Laryngeal Manipulation for Dysphagia with Muscle Tension Dysphonia

Integration of Dysphagia Therapy Techniques into Voice Rehabilitation: Design and Content Validation of a Cross-Therapy Protocol

BACKGROUND

The intricate relationship between swallowing and phonation, sharing anatomical and physiological substrates, underscores a clinical demand for integrated therapeutic approaches. Existing interventions often address these functions in isolation, overlooking their interconnected dynamics.

OBJECTIVE

To design and validate a cross-therapy protocol incorporating dysphagia therapy techniques (maneuvers/exercises) into voice rehabilitation. This protocol aims to exploit the shared biomechanical components of swallowing and phonation to improve both functions simultaneously in patients with underlying hypofunctional laryngeal pathology.

METHODS

A descriptive research design was employed, consisting of three phases: a comprehensive literature review and expert discussions in a German seminar format to conceptualize the protocol; detailed analysis and categorization of swallowing maneuvers/exercises; and content validation by a panel of seven experts through a structured evaluation instrument. The process integrated motor learning and exercise physiology principles to ensure the protocol's clinical applicability and theoretical coherence.

RESULTS

The developed cross-therapy protocol incorporates four core swallowing therapy techniques to voice therapy procedures. Selected swallowing therapy techniques target laryngeal excursion and vocal fold closure because they are critical components of swallowing and phonation. Expert validation yielded a Content Validity Coefficient exceeding 0.90 for most items, indicating high consensus on the protocol's relevance, clarity, and applicability. Adjustments were made based on feedback, enhancing the protocol's precision and user-friendliness.

CONCLUSION

We present a novel, evidence-based therapy protocol for voice and swallowing difficulties resulting from hypofunctional laryngeal pathology. Its development marks a significant step toward bridging the gap between swallowing and voice therapy. Future empirical studies are needed to assess its effectiveness in clinical settings.

The effects of Cricothyroid Visor Maneuver (CVM) therapy on the voice characteristics of patients with muscular tension dysphonia: A Case Series Study

OBJECTIVE

The purpose of this study was to assess the effects of a novel manual therapy, the Cricothyroid visor maneuver (CVM) therapy, on acoustic, auditory perceptual and self-assessment ratings in Muscle tension dysphonia (MTD) patients.

STUDY DESIGN

This was a retrospective study of 6 clinical cases.

MATERIALS AND METHOD

The study comprised 6 Persian speakers with MTD (2 men and 4 women) and mean age 38.50 ± 5.32 years. All patients underwent therapy between April and June 2021. Therapy was provided in five 30-minute sessions. This study used of acoustic measurement including smoothed cepstral peak prominence (CPPs), Dysphonia Severity Index (DSI), self-assessment scales include vocal tract discomfort scale (VTD), voice related quality of life (V-RQOL) and Consensus Auditory- Perceptual Evaluation of Voice (CAPE-V) for auditory perceptual assessment in pre- and post-CVM sessions.

RESULTS

In the present study the CPPs and DSI increased while only CPPs significantly changed in pre and post therapy (P < 0.05). Also, having done the therapy the total severity of dysphonia (CAPE-V) and VTD significantly decreased (P < 0.05) and V-RQOL significantly increased (P < 0.05).

CONCLUSIONS

These results suggest that CVM can be an effective method for promote significant improvements in acoustic measurements, auditory perceptual and self-assessment scales in patients with MTD.

Zebras in Adult Dysphagia Workup: Where to Look When You Think You Have Looked Everywhere

While many patients who present with dysphagia have a clinically identifiable cause of dysphagia, the etiology of swallowing difficulty is oftentimes a diagnostic enigma. The aim of this article is to review possible etiologies of dysphagia when objective evidence of dysphagia is lacking. Included in this discussion are cricopharyngeal spasm, retrograde cricopharyngeal dysfunction, muscle tension dysphagia, dysphagia secondary to medications, and functional dysphagia.

Muscle Tension Dysphagia: An Expanded Investigation of Clinical Presentations and Swallowing Kinematics

PURPOSE

This study retrospectively examined patient-reported symptoms, quality of life, and swallowing kinematics in individuals with presumed muscle tension dysphagia (MTDg).

