Original Research
Otolaryngology–
Muscle Tension Dysphagia:
Symptomology and Theoretical
Framework
Christina H. Kang, MM, MS, CCC-SLP1, Joseph G. Hentz, MS2,
and David G. Lott, MD1
No sponsorships or competing interests have been disclosed for this article. Received February 12, 2016; revised June 3, 2016; accepted June 8,
2016.
Abstract
Objective. To identify symptoms, common diagnostic findings,
pattern of treatments and referrals offered, and their effi-cacy in a
group of patients with idiopathic functional dyspha-gia in an
otolaryngology setting with multiple providers.
Study Design. Case series with chart review.
Setting. Tertiary academic center.
Subjects and Methods. Following Mayo Clinic Institutional Review
Board approval, a retrospective chart review was con-ducted of
patients with dysphagia who had a videofluoroscopic swallow
study between January 1, 2013, and April 30, 2015. Each
patient’s dysphagia symptomology, videofluoroscopic swal-low
study, flexible laryngoscopy, and medical chart were reviewed to
identify the treatment paradigms that were utilized.
Results. Sixty-seven adult patients met the inclusion criteria.
Abnormal laryngeal muscle tension was present in 97% of
patients. Eighty-two percent of patients also demonstrated signs
of laryngeal hyperresponsiveness. Nonspecific laryngeal
inflammation was evident in 52% of patients. Twenty-seven
patients were referred to speech-language pathology for
evaluation. Thirteen patients completed a course of voice therapy
directed toward unloading muscle tension. All 13 patients self-
reported resolution of dysphagia symptoms.
Conclusion. The study results suggest that laryngeal muscle
tension may be a factor in the underlying etiology in patients
with idiopathic functional dysphagia. We propose the diag-
nostic term muscle tension dysphagia to describe a subset of
patients with functional dysphagia. Further prospective stud-
ies are needed to better evaluate potential gastroesophageal
confounders in this group of patients and to identify an
effective paradigm for treatment. In our limited series,
speech-language pathology intervention directed toward
unloading muscle tension appears effective.
Keywords
laryngeal sensitivity, laryngeal hyperresponsiveness,
muscle tension dysphonia, functional dysphagia,
laryngeal paresthe-sia, irritable larynx
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Head and Neck Surgery
American Academy of
1–6
Otolaryngology—Head and Neck
Surgery Foundation 2016
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599816657013
http://otojournal.org
S wallowing difficulties are common among patients who present to
otolaryngologists. Unfortunately, the etiology of dysphagia is often
elusive. An epidemiologic study
of patients with swallowing symptoms documented a low
inci-dence of serious organic disease.1 In our
multidisciplinary clinic, patients with dysphagia typically
undergo endoscopic laryngeal examination and instrumental
swallow studies to rule out potential organic etiologies. Much
of the time, the assess-ment (history, physical examination,
swallow study evaluation, and gastroenterology referral)
reveals no underlying etiology for the dysphagia, leading to a
diagnosis of idiopathic func-tional dysphagia. These patients
report a significant impact of their dysphagia on quality of
life and increased medical expen-ditures due to repeated
specialist evaluation with no diagnosis or treatment offered.
There are very few studies that describe idiopathic func-
tional dysphagia in the literature. The Rome Foundation
Classification of Functional Esophageal Disorders III
identifies functional dysphagia as a subcategory of functional
esophageal disorders: 1 of the 6 major domains of functional
gastrointest-inal disorders.2,3 Factors such as genetic
predisposition, early family environment, psychosocial
factors, abnormal motility, visceral hypersensitivity,
inflammation, and bacterial flora are discussed.4
In our clinical experience, we noticed a population of
patients who had abnormal swallowing symptomatology, a
normal videofluoroscopic swallowing study (VFSS; also
known as a modified barium swallow), and evidence of
1Department of Otorhinolaryngology–Head and Neck Surgery, Mayo
Clinic Arizona, Phoenix, Arizona, USA
2Department of Health Science Research, Mayo Clinic Arizona,
Phoenix, Arizona, USA
This article was presented at the Fall Voice Conference; October 17,
2015; Pittsburgh, Pennsylvania.
Corresponding Author:
Christina H. Kang, MM, MS, CCC-SLP, Department of
Otorhinolaryngology–Head and Neck Surgery, Mayo Clinic Arizona,
5777 East Mayo Boulevard, Phoenix, AZ 85054, USA. Email:
Kang.Christina@mayo.edu
2 Otolaryngology–Head and Neck Surgery
laryngeal muscle tension on laryngoscopic examination.
Many of these patients also had evidence of laryngeal
hyperrespon-siveness (LHR) manifested as cases of
refractory chronic cough, paradoxical vocal fold movement,
or muscle tension dysphonia (MTDa).
