Posted by We often learn in academic, clinical experience, or continued education about the wide array of etiologies for a dysphagia (and I mean WIDE in every sense of the word!). But what if we don’t know? What if there’s nothing you can see on any of the swallow studies, no cause for concern? What happens when there’s no explanation for our patient’s symptoms not being addressed?
If your brain speeds straight to psych or malingering, pump those breaks and keep reading to find not only some possible approaches for this kind of patient but some sweet spoilers along the way!🤫🤯
I was pretty excited about this topic as I’ve never personally worked with this subset population, but have been intrigued ever since I did a second take after hearing dysphagia instead of dysphonia when it comes to tension.
First and foremost, let’s define just what this muscle mystery is:
“Muscle Tension Dysphagia (MTDg) is a diagnosis of exclusion after careful consideration with comprehensive interdisciplinary evaluation.” p.1
Well, remember having to figure out which multiple-choice answer is correct even when you’re not entirely sure? That’s exactly what MTDg requires by first eliminating any of the following diagnoses:
- neurological disease
- esophageal diseases (GERD does not count)
- structurally abnormal laryngoscopic exam
- history of head&neck cancer (or radiation to head/neck/chest)
- structural and/or functional abnormalities of deglutition from VFSS (including structural concerns such as web, cricopharyngeal hypertrophy, eosinophilic esophagitis, cervical osteophytes, etc.)
Easy enough?
🛑Not too fast🛑 Don’t forget that when muscle tension forms by an effort to adapt because of other underlying issues, this tension can still persist even if the initial problem is resolved/treated!
Example: If you start walking differently because you broke your ankle by putting more weight on the other side of your body (to compensate and avoid making your initial injury worse), you might end up not only creating more tension in other muscles (due to this sudden imbalance and overuse), but also create a whole new secondary problem even after your first injury heals! Hence our lovely physical therapists! (If that didn’t make sense, feel free to bring this topic up to an actual PT to get what I’m sayin😅). So keep this in mind if your patient not only doesn’t have anything else going on that could be the cause but also if other causes are resolved yet the subjective symptoms still continue. . .
What are the symptoms of MTDg?
Who is more likely to have them?
“These patients report a significant impact of their dysphagia on quality of life and increased medical expenditures due to repeated specialist evaluations with no diagnosis or treatment offered..They often present to us after having been evaluated by multiple specialists with no answers, thus resulting in increased anxiety and even fear of swallowing.” p.1
“Women represent greater prevalence compared to men(>60%). Ages greater than 50 years represent higher prevalence(>50%).” p.2
Common swallow-related symptoms often reported:
- hard to swallow
- odynophagia
- choking
- sensation of food sticking in throat
- coughing with eating/drinking
- Most difficult textures (in order): solids, liquids, saliva
- Dysphagia is frequently reported as primary complaint
Concurrent laryngeal signs/symptoms that can often also be present (remember, reflux-related issues can also be simultaneous!):
- Laryngeal hyperresponsiveness (LHR) disorders such as:
- irritable larynx syndrome
- chronic cough
- paradoxical vocal fold motion
- globus pharyngeus
- muscle tension dysphonia
The authors cite their original theoretical framework (Kang et al., 2016) that revealed: “patients with idiopathic dysphagia demonstrated normal findings on videofluoroscopic swallow study yet showed evidence of excessive laryngeal muscle tension with laryngoscopy” along with their own 2017 prospective study which demonstrated “MTDg appears to be a functional swallowing disorder associated with abnormal laryngeal muscle tension that can occur with or without accompanying disorders of LHR” (with data on actual patient pre/post quality of life measures awaiting publication!😮).
Take a peek at this awesome illustration the authors even provide to help you understand this umbrella laryngeal muscle tension symptom:
SPOILER #1:
Just like pretty much anything in our field, there is NO one-size-fits-all approach for this area either!ðŸ¤
As far as evaluation goes, here’s what the authors’ comprehensive approach looks like though:
- VFSS (using MBSImP)
- Stroboscopy for thorough evaluation of laryngeal structure/function (either trained laryngologists or voice specialist SLPs)
- “includes assessment of suspicious mass or lesions; presence of nonlaryngeal inflammation (NLI) evidenced by erythema or edema of the arytenoids, postcricoid region and/or true vocal folds, interarytenoid pachydermia, and hypopharyngeal wall cobblestoning; glottic closure and vocal fold vibratory characteristics; phonatory presence of supraglottic compression and pharyngeal wall compression; and laryngeal LHR evidenced by glottic narrowing (>50% vocal fold adduction) during quiet breathing” p.2
- Gastroenterology clinic for those with signs of NLI (if not already completed)
- esophagogastroduodenoscopy with biopsies for eosinophilic esophagitis
- high-resolution manometry (HRM) with stationary impedance
- Bravo pH probe off proton pump inhibitors (PPI)
- esophagogastroduodenoscopy with biopsies for eosinophilic esophagitis
- Comprehensive perceptual/objective clinical voice evaluation
SPOILER #2:
Just like with about everything else in our field, patient-centered treatment is also a critical element for MTDg!!🤯
“Although the patients do not exhibit clinical signs of dysphagia, they are offered patient-centered treatment options with the goal of restoring optimal laryngeal function in an effort to treat their symptoms.” p.2
Primary MTDgº:
- Voice Specialist SLP targeting unloading of tension
Secondary MTDgº:
- Emphasizes management for:
- sinonasal, laryngeal, gastroenterological, psychosocial irritants
- laryngeal hypersensitivityº
- Multidisciplinary team may include:
- pulmonology
- gastroenterology
- allergist
- psychiatry
- Voice Specialist SLP targeting unloading of tension
Get your tuning forks and dusty microphones out from your speech closet!
“Voice therapy techniques that are well known to unload laryngeal muscle tension include, but are not limited to”:
- semi-occluded vocal tract exercises
- stretch-and-flow phonation
- manual therapy
- conversation training therapy
Wondering if you should also toss in some sweet ‘ole swallowing exercises too?🤔😬
“Our experience has shown that swallowing exercises targeting strengthening were shown to worsen the MTDg symptom complaints as they increased laryngeal muscle tension.”
“Our past studies revealed an average of four voice therapy sessions before patients reported 80%–100% symptom relief regardless of the primary or secondary classification.” p.3
Now, does that mean this is what your therapy session should look like or how many sessions your patient has to complete?
But seriously, patient-centered = individualized.
Individualized = what YOUR patient needs, where they are, at that time.
To prove this point while also giving you a comprehensive example, the authors even provide their own patient case study to get your SLP juices flowing and questions forming!
Make sure to check out the whole article and keep an eye out for more research in this area in the future!
“The authors of this manuscript and other investigators are currently performing studies to better identify the role of laryngeal muscle tension in this population. High-definition pharyngeal manometry shows promise in objective measures of pre/post-therapy outcomes.” p.4
Article Referenced: [ASHA FREE ACCESS]
Muscle Tension Dysphagia Evaluation and Treatment. (2020). Retrieved 15 December 2021, from https://pubs.asha.org/doi/abs/10.1044/2020_PERSP-20-00069
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