Classification and approach to patients with functional voice disorders

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

OBJECTIVE

To investigate the risk of fibromyalgia in patients with primary muscle tension dysphonia (MTD) in comparison to subjects with no dysphonia.

STUDY DESIGN

Prospective cohort study.

METHODS

The medical records and video recordings of all patients presenting to the Voice and Swallowing unit at a tertiary referral center between October 2022 and October 2023 and who were diagnosed with primary MTD were prospectively reviewed. The risk of fibromyalgia was assessed using the "Fibromyalgia Rapid Screening Tool" (FiRST). Demographic data included age, gender, history of smoking, and history of high vocal load. The impact of dysphonia on quality of life was also analyzed using the Voice Handicap Index-10 (VHI-10).

RESULTS

A total of 42 patients who had filled the FiRST questionnaire were enrolled in this study. These included 20 patients diagnosed with primary MTD and 22 healthy subjects with no history of dysphonia and normal laryngeal examination. Forty percent of the study group tested positive using the FiRST questionnaire as compared to only 9.1% in the control group. The difference between the two groups was statistically significant (P = 0.03). The risk of having fibromyalgia was 6.67 times among patients with primary MTD in comparison to controls (RR=6.67; 95% CI [1.21-36.74]).

CONCLUSION

The results of this investigation indicate that the risk of fibromyalgia is significantly higher in patients with primary MTD vs controls. A holistic approach in the diagnosis and treatment of MTD is advocated.

Development and Psychometric Evaluation of the Laryngeal Palpation Pain Scale (LPPS)

INTRODUCTION

One of the most important assessment and therapy methods for patients with muscle tension dysphonia (MTD) and other voice disorders is laryngeal palpation. However, there is no comprehensive scale for measuring pain during laryngeal palpation. The goal of the present study was to develop and validate a new scale to evaluate pain during palpation for patients with MTD.

METHODS

The present study consisted of two phases: (1) Development of the Laryngeal Palpation Pain Scale (LPPS) based on an in-depth literature review, the palpatory evaluation of MTD patients, interviews with experts in the field of voice disorders, and consultation with a registered pain expert, and (2) evaluation of the validity and reliability of the LPPS. The validity of the LPPS was investigated using qualitative and quantitative content validity, qualitative face validity, discriminant validity, and convergent validity. Content validity of the LPPS was assessed by experts' opinions (10 speech-language pathologists and five laryngologists), and face validity was investigated using the opinions of speech-language pathologists. The reliability of the LPPS was determined using test-retest and inter-rater reliability.

RESULTS

The item generation phase of the study led to the development of a scale to assess pain during palpation that included eleven locations in the neck region for palpatory assessment. These 11 items were divided into 13 different items (neck locations) based on the opinions of the experts. The content validity ratio values of all scale items were higher than 0.78. The content validity index (CVI) value for each of the items of the scale was higher than 0.79 and for the entire scale CVI (S-CVI) was 0.915. The results of the reliability of the LPPS items were satisfactory with weighted kappa values ranging from 0.655 to 1 for the test-retest and 0.77-1 for the inter-rater reliability. Convergent validity of the LPPS was shown with a significant positive correlation (r = 0.68) between the LPPS and the pain severity of vocal tract discomfort (P < 0.001). Moreover, MTD patients had more pain severity than the control group in all items of the LPPS (P < 0.05) except for the submental item (P = 0.89). These results indicate that the LPPS can differentiate MTD patients from healthy subjects. The final version of the LPPS includes 13 potential pain locations. The severity of pain at each of these locations is determined on a numeric pain rating scale of zero (no pain) to ten (the most severe pain).

CONCLUSION

The study showed that the LPPS is a valid and reliable scale to assess pain in MTD patients during palpation evaluations. More studies are recommended for further psychometric evaluation of the LPPS including responsiveness to change (the use in before-and-after intervention studies) and concurrent validity of the LPPS. The LPPS can be used for clinical and research purposes.

Characterization of Primary Muscle Tension Dysphonia Using Acoustic and Aerodynamic Voice Metrics

OBJECTIVES/HYPOTHESIS

The objectives of this study were to (1) identify optimal clusters of 15 standard acoustic and aerodynamic voice metrics recommended by the American Speech-Language-Hearing Association (ASHA) to improve characterization of patients with primary muscle tension dysphonia (pMTD) and (2) identify combinations of these 15 metrics that could differentiate pMTD from other types of voice disorders.

STUDY DESIGN

Retrospective multiparametric METHODS: Random forest modeling, independent t-tests, logistic regression, and affinity propagation clustering were implemented on a retrospective dataset of 15 acoustic and aerodynamic metrics.

RESULTS

Ten percent of patients seen at the New York University (NYU) Voice Center over two years met the study criteria for pMTD (92 out of 983 patients), with 65 patients with pMTD and 701 of non-pMTD patients with complete data across all 15 acoustic and aerodynamic voice metrics. PCA plots and affinity propagation clustering demonstrated substantial overlap between the two groups on these parameters. The highest ranked parameters by level of importance with random forest models-(1) mean airflow during voicing (L/sec), (2) mean SPL during voicing (dB), (3) mean peak air pressure (cmH2O), (4) highest F0 (Hz), and (5) CPP mean vowel (dB)-accounted for only 65% of variance. T-tests showed three of these parameters-(1) CPP mean vowel (dB), (2) highest F0 (Hz), and (3) mean peak air pressure (cmH2O)-were statistically significant; however, the log2-fold change for each parameter was minimal.

CONCLUSION

Computational models and multivariate statistical testing on 15 acoustic and aerodynamic voice metrics were unable to adequately characterize pMTD and determine differences between the two groups (pMTD and non-pMTD). Further validation of these metrics is needed with voice elicitation tasks that target physiological challenges to the vocal system from baseline vocal acoustic and aerodynamic ouput. Future work should also place greater focus on validating metrics of physiological correlates (eg, neuromuscular processes, laryngeal-respiratory kinematics) across the vocal subsystems over traditional vocal output measures (eg, acoustics, aerodynamics) for patients with pMTD.

LEVEL OF EVIDENCE

II.

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

PURPOSE

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.

METHODS

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 100 mm visual analog scale.

RESULTS

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).

CONCLUSIONS

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.

Evaluation of the Effectiveness of Resonant Voice Therapy in Patients with Functional Voice Disorder

OBJECTIVE

This study aims to determine the effectiveness of resonant voice therapy (RVT) in patients with functional voice disorder and to examine the subjective and objective voice changes after the therapy.

STUDY DESIGN

This study adopted an experimental research design with a pretest-posttest control group.

METHOD

Thirty-four women participated in the study-17 in the experimental group and 17 in the control group. Voice hygiene training and RVT were applied to the experimental group. The Turkish version of the Voice Handicap Index (VHI-10) and GRBAS (Grade, Roughness, Breathiness, Asthenia, and Strain) scale were used for subjective voice assessment. Voice recordings were subjected to acoustic analysis on the PRAAT program. After an 8-week therapy program, the same process was repeated for post-test assessment.

RESULTS

In the voice analyses performed after RVT, which was applied to patients with functional voice disorders, the results of the acoustic analysis showed statistically significant differences in jitter, PPQ5, RAP, shimmer, APQ11, and NHR parameters. Subjective voice analysis indicated a statistically significant decrease in VHI-10 scores from 20.88 ± 5.33-9.06 ± 3.3 in the experimental group. The GRBAS score was 4.29 ± 1.2 before the therapy and 1.71 ± 1.1 after the therapy, which is a statistically significant decrease. The results point out that RVT has been effective in improving the objective and subjective parameters of patients with functional voice disorders.

