A Singer With Muscle Tension Dysphonia (MTD)

This is my first blog post as a singing voice rehabilitation specialist.

It is important that I state that I do not work in a clinical setting, but privately, on referral from Speech-Language Pathologists and other Singing Voice Rehabilitation Specialists. This is one case, one approach. For every singer recovering from MTD, there will be different needs, different reasons for the condition, and different exercises.

If you’d like a good article on MTD and solutions, read “Collaboration and Conquest: MTD as Viewed by a Singing Voice Specialist and a SLP,” by  Goffi-Fynn and Carroll. (PubMed) Communicating in a unified medical language is important so that the team of an otolaryngologist, speech-language pathologist and voice teacher can communicate about their patient-student.

However, translating my quick-as-lightening intuition to speaking quantifiable medical language with others is my weak suit and, even after almost 10 years as a SVS, I am constantly trying to learn how to do it. Different parts of the brain are responsible for speech and for language processing. Evidently my Broca’s Area is not as strong as my Wernicke’s….So, what follows is an accurate, but unclinical, account of working with Roz.

Roz is in her late 20’s and has already experienced more than her share of vocal pathology and vocal issues. She holds a BM degree in vocal performance and is a professional chorister with excellent musicianship and a beautiful voice. She loves to sing early Western choral music and was employed at a large cathedral as a soprano in their octet. She is an event photographer as her day job.

She recently left her church job to seek medical help when her voice started skipping pitches. She also was not able to phonate the beginnings of phrases that started with vowels. Then her singing became breathy and cut out at about C-5. Her speaking voice seemed ok but she was afraid that would start to be a problem, too.

Roz’ SLP from John’s Hopkins’ Voice Center forwarded me her diagnosis and history, which included treatment for reflux, pre-nodules, partial paresis of the left vocal fold, vocal fold scarring and a non-vocal surgery. This history had left her ultra-aware of when to seek help.

Right now, the suggested medical protocol for a singer with vocal fold dysfunction is to first see a qualified otolaryngologist who truly understands a singers’ needs. Many otolaryngologists and ENT doctors do not have this sub-specialty, and even those who say they work with singers often are inexperienced or have surgical solutions as the only options to severe pathology. A prized otolaryngologist knows that small changes that might not be important to a non-singer’s voice can make or break a singer’s ability to sing what they want or need to sing.

Then, a speech-language pathologist, usually associated with the voice clinic, sees the patient for voice therapy. Some speech-language pathologists are singing voice specialists, and many are not. (Just like some voice teachers are singing voice specialists and many are not.) I had been teaching singing for about 27 years before I began to move in this direction, and it became a way to turn lemons into lemonade after I was diagnosed with bi-lateral vocal fold paralysis in early 2013. My singing voice specialist is Jeanie Lovetri, founder of Somatic Voicework tm: The Lovetri Method and The Voice Workshop in New York City.

The SLP saw Roz for one session and showed her manual neck massages to begin to unwind her tension responses. I introduced Roz to Vibrant Voice Technique and the use of a vibrator to help make the manual massages more effective. The wise use of a vibrator helps relax muscles that do not belong in the singing process, and allows “the right” muscles to begin to work before strengthening them.  In pathology patients, it is not an instant fix but improvement is seen and felt almost right away.

MTD’s pathology is not life-threatening and can be solved, but is insufficient to explain the degree of dysphonia is causes. There are many reasons why someone can develop this frustrating condition. In Roz’s initial consultation with me, she shared that she had been singing in an abusive situation. She knew that she was reacting to, and recoiling from, the abysmal choral conducting and not-so-subtle emotional abuses of the church organist who was also the choral conductor at the cathedral where she sang.

