Use of Inhalation Phonation in treating Muscle Tension Dysphonia (MTD) in Singers
Extreme muscle tension dysphonia (MTD) during phonation
Muscle tension dysphonia (MTD) is characterized by excessive muscle recruitment resulting in incorrect vibratory patterns of vocal folds and an alteration in voice production. It is the technical term for stressful or strenuous overuse of the voice, resulting in vocal dysfunction. Over time, untreated MTD results in worsening of symptoms, including loss of vocal range and pain when singing/performing, as well as development of benign vocal fold lesions, vocal fold tear, or vocal fold hemorrhage.
Physical Correlates of Muscle Tension Dysphonia:
▪ Increased compression of ventricular folds
▪ Increases tension in the thyroarytenoid muscle
▪ Imbalance of intrinsic and extrinsic laryngeal musculature
▪ Increased compression of true vocal folds during phonation
▪ Restriction of Cricothyroid joint
▪ Imbalances in surrounding musculature, e.g, scalenes, SCM, masseter, etc
▪ Elevation of larynx high in neck, disturbing pharyngeal space/resonance
▪ Narrowing of pharyngeal cavity
▪ Restricts the movement of the laryngeal cartilages (altering vocal range)
▪ Global tension in head and neck musculature
▪ Decreased mouth opening
▪ Depressed sternum, rounded shoulders, forward head position
▪ Tongue and jaw tension
▪ Decrease in power
▪ Fatigue
Etiology of MTD typically seen in singers :
▪ As a response to a weakness (paresis) of the vocal folds (SLNp)
▪ As a response to changes on the vibratory edges of the vocal folds (e.g., swelling or masses resulting in insufficient glottic closure)
▪ As a response to insufficient breath management for singing voice
▪ As a result of the lack of or sub-optimal vocal training (effortful production)
▪ In response to irritation from an infection or reflux
▪ Because of improper postural alignment (including shoe choice)
▪ Singing without feedback (poor monitors when singing amplified)
▪ Stress (work, relationship, loss)
▪ As a result of mood issues such as anxiety and depression
▪ Physical weakness from an eating disorder
▪ Pelvic floor dysfunction
Inhalation
When we inhale, the vocal folds open and the muscular architecture in the supraglottic tract expands and opens.
This action results in:
*ventricular distention/widening
*pharyngeal widening
*descent of laryngeal carriage
*velar ascent
Inhalation Phonation (IP)
▪ Production of voice during inspiration in paradox to normal voice production
▪ Deliberate sound production on ingressive airflow
▪ Otherwise known as “Reverse Phonation” or “Ingressive Voice Production”
Rationale for use of IP with Singers
▪ Organic in nature, e.g., naturally occurs in laughing, crying and gasp
▪ Maintains open posture of inhalation during phonation
▪ Assists in vocal fold entrainment through Bernouli Effect in reverse
▪ Ventricular compression abates eliminating pressed phonation
▪ Promotes inverse mucosal wave /improved vibratory characteristics of vfs
▪ Improves physiological control of vocal folds
▪ Promotes a more symmetrical pattern of vocal fold contact
▪ Models appropriate physiology for restructuring muscle tension
▪ Trains coordination of inspiratory diaphragm and pelvic floor musculature
▪ Contracts cricothryoid muscles resulting in stretching of vocal folds
▪ Increases fundamental frequency (for restructuring inappropriately low Fo)
▪ Naturally lowers larynx
▪ Increases airflow associated with phonation
▪ Can produce on specific pitches and pulse mode of phonation
▪ Promotes a global improvement of the vocal fold signal and sensations
Using Inhalation Phonation in Singers
▪ Begin with training inhalation phonation in isolation
▪ Sometimes need to start with phonation and move to IP (Eeyore)
▪ Best to do IP immediately followed by voice on the exhalation
▪ Once IP is achieved in speaking voice, move to sung vowels
▪ If singer is not able to produce IP with pitch, use speaking voice IP
▪ Nasal inhalation/reverse hum is a good starting place