METHOD

Twenty-six individuals met the inclusion criteria. Data were gathered from patient-reported outcome measures (PROs), symptomology, clinician reports of palpation, and hyolaryngeal and hyoid movements measured on a 20-ml thin liquid bolus during videofluoroscopic swallowing studies.

RESULTS

All PROs were outside of typical limits, except for the Voice Handicap Index-10. Mean hyoid excursion was 1.52 cm (SD = 0.46, range: 0.76-2.43), and hyolaryngeal excursion was 0.77 cm (SD = 0.44, range: -0.42-1.68). A minority of participants (4%-19%) demonstrated atypical hyoid and/or hyolaryngeal excursion compared to the available normative reference value sets.

CONCLUSIONS

Individuals demonstrated abnormalities in the clinical evaluation of the areas of palpation and reported perilaryngeal discomfort and symptoms of laryngeal hyperresponsiveness, with a negative impact on their quality of life across various PROs. Atypical hyoid and/or hyolaryngeal excursion during swallowing was rare when compared to available normative reference values. The clinical evaluation of MTDg may be enhanced by including components related to muscle tension and laryngeal hyperresponsiveness in order to differentiate MTDg from idiopathic functional dysphagia and lead the patient to the otolaryngology/speech-language pathology clinic for intervention and management.

Relative Fundamental Frequency in Individuals with Globus Syndrome and Muscle Tension Dysphagia

OBJECTIVE

Relative fundamental frequency (RFF) has been investigated as an acoustic measure to assess for changes in laryngeal tension. This study aimed to assess RFF in individuals with globus syndrome, individuals with muscle tension dysphagia (MTDg), and individuals with typical voices.

METHODS

RFF values were calculated from the speech acoustics of individuals with globus syndrome (n = 12), individuals with MTDg (n = 12), and age- and sex-matched controls with typical voices (n = 24). An analysis of variance was performed on RFF values to assess the effect of group.

RESULTS

There was no statistically significant effect of group on RFF values, with similar values for individuals with globus syndrome, individuals with MTDg, and control participants.

CONCLUSIONS

These results suggest that individuals with these disorders do not appear to possess paralaryngeal muscle tension in a locus and/or manner that directly impacts voice production.

Clinical and Electromyographic Assessment of Swallowing in Individuals with Functional Dysphonia Associated with Dysphagia Due to Muscle Tension or Atypical Swallowing

Introduction: Over the past few years, attention has been paid to the coexistence of dysphonia with dysphagia, in the context of functional disorders. The aim of this work was to objectify logopaedic examination of dysphonic patients with coexisting swallowing difficulties by surface electromyography. Methods: The material of the work included 58 patients with muscle tension dysphonia (MTD). Each patient underwent otolaryngologic, phoniatric and logopaedic examination. We collected information about medical history and asked patients to fill out Reflux Symptom Index (RSI), Eating Assessment Tool (EAT-10), Dysphagia Handicap Index (DHI) and Swallowing Disorder Scale (SDS). The algorithm of dysphagia diagnostics in our clinic assumes parallel surface electromyography (SEMG) during Functional Endoscopic Evaluation of Swallowing. Results: In comparison to patients suffering from atypical swallowing, patients with muscle tension dysphagia (MTDg) obtained higher values from almost all questionnaires. Logopaedic evaluation revealed abnormalities in the structure and efficiency of the articulatory organs and in the assessment of primary functions. Patients with more abnormalities in logopaedic examination had significantly higher infrahyoid muscle activity during swallowing observed in EMG. Patients with non-normative swallowing pattern had significantly greater asymmetry of the average and maximum amplitude of masseters, as well as submental muscles. Patients with higher percent of muscles asymmetry gained higher scores in questionnaires. Conclusions: Surface electromyography objectifies logopaedic examination of patients with swallowing difficulties. The results of this work showed that, apart from longer swallows, patients with MTDg differ from patients with non-normative swallowing patterns in the muscle activity measured by SEMG, abnormalities in logopaedic evaluation and the severity of complaints reported by patients.

