What is Muscle Tension Dysphonia in Singers?
Muscle tension dysphonia (MTD) is a common cause of vocal problems for singers, and occurs, to put it very plainly, when muscles that should not be used are being used for sound production. During normal, healthy singing, only the vocal chords should move, and there should be no tension in surrounding musculature. Instead, we have abnormal patterns of muscle activation resulting in very poor sound quality, pain, and an absence of vocal stamina. MTD is characterized by the vocal folds failing to come completely together, the cause being two muscles pulling in opposite directions simultaneously. It presents as a posterior glottic gap when viewed during a scope. It is generally a long term learned behaviour, and requires specific therapy or vocal training to correct – or at least improve – the problem. Sometimes, Muscle Tension Dysphonia can be referred to as Vocal Strain, but I tend to dislike the term because it infers that the only cause is over singing.
In most cases, MTD produces vocal symptoms without any actual physical damage, however if left unchecked, it can lead to serious or permanent damage.
Symptoms of Muscle Tension Dysphonia can include any or all of the following: vocal fatigue, difficulty projecting, pain in the area, an aspirated (breathy) sound, hoarseness, weakness, changes in pitch, strained and tense sound, loss of higher register, and poor vocal endurance overall.
What causes Muscle Tension Dysphonia?
There are many theories about the exact nature and causes, and little is known for certain. Causes vary significantly with individuals, and usually, there is more than one contributing factor.
Sometimes, untrained singers use muscles incorrectly to achieve a particular sound, or to project their voice with volume. Without doubt, improper vocal training is one of the major causes. Some trained singers with accomplished technique may undergo an injury or illness that causes them to compensate by using the muscles incorrectly. Over zealous singers, regardless of their level of training, can develop this condition by trying to sing more loudly than those around them…. and we almost all know one of these types of vocalists!
MTD can be caused by the body’s system reacting to environmental (external) or systemic (internal) irritants. These irritants commonly include upper respiratory infection, second-hand smoke, over-singing, demanding performances or practise, or stress and tension in the body.
There is another theory that Muscle Tension Dysphonia can be caused by incomplete relaxation of the posterior cricoarytenoid muscle. This muscle is responsible for opening the vocal folds. Incomplete relaxation can lead to incomplete opening of the vocal folds during each vibratory cycle of phonation. As a result, the thyroarytenoid muscle (the body of the vocal folds) over-contracts in compensation. This aberration of muscle activity is one possible cause of the problem in singers, especially those who tend to over sing, or who are holding a lot of tension in that area.
Another culprit can be excessive contraction of the muscles of the vocal folds – and those that connect the vocal folds and cartilages – and the muscles that connect parts of the larynx to other structures. Still another possibility is in-coordination of laryngeal muscle contraction with breathing. Generally, we can safely say that most theories, health issues aside, point to the singer holding tension, failing to co-ordinate controlled and relaxed breathing, and over – singing, causing muscle aberrations resulting from excessive contraction and pressure.
This problem should always be dealt with by a qualified Speech Pathologist or Therapist.
There are, however, some things you can do to help yourself prevent or resolve the problem.
Maintaining good vocal care is your first line of defence. (See blog on Vocal hygiene.) Always adequately warm up the voice (There are many warm up exercises on this site, all of which are useful for singers to train their voices, work on breathing, and can be used for warming up the voice prior to practise or performance.) What? Warm it up prior to practise, you say? YES! Prior to practise, warm up your voice!
And avoid the following as per the Vocal Hygiene post.
- Whispering
- Speaking or singing loudly, especially over noise.
- Speaking or singing outside of a pitch range that is comfortable for you, both high or low register
- Speaking or singing with excessive tension in the vocal muscles
- Singing in the “back of the throat”
- Coughing and throat clearing, especially in an excessive manner
- Speaking with a hard glottal attack
- Speaking or singing when out of breath, and forcing through to finish the sentence.
- Yelling, shouting, screaming.
Treatment of Muscle Tension Dysphonia.
The only safe treatment for Muscle Tension Dysphonia is voice therapy in the care of a qualified Speech Pathologist. It generally requires a course, starting more intensively with sessions perhaps twice or three times per week, but with progression, this usually tapers off to regular visits weekly, and then less frequently as the behaviour is adjusted. Do not attempt to self-diagnose, or self treat, this condition.
Untreated Muscle Tension Dysphonia can Lead to Permanent Injury and Loss of Vocal Quality.
If you are concerned that you may have MTD, please do not ignore symptoms and continue to perform. Untreated MTD carries several potential risks, two of which are Haemorrhage and Nodule formation. If left untreated for any length of time, the vocal folds themselves can be become damaged. Please immediately rest your voice (stop singing altogether!) , and seek professional guidance.