CONCLUSION

RVT applied to patients with functional voice disorders provides significant improvement in acoustic and perceptual voice parameters. The RVT is an effective therapy method in the treatment of patients with functional voice disorders and should be considered as a therapeutic option.

Prevalence of Laryngeal Muscle Tension in Patients With Obstructive Sleep Apnea

OBJECTIVE/HYPOTHESIS

To determine the prevalence of laryngeal muscle tension in patients with obstructive sleep apnea (OSA).

STUDY DESIGN

Retrospective case-control.

METHODS

A total of 75 patients were included in this study. These were divided into a study group with a history of OSA (n = 45), and a control group with no history of OSA matched according to age and gender (n = 30). The risk of OSA was assessed using the STOP-BANG questionnaire. Demographic data included age, gender, body mass index, smoking, history of snoring, history of use of continuous positive airway pressure, and history of reflux disease. Symptoms such as hoarseness, throat clearing/cough, and globus sensation were also noted. The video recordings of the flexible nasopharyngoscopy of both groups were analyzed for the presence or absence of four laryngeal muscle tension patterns (MTPs).

RESULTS

Twenty-five patients of the study group (55.6%) had signs of laryngeal muscle tension on laryngeal endoscopy compared to nine in the control patients (30%) (P = 0.029). The most common MTP observed in the study group was MTP III (n = 19), followed by MTP II (n = 17). Laryngeal muscle tension was more prevalent in patients of the intermediate and high-risk categories compared to those of the low-risk category (73.3% and 62.5% vs 28.6%, respectively) (P = 0.042). Patients with at least one MTP had more dysphonia and throat clearing than patients without any MTP.

CONCLUSION

Patients with a history of OSA have a higher prevalence of laryngeal muscle tension in comparison to subjects with no history of OSA. Moreover, patients at high risk of OSA have a higher prevalence of laryngeal muscle tension than those at low risk of OSA.

Methods of Measuring Laryngeal Muscle Tension in Patients with Muscle Tension Dysphonia: A Scoping Review

BACKGROUND

In clinical practice and research relating to Muscle Tension Dysphonia (MTD), several laryngeal muscle tension measurement methods are used to diagnose, to identify specific muscle strengths and deficits, and to measure therapeutic outcomes. The variety and reliability of available measurement methods presents challenges within diagnosis and treatment. The lack of methodical standardization presents a barrier to homogeneous practice in this area. There is a need for a comprehensive scoping review of laryngeal muscle tension measurement methods.

STUDY DESIGN

Scoping review.

OBJECTIVES

(1) To identify current methods of laryngeal muscle measurement which have been developed or tested with people with MTD; and (2) To identify the construct/s measured, reliability, validity, ability to detect change, efficiency and accessibility of identified methods.

METHOD

This scoping review was conducted using the Arksey and O'Malley framework. Studies were identified through searches of 4 major databases. The reviewer independently assessed titles, abstracts, and full-text articles.

RESULTS

Twenty seven papers published from 2000 to 2022 that satisfied the inclusion criteria were selected from 194 studies. The papers showed a variety of approaches with regards to the measurement of laryngeal activity and tension in subjects with MTD. Just over a quarter (25.9%) were reviews of the validity of assessment methods of MTD, including surface electromyography (sEMG), while 22.2% discussed surface electromyography as a measurement of muscle activity in subjects with MTD. 96.3% used a published methodological framework.

CONCLUSIONS

Assessment methods for Primary MTD are multifaceted, including patient history, laryngoscopic examination, and voice-related musculoskeletal features. Potential use of objective measurement methods, including sEMG, Real Time Elastosonography, Magnetic Resonance Imaging was noted. Due to variability in assessment methods and results, there is a need for greater objective practical methodological standardization to ensure accurate diagnosis, appropriate care, and chart patient progress.

Effects of Virtual Teaching on Swedish Teachers' Voices During the COVID-19 Pandemic

PURPOSE

Since the beginning of 2020, teachers all over the world have had to switch over to virtual teaching because of the COVID-19 pandemic. This change of teaching mode has unknown consequences on the vocal health of teachers who already experience voice disorders at a rate nearly double that of the general population. Therefore, the purpose of this study is to investigate teachers' self-reported voice problems during virtual teaching compared to face-to-face teaching and how they are associated to perceived risk factors in the work environment.

METHOD

Participants included 141 teachers (49 males, 92 females) in high schools and higher education in Sweden who responded to an internet-based survey. Information was collected about participants' self-reported voice handicap using a translated version of the Voice Handicap Index-10 (VHI-10). Information about self-reported VTD (Vocal Tract Discomfort) symptoms and dysphonia was collected in regard to both modes of teaching (virtual vs face-to- face). The survey also included questions on risk factors related to vocal health.

RESULTS

Self-reported voice handicap and VTD symptoms were slightly lower during periods of virtual teaching compared to periods of face-to-face teaching. There was a lower frequency of dysphonia symptoms during virtual teaching compared to face-to- face teaching, however the difference was not statistically significant. In addition, 34% of teachers reported experiencing more voice problems when teaching face-to-face while 15% reported more voice problems when teaching virtually. The most reported VTD symptoms during both virtual and face-to-face teaching were having a dry and a tight throat. The dysphonia symptoms with the highest reported frequency were a tense voice and hoarseness in both modes of teaching. Risk factors associated with higher prevalence of voice symptoms and/or higher levels of voice handicap during virtual teaching were air quality and straining the voice while teaching face-to-face. In addition, those teachers who reported more voice problems while teaching virtually also reported feeling more stressed.

CONCLUSION

The results showed a slight decrease in voice symptoms and voice handicap during virtual teaching compared to face-to-face teaching. Although multifactorial, results suggest that a potential positive effect may be attributed to better air quality in the work environment and more favorable acoustic conditions preventing teachers from straining their voice.

The Use of Laryngeal Electromyography to Determine Surgical Success Following Anastomosis and Implantation Reinnervation Surgeries for Vocal Fold Paralysis: A Systematic Review

BACKGROUND

The goal of this systematic review is to elucidate an evidence-based review of the benefit of laryngeal electromyography (LEMG) in determining surgical success following reanastamosis and implantation reinnervation surgery for treating vocal fold paralysis.

METHODS

We searched the following databases: PubMed, Embase and MEDLINE from inception to September 2022. Articles that included postoperative LEMG as a tool to evaluate patients after surgery for vocal fold paralysis were included.

RESULTS

A total of 203 studies were identified, 106 were read in full, and 11 that met the inclusion criteria were systematically reviewed.

CONCLUSION

The available evidence suggests that postoperative LEMG data is consistent with visual, perceptual, and acoustic analysis and therefore is a reliable tool in determining surgical success. LEMG provides both qualitative and quantitative evaluation, rather than the qualitative evaluation provided by standard methods, which yields additional parameters that more effectively and definitively characterize percent of muscle reinnervation at each stage and timeline the patient's recovery.