Whiplash-Associated Dysphagia and Dysphonia: A Scoping Review

Swallowing and voice complaints after a whiplash injury have been observed and reported in several studies; however, variability in study design complicates current understanding of whether dysphagia and dysphonia should be recognised as potential adverse outcomes. A scoping review was conducted across six databases from 1950 to March 2019. A total of 18 studies were included for review. Data regarding study purpose, design, outcome measures, participant characteristics and outcomes reported were extracted. Level of evidence (LOE) was assessed by the American Speech-Language Language Association (ASHA)'s LOE system. All studies were exploratory, with 68% rated as poor (< 3) on quality ratings. Nearly half (n = 6) were single case reports. Only three studies investigated some type of swallow-related outcome specifically within the study aim/s. Incidence of swallow-related problems ranged from 2 to 29%, with unspecified complaints of "swallowing difficulty", "dysphagia" and fatigue and pain whilst chewing reported. Neither swallowing biomechanics nor the underlying pathophysiology of swallow or voice complaints was investigated in any study. Four case studies presented post-whiplash voice complaints; two of which described loss of pitch range. Others described hoarseness, loss of control and weak phonation. Most studies only mentioned swallow- or voice-related deficits when reporting a wider set of post-injury symptomatology and six did not describe the outcome measure used to identify the swallow and voice-related problems reported. The existing literature is limited and of low quality, contributing to an unclear picture of the true incidence and underlying mechanisms of whiplash-related dysphagia and dysphonia.

Mucosal wave measurements in the diagnosis of functional dysphonia

ntroduction: The publication describes the characteristics of the glottis in FDs objectified by OQ, measured with VSK and EGG.

AIM

The aim of the study was to objectify glottal function in different types of FDs. The scope was to use open quotients gained from various mucosal wave imaging techniques for differential diagnosis of FDs.

MATERIAL AND METHOD

The study included 204 individuals. In the study, each patient underwent otolaryngological and phoniatric examination. LVS, EGG and VSK were conducted, their results were recorded and stored using an EndoSTROB-DX- -Xion GmbH (Berlin) device with DIVAS software.

RESULTS

All patients with FDs had abnormalities in LVS. A statistical analysis showed differences in LVS characteristics according to the type of FD. The mean value of OQVSK was 0.521 in the control group and 0.565 in the study group (P &lt; 0.05). Significant differences were found between patients with hypofunctional - 0.584 and hyperfunctional dysphonia - 0.55. The QOQEGG mean value in patients with FDs was 0.581 and in the control group 0.549 (P &lt; 0.01). There were statistically significant differences between groups of patients with hyper- and hypofunctional dysphonias. Medians amounted to 0.574 and 0.604, respectively. Authors observed different relations of OQ with the type of FD. They decided to introduce a new parameter, illustrating the proportion of QOQEGG/OQVSK.

CONCLUSIONS

Videostrobokymographic and electroglottographic open quotients differentiate euphony from dysphony. The value of OQVSK and QOQEGG and their proportion varies depending on different types of functional dysphonias. The OQVSK and QOQEGG should be included in the diagnostic algorithm of voice.

Prevalence of dysphagia in patients with muscle tension dysphonia

Background

It is hypothesised that patients with muscle tension dysphonia have a high prevalence of dysphagia in comparison to normative values reported in the literature.

Methods

This prospective study included 44 subjects diagnosed with muscle tension dysphonia, based on symptoms and laryngoscopic findings, and 25 control subjects with no history of dysphonia and normal laryngeal examination findings. Demographic data included age, gender and smoking history. The aetiology of muscle tension dysphonia was classified as primary or secondary. Evaluation involved the Eating Assessment Tool (‘EAT-10’) questionnaire.

Results

Patients’ mean age was 45.93 ± 14.95 years, with a female to male ratio of 1.2:1. Fourteen patients had primary muscle tension dysphonia, while 30 had secondary muscle tension dysphonia. Among patients with secondary muscle tension dysphonia, Reinke's oedema was the most common aetiology. There was a significant difference in the prevalence of dysphagia between the study group and the control group (40.9 per cent vs 8 per cent respectively, p &lt; 0.05).

Conclusion

This study demonstrates a higher prevalence of dysphagia in patients with the presenting symptom of dysphonia and diagnosed with muscle tension dysphonia in comparison to subjects with no dysphonia.