Articles - Opportunity for In-Depth Discussion of
Postnasal Drip as a Cause of Muscle Tension Dysphonia
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.
Once throat tension is alleviated, sinus drainage has consistently been observed to begin immediately. Facial pain and sinus headaches end.
(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.
MUSCLE TENSION DYSPHONIA
The voice as a finely tuned instrument is capable of wonderful expression. However, it is also
Although prevalent in professional voice users, many individuals are at risk of MTD. There is a
It is important to recall that phonation involves the ordered and integrated control of the
There are three local causes of laryngeal irritation with discrete signs and symptoms. These are
Laryngo-pharyngeal reflux is common in 10% of the general population, but occurs in 46% of
An understanding of daily behaviour is essential. Whilst MTD can affect anyone, often sufferers
• Teachers are likely to have to speak above background noise in rooms with poor acoustics
• Singers and actors may have had plenty of voice craft for “work” but they often have a
• People talking on the telephone all day often use an inappropriate pitch, have few rests or
• Aerobics instructors have to shout above the music level to be heard and to motivate. They
Body posture may be poor and there is raised overall body tension (including the neck and
Indirect laryngoscopy (mirror examination) will afford a three dimensional view of the larynx.
Videostroboscopic laryngoscopy also involves a peri-oral examination holding the patient’s
Fibreoptic laryngoscopy via the nose is the best method of providing a clear view of the larynx
• antero-posterior squeezing with arytenoid and epiglottic apposition severely restricting vocal
• 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. posture and muscle usage
1. Posture and muscle usage
The compensatory laryngeal hyperfunction and the causes need to be identified and removed by
• a thorough explanation of the anatomy and physiology of the vocal tract with particular
• reassurance with the patient’s own laryngeal video that there is no serious pathology
• laryngeal “deconstriction” exercises in addition to altering the focus of resonance and tongue
• improvement in overall body posture and muscle relaxation particularly in the head, neck,
An understanding of the environmental and behavioural aspects of voice use allows
Personal behaviour can be adjusted with regard to smoking/alcohol/caffeine, whispering,
3. Laryngo-pharyngeal reflux
Individuals with LPR need a course of an acid reducing drug (ie. Zantac or Losec) and a
4. Psychological platform
As indicated at the beginning, the psyche and the voice are intimately related. Indeed the voice
Muscle tension dysphonia is a common condition in which poor vocal skills and excess muscle
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.
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
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
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.
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.