Original ArticleCurrent and Emerging Concepts in Muscle Tension Dysphonia: A 30-Month Review
Introduction
Voice literature has long recognized functional dysphonia as an umbrella diagnosis for impairment of voice production in the absence of structural change or neurogenic disease of the larynx. Muscle tension dysphonia (MTD) semantically lies within the bounds of functional dysphonia, although it has only occasionally been investigated as a distinct entity in the spectrum of functional voice disorders, despite its widely accepted clinical presence. Early mention is made of voice disorders stemming from apparent increased laryngeal tension and poor habits of phonation,1 and terms such as “myasthenia laryngis”2 and “psychophonasthenia”3 have been suggested. Several authors have more recently proposed categorization schemes for the range of underlying behaviors in functional dysphonia, which include an MTD classification.4, 5, 6
Delineation of MTD from functional dysphonia has been suggested based on history, laryngoscopic, perceptual-acoustic, musculoskeletal, and psychological features.7 These data suggested that key features of MTD include posterior glottal chink, mucosal vocal cord changes, larynx rise, suprahyoid muscle tension, breathiness, glottal fry, glottal attack, and stridency.7, 8 Along with classification schemes, authors have suggested myriad titles for MTD in the literature (Table 1), suggesting various underlying etiologies and characteristics. This is curiously analogous to the modern theory of hoarseness, where there are multifactorial etiologies contributing to the voice problem. The hypothesis of this study is that muscle tension dysphonia is multifactorial with various contributing etiologies. Results of this retrospective chart review are put into the context of the present understanding of MTD with a thorough review of the literature.
Section snippets
Methods
This project was approved by the Northwestern University Institutional Review Board Human Subjects Committee and preceded the need for Health Insurance Portability and Accountability Act (HIPAA) compliance. A retrospective chart review was performed of all patients seen in the Voice Speech and Language Service and Swallowing Center at Northwestern Memorial Hospital with a diagnosis of muscle tension (functional hypertensive) dysphonia over a 30-month period from January 1, 2000 through June 30,
Results
One hundred fifty subjects were identified, 94 female (63%) and 56 male (37%). The median age was 42.3 years, with a female median age of 41.7 and a male median age of 44.7. Pertinent voice complaints on initial presentation are summarized in Table 2. The most common complaints were hoarseness 83%, vocal fatigue 26%, vocal strain 23%, and pain related to phonation 17%. Pertinent medical history of these subjects is summarized in Table 3. Notably, a prior history of gastroesophageal (or
Discussion
It is clear that muscle tension dysphonia in these patients was multifactorial in nature with respect to underlying etiology and contributing factors. Common clinical features of MTD in our series was consistent with well-known qualities of this disorder, including poor control of the breath stream, an abnormally low-pitched speaking voice,9 and increased frequency of hard glottal attacks,10 and possible increased prevalence in female patients. Multifactorial contributions leading to functional
Conclusions
There are many contributing factors leading to MTD, with multifactorial etiologies in many patients. Our results and review of the literature indicate that MTD is not a solitary disease or dysfunction and that it is interrelated with comorbid conditions, such as medical/neoplastic/movement issues affecting the larynx, voice use demands, and personality/ behavior issues. A significant portion of MTD appears to be an unconscious attempt to compensate for conditions that result in suboptimal
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Presented at the Annual Meeting of the Voice Foundation, Philadelphia, PA, June 6, 2003.