Voice Disorder Classifications: A Scoping Review - Part A

Voice is a complex and multidimensional phenomenon of interest to different disciplines. Divergent terminologies and, consequently, classification systems constitute, historically, a difficulty in this field of knowledge, which limits communication between professionals from different countries, backgrounds, and clinical experiences, and well as limiting clinical management and discussion of scientific research findings. This article aims to map and analyze the different diagnostic classifications in voice by describing the findings of a scoping review, consisting of both electronic and manual searches. The results are presented in two parts. In Part A of this article, we explore propositions for comprehensive diagnostic classifications, which involve theoretical frameworks for the constitution of each proposal. The included studies were classified as either articles with theoretical propositions, called G1, or articles using automated computerized classification systems called G2. A total of 44 articles were included: 27 in G1 and 17 in G2. In G1, we found studies from 1947 to 2021, most of which were from the USA, the authors having created theoretical propositions on the subject, considering mainly the etiology of vocal disorder. In G2, we found studies from 2009 onwards, emphasizing automated extraction of acoustic measurements and machine learning to create classification systems. G1 shows the propositions of classifications ranging from two to 11 main groups, each with possible subgroups. In G2, the classifications ranged from four to seven groups, showing preference to distinguish them by descriptions of laryngeal conditions. Conclusion: There is limited convergence between the different theoretical classifications, which is highlighted by the need to create different subgroups, or categories, to include different vocal disorders. The studies with a computerized approach reduce this variability to a certain extent; however, although promising, they should consider theoretical foundations in the proposition of classifications to be applicable to clinical setting.

Muscle Tension Dysphonia: Experience from a Conflict Zone

We sought to explore the frequency of stress among OPD attending Kashmiri public diagnosed as muscle tension dysphonia (MTD) and determine the subjective consequences of voice therapy in management of muscle tension dysphonia. 72 subjects that attended to ENT and HNS OPD with change of voice were prospectively evaluated and also underwent an extensive otolaryngological examination. Patients identified as MTD were provided a questionnaire which was split into 3 parts: First part dealt with the identification of the subject (age, geography, gender, profession) and also provided evaluation of perceived anxiety using Perceived Stress Scale-10. In the next part the individuals needed to assess their vocal quality based on parameters of GRBAS 4-point score scale before and also after the treatment. In the final component the subjects also needed to answer the VHI-10 (Voice Handicap Index) and also the outcome was compared with those acquired at the assessment before the beginning of the treatment. The mean age of the cohort was 30.31 ± 07.43 (age range, 12-71) and every subject was an indigenous Kashmiri. As expected, vast majority of subjects were females (43 patients). In the pooled information set, women had numerically higher PSS-10 scores than males. For women, the typical stress score was M = 18.6 and for men the average stress score was M = 16.65. In a healthy population, the typical PSS stress score is described to be 13.7 (SD = 6.6) for women and 12.1 (SD = 5.9) for men. At the Wilcoxon test for paired data, we observed a significant difference between the VHI pretreatment (mean = 19.7) and VHI post-treatment, that's at time of the research (mean = 9.73; P = 0.017). The grade (G) was assessed in terms of improvement of the vocal quality as opposed with before treatment and also the individuals demonstrated a high level of satisfaction (mean = 0.65). When looking at roughness (R) as well as breathiness (B), the individuals remember that their speech is seldom rough (mean = 0.62) and also less breathy (median = 0.44). Patients likewise noted improvement in other variables of GRBAS scale. Stress is persistent, pervasive and nearly unavoidable in contemporary life. The decades old perplexing and mind baffling pandemonium hovering around the Kashmiri population has had a tremendous impression on the psychological development of people in this region. A careful conclusion is the fact that emotional stress might play a major role in the upkeep of MTD. MTD has to be approached in a multidisciplinary environment in which closer cooperation between a laryngologist, a speech language pathologist and also a psychologist is likely.

Integrative Review and Framework of Suggested Mechanisms in Primary Muscle Tension Dysphonia

PURPOSE

Despite the high prevalence of primary muscle tension dysphonia (MTD-1), its underlying mechanisms and their interrelationships have yet to be fully identified. The objectives of this integrative review were (a) to describe and classify the suggested underlying mechanisms for MTD-1, (b) to appraise the empirical evidence supporting each of the proposed mechanisms, and (c) to summarize the information in an integrative model.

METHOD

PubMed, Scopus, and CINAHL were searched for all publications pertaining to muscle tension dysphonia. Papers were retained if they included theoretical or empirical data pertaining to underlying mechanisms of MTD-1. A total of 921 papers initially qualified for screening, of which 100 remained for consideration in this review. Underlying mechanisms of MTD-1 were extracted using a consensus approach.

RESULTS

Seven broad categories of putative mechanisms involved in MTD-1 were identified: psychosocial, autonomic, sensorimotor, respiratory, postural, inflammatory, and neuromuscular. These categories were further divided into 19 subcategories detailed in the body of this review article. Based on the reviewed evidence, our proposed integrative model presents MTD-1 as an idiosyncratic motor adaptation to physiological perturbation or perceived threat. Under this model, physiologically or psychologically aversive stimuli can instigate a series of motor adaptations at multiple levels of the nervous system, ultimately disturbing muscle activation patterns and their biomechanical outcomes. Importantly, these adaptations appear to have the potential to become chronic even after threatening stimuli are withdrawn.

CONCLUSIONS

The proposed model highlights the importance of personalized rehabilitation in MTD-1 treatment. Limitations of the literature are discussed to provide guidance for future research aimed at improving our understanding of MTD-1.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19586065.

Frameworks, Terminology and Definitions Used for the Classification of Voice Disorders: A Scoping Review

BACKGROUND

A challenge for clinicians and researchers in laryngology is a lack of international consensus for an agreed framework to classify homogenous groups of voice disorders. Consistency in terminology and agreement in how conditions are classified will provide greater clarity for clinicians and researchers.

OBJECTIVE

This scoping review aimed to examine the published literature on frameworks, terminology, and criteria for the classification of voice disorders.

DESIGN

Seven online databases (MEDLINE, Embase, CINAHL, PsycInfo, Scopus, Cochrane Collaboration, Web of Science) and grey literature sources were searched. Studies published from 1940 to 2021 were included if they provided a descriptive detail of a classification framework structure and described the methodological approaches to determine classification. A narrative synthesis of the main concepts including terminology, classification criteria, grouping of conditions, critical appraisal items and gaps in research was undertaken.

RESULTS

A total of 2,675 publications were screened. Twenty sources met inclusion criteria, including published articles and grey literature. Thirty-five classification groups and over 150 sub-groups were described. The classification group labels, and criteria for inclusion of conditions varied across the frameworks. Several key themes in terminology and criteria useful for classification are discussed, and a core set of suggested terms and definitions are presented.

CONCLUSIONS

The quality of research on classification frameworks for voice disorders is low and not one system encompasses all voice disorders across the whole spectrum. Continued high quality research using consensus methodology and inter-rater reliability scores is recommended to develop and test an internationally agreed classification framework for voice disorders.

Correlation Between a Diagnosis of Anxiety or Depression and Initial VHI-10 Scores in Benign Dysphonia

OBJECTIVE

Anxiety and depression have demonstrated a positive correlation with vocal handicap among patients with benign causes of dysphonia. Our objective is to explore differences in initial Vocal Handicap Index-10 (VHI-10) scores between patients with a mental health history of anxiety or depression and those without.

STUDY DESIGN

Retrospective cohort study.

SETTING

Demographic data, diagnoses, and initial VHI-10 scores were collected for patients presenting with dysphonia to 2 tertiary laryngology clinics.

METHODS

A Kruskal-Wallis test and subsequent Mann-Whitney U test for pairwise comparisons were used to compare distribution of VHI-10 scores among patients with anxiety, depression, anxiety and depression, and no such conditions. Bonferroni correction was used to control for multiple comparisons. Robust regression was used for multivariable analysis.

RESULTS

A total of 620 cases of benign dysphonia were analyzed. Forty-two percent of the patient cohort had a preexisting diagnosis of anxiety (n = 121, 20%), depression (n = 64, 10%), or anxiety and depression (n = 74, 12%). VHI-10 scores were higher in patients with depression than in those without anxiety or depression (median difference, 4 [95% CI, 1-8]; P = .005) but did not differ significantly among the other groups. The effects of depression and anxiety status on initial VHI-10 scores among the causes of benign dysphonia varied.