For the purposes of this article, the suffix -responsiveness
describes all components of the efferent motor pathway result-
ing in laryngeal motion secondary to a sensory stimulus. There
is no unifying terminology in the research literature describing
LHR, and various terms have been used interchangeably, such
as irritable larynx syndrome,5laryngeal hypersensitivity syndro-
me,6laryngeal dysfunction syndrome,7 and airway hyperreactiv-
ity syndrome.8 LHR has been noted to manifest as a refractory
chronic cough,9-11 paradoxical vocal fold motion,12,13 globus
pharyngeus,6 and MTDa.14 Paradoxical vocal fold motion is
also described in the literature as paradoxical vocal cord motion,
paradoxical vocal cord dysfunction, and vocal cord dys-
function. The role of LHR in swallowing dysfunction has not
been significantly addressed.
A retrospective chart review was conducted to better under-
stand the symptomology and etiology of this group of patients
with idiopathic functional dysphagia and to identify the pattern
of intervention strategies used and their efficacy. We hypothe-
sized that laryngeal muscle tension and hyperresponsiveness
were prevalent in patients with so-called functional dysphagia
and likely played a role in its etiology.
Methods
Following Mayo Clinic Institutional Review Board approval,
a retrospective chart review was conducted of 595 patients
with dysphagia who had a VFSS between January 1, 2013,
and April 30, 2015. Patients were included in the study if
they met the following criteria: men and women
.18 years old, swallowing difficulty as a primary com-plaint,
referral for a VFSS by a provider in the otolaryngol-ogy
clinic with documented laryngeal function examination via
transnasal laryngoscopy, and no physiologic impairment
evident on the VFSS. Patients were excluded from the study
if they had a history of head and neck cancer; a history of
radiation to the head, neck, or chest; videofluoroscopic find-
ings of structural anomalies of deglutition; pharyngoesopha-
geal segment disorders; presence of significant cervical
osteophytes; or esophageal retention. A chart review, a
review of the VFSS, and a review of the office transnasal
laryngoscopy assessment were conducted for each subject.
Patients were defined as having muscle tension dysphagia
(MTDg) if they had (1) swallowing difficulty as a primary com-
plaint, (2) laryngeal function examination demonstrating signifi-
cant laryngeal muscle tension via transnasal laryngoscopy, and
(3) no physiologic impairment evident on the VFSS. Signs and
symptoms of LHR and nonspecific laryngeal inflammation
(NLI) were documented but not considered as defining criteria
for MTDg. Patients were considered to have primary MTDg if
they met the above criteria but did not have any other contribut-
ing organic cause. Patients were considered to have secondary
MTDg if they met the above criteria and did have a contributing
organic cause, such as LHR and/or NLI.
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Each VFSS was conducted by a speech-language pathol-
ogist (SLP) with a radiologist present. Barium consistencies
administered were thin liquid, nectar-thick liquid, honey-
thick liquid, puree, pudding, crackers tagged with barium
paste, and a 12.7-mm barium tablet. Components of swal-
lowing were assessed based on the Modified Barium
Swallow Impairment Profile (MBSImp).15
Information gathered during the chart review included patient
demographics (sex, age, and race), dysphagia symp-toms,
laryngeal symptoms (eg, globus sensation, sensation of mucus in
the throat, tightness of throat, throat pain, throat clearing,
nonproductive cough, and throat spasms), gastroeso-phageal
symptoms, and other medical comorbidity. All office transnasal
laryngoscopies were performed by an otolaryngolo-gist,
physician’s assistant, SLP, or medical resident. Evidence of
laryngeal muscle tension, LHR, and/or NLI was reviewed and
confirmed on the recorded office laryngoscopy examina-tions by
the study investigators, who are trained specialists in voice and
swallowing disorders. Pentax Medical flexible distal chip
laryngoscopes were used for all laryngoscopic examina-tions.
Findings were as defined as follows.
Laryngeal muscle tension was evident in the form of the
phonatory presence of plica ventricularis, medial-lateral
supraglottic compression, and anterior-posterior supraglottic
compression. Coupled with patient complaint of laryngeal
symptoms, laryngeal hypersensitivity and LHR were evi-
denced by increased adductory vocal fold movement during
inspiration (.50% vocal fold adduction)16,17 and/or quiver-
ing of the arytenoids and/or excessive cough/gag. NLI was
evidenced by erythema or edema of the arytenoids, postcri-
coid region, and/or true vocal folds, as well as by interaryte-
noid pachydermia and hypopharyngeal wall cobblestoning.
Results
A total of 595 VFSS results and charts were reviewed. Sixty-
seven subjects met the inclusion criteria. Women represented
64% of the study sample, and men represented 36%. Ages
ranged from 22 to 85 years, with a mean of 53 years (SD, 16).
