Anterior-Posterior and medial compression of the supraglottis: signs of nonorganic dysphoniaor normal postures?

Summary: Two vocal tract postures commonly identified as hallmarks of nonorganic dysphonia are anterior–posterior and medial compression of the supraglottis. However, insufficient data exist to support their diagnostic utility. The purpose of this study was to compare these two postures in patients with nonorganic dysphonia and normal controls using interval data derived from quantitative measures of videostroboscopic images obtained with an oral endoscope. Retrospectively, 40 patients with nonorganic dysphonia and 40 normal controls were selected. Relative anterior–posterior compression (LO_AP) was calculated as the laryngeal outlet (LO) (the view of the true vocal folds during phonation) normalized to the anterior–posterior dimension in pixels. Relative ventricular fold medial compression (LO_W) was calculated as the laryngeal outlet normalized to the medial dimension in pixels. Results were as follows: (1) LO_AP was significantly greater for the dysphonic group, (2) the range of LO_AP values between the two groups overlapped considerably, (3) no significant difference was found between groups for LO_w, (4) the correlation between LO_AP and LO_W within each subject yielded r values of 0.71 and 0.67 for the nonorganic dysphonia and normal control groups, respectively. It is concluded that medial compression of the ventricular folds can be a normal laryngeal posture, and that although anterior–posterior compression is present in greater degree in dysphonics, it is sufficiently common in normals to question its utility as a diagnostic sign of phonatory dysfunction.     

Current and Emerging Concepts in Muscle Tension Dysphonia: A 30-Month Review

The modern theory of hoarseness is that there are multifactorial etiologies contributing to the voice problem. The hypothesis of this study is that muscle tension dysphonia is multifactorial with various contributing etiologies. METHODS: This project is a retrospective chart review of all patients seen in the Voice Speech and Language Service and Swallowing Center at our institution with a diagnosis of muscle tension (functional hypertensive) dysphonia over a 30-month period. A literature search and review is also performed regarding current and emerging concepts of muscle tension dysphonia. RESULTS: One hundred fifty subjects were identified (60% female, 40% male, with a mean age of 42.3 years). Significant factors in patient history believed to contribute to abnormal voice production were gastroesophageal reflux in 49%, high stress levels in 18%, excessive amounts of voice use in 63%, and excessive loudness demands on voice use in 23%. Otolaryngologic evaluation was performed in 82% of patients, in whom lesions, significant vocal fold edema, or paralysis/paresis was identified in 52.3%. Speech pathology assessment revealed poor breath support, inappropriately low pitch, and visible cervical neck tension in the majority of patients. Inappropriate intensity was observed in 23.3% of patients. This set of multiple contributing factors is discussed in the context of current and emerging understanding of muscle tension dysphonia. CONCLUSIONS: Results confirm multifactorial etiologies contributing to hoarseness in the patients identified with muscle tension dysphonia. An interdisciplinary approach to treating all contributing factors portends the best prognosis.     

Effects of Muscle Tension Dysphonia on Tone Phonation: Acoustic and Perceptual Studies in Vietnamese Female Teachers

Muscle tension dysphonia (MTD) is a hyperfunctional voice disorder commonly seen in professional voice users. To date, published acoustic studies of this disorder have mainly focused on nontonal language speakers, and no publication has documented its impact on lexical tone characteristics. In this study, we examined whether and how this voice disorder affected acoustically and perceptually the characteristics of tones in Vietnamese teachers. Voice data were obtained from 42 Vietnamese female primary school teachers diagnosed with MTD and 30 vocally healthy teachers. Tonal data were analyzed using Computerized Speech Lab (CSL-4300B) and Speech Analyzer. Parameters analyzed included the two most important acoustic cues in Vietnamese tones, that is, tonal fundamental frequency (F₀) and laryngealization. Tonal F₀ was assessed using a factorial analysis of variance with group and career durations as independent variables. Tonal samples were also perceptually assessed by a panel of native speakers of the same dialect. The results showed that MTD lowered tonal F₀ in high tones and tones with extensive fundamental frequency variation. There was also a significant main effect for career duration; in MTD group, tonal F₀ was lower in teachers with longer career duration. The teachers with MTD showed different patterns of laryngealization compared with the control group. Tone perception was poorer for tones with extensive fundamental frequency variation and without a typical phonation type. The results in this group of teachers supported our hypothesis that MTD impairs lexical tone phonation.     

