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Table of Contents
CASE REPORT
Year : 2016  |  Volume : 6  |  Issue : 1  |  Page : 25-27

Muscle tension dysphonia mimicking vocal fold paralysis


1 Otolaryngology Head and Neck Surgery Department, Gaziosmanpaşa Taksim Education and Research Hospital, Gaziosmanpaşa, Turkey
2 Üsküdar University, Faculty of Healh Sciences, Istanbul, Turkey

Date of Web Publication5-Apr-2017

Correspondence Address:
Dr. Ceki Paltura
Gaziosmanpaşa Taksim Education and Research Hospital Karayollari Quarter, Osmanbey Street 616 St. No.: 10 Gaziosmanpaşa Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2230-9748.203890

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   Abstract 

Muscle tension dysphonia (MTD) is a subtype of functional dysphonias that believed to be the result of misuse or abuse of an anatomically and neurologically intact larynx. MTD is usually seen in young to middle aged population who use his/her voice extensively in stressful situations. We had a 56-year-old female patient who underwent total thyroidectomy surgery and developed bilateral vocal fold paresis after the surgery. She had immediate tracheotomy and followed with tracheotomy tube for years. In our clinic examination, we found hyperadduction of the vocal folds and minimum activity and performed Botox® (Allergen, Irvine, California, USA) injection to the thyroarytenoid muscles. After 1 week, she decannulated. MTD is a rare and special disease. The disease can be primary without any organic pathology or secondary to a glottic closure problem. First treatment option must be speech therapy, but in resistant cases, surgery or Botox® (Allergen, Irvine, CA, USA) is suggested.

Keywords: Botox, functional dysphonia, muscle tension dysphonia, thyroidectomy, tracheotomy


How to cite this article:
Paltura C, Yelken K. Muscle tension dysphonia mimicking vocal fold paralysis. J Laryngol Voice 2016;6:25-7

How to cite this URL:
Paltura C, Yelken K. Muscle tension dysphonia mimicking vocal fold paralysis. J Laryngol Voice [serial online] 2016 [cited 2021 Aug 1];6:25-7. Available from: https://www.laryngologyandvoice.org/text.asp?2016/6/1/25/203890


   Introduction Top


Muscle tension dysphonia (MTD) is a subtype of functional dysphonias that believed to be the result of misuse or abuse of an anatomically and neurologically intact larynx.[1] There is an impairment of voice production, but no mucosal or neurologic disease.[2] Due to the intangibility of any organic pathology, the disease is widely accepted as psychologic disease.[1],[2] There is an alteration in laryngeal physiology during phonation as a result of excessive muscle tension.[2]

MTD is usually seen in young and middle aged population who use his/her voice extensively in stressful situations.[3] In physical examination, there is a muscle tension around the larynx that can be seen and palpated at suprahyoid region. The larynx is elevated. The main laryngoscopic feature of increased laryngeal tension is an open posterior glottic chink between the arytenoid cartilages.[3],[4] Excessive laryngeal or perilaryngeal hyperactivity can cause hyperadduction, constriction, or bowing of the vocal folds.[4],[5] The voice in MTD is breathy, strident, or harsh.[3] Patients usually complain of hoarseness, vocal fatigue or strain, painful phonation, or tightness in throat.[5] There are two forms of MTD. In primary MTD, there is a dysphonia without any organic vocal fold pathology. It usually occurs in middle-aged women and accounts for 10%–40% of voice clinic visits.[2],[6] Secondary MTD is dysphonia with the presence of underlying organic pathology.[6]

Botulinum toxin A (Botox) is a neurotoxin that blocks the release of acetylcholine from the presynaptic surface of a neuromuscular junction. This blockade causes paresis or paralysis till the new synapses occur.[7] For medical purposes, it was first used to treat strabismus by Scott et al. in 1981.[8] Then, it is successfully used to treat medical conditions such as dystonias, segmental dystonias, and postparalytic spasticity.[8]

We report a case of a patient that developed excessive hyperadduction of the false vocal folds (FVFs) after a thyroidectomy surgery that was mimicking bilateral vocal folds paralysis and needed tracheotomy.


