Transcript Manual Circumlaryngeal Techniques

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