Psychogenic dysphonia: Peeling back the layers

Resolution of psychogenic dysphonia is often quick and effortlessfor client and therapist alike. In such instances, the therapeutic interventions are simple and straightforward, insights are reached without difficulty, and once normal voice has been established, resumption of dysphonia or other psychosomatic symptoms rarely occurs. Sometimes, however, psychogenic dysphonia is extremely difficult to overcome, requiring considerable time, effort, and determination on the part of the client, coupled with confident, skilled persistence and psychotherapeutic insight from the therapist. In such cases one feels a sense of working through many complex layers before obtaining satisfactory voice or reaching an understanding of the psychogenic factors that precipitated onset and/or maintenance of the dysphonia.

Two cases that illustrate this involved process of peeling back the layers are presented. For resolution of severe psychogenic dysphonia, the therapist must be able to recognize and establish the complex relationship between the neurophysiological, intrapsychic, and interpersonal levels of function as they affect the client's voice and person, as a whole. This work requires considerable courage and skill on the part of the therapist to question, explore, change direction, and select alternative approaches. It is important that the problem can be resolved with a depth of understanding which is relevant for the client, and with due attention to the social context and wider systems of which he or she is a part.     

Neurovegetative symptoms and complaints before and after voice therapy for nonorganic habitual dysphonia

In a previous study, female patients in all age categories with a nonorganic dysphonia were found to report significantly more autonomic symptoms and complaints than healthy controls. This could not be confirmed for the male subgroup. The present study is to corroborate and nuance this observation by investigating larger groups, and to determine if, after voice therapy, the number of autonomic symptoms and complaints-particularly those ones that have no obvious relation to voice function-decreases. It is a prospective study with a matched control group; 184 patients with nonorganic dysphonia and 126 normal controls answered a questionnaire of 46 questions with 3 subsets and a consistency control. One hundred and one patients received functional voice therapy and completed the questionnaire before and after treatment. A matched control group of 42 normal subjects also filled in the questionnaire two times, with an interval of about 6 months. Neurovegetative symptoms and complaints-voice related and not related-are reported in highly significant excess by patients (especially but not exclusively females) with habitual nonorganic voice disorder. After therapy, there is a highly significant reduction in the number of autonomic symptoms and complaints (related or not related to voice), to such an extent that patients report on average no more general neurovegetative symptoms and complaints than healthy controls (even less). The number of neurovegetative symptoms and complaints connected with voice function is also strongly reduced in patients after therapy, but remains in significant excess when compared with controls.     

Outcome of laryngeal manual therapy in four Dutch adults with persistent moderate-to-severe vocal hyperfunction: a pilot study

A relatively new management strategy for the treatment of voice disorders is the use of laryngeal manual therapy. The main purpose of the present pilot study is to document the outcome of vocal quality after a well-defined laryngeal manual therapy (LMT) program. Four Dutch professional voice users with a persistent moderate or severe muscle tension dysphonia were studied pretreatment (1 week before LMT) and posttreatment (1 week) after completion of manual therapy (25 sessions). These subjects had received several months of traditional voice therapy, without any success. To measure and compare, the effect of LMT objective and subjective assessment techniques were used. Perceptual voice assessment included a perceptual rating of the voice using the GRBAS scale. Furthermore, the vocal quality in this population was modeled by means of the Dysphonia Severity Index (DSI). All of the subjects selected for LMT showed improvement in perceptual vocal quality and DSI values. As the DSI is a weighted variable including aerodynamic and acoustic measures, small improvements (closer to 5) are very indicative of vocal quality improvement.¹ The use of LMT in professional voice users with persistent moderate-to-severe muscle tension dysphonia, especially in some subjects who have not responded to traditional voice therapy, is supported by this pilot study.     

