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Postnasal Drip as a Cause of Muscle Tension Dysphonia
Survey of literature by Micki Nellis

Disclaimer: I am not a doctor. This is not medical advice. I researched this topic to help understand my own voice problem, which I believe was brought on by several months of allergies and postnasal drip. I sought to investigate the hypothesis that sustained postnasal drip caused the back of the throat muscles and the tongue muscle (genioglossus muscle) to tense, thereby disrupting the ability to speak easily.
Here's what I found:


***
From http://www.somatics.com/headaches.htm
Dr. Lawrence Gold

SINUS HEADACHES

Sinus headaches are linked to the musculature that lines the front of the neck vertebrae (back of the throat). This musculature affects tensions of the lining of the throat, which passes behind the nasal cavity. Excessive tension, there prevents normal sinus drainage.

Once throat tension is alleviated, sinus drainage has consistently been observed to begin immediately. Facial pain and sinus headaches end.
***
My hypothesis: If tense throat muscles affect sinus drainage, then sinus drainage can cause tense throat muscles. (MN)
***
From http://www.skullsurgery.aust.com/html/muscletension.html

Muscle Tension Dysphonia

(Abridged and reprinted from "Voice" 1997 - The Journal of the Australian Voice Association)

The voice as a finely tuned instrument is capable of wonderful expression. However, it is also the workhorse of every human for day to day communication. People have variable levels of vocal skill for their required tasks. Younger vocal folds are more resilient to poor usage whilst ageing requires more efficient technical ability to maintain "normal" voice.

Poor technique requires a compensatory hyperfunction to maintain phonation at a desired level. This increased effort results in fatigue. Clinical examination is generally "normal" hence the term "functional dysphonia" has been used indicating there is no organic abnormality. A more appropriate term is "muscle tension dysphonia" (MTD) due to excessive tension in the intrinsic and/or extrinsic laryngeal muscles.

Although prevalent in professional voice users, many individuals are at risk of MTD. A detailed history of the amount and type of voice use at home, socially and at work is essential. Phonation becomes breathy or harsh with use through the day and recovers with rest. It may involve severe vocal restrictions or complete loss of voice.

Fine control of the middle vocal frequencies is lost first and whispering or shouting later. Loss of control is generally due to some form of environmental stress rather than the effect of the vocal disorder. It evokes a psychomotor disturbance affecting muscle tension and thus posture, respiration and voice control. Organic changes in the vocal cords may occur secondary to such faulty use or overloading.

There are three local causes of laryngeal irritation with discrete signs and symptoms. These are post nasal drip, gastro-oesophageal reflux (GERD) and globus.

The sinuses secrete about a litre of mucus a day which is swallowed and aids lubrication. Complaints about a post nasal drip or a "frog in the throat" with frequent throat clearing are often due to increased awareness of this normal situation. However, both sinus disease and the effects of tobacco smoke on the nasal mucosa do produce thickened mucus.

Gastro-oesophageal reflux is common in 10% of the general population but occurs in 46% of professional voice users. Symptoms include: heartburn, acid tastes in the mouth, nocturnal coughing, an unpleasant taste in the mouth in the morning and halitosis (bad breath). Acid irritation causes hypertrophy of the laryngeal mucosa with thicker mucus and frequent throat clearing and coughing.

'Globus' is a "spasm" of the muscles of the lower part of the pharynx and literally means a "lump in the throat". Symptoms are described in a variety of ways including: a sore throat, vague rawness or dry feeling localised to the area of the larynx or below. In severe cases, the neck muscles can become tender with the ache extending up the neck muscles to behind the ear. The symptoms resolve during eating because swallowing allows the muscles to relax.

Alternatively people have intermittent hoarseness or "voice fatigue". The voice always returns to normal at certain times of the day. Globus can be precipitated by a postnasal drip or GERD.

Thorough clinical examination is mandatory. Treatment is based upon which one, or more, of these four parameters exists: 1. Body posture, voice and muscle usage 2. Behavioural aspects of vocal usage 3. Gastro-oesophageal reflux 4. Psychological issues.