CONCLUSIONS

Patients with a history of depression who presented with dysphonia had worse vocal handicap than those without anxiety/depression history. Future studies may clarify how optimization of anxiety and depression can affect patient-reported vocal handicap.

Impaired auditory discrimination and auditory-motor integration in hyperfunctional voice disorders

Hyperfunctional voice disorders (HVDs) are the most common class of voice disorders, consisting of diagnoses such as vocal fold nodules and muscle tension dysphonia. These speech production disorders result in effort, fatigue, pain, and even complete loss of voice. The mechanisms underlying HVDs are largely unknown. Here, the auditory-motor control of voice fundamental frequency (f_o) was examined in 62 speakers with and 62 speakers without HVDs. Due to the high prevalence of HVDs in singers, and the known impacts of singing experience on auditory-motor function, groups were matched for singing experience. Speakers completed three tasks, yielding: (1) auditory discrimination of voice f_o; (2) reflexive responses to sudden f_o shifts; and (3) adaptive responses to sustained f_o shifts. Compared to controls, and regardless of singing experience, individuals with HVDs showed: (1) worse auditory discrimination; (2) comparable reflexive responses; and (3) a greater frequency of atypical adaptive responses. Atypical adaptive responses were associated with poorer auditory discrimination, directly implicating auditory function in this motor disorder. These findings motivate a paradigm shift for understanding development and treatment of HVDs.

Functional Dystonia: Differentiation From Primary Dystonia and Multidisciplinary Treatments

Dystonia is a common movement disorder, involving sustained muscle contractions, often resulting in twisting and repetitive movements and abnormal postures. Dystonia may be primary, as the sole feature (isolated) or in combination with other movement disorders (combined dystonia), or as one feature of another neurological process (secondary dystonia). The current hypothesis is that dystonia is a disorder of distributed brain networks, including the basal ganglia, cerebellum, thalamus and the cortex resulting in abnormal neural motor programs. In comparison, functional dystonia (FD) may resemble other forms of dystonia (OD) but has a different pathophysiology, as a subtype of functional movement disorders (FMD). FD is the second most common FMD and amongst the most diagnostically challenging FMD subtypes. Therefore, distinguishing between FD and OD is important, as the management of these disorders is distinct. There are also different pathophysiological underpinnings in FD, with for example evidence of involvement of the right temporoparietal junction in functional movement disorders that is believed to serve as a general comparator of internal predictions/motor intentions with actual motor events resulting in disturbances in self-agency. In this article, we present a comprehensive review across the spectrum of FD, including oromandibular and vocal forms and discuss the history, clinical clues, evidence for adjunctive "laboratory-based" testing, pathophysiological research and prognosis data. We also provide the approach used at the Massachusetts General Hospital Dystonia Center toward the diagnosis, management and treatment of FD. A multidisciplinary approach, including neurology, psychiatry, physical, occupational therapy and speech therapy, and cognitive behavioral psychotherapy approaches are frequently required; pharmacological approaches, including possible targeted use of botulinum toxin injections and inpatient programs are considerations in some patients. Early diagnosis and treatment may help prevent unnecessary investigations and procedures, while facilitating the appropriate management of these highly complex patients, which may help to mitigate frequently poor clinical outcomes.

The Patient's Opinion Regarding Different Service Delivery Models for Voice Therapy

Purpose The purpose of this study was to compare the voice patient's opinion regarding three service delivery models for voice therapy: a short-term intensive voice therapy with individual sessions (IVT-I), a short-term intensive voice therapy with group sessions (IVT-G), or a long-term traditional voice therapy with individual sessions (TVT). Method Forty-six adult voice patients who followed either IVT-I, IVT-G, or TVT were contacted by e-mail with the request to fill in an online questionnaire reviewing their opinion about the received therapy. Several items concerning satisfaction, progress, time-related variables, transfer, and need for further therapy were scored by means of visual analog scales. Participants were also asked whether or not they continued voice therapy after the study. Results There were no significant differences between the three groups regarding the patients' perception of vocal quality improvement, degree of resolution of the voice disorder, duration of one session, total therapy duration, degree of transfer, need for further therapy, and actual continuation of therapy. A higher satisfaction rate was found for patients of the IVT-I and TVT groups than patients of the IVT-G group. The IVT-I group rated the therapy as too frequent compared with the TVT group who rated the frequency as optimal. Conclusion Results suggest that patients are equally satisfied and perceive a similar progress after individual short-term intensive voice therapy and individual long-term traditional voice therapy. This finding creates flexibility in selecting time-related variables depending on the specific case and situation. Patients who received individual therapy were more satisfied than patients who received group therapy. Future larger scale investigation is needed to confirm these results.

Psychosocial interventions for conversion and dissociative disorders in adults

BACKGROUND

Conversion and dissociative disorders are conditions where people experience unusual neurological symptoms or changes in awareness or identity. However, symptoms and clinical signs cannot be explained by a neurological disease or other medical condition. Instead, a psychological stressor or trauma is often present. The symptoms are real and can cause significant distress or problems with functioning in everyday life for the people experiencing them.

OBJECTIVES

To assess the beneficial and harmful effects of psychosocial interventions of conversion and dissociative disorders in adults.

SEARCH METHODS

We conducted database searches between 16 July and 16 August 2019. We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and eight other databases, together with reference checking, citation searching and contact with study authors to identify additional studies.  SELECTION CRITERIA: We included all randomised controlled trials that compared psychosocial interventions for conversion and dissociative disorders with standard care, wait list or other interventions (pharmaceutical, somatic or psychosocial).  DATA COLLECTION AND ANALYSIS: We selected, quality assessed and extracted data from the identified studies. Two review authors independently performed all tasks. We used standard Cochrane methodology. For continuous data, we calculated mean differences (MD) and standardised mean differences (SMD) with 95% confidence interval (CI). For dichotomous outcomes, we calculated risk ratio (RR) with 95% CI. We assessed and downgraded the evidence according to the GRADE system for risk of bias, imprecision, indirectness, inconsistency and publication bias.