Psychological correlates of functional dysphonia:An investigation using the Minnesota multiphasic personality inventory

Abnormal psychological factors have been implicated in the development of functional dysphonia (FD). This investigation describes the personality and psychological characteristics of 25 female subjects who had received the diagnosis of FD. In all subjects symptoms were resolved after voice therapy. While vocally asymptomatic, these remitted subjects with FD completed the Minnesota Multiphasic Personality Inventory (MMPI), an objective personality questionnaire. When compared with a medical outpatient control group, the results showed that subjects with FD scored significantly higher on 7 of 10 clinical scales, suggesting an elevated degree of emotional maladjustment. A stepwise logistic discriminant analysis identified 2 clinical scales that provided valuable discriminatory power between the two groups. Scale I (Hs-hypochondriasis), which measures the number and type of reported somatic complaints, and scale 7 (Pt-psychasthenia), a measure of diffuse anxiety, discriminated the groups with 88% sensitivity and 89% specificity. The results suggested that in spite of symptom improvement after voice therapy, the subjects with FD continued to exhibit poor levels of adaptive functioning, which may represent trait-like vulnerability. The clinical implications of these results for voice practitioners are discussed.     

Adductor spasmodic dysphonia and muscular tension dysphonia: Acoustic analysis of sustained phonation and reading

Acoustic phonatory events were identified in 10 women diagnosed with adductor spasmodic dysphonia (ADSD) and compared to 5 women and 5 men diagnosed with muscle tension dysphonia (MTD). The three acoustic parameters examined during sustained vowel production and reading included phonatory breaks, aperiodicity, and frequency shifts. Intra- and intermeasurer correlations showed high reliability for the measures. Findings indicated that those with ADSD produced a greater number of aberrant acoustic events than those with MTD. The results suggested that: (1) only those with ADSD show evidence of phonatory breaks during vocalization, albeit a sustained vowel or voicing during reading; (2) those with ADSD demonstrate greater variation in the type of aberrant acoustic events produced as a function of speech task. The latter point suggests that control of the larynx varies as a function of task demand, a finding not evident in the functionally based disorder of MTD. MTD is a disorder that often presents itself in a similar clinical manner to ADSD because of its perceptual commonalties and resembling laryngoscopic characteristics. The acoustic analysis presented in this study could be used as a method to assist in distinguishing between the two disorder types.     

Psychogenic spasmodic dysphonia: A case study with expert opinions

Spasmodic (spastic) dysphonia (SD) is considered by some to be a neurologic syndrome and by others a symptom complex of multiple etiologies, neurologic and psychogenic. A case of a 26-year-old female psychiatric nurse with psychogenic SD (PSD) is presented. The dysphonia was alleviated within one session of voice therapy. Psychogenic etiology was established by the author, based on three diagnostic criteria—symptom incongruity, symptom reversibility, and symptom psychogenicity. Seven nationally recognized voice experts listened to audio-recorded samples of the patient's pre- and posttherapy voice during conversational speech. The experts agreed that the dysphonia was psychogenic and characterized it as staccato-like speech, effortful phonation, and interrupted flow of speech; six characterized it with intermittent voice arrests (voice stoppages); five with hoarse-harsh voice; and four with waxing and waning, strained-strangled phonation. These are often described as salient features of SD. Nevertheless, the experts disagreed among themselves as to whether the dysphonia was characteristic of SD and should be labeled as such. The author argues that as long as the voice characteristics and pathophysiologic findings that constitute SD are not well delineated, and as long as the diagnosis of SD is based on symptoms alone, patients with psychogenic or poorly understood voice disorders are likely to be misdiagnosed with organic (neurologic) SD and thus subjected to undue medical treatment. The author also argues that the debate over the etiology of SD can be resolved if SD is considered a neurologic syndrome, PSD a nonorganic phonatory disorder that mimics the syndrome, and if the voice symptoms and pathophysiologic characteristics of SD are well defined and agreed on.     

