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Dysphonia/ Muscle Tension Dysphonia: Pediatric Implications - October 2009

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Functional Dysphonia/ Muscle Tension Dysphonia: Pediatric Implications

By: Bridget Russell, PhD, CCC-SLP

Functional Dysphonia (FD) is a voice disorder that presents with vocal quality aberrations including aphonia, strain, and/or severe dysphonia with no presence of structural abnormality of the vocal folds or the existence of benign organic lesions. Other voice disorders in this category can be described similarly and include muscle tension dysphonia (MTD), persistent falsetto, conversion dysphonia/aphonia and hyperfunctioning of the larynx (Aronson, 1990; Roy & Leeper, 1991). Voice disorders that are categorized as functional in adults have been attributed to such variables as psychological stress, anxiety, certain personality traits, learned adaptations after respiratory infection, compensation for underlying vocal diseases (i.e. vocal fold paralysis, paresis), and misuse of the laryngeal structures during demanding vocal tasks (Demmink-Geertman & Dejonckere, 2002; Roy, Ford & Bless, 1996; Roy, McGory, Tasko, Bless, Heisey, & Ford, 1997). In adolescents, some of the same etiologic variables are indicted, such as, psychogenic, psychosocial, personality traits and psychosexual bases along with learned patterns (not psychogenic in nature) (Aronson, 1969; Peppard, 1996). Peppard, 1996, also identifies high-risk factors that may lead to FD in children including other communication deficits (i.e. hearing loss, cleft palate, stuttering , and misarticulations), medical problems (i.e. respiratory difficulty, colds, allergies, and sinus infections), vigorous vocal activity (i.e. cheering, singing, and acting), vigorous physical activity (i.e. weight lifting, and sports), educational performance, psychosocial problems, substance abuse, eating disorders, time of secondary sex characteristics, and dramatic pitch change at puberty. It is likely that a functional voice disorder could present if a child has any or all of these high-risk factors (Peppard, 1996).

Diagnostic symptoms of MTD and FD can include specific visible characteristics seen during direct observation of the larynx, including ventricular fold activation, narrowing of the pharyngeal structures and antero-posterior squeezing of the muscles that surround the vocal folds (Morrison, Rammage & Gilles, 1983). Pharyngeal and/or laryngeal muscle tension which may completely obstruct the view of true vocal fold vibration during an endoscopic examination may also be present in FD patients. FD can have related MTD symptoms or have no visible, physical evidence of muscle tension. Although muscular tension does not have to coexist with other symptoms of FD, it usually is present in most patients (Koufman & Blalock, 1988; Roy & Leeper, 1993).

In contrast to adults, there have been consistent characteristics of FD found in adolescents. In this population, diagnostic signs include auditory perceptual symptoms such as severe aphonia (not typically seen in organic pathology), no struggle symptoms to achieve phonation such as changes in speaking rate, rhythm or facial tension (also seen more frequently in organic pathology) (Peppard, 1996). Other signs of FD found in adolescents include acoustic indications such as, an increased, decreased or variable fundamental frequency; reduced pitch range and increased perturbation (i.e. jitter and shimmer %). Increased or decreased vocal loudness and decreased loudness range are also common in children with FD. Laryngoscopic observations can include a continuum from edematous to normal appearing vocal folds.

Generally, perceptual voice qualities associated with FD include a range of difficulties including a breathy high-pitched quality, a complete loss of voice where the patients simply whisper and a gravely hoarse voice quality where there are periods of complete aphonia. Typically patients will fall into one of these aforementioned vocal categories.

A psychological etiology has been indicated as a major cause of FD and recently has been investigated. Roy and colleagues studied FD patients to determine if there was a specific personality type that was more likely to contract FD. The personality traits associated with FD and MTD have been identified as neuroticism and a propensity to be meticulous and organized (Roy, McGory, Tasko, Bless & Ford, 1997). The ability of these individuals to relax and take life with ease is difficult. All age groups were diagnosed with either FD or MTD.

Treatment regimes for FD and MTD have had success with using manual tension reduction techniques such as circumlaryngeal massage (CM) in adults (Aronson, 1990; Roy, 1996; Roy & Leeper, 1993; Roy, Bless, Heisey, & Ford, 1997; Van Lierde, De Ley, Clement, De Bodt & Van Cauwenberge, 2004). CM employs a massage or manipulation designed to relax the musculature and re-organize the position of the larynx. The circumlaryngeal technique involves encircling the thyrohyoid space with the thumb and forefinger and firmly bringing the fingers in a forward downward movement intended to open the space and essentially reduce the suprahyoid muscular tension that is responsible for bringing the larynx into an elevated hypertensive state. After the thyrohyoid space is found and manipulated the fingers can provide pressure on the top of the thyroid lamina in order to push down on the thyroid cartilage and depress the larynx. Once the larynx has been depressed the clinician can hold the thyroid in a downward position and ask the patient to vocalize by rote counting or saying the days of the week in sequence. Once a change in voicing can be heard the clinician will try and manipulate that position to improve the quality and duration of voicing while continuing to have the patient complete rote voicing drills. The object is to get the patient to accomplish clear voicing and then to remove the clinician’s hand slowly until the patient is able to maintain the voicing on their own. It should be noted that during the repositioning of the thyroid cartilage and downward depression, there is also a massage of the thyroid all the way down the length of the larynx and then the fingers are repositioned back in the thyrohyoid space once again, this is repeated before the voicing begins. The general relaxation of the laryngeal musculature is important to reorient the client to the feeling or sensation of the laryngeal position that they had prior to the loss of voice.