Conclusion Muscle tension dysphonia is a common condition in which poor vocal skills and excess muscle tension result in early vocal fatigue. The patient needs reassurance that there is no serious pathology (i.e. cancer), which in itself is a stressor. Management demands a broad based multidisciplinary team approach which in our clinic include an otolaryngologist, speech pathologist and counsellor. The multifactorial basis of this condition must be appreciated, with targeted treatment for each individual.

*******
From http://www.voiceconnection.com.au/pdf/muscletension.pdf

MUSCLE TENSION DYSPHONIA
(Reprinted from “Voice” 1997 - The Journal of the Australian Voice Association) (Full Text of above synopsis)

The voice as a finely tuned instrument is capable of wonderful expression. However, it is also
the workhorse of every human for day to day communication. People have variable levels of
vocal skill for their required tasks. Younger vocal folds are more resilient to poor usage whilst
ageing requires more efficient technical ability to maintain “normal” voice. Consequently the
passage of time, with it’s changing physiological and psychological influences, means that poor
vocal skills result in diminishing vocal ability. Poor technique requires a compensatory
hyperfunction to maintain phonation at a desired level. This increased effort results in fatigue.
Frequently, an individual reports that whilst their career and lifestyle have not altered, their voice
has deteriorated. Clinical examination is generally “normal” hence the term “functional
dysphonia” has been used indicating there is no organic abnormality. A more appropriate term is
“muscle tension dysphonia” (MTD) due to excessive tension in the intrinsic and/or extrinsic
laryngeal muscles.

Although prevalent in professional voice users, many individuals are at risk of MTD. There is a
female predominance. A detailed history of the amount and type of voice use at home, socially
and at work is essential. Phonation becomes breathy or harsh with use through the day and
recovers with rest. Often this means over the weekend, away from work. It may involve severe
vocal restrictions or complete loss of voice by Thursday or Friday, with a weekend barely
providing sufficient recovery time. Fine control in the middle vocal frequencies is lost first and
whispering or shouting later.

It is important to recall that phonation involves the ordered and integrated control of the
respiratory system, larynx (voice box), pharynx (throat) and oral cavities (mouth) by the brain.
Loss of control is generally due to some form of environmental stress rather than the effect of the
vocal disorder. It evokes a psychomotor disturbance affecting muscle tension and thus posture,
respiration and voice control. Organic changes in the vocal cords may occur secondary to such
faulty use or overloading.

There are three local causes of laryngeal irritation with discrete signs and symptoms. These are
post nasal drip, laryngo-pharyngeal reflux (LPR) and globus. They will be discussed in turn. The
sinuses secrete about a litre of mucus a day, which is swallowed and aids lubrication. Complaints
about a post nasal drip or a “frog in the throat” with frequent throat clearing are often due to
increased awareness of this normal situation. However, both sinus disease and the effects of
tobacco smoke on the nasal mucosa do produce thickened mucus.

Laryngo-pharyngeal reflux is common in 10% of the general population, but occurs in 46% of
professional voice users. Symptoms include heartburn, acid tastes in the mouth, nocturnal
coughing, an unpleasant taste in the mouth in the morning and halitosis (bad breath). Acid
irritation causes hypertrophy (swelling) of the laryngeal mucosa with thicker mucus and frequent
throat clearing and coughing. Reflux of gastric acid and digestive juices through oesophageal
receptors, causes a reflex increase in muscle tension in the pharynx and larynx. Page 2
“Globus” is a spasm of the muscles of the lower part of the pharynx and literally means “a lump
in the throat”. It is a very common problem causing people a great deal of worry. Symptoms are
described in a variety of ways including a sore throat, vague rawness or dry feeling localised to
the area of the larynx or below. In severe cases the neck muscles can become tender with the
ache extending up the neck muscles to behind the ear. The symptoms resolve during eating
because swallowing allows the muscles to relax. Alternatively people have intermittent
hoarseness or “voice fatigue”. This varies depending upon the degree of cramping of the
muscles. The voice always returns to normal at certain times of the day. Globus can be
precipitated by a post nasal drip or LPR.

