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Voice Therapy in Muscle Tension Dysphonia Cases 1Sachender Pal Singh, 2Smrity Rupa Borah Dutta

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Voice Therapy in Muscle Tension Dysphonia Cases 1Sachender Pal Singh, 2Smrity Rupa Borah Dutta IJOPL Sachender Pal Singh, Smrity Rupa Borah Dutta 10.5005/jp-journals-10023-1097 ORIGINAL ARTICLE Voice Therapy in Muscle Tension Dysphonia Cases 1Sachender Pal Singh, 2Smrity Rupa Borah Dutta ABSTRACT laryngeal tension fatigue syndrome.1 It has multifactorial Muscle tension dysphonia (MTD) is a condition where phonation etiologies. It can be primary or secondary MTD. The letter is associated with exces sive muscular tension or muscle is due to compensatory behavior of phonation in diseases misuse. It has multifactorial etiologies. It can be a primary or which affects either the aerodynamic configuration (like secondary MTD. While it can affect anyone, sufferers usually vocal fold paralysis), or the vibratory property of glottis belong to a particular group. It has very serious impact on (like vocal cord nodule). However, when the MTD is sufferer’s personal, social and pro fessional life. We are presenting here, our 20 months prospective study present without the anatomic or neurologic factors, then done in the department of otorhinolaryngology, Silchar Medical it is called as primary MTD. While it can affect anyone, College and Hospital from June 2012 to July 2013. sufferers usually belong to a particular group like Voice therapy was given to every patient, whether primary teachers, singers and actors, frequent cell phone users and or secondary MTD. Pre-therapy vs post-therapy comparisons were made of self-ratings of voice handicap index, auditory- instructors, etc. who are likely to speak loudly, for long perceptual ratings as well as visual-perceptual evaluations of hours with inappropriate pitch or without following vocal laryngeal images. hygiene. A detailed history and complete examination is Outcome of voice therapy results (Graphs 1 and 2) in such necessary to diagnose MTD. It has very serious impact patients were found to be very good. As the disease is multi- on sufferer’s personal, social and professional life and factorial, treatment approach should be broad-based involving multidisciplinary team. significantly decreases the quality of life. Keywords: Circumlaryngeal massage, Dysphonia plica MATERIALS AND METHODS ventricularis, GRABS score. This study is a prospective study during the period of Abbreviations: Vocal Cord Nodule (N), Vocal Polyp (P), Laryngopharyngeal Reflux (LPR), Presbylaryngis (PL), Cut June 2012 to January 2014 carried out at Department of Throat injury (CT), Primary Muscle Tension Dysphonia (PMTD), ENT, at Silchar Medical College, Silchar, Assam. Dysphonia Plica ventricular (DPV). Subjects How to cite this article: Singh SP, Dutta SRB. Voice Therapy in Muscle Tension Dysphonia Cases. Int J Phonosurg Laryngol Twenty ­seven subjects with MTD were selected for the 2015;5(1):20-24. study after making a proper diag nosis on the basis of Source of support: Nil history, clinical and laryngoscopic examination. The Conflict of interest: None patients were in the age group of 20 to 70 years. Patients included in the study were: Primary MTD (13), INTRODUCTION secon dary MTD (14): vocal cord nodule (5), vocal cord polyp (2), cut throat injury (1), laryngo pharyngeal reflux Muscle tension dysphonia (MTD) is a condition where (4), presbylaryngis (2). excessive muscular tension, in laryngeal and para laryn­ geal areas, or muscle misuse, occur during phonation. Patients excluded from the study were: Those who did not Various synonyms have been used for this entity like come for follow­up. hyperkinetic dysphonia, musculoskeletal tension All the excised tissues of secondary MTD (vocal cord dysphonia, hyperfunctional dysphonia, mecha nical voice nodule and polyp) cases were sent for histopathological disorder, functional hypertensive dysphonia, muscle examination. misuse dysphonia, laryngeal isometric dys phonia, Voice Outcome Measures The voice was recorded before and after voice therapy and 1Postgraduate, 2Assistant Professor voice outcome was based on auditory­perceptual ratings, 1,2Department of Otorhinolaryngology, Silchar Medical College quality of life measures and visual­perceptual ratings. and Hospital, Silchar, Assam, India Auditory-Perceptual Ratings Corresponding Author: Sachender Pal Singh, Postgraduate Depart ment of Otorhinolaryngology, Silchar Medical College Subjects were asked to read ‘The Rainbow passage’ and Hospital, Silchar, Assam, India, Phone: 07023733126 (operating techniques in laryngology) or to count 1 to e-mail: [email protected] 20 and voice was recorded. Perceptual ratings of voice 20 IJOPL Voice Therapy in Muscle Tension Dysphonia Cases quality were conducted with the ‘GRBAS scale’.13 The that voice of the patients has improved a lot after the