A Singer With Muscle Tension Dysphonia (MTD)—One Case

For my work as a singing voice rehabilitation specialist, it is important to 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 and protocols.

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 can be important, so that the team of an otolaryngologist, speech-language pathologist and voice teacher can communicate about their patient-student.

“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 was starting to ‘catch’ in the middle of phrases.

Roz’ SLP  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.

In 2022, the suggested standard 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’s do not have this sub-specialty, and even those who say they work with singers often are inexperienced or don’t use the proper equipment to view vocal fold behavior.

After evaluation, then a speech-language pathologist, usually associated with the medical voice clinic, sees the patient for “voice rehabilitation.” Generally this is speaking voice rehabilitation, which requires a different sort of therapy than singing rehabilitation. Some speech-language pathologists are also qualified singing voice specialists, and many are not. Just like some voice teachers are vetted singing voice specialists, and many are not.)

MTD’s pathology is not life-threatening and can be solved, but this name is totally 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 professionally 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 usually effective vocal technique became unable able to respond to the glorious music, collaboration with other singers and the conductor. She also was stiffening or 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 have emotionally strong boundaries and can focus solely on what you need to do, blocking out everything else that does not serve your goals. These are skills that can develop over time with effective coaching.

“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 and noises 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, both the muscles of her throat and body were locked in hyper-function, but this masked hypo-function.

In her 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.

She practiced about ten minutes a day and also kept up her speaking voice exercises. A week later we removed the “th” and went through a similar procedure. Every single time, she phonated on a vowel when she related it to what phonation had 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 what she had learned about throat massage. 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 tongue attachments to the hyoid bone were sufficiently released that we could add tiny squeaks and squeals to help activate her cryco-thyroid muscles. This had to be done slowly to allow some time for her to feel if there was 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 an easy conscious use of transverse abdominals and intercostal muscles 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

And here’s the thing: She absolutely could not start with the exercises by Stempler or semi-occluded variations with a straw, because they tied her up immediately.

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!