▪ Use hierarchy of sounds, e.g., vowel, syllable, word, partial phrase
▪ Important to cue relaxed inhalation
▪ Cue release of pelvic floor/lower abdominal musculature
▪ Can be used on specific pitches and pulse mode of phonation
▪ With advanced students, can use inhalation straw phonation
Singing Voice Exercises
▪ IP vowel followed immediately by descending 5-note scale
▪ Alternating IP/EP on descending 3- or 5-note scale
▪ Alternating IP/EP on ascending 3- or 5-note scale
▪ Increase range of exercise and extent of IP
▪ Add an /h/ or /m/to the vowels to move to syllable level
▪ IP on 1st word of phrase, EP on entire phrase (chanting)
▪ IP on 1st word of a phrase of a song, EP on remainder of phrase
▪ Extend IP to multiple words, EP on remainder of phrase
▪ IP before sung phrase, EP entire phrase
▪ IP as a pre-phonatory gesture without sound but with benefit of IP
Other Rationale for using Inhalation Phonation
▪ Pre-phonatory gesture to restructure narrowed pharynx
▪ Restoring vocal function with vocal fold paresis (SLNp)
▪ Improving vf entrainment with benign vocal fold lesions
▪ Post-op restoration of vibratory characteristic of vfs
▪ Cueing or training abdominal/pelvic floor musculature
▪ Optimizing vocal technique in healthy singers
▪ Diagnosing location and presence of lesions w/strobe exam
▪ Restoring true vf phonation in pts w/ventricular phonation
▪ Increasing ease in phonation w/ pts with SD
▪ Improving vibratory characteristics of vfs w/pts w/ vf scar
▪ Decreasing pressed phonation
References
(1) Finger, L.S., Cielo, CA. (2007). Reverse phonation-physiologic and clinical aspects of this speech voice therapy modality. Rev Bras Otorrinolaringol 73(2): 271-7.
(2) Orlikoff, R.F., Baken, R.J., Kraus, D.H. (1997). Acoustic and physical characteristics of inspiratory phonation. J Acoust Soc America, 102(3): 1838-1845.
(3) Robb, M.P., Chen, Y., Gilbert, H.R., Leiman, J.W. (2001). Acoustic comparison of vowel articulation in normal and reverse phonation. JSHR 44, 118-127.
(4) Shulman, S. (2000) Symptom modification for abductor spasmodic dysphonia: Inhalation phonation. In J.C. Stemple (eds). Voice Therapy: Clinical Studies (2nd ed). San Diego, CA: Singular Publishing Group.
(5) Colton, R.H., Casper, J.E., Leonard, R. (2006). Understanding Voice Problems: A Physiological Perspective for Diagnosis and Treatment (3rd ed.) Baltimore, MD: Williams & Wilkins.
(6) Tomlinson, C.A., Archer, K.R. (2014). Manual Therapy and Exercises to Improve Outcomes in Patients with Muscle Tension Dysphonia. Physical Therapy.
(7) Kelly, C., Fisher, K. Stroboscopic and acoustic measures of inspiratory phonation. (1999). J of Voice 13(3): 389-402.
(8) Wattremez, A., Delpech, C., DeBrugiere, C., Chevaillier, G. (2011). Reverse phonation: Pathological and therapeutic aspects. Study of a clinical case. Revue de laryngologie-otologie-rinologie.
(9) Lopes, M.V., Behlau, M., DoBrasil, O.O.C., Andrade, D. (1999). The use of inspiratory phonation to characterize laryngeal benign lesions. Revista Brasileira de Otorinolaringologia.
(10) Zimmer, V., Cielo, C.A., Finger, L.S. (2010). Spectrography of acoustic vocal modifications produced by reverse phonation. Revisit CEFAC, Jul-Aug 12(4): 535-542.
(11) Finger, L.S., Cielo, C.A. (2008). Acoustic vocal modifications produced by reverse phonation. Revista da Sociedade Brasileira de Fono.
(12) Behlau, M. (2000). The use of inspiratory phonation to characterize laryngeal benign lesions. Rev Bras Otolaringol Jan.
(13) Vanhecke, F., Lebacq, J., Manfredi, C., Raes, G-W., DeJonckere, P.H. (2016) Physiology and Acoustics of Inspiratory Phonation. J of Voice (In Press).
(14) Moerman, M., Vanhecke, F., Van Assche, L., Vercruysse, J., Daemers, K, Leman, M. (2016). Vocal Tract Morphology in Inhaling Singing: An MRI-Based Study. J of Voice (In Press).
(15) Goff-Fynn, J., Carroll, L.M. (2012). Collaboration and Conquest: MTD as viewed by voice teacher (Singing Voice Specialist) and Speech-Language Pathologist, J of Voice 27(3): 391e9-e14.
Copyright © 2016, Kate A. Emerich