I have written a separate post on Hyperfunctional Phonation and Vocal Fatigue – they are well worth reading. Please note that I am not a Speech Pathologist and would never try to diagnose or treat MTD. I would always advise complete vocal rest, and an examination by a Healthcare Professional. These notes are only to help students of singing better understand some of the perils of misuse of the voice.
Some terms used in the past include ‘Vocal Hyperfunction’, ‘Muscle Imbalance or Muscle Misuse Dysphonia’. They share in common incorrect use of the muscles during phonation.
Basic corrective Procedures for Hyperfunctional Phonation.
Please refer to previous notes on Hyperfunctional Phonation prior to reading this chapter.
There are many reasons why singers develop a habit of “throat holding”, or restricting the extrinsic muscles of the larynx. Some causes are discussed in previous notes on this website, and include, but are not limited to, the following: poor posture, excessive use of “straight singing”, past trauma, both physical and psychological, incorrect use of the popular “belt” technique, and throat pressure/vocal pushing in order to achieve more volume and a bigger, richer sound. (By the term “straight singing”, I am referring to the straight tone without vibrato commonly used in many styles of singing from Popular and Country styles of Music, to Musical Theatre and some very early singing such as Gregorian chant.) Regardless of cause or underlying behavior, the net result is excessive laryngeal tension and rigidity – in plain terms, the vocal cords are under too much tension to function fluidly and effectively. Thus, the goal will always be elimination of tension.
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Relaxation.
Relaxation must be viewed from a holistic point of view. Firstly, the teacher must prepare a structured lesson that does not cause the student to experience a lack of direction and thus anxiety. The studio atmosphere needs to be both structured, yet fun and friendly, and the student needs to feel that they are being heard, and given the training, support, and direction needed to realise their ambitions. Furthermore, there needs to be recognition of the need for relaxation in the body as a whole. Time constraints allowing, it is of value to spend a few minutes working on bending and stretching exercises, rolling the head, doing exercises to loosen the tongue and jaw, and shaking out of arms and legs. These exercises are described in other notes on this website. In order to save valuable lesson time, students could be taught, and encouraged, to perform these exercises before attending, or while waiting for, their lesson. In order to reduce tension, students should not be “overfaced” like a young horse sent at too high a jump. Material that is realistic and achievable for the age, level of experience and the vocal fach of the student must be selected. I have seen eight year old students wobbling their way through uncertain renditions of operatic arias, gasping for air, arms flailing, singing in their throats to achieve a mature sound. This is not just a teaching issue. In the bigger picture, this is a social issue. What have we become, as a society, that we expect children to perform arias written for mature, highly trained voices, to interpret songs about love and death from so little experience in life, and to risk permanent damage to the beautiful young voices with which they have been gifted? Appropriate material is the basis for a relaxed performance.
2. Posture, breathing and support.
The next part of the lesson cycle should be, especially with less experienced students, a discussion on posture, breathing and support. I expect that singers and students, rather than teachers, will be reading these notes. If you are working under the tutelage of a mentor, please note that the first lesson should be a discussion on this topic prior to commencement of any singing. If not, my recommendation would be that you find another teacher. It should be an ongoing topic, monitored in every lesson. Sometimes, singers can be working with excellent alignment, only to develop a “habit” for one reason or another. It can be something as simple as a sore shoulder, with the singer protecting and avoiding pain in the area. Always remember that singing is a holistic art, engaging the entire mind and body, and everything that is happening at the time. Thus, every lesson, posture should be checked for alignment, and students encouraged to perform the same check at home before singing. Students, and indeed seasoned professionals, should be singing warm up exercises, scales, and vocalises at the start of their lesson or prior to performance. This time can be used to relax into correct posture, breathing technique, and engaging good support. Tense students tend to over support, pull in too strongly on the abdomen, or take in far more air than is required. Scales and vocalises are a critical path to good phonation. There is no substitution for exercises, be they singing on vowels, scales, arpeggios, or singing vocalises on both constant, and changing, vowels. No singer can learn from a book, or from notes on a website. For this reason, there are vocalises and exercises on this website, and I will refer in these notes to them, and how they can be of use. Students singing vocalises, without the complication of consonants or lyrics, are able to work exclusively on technique. Singers should be watched for any sign of tension, and can use a mirror at home when practising. Honest, ongoing, self evaluation is a critical part of learning.
3.Panic Breathing and Packing in the air. Some singers anticipate long phrases and cadenzas, and incorporate fear and panic breathing into their singing. This attitude will produce tension in the voice, and particularly where there are high notes involved. It is one thing to sing with focus, and quite another to sing with attack born out of apparent fear. The response created will be the temptation to take in too much air, and hold it. Again, this creates a type of tension which can easily be heard in the voice. I have always said to students that it is not necessary to suck in air like a whale swallowing krill. It is not about the amount of air, but the ability to control EXPIRATION.