An understanding of daily behaviour is essential. Whilst MTD can affect anyone, often sufferers
belong to a particular group. The following examples illustrate a variety of lifestyles with
different effects upon the larynx:

• Teachers are likely to have to speak above background noise in rooms with poor acoustics
and dust. Teaching is a stressful job with rising pupil disruption, diminishing resources etc.
Smoking may also be a factor. Teachers rarely have received any education about voice care
or use despite years of training.

• Singers and actors may have had plenty of voice craft for “work” but they often have a
lifestyle with many adverse effects upon voice and health. These include episodic work,
living away from home, unsociable hours, late and inappropriate eating (eg. spicy foods
before going to bed) and socialising in noisy places with tobacco smoke and alcohol.

• People talking on the telephone all day often use an inappropriate pitch, have few rests or
appropriate drinks and limited vocal recovery time. The office atmosphere may be dry due
to air-conditioning.

• Aerobics instructors have to shout above the music level to be heard and to motivate. They
get dehydrated so have a high water intake, but exercise causes a type of reflux called “water
siphonage”.

Examination
Thorough clinical examination is mandatory to exclude organic laryngeal pathology. This
includes a voice laboratory analysis, psychological assessment and thorough examination of the
upper aerodigestive tract, neck and chest.

Body posture may be poor and there is raised overall body tension (including the neck and
laryngeal muscles) with MTD. This tends to be the result of bad habits laid down over the years
and accepted as normal. There is elevation of the larynx and hyoid bone due to increased tone in
the thyrohyoid and tongue base muscles. Tenderness of the thyrohyoid occurs unilaterally if not
bilaterally due to overuse. The increased tone also means it is difficult to move the larynx up and
down and from side to side. Laryngeal elevation may occur on phonation. Gentle downward
traction on the larynx after massage of the tender areas will bring it to a better position. This Page 3
should result in a reduction of the hoarseness and breathy nature of phonation. This is obviously
diagnostic. Similarly the cricothyroid muscle between the lower border of the thyroid cartilage
and the cricoid is likely to be tense and tender with reduced movement.

Indirect laryngoscopy (mirror examination) will afford a three dimensional view of the larynx.
This is essential in order to confirm that the vocal folds are at the same level. Furthermore, it
provides the most natural light for assessing mucosal colour and inflammation. Mucosal
inflammation may be localized or generalized. When involving the interarytenoid area alone it
indicates that there is LPR. Inflammation of the petiole (back of the epiglottis) is associated with
excessive coughing. Supraglottic inflammation often indicates a post nasal drip. Generalized
inflammation of the laryngeal and hypopharyngeal mucosa may occur with smoking, alcohol and
gross reflux.

Videostroboscopic laryngoscopy also involves a peri-oral examination holding the patient’s
tongue and this limits phonation to a single vowel. However, it allows a detailed assessment of
the vocal fold symmetry and regularity of vibration, glottal closure, amplitude of vocal fold
excursion, mucosal wave and non-vibrating portions of the vocal folds. It is only with the advent
of this great tool that changes like mucosal tethering due to scarring or tumour and vocal sulcas
(congenital vocal fold pocket) have been defined. Such changes cause dysphonia which
previously would have been mistaken for MTD.

Fibreoptic laryngoscopy via the nose is the best method of providing a clear view of the larynx
during normal phonation. The health of the nasal cavities and post nasal space can be verified
during this procedure. The vocal range and limits can be assessed, as well as the changing shape
of the larynx. Muscle tension dysphonia may be seen in a number of ways on phonation:

• antero-posterior squeezing with arytenoid and epiglottic apposition severely restricting vocal
fold output.

• false fold adduction with ventricle compression restricting vocal fold output.

• vocal fold shortening with increased mass and stiffness.

• abnormal vocal fold closure producing breathy and thus inefficient phonation.