GRBAS scale is considered by many authors to be the most implication of voice therapy (Table 1). reliable auditory perceptual scale currently available for DISCUSSION use as an outcome measure.2,3 Muscle tension dysphonia is one of the common voice Quality of Life Measures disorders, with primary MTD accounting for approxi­ mately 10 to 40% of the case load of a typical voice center ‘Voice handicap index’ (VHI) was used to assess the (Roy, 2003). impact of the voice in terms of physical complaint and In our study, we made the diagnosis on the basis of restriction in participation in daily activities and response history, clinical and videolaryngoscopic examination. to treatment.4­8 We found tenderness over different sites in the neck Visual-Perceptual Ratings which were related to their respective excessive muscle tension. We started voice therapy before the surgery, in It was based on comparison of Transnasal flexible cases of vocal cord nodule/polyp so that their habits of Videolaryngoscopy (TFL) done before and after the voice voice abuse and misuse and compensatory behavior therapy. do not have worse affect postoperatively. Patients were informed about their diagnosis, anatomy and physiology RESULTS (GRAPHS 1 AND 2) of normal vocal tract in order to minimize the anxiety and Results of voice outcome measure are depicted in graph 1 stress and also to develop their belief in the voice therapy (GRABS score) and graph 2 (VHI score) which shows (Table 1) so that drop­out cases may be reduced. Vocal Graph 1: Grabs score Graph 2: Voice handicap index score (N: Vocal cord nodule; P: Vocal polyp; LPR: Laryngopharyngeal reflux; PL: Presbylaryngis; CT: Cut throat injury; PMTD: Primary muscle tension dysphonia; DPV: Dysphonia plica ventricular) International Journal of Phonosurgery and Laryngology, January-June 2015;5(1):20-24 21 Sachender Pal Singh, Smrity Rupa Borah Dutta Table 1: Voice therapy and tongue base muscles, there is elevation of the 9 • Vocal hygiene larynx and hyoid bone which stiffen the vocal folds 10 • Symptomatic voice therapy: Circumlaryngeal massage, and produce anteroposterior supraglottic contraction chewing exercises, yawn sigh approach, phonation on affecting the phonatory patterns. Overuse of specific inhalation muscles will cause tenderness over that particular site; • Respiratory retraining: Breath support, confidential voice this can be elicited by slight pressure with forefingers. therapy Muscle tension dysphonia patients are usually assessed • Physiologic voice therapy: Vocal function exercises, accent method, resonant voice therapy by palpation for elevated laryngeal position, increased extrinsic laryngeal muscle activation10­15 shortening • Psychogenic voice therapy of the sternocleidomastoid and stylohyoid muscles.12 hygiene was instructed to every patient to eliminate the Muscle misuse and non muscle­misuse dysphonia environmental and behavioral factors. Posture and mouth can be differentiated with increased palpable tension opening during phonation were corrected. Inappropriate (Angsuwarangsee and Morrison). muscle usage causing muscle tension at neck, floor of Auditory perceptual features of MTD include strained mouth or jaw were managed accordingly by massaging or effortful voice quality, aberrant pitch, breathiness or the muscle in tension, in the line of their muscle fibers. vocal fatigue.15,16 Treatment generally targets the increased hyolaryngeal Physiologic features of MTD are elevated hypo­ elevation and laryngeal and perilaryngeal muscular pharyngeal position, decreased space between hyoid tension. Circumlaryngeal massage was considered to and larynx and increased extrinsic laryngeal muscle treat extrinsic laryngeal muscle tension. Patients were tension. Hyolaryngeal elevation and excessive extrinsic considered for symptomatic, physiologic and psychogenic laryngeal muscle activation can influence the mechanics voice therapy in addition to respiratory retraining as and of vocal fold vibration9,17 and are considered important when required. In one of our cases, i.e. dysphonia plica contributors to the dysphonia in MTD. ventricularis, we considered psychotherapy because he Muscle tension dysphonia can be diagnosed on was having anxiety and depression due to failure in transnasal fiberoptic video laryngoscopy on the basis of examination during the onset of symptoms. Another presence of anteroposterior squeezing with arytenoid case, i.e. cut throat injury, was interesting. He presented and epiglottic apposition severly affecting vocal fold with homicidal cut throat injury and was managed output, shortening of vocal folds with increase in mass accordingly. But, during the course, he developed MTD, and stiffness, adduction of false vocal cords with ven­ as a compensatory behavior. A bulge in the neck above tricle compression, increased adductor muscle tone or the larynx could easily be appreciated during
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