Singers who have not had an opportunity to learn how to deflect this kind of negativity will have it reflect in their bodies and throats. In her case, over time, her effective vocal technique became unable able to respond to the glorious music, collaboration with other singers and the conductor. She also was stiffening and collapsing muscles in her throat to create the stylized “no vibrato” sound and was anxious because she could not follow the director’s waving and stabbing of his fingers in the air as he played the organ. And she was cowing under his constant criticism of the sopranos, of which she was one of two. While it is possible to sing in the musical style she loves with minimum vibrato, it becomes impossible under this kind of conductor unless you can focus solely on what you need to do and block out everything else that does not serve your goals.

“Learned vocalization for speech and song is developed by auditory input of one’s environment but not in the mammalian system.  In many people these two systems are often disassociated.”  (Christy Ludow, Communication Sciences and Disorders, James Madison University.)  I based all of Roz’s initial vocal exercises on sounds that come from our limbic system. (involuntary sounds made when we have not been severed from the spontaneous expressions of anger, fear, desire, surprise, etc.)

In Roz’s case, her muscles were in hyper-function, but this masked hypo-function. Her voice stopped speaking somewhere along the line so she kept forcing closure in order to get sound, which eventually led to the dysphonia. In this case, the exercises were kept very short, often on whatever pitch came out as opposed to specific pitches, using the syllables “thack” or (thae.) Roz had a great deal of anger and disappointment left over from her experience, so all the exercises were preceded with physical expression of those emotions by punching a pillow for a minute, or punching the air, etc, followed by one sound of emotional expression on that specific syllable.

A week later we removed the “th” and went through a similar procedure. Every single time, she phonated on a vowel when she allowed it to come from her emotional motor system! (limbic part of the brain.)

Pacing of the lesson was important to ensure she didn’t get tired or discouraged and she used the vibrator off and on all through the lessons. After about two lessons she was able to phonate short pitch patterns, moving up and down the scale, stopping for frequent short breaks. She could sing certain vowels over short intervals, which enabled her to really feel her progress.

After 3-4 lessons, the muscles where the tongue meets the hyoid bone and others were sufficiently released that we could add tiny squeaks and squeals to help activate the cryco-thyroid muscles. This had to be done slowly, with her using the vibrator and me manually massaging the back neck muscles to watch for a return to hyper-function of the neck muscles, but she progressed. Then we moved from one tiny squeak down an interval of a third. Then we moved to exercises involving more than one syllable like “ihi-(eehee)-ihi-ihi-ihi” on one pitch or a pattern, coordinating with conscious use of transverse abdominals to get things going.  She had no trouble accessing and isolating various abdominal muscles, which was a testimony to her former technique.

From there we moved to a sustained (i) over short traditional vocalize patterns. When the voice skipped, she’d rest, repeat all the patterns in sequence. and take off again. She is almost ready to move into the standard voice therapy exercises (Stempler, semi-occluded variations, straw bubbling in water, etc.) We absolutely could not start with those.

Slowly her beautiful voice is reemerging, and she realizes she will sing again before the year is out. But now she will look for a choral situation that is what she knows the experience can be!

If you liked this post, please comment, like or share. This helps me know that others found it useful or fun, and encourages me to post more like it! Thanks for being here!

The cover art is my contemporary collage “A Vocal Chord.” 🙂 The vocal fold shapes are stacked in bowls, like pitches in a chord! Come on people! If you guys don’t get it, no one will!

7 Comments Add yours

  1. Another absolutely fascinating read. Thanks so much for this!

    Liked by 1 person

  2. Jeff Costello says:

    Wonderful. Thanks for sharing.

    Like

  3. Thank you, Justin and Jeff! You guys rock for taking the time to read and comment.

    Like

  4. This is such important work, Cate. Very glad you have gone down this path.

    Like

  5. Sharny says:

    What a great article. Extremely educational. Thank you Cate!

    Like

  6. Nancy and Sharny, thanks for the votes of confidence and glad you found the article useful.

    Like

  7. Pati Wolfgang says:

    Just beautiful! What a bundle of good information! Please tell Roz we’re pulling for her!! I’m glad she’s found such a safe team! It made me tear up to think. As the therapist Ann Smith said, “Positive people need a positive environment.”

    Liked by 1 person

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