4. A Balanced Onset. There are many articles on “attack” (I prefer the term “onset” since I don’t think any song should be “attacked”) to be found on the internet, and I will attempt to be brief with reference to onset in relation to tension. A singer with tense vocal folds will have great difficulty making a balanced attack. Usually, the result is essentially what is a tight “attack” with an explosion of air. This is known as a “glottal plosive”. The reason for this is that the glottis is closed, and it is necessary for the singer to use a great deal of breath pressure to blow the folds apart. It sounds violent, and is also often described as “glottal shock”. Because of the excessive strain produced, the delicate laryngeal musculature and membrane covering the vocal folds can be damaged by friction and impact. There is no doubt that this type of onset of sound can result in vocal nodules and polyps. It is imperative that students master a softer approach which involves synchronization of breath pressure with closure of the glottis. There should be no evidence of strain or wasted breath.
5. Exercises for a Balanced Onset. Once the relaxation exercises have been performed, and the singer has checked themselves – or been checked by the teacher – for correct posture, the following exercises will assist in the production of a soft attack without tension. Before singing or making any sound, the first step is to imagine or visualize the pitch, and dynamic level that is required for the piece of music. Take note of the dynamic markings, or if unmarked, use the lyrics and melody as a guide to decide how you would like to introduce the song. Take into account the quality of sound, and the genre of the music. Different genres are stylistically different in performance, and the singer who crosses genres without paying any heed to the style of the piece will not be well received by a knowing audience.
6.Using Imagination for Onset without Tension It is helpful for the singer to imagine that the tone starts in the head rather than in the larynx. Now breathe in easily and in a relaxed manner as though beginning a light yawn. Instead of following through with the yawn, suspend the breath, and start phonation very gently by imagining the sound and thinking about the sound rather than using musculature in the neck. It is vital to make sure that the tongue root does not become involved in this action, and that the action is kept gentle and tension free. Speak a light “an” concentrating on keeping the sound legato, without placing any stress on the throat, musculature, or abdomen. Imagine the sound and allow it to easily flow as though coming from the mind and head rather than from the larynx. When the exercise feels very free of any tension, change to lightly singing the same word, and then repeat using other words, “no”, “nay”, “nee”. When the exercise feels free of all tension, try singing it to one of the slower vocalizes, in high or low voice. Vocalise number 1 or 3 in the Nellie Melba vocalizes would be excellent for this purpose.
7. Jaw Tension, Tongue Tension. There are notes on tongue tension on this website. It is a very real problem for many singers, and I strongly encourage you to read them. Jaw tension is another culprit that can inhibit good phonation. The back vowels are less tense then the front vowels, and can be used in combination with consonants, to combat tension, and encourage the singer to relax. Again, using the “beginning of a yawn”, sing the back vowels gently, placing a consonant in front of them. Thus, we have “moo, mo, mon’ and “you, yo, yon” – a combination of back vowels and consonants. Try singing these as above, with a relaxed throat, and importantly, attitude.
Useful Corrective Exercises
- The Sob or Suppressed Laugh. The following notes are based on the brilliant work of Jo Estill. (Estill, J. [1996] Primer of Basic Figures [2nd ed.] Santa Rosa, CA: Estill Voice Training Systems.) This exercise is based upon the work of Jo Estill. As a young singer, I was told by one of my teachers that we sing best on a laugh or a sob. Using the major scale exercises, or any of the arpeggios, modes or scales on this site, give voice to them in a light “sob”. This is thought to widen the laryngopharynx. This sob and collar engagement is an exercise recommended by Janice Champman, in her work, “Singing and Teaching Singing”, 2nd Edition, [Plural Publishing, 2012.] It is considered to assist the engagement of the sternothyroid muscles. Stretch the thumb and forefinger around the throat, the singer will feel the base of the neck widen as in the case of a bird. It is important, when performing this exercise, to monitor alignment of neck and head either by the teacher – for inexperienced students – or using a mirror for more experienced singers. When recovering from thyroid surgery, and complete vocal loss, I found these exercises to be of the utmost value. There were some which I was already using, but others which I discovered in my research and and the daily practice of which set me on the path to recovery.
Absence of Vibrato.
There are many reasons why vibrato can be absent, and with reference to this topic, it is worthwhile to note that it can indicate laryngeal tension. It can also be the result of tongue tension – please refer to notes on the topic on this site. Often, when tension is resolved, vibrato will appear or return.
The following exercises will be useful for singers who wish to improve their technique, and can be easily downloaded from this site. Some of these exercises are also set vocalises for AMEB examinations. http://helencolemansinging.com.au/product-category/exercisefiles/
© Helen Coleman 2016