MAIN RESULTS

We included 17 studies (16 with parallel-group designs and one with a cross-over design), with 894 participants aged 18 to 80 years (female:male ratio 3:1).  The data were separated into 12 comparisons based on the different interventions and comparators. Studies were pooled into the same comparison when identical interventions and comparisons were evaluated. The certainty of the evidence was downgraded as a consequence of potential risk of bias, as many of the studies had unclear or inadequate allocation concealment. Further downgrading was performed due to imprecision, few participants and inconsistency. There were 12 comparisons for the primary outcome of reduction in physical signs. Inpatient paradoxical intention therapy compared with outpatient diazepam: inpatient paradoxical intention therapy did not reduce conversive symptoms compared with outpatient diazepam at the end of treatment (RR 1.44, 95% CI 0.91 to 2.28; 1 study, 30 participants; P = 0.12; very low-quality evidence). Inpatient treatment programme plus hypnosis compared with inpatient treatment programme: inpatient treatment programme plus hypnosis did not reduce severity of impairment compared with inpatient treatment programme at the end of treatment (MD -0.49 (negative value better), 95% CI -1.28 to 0.30; 1 study, 45 participants; P = 0.23; very low-quality evidence). Outpatient hypnosis compared with wait list: outpatient hypnosis might reduce severity of impairment compared with wait list at the end of treatment (MD 2.10 (higher value better), 95% CI 1.34 to 2.86; 1 study, 49 participants; P < 0.00001; low-quality evidence). Behavioural therapy plus routine clinical care compared with routine clinical care: behavioural therapy plus routine clinical care might reduce the number of weekly seizures compared with routine clinical care alone at the end of treatment (MD -21.40 (negative value better), 95% CI -27.88 to -14.92; 1 study, 18 participants; P < 0.00001; very low-quality evidence). Cognitive behavioural therapy (CBT) compared with standard medical care: CBT did not reduce monthly seizure frequency compared to standard medical care at end of treatment (RR 1.56, 95% CI 0.39 to 6.19; 1 study, 16 participants; P = 0.53; very low-quality evidence). CBT did not reduce physical signs compared to standard medical care at the end of treatment (MD -4.75 (negative value better), 95% CI -18.73 to 9.23; 1 study, 61 participants; P = 0.51; low-quality evidence). CBT did not reduce seizure freedom compared to standard medical care at end of treatment (RR 2.33, 95% CI 0.30 to 17.88; 1 trial, 16 participants; P = 0.41; very low-quality evidence). Psychoeducational follow-up programmes compared with treatment as usual (TAU): no study measured reduction in physical signs at end of treatment. Specialised CBT-based physiotherapy inpatient programme compared with wait list: no study measured reduction in physical signs at end of treatment. Specialised CBT-based physiotherapy outpatient intervention compared with TAU: no study measured reduction in physical signs at end of treatment. Brief psychotherapeutic intervention (psychodynamic interpersonal treatment approach) compared with standard care: brief psychotherapeutic interventions did not reduce conversion symptoms compared to standard care at end of treatment (RR 0.12, 95% CI 0.01 to 2.00; 1 study, 19 participants; P = 0.14; very low-quality evidence). CBT plus adjunctive physical activity (APA) compared with CBT alone: CBT plus APA did not reduce overall physical impacts compared to CBT alone at end of treatment (MD 5.60 (negative value better), 95% CI -15.48 to 26.68; 1 study, 21 participants; P = 0.60; very low-quality evidence). Hypnosis compared to diazepam: hypnosis did not reduce symptoms compared to diazepam at end of treatment (RR 0.69, 95% CI 0.39 to 1.24; 1 study, 40 participants; P = 0.22; very low-quality evidence). Outpatient motivational interviewing (MI) and mindfulness-based psychotherapy compared with psychotherapy alone: psychotherapy preceded by MI might decrease seizure frequency compared with psychotherapy alone at end of treatment (MD 41.40 (negative value better), 95% CI 4.92 to 77.88; 1 study, 54 participants; P = 0.03; very low-quality evidence). The effect on the secondary outcomes was reported in 16/17  studies. None of the studies reported results on adverse effects. In the studies reporting on level of functioning and quality of life at end of treatment the effects ranged from small to no effect.

AUTHORS' CONCLUSIONS

The results of the meta-analysis and reporting of single studies suggest there is lack of evidence regarding the effects of any psychosocial intervention on conversion and dissociative disorders in adults. It is not possible to draw any conclusions about potential benefits or harms from the included studies.

Massed Versus Spaced Practice in Vocology: Effect of a Short-Term Intensive Voice Therapy Versus a Long-Term Traditional Voice Therapy

Purpose The aim of this study was to compare the effect of a short-term intensive voice therapy (IVT) with a long-term traditional voice therapy (TVT) on the vocal quality, vocal capacities, psychosocial impact, vocal tract discomfort, laryngological anatomy/physiology, and session attendance of patients with dysphonia. An additional comparison was made between an individual IVT (IVT-I) and a group IVT (IVT-G). Method A longitudinal, prospective controlled trial was used. Forty-six adults diagnosed with dysphonia were assigned to 1 of the 3 treatment groups. The IVT groups practiced with a frequency of 1 hr 20 min a day and a duration of 2 weeks. The TVT group practiced with a frequency of two 30-min sessions a week and a duration of 6 months. Both therapy programs were content-identical and guided by the same voice therapist. A multidimensional voice assessment consisting of both objective (maximum performance task, aerodynamic measurements, voice range profile, acoustic analysis, multiparametric voice quality indices) and subjective (subject's self-report, auditory-perceptual evaluation, flexible videolaryngostroboscopy) outcomes was used to evaluate the participants' voice. Results IVT made an equal progress in only 2 weeks and 12 hr of therapy compared with TVT that needed 6 months and 24 hr of therapy. IVT-I and IVT-G showed comparable results. Session attendance was clearly higher in IVT compared with TVT. Long-term follow-up results (1 year) were positive for the 3 groups, except for the self-reported psychosocial impact that increased in the IVT-I group. Conclusions Short-term IVT is at least equally effective in treating patients with dysphonia as long-term TVT. Group treatment seemed as effective as individual treatment. Attendance and cost-effectiveness are important advantages of IVT. A potential drawback might be an insufficient psychosocial progress. The golden mean between intensive and traditional treatment might therefore be an achievable, effective, and efficient solution for everyday clinical practice. Supplemental Material https://doi.org/10.23641/asha.7761872.

Comorbid Dysphagia and Dyspnea in Muscle Tension Dysphonia: A Global Laryngeal Musculoskeletal Problem

Objective

To characterize the associated symptoms of dysphagia and dyspnea among patients presenting with muscle tension dysphonia (MTD).

Study Design

Retrospective chart review performed over a 14-month period from October 2014 to December 2015.

Setting

Voice and swallowing center of a tertiary academic medical center.

Subjects and Methods

Thirty-eight patients with MTD were included for analysis. Clinical data were collected and analyzed, including perceptual voice evaluation and patient-reported outcomes measures.

Results

Among patients with a diagnosis of MTD, the incidence of reported dysphagia during clinical history and examination was 44.7%. Among patients with MTD, 60.5% had an EAT-10 (10-item Eating Assessment Tool) score ≥3 (ie, abnormal). Patients who reported dysphagia and/or had abnormal EAT-10 score (≥3) had significantly greater voice impairment than that of patients without dysphagia (P = .02). Patients who reported dysphagia also had significantly higher Clinical COPD Questionnaire scores than those of patients who reported only dysphonia (P = .002).

Conclusions

Patients presenting for dysphonia who are diagnosed with MTD have a high rate of comorbid dysphagia. Patients who reported dysphagia had significantly higher self-reported voice impairment and greater severity of breathing dysfunction as measured by the Clinical COPD Questionnaire. The coincidence of these symptoms in this patient cohort may suggest an underlying pathophysiology that has yet to be elucidated. Further prospective studies are needed to clarify the underlying cause of dysphagia and breathing dysfunction in the setting of MTD and to investigate diagnostic and therapeutic paradigms.

Preoperative evaluation and intraoperative protection of the facial nerve in congenital aural atresia

We conducted a prospective study to assess the value of high-resolution computed tomography (HRCT) in identifying facial nerve variations in patients with congenital aural atresia and to determine how they affect otologic reconstruction surgery. Our study population was made up of 65 patients (69 ears) aged 6 to 22 years (mean: 13.7) without regard to sex. They were classified into three groups according to their scores on the Jahrsdoerfer grading scale: 46 ears scored 8 or more, 18 had a score of 6 or 7, and 5 scored 5 or less. The course of each facial nerve as determined intraoperatively was compared with the preoperative HRCT findings. HRCT revealed that in most of the facial nerves, the tympanic segments overlapped the oval window partly or completely; this was confirmed by surgical findings in most cases. Three of the 69 facial nerves (4.3%) were bifurcated. It is interesting that in 1 ear in which the facial nerve completely covered the oval window, the angle of the second genu was acute, exhibiting a "sharp turn." We conclude that HRCT is undoubtedly of value in identifying the course of the facial nerve and is of critical importance in helping surgeons make correct decisions in otologic reconstruction surgery.