There are six types :
1. posterior chink
2. variable position of glottal opening
3. eliptical opening or bowing
4. incomplete closure along most of the length of the fold
5. hour-glass shape
6. anterior chink
• increased adductor muscle tone
• increase in subglottal pressure and expiratory force

Management
A multi-disciplinary team (otolaryngologist, speech pathologist and counsellor at least) is
required to deal with the inter-relationship of the precipitating factors. Morrison classifies these
into four “platforms”:

1. posture and muscle usage
2. behavioural
3. LPR
4. psychological

1. Posture and muscle usage

The compensatory laryngeal hyperfunction and the causes need to be identified and removed by
re-education. The tug of war between the laryngeal elevators and depressors must end. The voice
needs to be sustained by correct breath support in a relaxed and unstrained manner. Less
laryngeal effort should enable greater vocal efficiency and output. These are achieved by a
combination of strategies including:

• a thorough explanation of the anatomy and physiology of the vocal tract with particular
reference to the patient’s own laryngeal video.

• reassurance with the patient’s own laryngeal video that there is no serious pathology
(ie.cancer)

• laryngeal “deconstriction” exercises in addition to altering the focus of resonance and tongue
and mouth placement

• improvement in overall body posture and muscle relaxation particularly in the head, neck,
back and shoulders. (ie. Alexander Technique)

2. Behavioural

An understanding of the environmental and behavioural aspects of voice use allows
improvements to be made. The environment can be improved to overcome poor
acoustics/amplification, dry air, dust or smoke, background or competing noise (bars, sporting
arenas, large family gatherings, airplanes and buses), inadequate rest.

Personal behaviour can be adjusted with regard to smoking/alcohol/caffeine, whispering,
shouting or screaming (ie. sporting events or night clubs), poor timing or types of eating, throat
clearing or coughing, dehydration, voice use at a lower or higher pitch than is comfortable.

3. Laryngo-pharyngeal reflux

Individuals with LPR need a course of an acid reducing drug (ie. Zantac or Losec) and a
“lifestyle” advice chart. If symptoms or the laryngeal mucosa fail to respond then the dose needs
to be doubled and a gastric emptying drug added (ie. Prepulsid). This is because reflux of gastric
digestive fluid (without acid) can have a similar effect on the larynx. Should symptoms persist
then dual pH monitoring is indicated. This technique uses a pH probe in the oesophagus and one
in the hypopharynx to identify and differentiate between hypopharyngeal and oesophogeal
reflux. In the presence of documented reflux resistant to medication, surgery to improve the
gastro-oesophogeal junction (oesophagus to stomach valve) is indicated ie. Nissen
fundoplication.

4. Psychological platform

As indicated at the beginning, the psyche and the voice are intimately related. Indeed the voice
may be seen as the mirror of the psyche. This is clearly found if one is about to speak to a group
of people: there is a lump in the throat, no voice and a desire to attend the bathroom again. A
normal stress response. In the bigger psychological picture, life has been described as “walking
along dragging a rope over one shoulder. Every now and then one picks up a boulder and ties it
into the rope and keeps walking.” Therefore our psychological load gets heavier with each step
and the mental energy required to keep walking increases. This may manifest as increased
muscle tension. Individuals may benefit from counselling to confront some of their fears or to
heal emotional trauma. Some need to know how to identify and understand past behavioural
patterning and learn new behaviour. Combined with the release of emotional blocks and
negativity, individuals can become relaxed, self-confident and more outgoing. Voice is one of
the major beneficiaries.