   Case Report Top


A 56-year-old female patient consulted to our voice clinic. She had history of total thyroidectomy surgery 11 years ago. After the operation, she underwent emergent tracheotomy due to severe dyspnea and bilateral vocal fold paralysis on physical examination. Later, there were several attempts to close the tracheotomy, but she could not tolerate the procedure. In our physical examination, we found hyperadduction of both false and true vocal folds [Figure 1]. That finding allowed us to think about MTD. We did laryngeal electromyography and found an increased electrical activity on both sides. We had injected (2.5) IU of Botox ® (Allergen, Irvine, California, USA) to both thyroarytenoid muscles [Figure 2]. On postoperative 7th day, we closed the tracheotomy, and after a year and a half of follow-up period, she did not require Botox ® nor tracheotomy again.
Figure 1: Prebotox injection

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Figure 2: Postbotox injection

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   Discussion Top


MTD is a disease of patients who cannot cope with stressful conditions. On physical examination, tightness at paralaryngeal region can be visualized and palpated. Normally, phonation occurs with harmony of simultaneous contraction of the lateral cricoarytenoid and interarytenoid muscles and relaxation of the posterior cricoarytenoid muscles. However, in MTD, the relaxation of posterior cricoarytenoid does not occur properly, and arytenoids cannot move medially to close the glottis. To compensate for this space, thyroarytenoid and supraglottic muscles contract extensively.[3] This mechanism explains the physical appearance and possible complications of the disease.

According to Belafsky et al.[1] MTDs, “supraglottic hyperfunction is a physiologic attempt by the larynx to compensate for underlying glottal closure problems, such as vocal fold paralysis, paresis, or presbylaryngis.” They believe that most of the patients with organic vocal fold pathology develop MTD to compensate the defect in glottic inclosure.[1] This may be the problem in our patient. Our patient had a thyroidectomy and after the surgery developed bilateral vocal fold paresis not paralysis. The surgeons performed immediate tracheotomy. After a while, she gained control on her vocal cords and hyperadducted them. This prevented the decannulation of the patient. This tracheotomy and “never can talk or breath properly” stress lead her to supraglottic overcontraction and hyperadduction of both false and true vocal folds.

Hyperadduction of the FVFs is a form of MTDs. It is usually treated with speech therapy.[7] However, in very severe cases, surgery can be suggested.[9],[10] Botox ® injection to the FVF is now another treatment option for hyperadduction of the FVFs.[7] Rosen et al.[7] used Botox ® to treat a patient with severe FVFs hyperadduction disorder. This patient presented with severe dysphonia for a year and was found to demonstrate severe hyperadduction of the FVFs with all laryngeal activities except respiration. The patient had speech therapy and laryngopharyngeal reflux treatment but the symptoms did not subside. They administered Botox ® injection of 20 units/side.[7] After this treatment, the patient had improved and never needed an injection or therapy again. In laryngeal examination, we saw hyperadduction of both false and true vocal folds. This finding made us to think about the possibility of MTD. Laryngeal electromyography lead us to correct diagnosis. After Botox ® injection, we waited for a week for decannulation because of the previous unsuccessful attempts. It has been a year and a half now and our patient is tracheotomy free and never needed injection again.


   Conclusion Top


MTD is a rare disease for a general ear, nose, and throat specialist. However, it is seen frequently in voice clinics. The disease can be primary without any organic pathology or secondary to a glottic closure problem. First treatment option must be speech therapy, but in resistant cases, surgery or Botox ® is suggested.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Belafsky PC, Postma GN, Reulbach TR, Holland BW, Koufman JA. Muscle tension dysphonia as a sign of underlying glottal insufficiency. Otolaryngol Head Neck Surg 2002;127:448-51.  Back to cited text no. 1
    
2.
Sama A, Carding PN, Price S, Kelly P, Wilson JA. The clinical features of functional dysphonia. Laryngoscope 2001;111:458-63.  Back to cited text no. 2
    
3.
Morrison MD, Nichol H, Rammage LA. Diagnostic criteria in functional dysphonia. Laryngoscope 1986;96:1-8.  Back to cited text no. 3
    
4.
Morrison MD, Rammage LA, Belisle GM, Pullan CB, Nichol H. Muscular tension dysphonia. J Otolaryngol 1983;12:302-6.  Back to cited text no. 4
    
5.
Altman KW, Atkinson C, Lazarus C. Current and emerging concepts in muscle tension dysphonia: A 30-month review. J Voice 2005;19:261-7.  Back to cited text no. 5
    
6.
Van Houtte E, Van Lierde K, Claeys S. Pathophysiology and treatment of muscle tension dysphonia: A review of the current knowledge. J Voice 2011;25:202-7.  Back to cited text no. 6
    
7.
Rosen CA, Murry T. Botox for hyperadduction of the false vocal folds: A case report. J Voice 1999;13:234-9.  Back to cited text no. 7
    
8.
Scott AB. Botulinum toxin injection of eye muscles to correct strabismus. Trans Am Ophthalmol Soc 1981;79:734-70.  Back to cited text no. 8
    
9.
Kosokovic F, Lenarcic-Cepelja I. Surgical therapy of dysphonia plica ventricularis. Ann Otol Rhinol Laryngol 1973;82:386-8.  Back to cited text no. 9
    
10.
Feinstein I, Szachowicz E, Hilger P, Stimson B. Laser therapy of dysphonia plica ventricularis. Ann Otol Rhinol Laryngol 1987;96 (1 Pt 1):56-7.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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