Psychogenic voice disorders and traumatic stress experience: a discussion paper with two case reports

Psychogenic dysphonia refers to loss of voice where there is insufficient structural or neurological pathology to account for the nature and severity of the dysphonia, and where loss of volitional control over phonation seems to be related to psychological processes such as anxiety, depression, conversion reaction, or personality disorder. Such dysphonias may often develop post-viral infection with laryngitis, and generally in close proximity to emotionally or psychologically taxing experiences, where "conflict over speaking out" is an issue. In more rare instances, severe and persistent psychogenic dysphonia may develop under innocuous or unrelated circumstances, but over time, it may be traced back to traumatic stress experiences that occurred many months or years prior to the onset of the voice disorder. In such cases, the qualitative nature of the traumatic experience may be reflected in the way the psychogenic voice disorder presents. The possible relationship between psychogenic dysphonia and earlier traumatic stress experience is discussed, and the reportedly low prevalence of conversion reaction (4% to 5%) as the basis for psychogenic dysphonia is challenged. Two cases are presented to illustrate the issues raised: the first, a young woman who was sexually assaulted and chose to "keep her secret," and the second, a 52-year-old woman who developed a psychogenic dysphonia following a second, modified thyroplasty for a unilateral vocal fold paresis.     

Use of topical lidocaine in the treatment of muscle tension dysphonia

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.     

A study on the mechanism of functional dysphonia

A total of 333 patients with a diagnosis of functional dysphonia were studied by both laryngeal electromyography (EMG) and spectral analysis. EMG and acoustic analysis revealed that some patients with so-called functional dysphonia diagnosed by physical examination alone in fact suffered from a variable degree of laryngeal nerve paralysis. Laryngeal EMG plays an important role in determining whether patients with a diagnosis of functional dysphonia have organic disease of the laryngeal nerves.     

Revisiting the Pitch Controversy: Changes in Speaking Fundamental Frequency (SFF) After Management of Functional Dysphonia

Speaking fundamental frequency (SFF) and its perceptual correlate "habitual pitch" have been considered important and contentious parameters in voice assessment and treatment. In clinical circles, disagreement exists regarding the role of habitual pitch in the development, maintenance, and treatment of disordered voices. Despite these divergent opinions, few studies have objectively evaluated SFF changes associated with voice improvement after therapy. To determine whether consistent directional and magnitude changes in SFF occur after management, pretreatment and posttreatment audio recordings of 40 women with functional dysphonia were analyzed. All subjects were treated with manual circumlaryngeal therapy, a treatment approach that does not directly target pitch as a perceptual entity to be manipulated. Results indicated that, as a group, no significant change in mean SFF was observed after successful management. Although no consistent directional pattern was identified, 80% of the subjects experienced pitch changes greater than one semitone; this suggests that voice improvement is often accompanied by a shift in SFF. Clinical implications of the data are discussed.     

Spastic/spasmodic vs. tremulous vocal quality: motor speech profile analysis

Strained, strangled, and tremulous vocal qualities that are typically seen in adductor spasmodic dysphonia (ADSD), voice tremor (Tremor), and the spastic dysarthria of amyotrophic lateral sclerosis (ALS) may sound similar and be difficult to differentiate. The purpose of this study was to determine if these vocal qualities of neurologic origin could be differentiated on the basis of acoustic and motor speech parameters. Three groups of subjects (ADSD, ALS, and Tremor) were analyzed by the Motor Speech Profile System (Kay Elemetrics, Lincoln Park, NJ) for fundamental frequency (Fo), standard deviation of Fo, diadochokinetic rate (ddk), standard deviation of ddk, mean intensity and standard deviation of ddk, frequency and amplitude variability in connected speech, and speaking rate in connected speech. Profiles of the three groups are presented with the significant features that differentiated one from the other.