Conclusion

Muscle tension dysphonia is a common condition in which poor vocal skills and excess muscle
tension result in early vocal fatigue. The patient needs reassurance that there is no serious
pathology (ie. cancer) which of itself is a stressor. Management demands a broad based multidisciplinary
team approach. The multifactorial basis of this condition must be appreciated, with targeted
treatment for each individual.
Sources
1. Aronson, A.E. (1990) Clinical voice disorders. New York: Thieme
2. Morrison, M.D., Nichol, H. & Rammage, L.A. (1986)
Diagnostic criteria in functional dysphonia. Laryngoscope 94:1 Page 6
3. Morrison, M.D. (1997) personal communication
4. Damste, P.H. (1987) Scott-Brown’s otolaryngology, London: Butterworth
5. Sataloff, R.T. (1995) personal communication
6. Sataloff, R.T. (1991) Professional voice, The science and art of clinical care. Raven Press
7. Hirano, M. & Bless, D.M. (1993) Videostroboscopic examination of the Larynx.
Singular: San Diego
8. Alexander, F.M. (1984) The Use of Self, Centreline Press
Dr Jonathan Livesey
Jonathan Livesey is an Ear, Nose and Throat Surgeon with a special interest in voice. He is the
driving force behind the Voice Connection team and is a consultant at St Vincent’s Voice Clinic
at Darlinghurst. He has lectured internationally on his voice research and made a number of
instructional videos on voice including “The Voice and How it Sings”. Trained in England, he
had a Fellowship in Otorhinolaryngology, Head and Neck Surgery in Brisbane in 1995.

***

From http://www.yourtruevoice.com/health-article.html

Do lung problems cause voice disorders?

Respiratory problems are especially problematic to singers, other voice professionals, and wind instrumentalists, but they may cause voice problems in anyone. Support is essential to healthy voice production. The effects of severe respiratory infection are obvious and will not be enumerated. Restrictive lung disease such as that associated with obesity may impair support by decreasing lung volume and respiratory efficiency.

However, obstructive pulmonary disease is the most common culprit. Even mild obstructive lung disease can impair support enough to cause increased neck and tongue muscle tension and abusive voice use capable of producing vocal nodules. This scenario occurs even with unrecognized asthma and may be difficult to diagnose unless suspected, because many such cases of asthma are exercised-induced. Vocal performance is a form of exercise, whether the performance involves singing, giving speeches, sales or other forms of intense voice use. Individuals with this problem will have normal pulmonary function clinically and may even have normal or nearly normal pulmonary function test findings at rest. However, as the voice is used intensively, pulmonary function decreases, effectively impairing support and resulting in compensatory abusive technique. When suspected, this entity can be confirmed through a methacholine challenge test performed by a pulmonary (lung) specialist.
Treatment of the underlying pulmonary disease to restore effective support is essential to resolving the vocal problem. Treating asthma is rendered more difficult in professional voice users because of the need in some patients to avoid not only inhalers but also drugs that produce even a mild tremor. The cooperation of a skilled pulmonologist specializing in asthma and sensitive to problems of performing artists is invaluable.

Do allergy and post-nasal drip bother the voice?

Allergies and post-nasal drip alter the viscosity (thickness) of mucous secretions, the patency of nasal airways, and have other effects that impair voice use. Many of the medicines commonly used to treat allergies (such as antihistamines) have undesirable effects on the voice. When allergies are severe enough to cause persistent throat clearing, hoarseness and other voice complaints, a comprehensive allergy evaluation and treatment by an allergy specialist is advisable. "Post-nasal drip," the sensation of excessive secretions, may or may not be caused by allergy or sinus disease. Contrary to popular opinion, the condition usually involves secretions which are too thick, rather than too abundant. If post-nasal drip is not caused by allergy, it is usually managed best through hydration, and mucolytic agents such as those discussed below in the section on drugs for voice dysfunction. Reflux laryngitis can cause symptoms very similar to post-nasal drip, and it should always be considered in people who have the sensation of throat secretions, a lump in the throat, and excessive throat clearing.

Antihistamines and Mucolytics

Antihistamines may be used to treat allergies. However, because they tend to cause dryness and are frequently combined with sympathomimetic or parasympatholytic agents (decongestants) that further reduce and thicken mucosal secretions, they may reduce lubrication to the point of producing a dry cough. This dryness may be more harmful than the allergic condition itself. Mild antihistamines in small doses should be tried between voice commitments, but they should generally not be used for the first time immediately before performances if the vocalist has had no previous experience with them. Their adverse effects may be counteracted to some extent with mucolytic expectorants that help liquify thick mucous and increase the output of thin respiratory tract secretions. Guaifenesin, the most commonly prescribed mucolytic, thins and increases secretions. Humibid [Adams] is one of the convenient and most effective preparations of guaifenesin available. Entex [Baylor] is a useful expectorant and vasoconstrictor that increases and thins mucosal secretions. These drugs are relatively harmless and may be very helpful to patients who experience thick secretions, frequent throat clearing, or "postnasal drip." Steroids are a highly effective alternative to antihistamines for treating an acute allergic insult prior to voice commitment.