The Vocal Tract Discomfort Scale: Validity and Reliability of the Persian Version in the Assessment of Patients With Muscle Tension Dysphonia

OBJECTIVE

To cross-culturally adapt of Persian Vocal Tract Discomfort (VTDp) scale and evaluate its validity and reliability in the assessment of patients with muscle tension dysphonia (MTD).

STUDY DESIGN

A cross-sectional and prospective cohort design was used to psychometrically test the VTDp.

METHODS

The VTD scale was cross-culturally adapted into Persian language following standard forward-backward translations. The VTDp scale was administrated to 100 patients with MTD (54 men and 46 women; mean age: 38.05 ± 10.02 years) and 50 healthy volunteers (26 men and 24 women; mean age: 36.50 ± 12.27 years). Forty-five patients with MTD completed the VTDp 7 days later for test-retest reliability. Patients also completed the Persian Voice Handicap Index (VHIp) to assess construct validity.

RESULTS

The results of discriminative validity demonstrated that the VTDp was able to discriminate between patients with MTD and healthy participants. The internal consistency was confirmed with Cronbach α .77 and 0.73 for VTDp frequency and severity subscales, respectively. The test-retest reliability was excellent with an intraclass correlation coefficient (ICC_agreement) of 0.93 for the frequency subscale and 0.91 for the severity subscale. Construct validity of the VTDp was shown with significant correlations between the VTDp frequency and severity subscales and the VHIp total scores (0.36 and 0.37, respectively). The standard error of measurement and smallest detectable change values for VTDp frequency (2.11 and 5.85, respectively) and severity (2.25 and 6.23, respectively) were acceptable. The Bland-Altman analysis for assessing the agreement between test and retest measurements showed no systematic bias.

CONCLUSION

The VTDp is a valid and reliable self-administered scale to measure patient's vocal tract sensations in Persian-speaking population.

Features of Muscle Tension Dysphonia before and after Correction of Unilateral Vocal Cord Paralysis

Objectives:

We performed a retrospective, longitudinal study to compare the prevalence of hyperkinetic laryngeal features before and after successful correction in patients with unilateral vocal cord paralysis (UVCP).

Methods:

Eighty-six patients with UVCP who had a successful surgical correction were enrolled. Preoperative and postoperative videolaryngostroboscopy images were analyzed, and the muscle tension patterns (MTPs) were rated according to the Morrison-Rammage classification. A 4-item glottal closure index was used for each patient on study entry and for 40 normal subjects as the control group.

Results:

There was no significant difference in MTP prevalence before (57%) and after (55%) surgical correction for UVCP. Although the glottal closure symptoms were tremendously improved through surgical medialization for UVCP, they persisted and were more prevalent than those in normal individuals.

Conclusions:

Persistence of MTPs after correction of UVCP may be due to intractable vocal habits or psychogenic factors.

Refractory Dysphonia Due to Isolated Cricothyroid Muscle Dystonia

OBJECTIVE

To demonstrate the utility of electromyography (EMG) in the evaluation and management of treatment-resistant dysphonia.

METHOD

We report a case of refractory dysphonia in which EMG was used to identify and treat isolated cricothyroid (CT) dystonia.

RESULTS

The patient, a healthy 43-year-old woman, presented with 9 months of progressive hoarseness. Her symptoms were present across vocal tasks but were particularly bothersome while dictating. On presentation, her voice was rated grade 3, roughness 3, breathiness 1, asthenia 0, and strain 3 (G3R3B1A0S3). Videostroboscopy was remarkable for hyperfunction. Voice therapy was not beneficial despite appropriate effort. Microdirect laryngoscopy revealed no evidence of structural pathology. The patient was referred for EMG because of her normal examination and failure to improve with therapy. The CT muscle demonstrated an increased latency of 750 ms in all vocal tasks. One month after CT injection with 3 units of botulinum toxin (BTX), her voice was improved. Perceptual voice evaluation was rated G1R1B0A0S1. Voice Handicap Index improved from 87 to 35.

CONCLUSIONS

In the absence of structural pathology, EMG can be a useful adjunct in the diagnosis of dysphonia that persists despite adequate trials of voice therapy. To our knowledge, this is the only report of laryngeal dystonia due to isolated CT dysfunction successfully treated with BTX.

Telepractice Versus In-Person Delivery of Voice Therapy for Primary Muscle Tension Dysphonia

PURPOSE

The purpose of this study was to investigate the utility of telepractice for delivering flow phonation exercises to persons with primary muscle tension dysphonia (MTD).

METHOD

Fourteen participants with a diagnosis of primary MTD participated, 7 on site and 7 at remote locations. Each participant received 12 treatment sessions across 6 weeks. Treatment consisted of flow phonation voice therapy exercises. Auditory-perceptual, acoustic, aerodynamic, and quality-of-life measures were taken before and after treatment.

RESULTS

Perceptual and quality-of-life measures were significantly better posttreatment and were statistically equivalent across groups. Acoustic and aerodynamic measures improved in both groups, but changes did not reach statistical significance. Results for the 2 service delivery groups were comparable, with no significant differences observed for perceptual and quality-of-life measures.

CONCLUSIONS

Although the American Speech-Language-Hearing Association supports the use of telepractice for speech-language pathology services, evidence for the use of telepractice for providing behavioral treatment to patients with MTD has been lacking. The results of this study indicate that flow phonation exercises can be successfully used for patients with MTD using telepractice.

A clinical demonstration of the application of audiovisual biofeedback in the treatment of puberphonia

PURPOSE

The objective of this study was to demonstrate the effect of vocal audiovisual biofeedback in the treatment of puberphonia.

METHOD

This is a report of a single subject research study encompassing intervention and observation of results, involving three phases: baseline, treatment, and follow-up. Therefore, this study applied an A-B case study experimental design with follow-up for observation of treatment outcomes. Self-reported complementary data regarding feelings of voice usage included comparisons between pre and post intervention scores of the Voice Handicap Index (VHI) survey.

RESULTS

In this study, acoustic voice parameters measured revealed changes in vocal performance in the desired direction, as demonstrated by visual inspection and estimation of effect size of the data; changes were maintained during the follow-up phase. Examination of VHI results suggested post intervention improvement in functional and psychosocial aspects related to voice use.

CONCLUSIONS

Based on the results of this study, audiovisual feedback approaches are effective in the treatment of puberphonia. Results will apply to future considerations in the application of technology support for treatment of puberphonia and other voice related disorders.

Muscle Tension Dysphonia: A Rationale for Symptomatic Subtypes, Expedited Treatment, and Increased Therapy Compliance

This article will briefly identify the variable nature of muscle tension dysphonia (MTD). Causes such as psychogenicity and maladaptive “vocal posture” will be described and questioned. Special Interest Group (SIG) 3 members may benefit from identification of the strengths and weaknesses of an ongoing movement towards a symptomatically generic “MTD.” More specific subtyping of MTD into 9 categories will be proposed, as well as description of associated therapy methods. Increased patient awareness that some subtypes may be self-correctable could simplify intervention, increase compliance, and improve clinician and researcher effectiveness.

Functional voice disorders and their occurrence in 100 patients of hoarseness as seen on fibreoptic laryngoscopy

During a six month period, one hundred patients presenting with the primary complaint of hoarseness, in the out- patients department of otolaryngology at Safdarjung Hospital New Delhi were taken up fot the study Fach patient after being subjected to a detailed history- taking and examination, including a Fibreoptic Laryngoscopy was then put into one of ten categories on the basis of the ultimate diagnosis Functional voice disorders, forming the largest category with 51%, included lesions such as vocal nodules and polyps, which are secondary to vocal abuse A detailed study of the various types of functional voice disorders along with factors such as male female ratio and associated contributory factors was done the efficacy of the Fibreoptic laryngoscope as a diagnostic tool was also assessed.

