Traumatic Brain Injuries (TBIs) are typically treated behaviorally.