Eighty-four percent of subjects were white. Table 1 describes
the various swallowing symptoms reported by the subjects.
Difficulty swallowing solids (37%), throat discomfort with
swallowing (33%), and the sensation of food sticking in the
throat (30%) were the 3 most frequently reported symptoms.
Signs and symptoms of LHR were found in 45 of the 67
subjects (67%). As with dysphagia symptoms, most LHR
symptoms were nonspecific and multifactorial. Globus phar-
yngeus was the most common symptom (33%).
Of the 67 subjects, 65 (97%) exhibited laryngeal muscle
tension. Out of the 65 subjects with laryngeal muscle ten-
sion, 12 (18%) did not exhibit symptoms or examination
findings of LHR and/or NLI.
Signs and symptoms of NLI were present in 35 subjects
(52%). Patients with signs of NLI were significantly (chi-
square test) more likely to experience the sensation of food
sticking than the 32 patients without NLI (43% vs 16%, P =
.02). They also tended to have more LHR symptoms (74% vs
59%, P = .19) and inappropriate adductory vocal fold
Kang et al
Table 1. Prevalence of Dysphagia Symptoms among
Patients (N = 67).
Symptom
Difficulty swallowing solids
Throat discomfort when swallowing
Food sticking in the throat
Difficulty swallowing pills
Hard to swallow
Coughing when eating or drinking
Choking when eating or drinking
Difficulty swallowing liquids
Difficulty swallowing saliva
Aberrant sound when swallowing
Fatigue from swallowing
movement during quiet breathing (20% vs 3%, P = .06).
Twenty-six subjects (39%) exhibited signs of both LHR and
NLI.
Dysphonia was reported in 37 of 67 subjects (55%). It
was present in 15 of 26 subjects (58%) with signs of both
laryngeal inflammation and LHR, 10 of 19 (53%) with LHR
alone, 5 of 9 (56%) with laryngeal inflammation alone, and 7
of 13 (54%) with no signs of either laryngeal inflamma-tion
or LHR (P = .98, Fisher’s exact test).
Out of 67 subjects, 19 (28%) reported other concurrent
events or comorbidities. These were not consistent among
subjects, however. Intubation for surgery (5 of 19, 26%),
trauma to the neck (eg, being strangled, falling, and whi-
plash; 4 of 19, 21%), and upper gastrointestinal endoscopy (2
of 19, 11%) were the most prevalent.
In our study, 27 of the 67 subjects (40%) were referred for
SLP evaluation. Frequency of referral to SLP appeared to be
related to subspecialty within ENT. Laryngologists provided
more frequent referrals, while head and neck cancer surgeons
referred less frequently. Patients with LHR were more likely to
be referred for SLP evaluation by a provider. Of the 27 sub-jects
who were referred for SLP evaluation, 16 of 27 subjects (59%)
actually followed up. Of those 16 who underwent SLP voice
evaluation, 2 (13%) were unable to follow up in therapy; 1 (6%)
was referred for physical therapy18; and 13 completed SLP
therapy. Twelve of 13 patients who underwent SLP ther-apy
exhibited signs of laryngeal inflammation and/or LHR. Patients
were discharged from therapy either when they self-reported
resolution of their dysphagia symptoms to their satis-faction or
if therapy appeared ineffective at improving their dysphagia
symptoms. All 13 patients reported resolution of their dysphagia
symptoms. Mean therapy session numbers were 2.3 (SD, 1.0)
for men and 5.3 (SD, 3.1) for women. The mean age for therapy
participants was 55 years (SD, 24) for men and 50 years (SD,
16) for women. Unloading laryngeal muscle tension was the
documented therapy focus. Treatment methods included
circumlaryngeal massage,19-23 counseling as
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3
n (%)
25 (37)
22 (33)
20 (30)
10 (15)
9 (13)
8 (12)
8 (12)
8 (12)
3 (4)
3 (4)
2 (3)
Figure 1. Laryngeal muscle tension: a spectrum of causes
and resulting disorders. LHR, laryngeal
hyperresponsiveness; NLI, non-specific laryngeal
inflammation; PVFM, paradoxical vocal fold motion.
needed, semioccluded vocal tract exercises, low diaphragmatic
relaxation breathing, and resonant voice therapy.
Discussion
The findings from this study suggest that laryngeal muscle
tension may be one of the underlying etiologies in many of
the patients with so-called functional dysphagia. Although
future studies are needed to better support this, we hypothe-
size that, similar to MTDa, laryngeal hyperfunction results in
improper laryngeal motion during deglutition and contributes
to dysphagia symptoms. As such, we propose the diagnostic
term muscle tension dysphagia to describe patients with idio-
pathic dysphagia complaints, a ‘‘normal’’ VFSS, and evi-
dence of laryngeal hyperfunction on laryngoscopy. MTDg is
a laryngeal muscle tension disorder manifested as a swallow-
ing disorder rather than globus pharyngeus, cough, breathing,
or a voice disorder (Figure 1).