Comparison between palpatory findings of the hyoid position and their acoustic, videostroboscopic, and perceptual attributes in patients with muscle tension dysphonia (with and without organic lesions)

SUMMARY

The direction in which the hyoid is pulled may change as a result of muscle tension dysphonia (MTD). The disposition usually occurs owing to paralaryngeal muscular imbalance (decompensation), which can create laryngeal dysfunction and consequently deteriorating the voice quality. This study aimed at reporting on a comparison between palpatory findings of hyoid position and their acoustic and perceptual and stroboscopic attributes among patients with MTD.

DESIGN

Cross-sectional random triple-blinded study.

METHOD

Palpatory, acoustic, audioperceptual, and stroboscopic findings of 39 patients with MTD were analyzed descriptively and using independent sample t test.

RESULTS

Dominant perceptual vocal characteristic of patients with pulled-up hyoid position was rough and the degrees of jitter and shimmer were higher in patients with pulled-up hyoid position than in patients with pulled-down hyoid position (jitter, P=0.019; shimmer, P=0.004), whereas signal-to-noise (S/N) ratio was lower in patients with pulled-up hyoid position than in pulled-down hyoid patients, but not significantly (S/N ratio, P=0.56). The dominant perceptual characteristic of patients with pulled-up hyoid position was rough voice, whereas that for pulled-down hyoid patients was strained voice. On the other hand, the dominant observable pattern in patients with pulled-up hyoid was MTD type II (lateral constriction), whereas that in patients with pulled-down hyoid was MTD type III (moderate anteroposterior constriction).

CONCLUSION

There is a general congruence between the hyoid pulled direction and its perceptual, acoustic, and videostroboscopic findings in patients with MTD.

The management of vocal fold nodules in children: a national survey of speech-language pathologists

The purpose of this study was to determine the management options and voice therapy techniques currently being used by practicing speech-language pathologists (SLPs) to treat vocal fold nodules (VFNs) in children. The sources used by SLPs to inform and guide their clinical decisions when managing VFNs in children were also explored. Sixty-two SLPs completed a 23-item web-based survey. Data was analysed using frequency counts, content analyses, and supplementary analyses. SLPs reported using a range of management options and voice therapy techniques to treat VFNs in children. Voice therapy was reportedly the most frequently used management option across all respondents, with the majority of SLPs using a combination of indirect and direct voice therapy techniques. When selecting voice therapy techniques, the majority of SLPs reported that they did not use the limited external evidence available to guide their clinical decisions. Additionally, the majority of SLPs reported that they frequently relied on lower levels of evidence or non-evidence-based sources to guide clinical practice both in the presence and absence of higher quality evidence. Further research needs to investigate strategies to remove the barriers that impede SLPs use of external evidence when managing VFNs in children.

Pathophysiology and treatment of muscle tension dysphonia: a review of the current knowledge

OBJECTIVE

Muscle tension dysphonia (MTD) is a clinical and diagnostic term describing a spectrum of disturbed vocal fold behavior caused by increased tension of the (para)laryngeal musculature. Recent knowledge introduced MTD as a bridge between functional and organic disorders. This review addresses the causal and contributing factors of MTD and evaluates the different treatment options.

METHODS

We searched MEDLINE (Pubmed, 1950-2009) and CENTRAL (The Cochrane Library, Issue 2, 2009). Studies were included if they reviewed the classification of functional dysphonia or the pathophysiology of MTD. Etiology and pathophysiology of MTD and circumlaryngeal manual therapy (CMT) were obligatory based on reviews and prospective cohort studies because randomized controlled trials (RCTs) are nonexisting. Concerning the treatment options of voice therapy and vocal hygiene, selection was based on RCTs and systematic reviews.

RESULTS

Etiological factors can be categorized into three new subgroups: (1) psychological and/or personality factors, (2) vocal misuse and abuse, and (3) compensation for underlying disease. The effective treatment options for MTD are (1) indirect therapy: vocal hygiene and patient education; (2) direct therapy: voice therapy and CMT; (3) medical treatment; and (4) surgery for secondary organic lesions.

CONCLUSIONS

MTD is the pathological condition in which an excessive tension of the (para)laryngeal musculature, caused by a diverse number of etiological factors, leads to a disturbed voice. Etiological factors range from psychological/personality disorders and vocal misuse/abuse to compensatory vocal habits in case of laryngopharyngeal reflux, upper airway infections, and organic lesions. MTD needs to be approached in a multidisciplinary setting where close cooperation between a laryngologist and a speech language pathologist is possible.

Treatment for spasmodic dysphonia: limitations of current approaches

PURPOSE OF REVIEW

Although botulinum toxin injection is the gold standard for treatment of spasmodic dysphonia, surgical approaches aimed at providing long-term symptom control have been advancing over recent years.

RECENT FINDINGS

When surgical approaches provide greater long-term benefits to symptom control, they also increase the initial period of side effects of breathiness and swallowing difficulties. Recent analyses of quality-of-life questionnaires in patients undergoing regular injections of botulinum toxin demonstrate that a large proportion of patients have limited relief for relatively short periods due to early breathiness and loss-of-benefit before reinjection.

SUMMARY

Most medical and surgical approaches to the treatment of spasmodic dysphonia have been aimed at denervation of the laryngeal muscles to block symptom expression in the voice, and have both adverse effects as well as treatment benefits. Research is needed to identify the central neuropathophysiology responsible for the laryngeal muscle spasms in order target treatment towards the central neurological abnormality responsible for producing symptoms.

Development of a modified diagnostic classification system for voice disorders with inter-rater reliability study

Diversity in nomenclature and on-going dilemmas over the conceptual bases for the classification of voice disorders make it virtually impossible for the collation and accurate comparison of evidence-based data across different clinical settings. This has significant implications for treatment outcome studies. The first aim of this study was to develop a modified diagnostic classification system for voice disorders with clearly defined operational guidelines by which we might reliably distinguish voice disorders from one another. The second aim was to establish the face validity and reliability of the system as an effective diagnostic tool for the allocation of patients to different diagnostic groups for clinical and research purposes. After the Diagnostic Classification System for Voice Disorders (DCSVD) had been developed, it was used in an inter-rater reliability study for the independent assessment of 53 new consecutive patients referred to the Voice Analysis Clinics of three tertiary hospitals. There were three raters present for the assessment and diagnostic allocation of each patient. The high levels of inter-rater reliability suggest this may be a robust classification system that has good face validity and even at this early stage, strong construct validity.

Functional dysphonia during mental imagery: testing the trait theory of voice disorders

PURPOSE

Previous research has proposed that persons with functional dysphonia (FD) present with temperamental traits that predispose them to their voice disorder. We investigated this theory in a controlled experiment and compared them with social anxiety (SA) and healthy control (HC) groups.

METHOD

Twelve participants with FD, 19 participants with SA, and 23 HC participants were studied before, during, and after mental imagery of positive, neutral, and aversive scripts in a within-subject reversal paradigm with multiple experimental conditions using psychometric, self-report, and psychophysiological measures.

RESULTS

In psychometric tests, those with FD demonstrated increased fear in social situations but not increased avoidance. On measures of mood, all groups responded with predicted increases in pleasant mood for positive scripts and unpleasant mood for aversive scripts; on vocal effort ratings, those with FD reported greater effort for all scripts following imagery. Under experimentally controlled conditions, the SA and HC groups demonstrated predicted activation of EMG measures of mood, whereas the FD group demonstrated overall reduced activation of EMG measures.