The CLM technique has been used with several groups of patients including adults with FD, professional voice users and a small group of children with FD and associated nodules (Lee & Son, 2005; Roy & Leeper, 1993; Van Lierde et. al., 2004). All the studies demonstrated that manual tension reduction techniques were an effective treatment in the reduction of MTD and functional loss of voice. Case study evidence from treatment sessions using CLM has been successful in improving vocal quality (Roy et. al, 1996). Subjective measures including rating scales and objective measures of acoustic and aerodynamic parameters have been used to determine the effectiveness of using manual tension reduction as a treatment for FD (Roy & Leeper, 1993; Van Lierde et. al.,2004). Roy and Leeper measured perceptual and acoustic parameters of 17 adults patients with functional dysphonia before and after treatment using CM and found that these measures indicated a significant change in normalization of vocal quality in a single treatment session. There is also evidence that the positive effects on vocal quality using CM have long-term carry-over (Roy et al., 1997). In other studies, Van Lierde and colleagues used a series of objective and subjective measures to demonstrate the effectiveness of CM in professional voice users having FD. These authors found that all subjects demonstrated improvement in perceptual vocal quality, using the GRBAS scale (Hirano, 1981), and acoustic and aerodynamic measures of vocal quality using the Dysphonia Severity Index (DSI). The acoustic parameters of jitter and shimmer were improved in almost all of the patients (Van Lierde et. al., 2004).

Using manual tension reduction techniques, such as CM, to improve vocal quality in functional voice disorders has been demonstrated to have a positive effect on vocal quality in adults; however there is little evidence of its effectiveness in children. One study demonstrated voice therapy, including CM, effective in reducing the symptoms of MTD and associated vocal nodules in eight Korean male children (Lee & Son, 2005). Marked strained and breathy voices were detected in all patients. A variety of voice therapy techniques were used to treat these patients including improving awareness, relaxation, and easy onset phonation exercises and CM in coordination with respiratory relaxation exercises. The GRABAS scale was used to measure perceptual changes and acoustic measures of speaking fundamental frequency (SFF), jitter and shimmer percentages were collected. Results indicated that after treatment, which was an average of 1-2 months in duration, all children demonstrated an improvement in their GRABAS ratings especially grade, strain and pitch in connected speech, jitter and shimmer values returned to normative values. Other symptoms such as A-P contraction of the supraglottal cavity and incomplete closure were relieved into a relaxed normal configuration after therapy (Lee & Son, 2005). Vocal nodules were reduced or absent post treatment and long-term follow-up suggested no reoccurrence of vocal disorders (Lee & Son, 2005). In another report of management strategies used in functional disorders in adolescents, several case study examples utilized techniques such as negative practice, producing normal phonation during non-speech activities such as throat clearing, coughing, auditory discrimination tasks and vocal hygiene lessons. The resolution of functional aphonia symptoms resolved in 1-2 treatment sessions for one patient and after 6 months in another case (Peppard, 1996). Muscle tension reduction techniques have been shown to work in reducing muscle tension in adolescents with functional voice related problems and groups of children with vocal nodules. Although vocal nodules are an overuse organic pathology, their presence has been related excessive laryngeal muscle tension. The MTD exacerbates the presence of abuse and misuse of the vocal folds and adds to the pathologic condition. Other therapy techniques that have been useful in reducing MTD, other than manual reduction, have been the classic arrangement of voice therapy techniques such as easy onset, tongue anchoring exercises, yawn-sigh and chanting talk (Boone & McFarlane, 2005). However, there have been no investigations studying the effects of manual tension reduction techniques in children with FD without any other therapeutic techniques being administered.


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This Month's Featured Author Bridget Russell, PhD, CCC-SLP State University of New York College at Fredonia

We are extremely grateful to Dr. Russell for providing this article for our newlsetter.

Dr. Bridget A. Russell received her B.A., M.A., and Ph.D. from the State University of New York at Buffalo. She is an Associate Professor at the State University of New York College at Fredonia. Her research interests are professional voice, and voice/respiratory disorders affecting speech production. She has published works in JSHLR and Voice, Speech Review, Speech and has served as editorial consultant for JSHLR and Delmar Publishing Group. She is director of the Speech Production Laboratory at SUNY College at Fredonia and is researching the efficacy of voice therapy with patients at the Voice Center of Western New York. She is the founder of the Voice Consortium of Western New York (VCWNY)

Tags: October 2009 Newsletter SLP Voice Disorders Dysphonia Article