***

Thick mucous gives feeling of postnasal drip

http://www.voiceteacher.com/mathis.html

When outside temperature and humidity levels are uncomfortable, efforts to provide a healthy environment which contains a minimum humidity level of forty percent15 should often include running a vaporizer, humidifier, steamer, or hot shower, especially in homes or buildings which are centrally heated or air conditioned the year around. When outside humidity levels are too high, Stemple contends that the mucus of the respiratory tract may thin out, causing excessive drainage leading to throat clearing and coughing. He further states, though, that the presence of mucous drainage, or "postnasal drip," is a normal and natural function which should not be changed with over-the-counter "sinus" medicines which dehydrate the mucosal lining.16

Lawrence explains that normal mucus, which is watery, thin, and liquid, is rarely, if ever, perceived as being present. If overly aware of drainage, one is usually suffering from dehydration, although the thicker secretion can be the accompaniment of a problem such as sinusitis, upper respiratory infection, or a nasal allergy.17
Nasal allergies or sinus problems can make life miserable for the professional voice user, for these conditions can cause swelling of the tissues in the throat and larynx eventually leading to hoarseness.18 Severe or chronic allergies need specialized medical attention; however, if attacks are infrequent and mild and if problems are minimal, Sataloff advises the use of a mild antihistamine and/or decongestant. The drying effects of the antihistamine may be counteracted by mucolytic medications such as Entex, Organidin, Robitussin, or Humibid, which increase or thin upper respiratory secretions. These medications also help dryness caused by atmospheric conditions and overuse of the voice.19

***
From http://www.emedicine.com/ent/topic695.htm

Respiratory dysfunction

Respiratory impairment is especially problematic for professional performers. The importance of the breath has been well recognized in the field of voice pedagogy. Respiratory disorders are discussed at length in other literature. However, recognizing that obstructive pulmonary disease and its treatments may cause difficulty for voice professionals is important. Even mild asthma interferes with expiration, thereby undermining the power source of the voice. This commonly leads to compensatory hyperfunction, voice fatigue, and vocal injury.
Most pulmonologists treat asthma primarily with inhalers, which commonly cause laryngitis; steroid inhalers are also associated with fungal (candidal) laryngitis and possibly with vocal fold muscle atrophy. Whenever possible, singers and other voice professionals with obstructive lung disease should be treated with long-acting oral medications alone, minimizing or eliminating the need for inhalers. Recognizing that asthma can be induced by the exercise of phonation itself is particularly important, and in many cases, a high index of suspicion and a methacholine challenge test are needed to avoid missing this important diagnosis.

Allergy

Even mild allergies are more incapacitating to professional voice users than to others. Allergies commonly cause voice problems by altering the mucosa and secretions and causing nasal obstruction. Management of allergies is not covered in depth here, as this subject can be reviewed elsewhere. Patients with mild, intermittent allergies can usually be treated with antihistamines, although antihistamines should never be tried for the first time immediately before a performance. Because antihistamines commonly produce unacceptable adverse effects, trial and error may be needed to find a medication with an acceptable balance between positive effect and adverse effects for any individual patient, especially a voice professional.

Patients with allergy-related voice disturbances may find hyposensitization a more effective approach than antihistamine use, if they are candidates for such treatment. For voice patients with unexpected allergic symptoms immediately before an important voice commitment, corticosteroids should be used rather than antihistamines in order to minimize the risks of adverse effects (eg, drying and thickening of secretions) that may make performance difficult or impossible.
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