CONCLUSION

Results may suggest that those with FD respond to emotional stimuli with reduced behavioral expression, compared with SA and HC groups, consistent with the temperamental trait of behavioral constraint.

Articulatory changes following treatment of muscle tension dysphonia: preliminary acoustic evidence

PURPOSE

Primary muscle tension dysphonia (MTD), a voice disturbance that occurs in the absence of structural or neurological pathology, may respond to manual circumlaryngeal techniques, which ostensibly alter the posture of the larynx and/or the configuration of the vocal folds without directly targeting supralaryngeal articulatory structures. Although the phonatory benefits of these techniques have been documented previously, this investigation examined whether acoustic evidence exists for articulatory changes accompanying successful management.

METHOD

In this retrospective study of a clinical database, pre- and post-treatment speech samples from 111 women with MTD were analyzed for acoustic evidence of supraglottal vocal tract changes associated with voice improvement, which was confirmed by perceptual ratings of dysphonia severity. The slopes of the first and second formants in diphthongs, as well as global measures of speech timing were acquired. Twenty younger females with normal voices were recorded twice, across a similar time-span to the disordered speakers, to allow comparisons in performance.

RESULTS

Repeated measures analysis of variance was used to evaluate changes accompanying treatment. Significant time by group interactions for /I/ F2 slope, /eI/ F2 slope, sample duration, and speaking time ratio were observed. As compared to the controls, diphthong second formant transitions increased in slope, and timing measures showed increases in speech continuity for the speakers with MTD.

CONCLUSIONS

Collectively, these preliminary findings suggest that individuals with MTD experience changes in both articulatory and phonatory behavior following successful treatment that targets the larynx.

The role of psychogenic and psychosocial factors in the development of functional voice disorders

The primary objective of this discussion paper is to review the available evidence for the role of psychogenic and psychosocial factors in the development of functional voice disorders (FVD). Current theoretical models linking these factors to the aetiology of FVD and to vocal hyperfunction are then considered. Since there is a paucity of solid empirical evidence to date, general patterns of evidence derived from single case reports and case series are examined first, followed by those empirical studies using more sophisticated methodologies. The discussion is structured around a framework that includes the following psychosocial areas of enquiry: demographic profiles of individuals with FVD; stressful incidents preceding onset; personality traits; coping styles and psychiatric disorder. Current evidence and associated theoretical models suggest that cognitive, affective, neurophysiological and behavioural aspects culminate in the development of these complex voice disorders. The implications of these findings are discussed with respect to clinical practice and clinical training, with suggestions for future scientific research.

Assessment and treatment of musculoskeletal tension in hyperfunctional voice disorders

Poorly regulated activity of the perilaryngeal muscles affects phonatory function and contributes to a class of disorders known as hyperfunctional or musculoskeletal tension voice disorders. Recognizing the signs and symptoms of excess or dysregulated laryngeal muscle activity is critical to proper diagnosis and selection of appropriate treatment(s). Although numerous approaches exist to manage such hyperfunctional syndromes, manual circumlaryngeal techniques have recently received attention as valuable tools in both assessment and treatment. Therefore, the purpose of this article is to: (1) describe common phenomenological features of dysregulated laryngeal muscle tension, thereby facilitating its recognition, (2) highlight the role of manual circumlaryngeal techniques in assessment and management, (3) survey additional treatment approaches for laryngeal hyperfunction, and explore the evidence to support their effectiveness, and (4) identify unresolved issues and controversies surrounding tension-based voice disorders. A series of pre- and post-treatment audio examples are provided on the journal website at www.informaworld.com/ijslp .

Management of Supraglottic Squeeze in Adductor Spasmodic Dysphonia: A New Technique

OBJECTIVES

Spasmodic dysphonia is a disabling disorder of the voice characterized primarily by involuntary disruptions of phonation. Botulinum toxin injections of the thyroarytenoid muscles have been the treatment of choice for adductor spasmodic dysphonia (ADSD). We describe a new technique to address the problem of compensatory or supraglottic hyperadduction in some of these patients.

STUDY DESIGN

Case series.

METHODS

Four patients with ADSD with sphincteric supraglottic contraction were seen for evaluation of botulinum toxin injection. On fiberoptic exam, it was noted that they had type I hyperadduction of the true vocal cords with a significant type III, and/or type IV hyperadduction of the supraglottis. After standard management of the thyroarytenoid muscles, the strained/strangled voice continued. On fiberoptic exam it was noted that the vocal folds were weakened, but the supraglottic hyperfunction persisted. The patients were treated by speech therapists to unload their supraglottis without success. All patients then had their oblique portion of the lateral cricoarytenoid muscles injected with botulinum toxin A through a thyrohyoid approach. This was done in the office under electromyographic control.

RESULTS

On follow-up, all patients demonstrated improvement in the quality of their voices (as compared to thyroarytenoid injections alone).

CONCLUSIONS

We describe a new technique for injection of the supraglottic portion of the lateral cricoarytenoid muscles. We demonstrate this can be done safely and successfully in an office setting with electromyography control.

Common Diagnoses and Treatments in Professional Voice Users

Common problems among all patients seen by the laryngologist are also common among professional voice users. These include laryngopharyngeal reflux, muscle tension dysphonia, fibrovascular vocal fold lesions (eg, nodules and polyps), cysts, vocal fold scarring, changes in vocal fold mobility, and age-related changes. Microvascular lesions and their associated sequelae of vocal fold hemorrhage and laryngitis due to voice overuse are more common among professional voice users. Much more common among professional voice users is the negative impact that voice problems have on their ability to work, on their overall sense of well-being, and sometimes on their very sense of self. This article reviews the diagnosis and treatment options for these and other problems among professional voice users, describing the relevant roles of medical treatment, voice therapy, and surgery. The common scenario of multiple concomitant entities contributing to a symptom complex is underscored. Emphasis is placed on gaining insight into the "whole" patient so that individualized management plans can be developed. Videos of select diagnoses accompany this content online.

Long-Term Outcome of Hyperfunctional Voice Disorders Based on a Multiparameter Approach

SUMMARY

The purpose of this study is to determine the long-term voice outcome (6.1 years after a well-defined voice treatment program) of hyperfunctional voice disorders in 27 subjects. All patients showed a muscle tension pattern type I (MTP I). Perceptual ratings, aerodynamic and acoustical analyses, Voice Handicap Index (VHI) value, and a determination of the Dysphonia Severity Index (DSI) were performed. The laryngovideostroboscopic images indicated that 51% of the subjects still show pathological laryngological findings. The negative evolution of the DSI from -1 to -3.2 is in agreement with this finding. Analysis of the components of the DSI shows that the main responsible variable for this negative change is the lowest intensity (I-low) that increased with 8.1 dB, indicating that subjects generally speak too loud, which is a typical problem for vocal hyperfunction. The VHI-score indicates an unimportant psychosocial impact of the voice disorder. The more objective and laryngostroboscopic findings indicate a chronic situation for a substantial part of the subjects and even a worse situation for some of them. Whether the long-term voice outcome results can be changed with the insertion of several follow-up voice rehabilitation sessions over the years remains unanswered and is a subject for further research.

Direct laryngoscopic observations in progressive hoarseness of voice

Hoarseness is a common disorder of voice which indicates abnormality at the level of glottis. We present our study of forty cases of progressive hoarseness of voice who underwent direct laryngoscopy during a period of January 2003 to January 2004 in our hospital. The observations were recorded und the data was evaluated.