Our study suggests that MTDg can occur with or without
associated signs of LHR or NLI. Just as MTDa is categor-
ized into primary and secondary per the Classification
Manual for Voice Disorders–I,24 it stands to reason that
MTDg may also be categorized into primary and secondary
based on the presence or absence of an underlying or contri-
buting organic cause. Primary MTDg would include the
group of patients in our study with no symptoms or signs of
LHR or NLI, since they have (1) a disorder with no organic
cause and (2) strictly laryngeal muscle tension. Secondary
MTDg would be appropriate to describe the population with
LHR and/or NLI, as they demonstrate a disorder with an
underlying or contributing organic cause. It is important to
note that the dominant component contributing to dysphagia
in the secondary MTDg population appears to still be muscle
hyperfunction, as evidenced by the resolution of dysphagia
symptoms with therapy directed at unloading lar-yngeal
muscle tension. In this study, 18% of patients would
4 Otolaryngology–Head and Neck Surgery
be considered to have primary MTDg and 82% secondary
MTDg. This ratio between primary and secondary MTDg
may be an artifact of chart review, and we acknowledge that
various practitioners may have different thresholds for
categorizing a patient as having LHR or NLI.
This is the first report of dysphagia associated with laryn-
geal muscle tension in the presence or absence of LHR.
MTDg shares similarities with other conditions of the larynx
associated with hyperresponsiveness, such as a pre-
dominance of female patients and associated dysphonia. This
implies that MTDa and MTDg are not necessarily mutually
exclusive. The fact that 97% of our subjects had laryngeal
muscle tension on examination, coupled with the high
proportion of patients who also had MTDa, supports the
concept that laryngeal hyperfunction is likely the under-lying
cause of the dysphagia complaints.
The study results revealed only a 40% SLP referral rate
for these patients with functional dysphagia. As many as 20
otolaryngology providers were identified who were involved
in the care of these dysphagia patients; however, not every
provider may have been aware of the potential contributions
of laryngeal muscle tension in functional dysphagia, as evi-
denced by the low count in SLP referrals.
Research literature supports SLP intervention in the treat-
ment of primary laryngeal muscle tension, laryngopharyngeal
reflux, and laryngeal hypersensitivity.12,19,20,25-31 If present,
laryngopharyngeal reflux or other contributing causes should
be controlled in these patients for optimal management.
This clinical taxonomy is based on patient symptoms and
examination findings and may provide an effective algorithm for
care. MTDg offers a hypothesis for an individual patient’s
disease etiology and a personalized medical and behavioral
treatment plan. Since primary and secondary MTDg (like
MTDa) is characterized by excessive laryngeal muscle ten-sion,
we suggest that voice therapy focused on unloading lar-yngeal
muscle tension be the optimal behavioral intervention in both
groups. The secondary group should have the under-lying
organic cause managed in addition to therapy. Albeit small in
number, our study data show patient-reported symp-tom
improvement for those who completed voice therapy.
As mentioned in the introduction, a part of this retrospec-tive
study aim was to identify potential shortcomings in the
functional dysphagia patient care paradigm. Not all patients with
a normal VFSS should be presumed to have MTDg. Therefore,
further prospective studies investigating the concept of MTDg
are recommended and underway. The impact of lar-yngeal
irritants and NLI on secondary MTDg should be further
investigated. Gastroenterology testing should be conducted—
including pH probe manometry, esophagram, impedance test-
ing, and esophagogastroduodenoscopy—and any gastroesopha-
geal etiology documented. It is also important to note that 8
patients complained of ‘‘choking when eating’’ (12%); how-
ever, this was not seen on the VFSS. The VFSS is not an exact
replication of an actual meal, and patients may not exhi-bit
symptoms consistently. When patients complain of ‘‘choking,’’
the VFSS should be conducted to replicate the meal by having
the patients bring food or beverages that they
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experience ‘‘choking.’’ The severity of supraglottic compres-
sion and the threshold for LHR should be better elucidated in
future study with the use of a laryngeal hypersensitivity ques-
tionnaire7 and stroboscopic assessment form.32 The objective
efficacy of treatment of laryngeal muscle tension for primary
and secondary MTDg should also be better elucidated. Quality-
of-life measures (eg, the Eating Assessment Tool-10,33 MD
Anderson Dysphagia Inventory,34 and Reflux Symptom
Index35), a laryngeal hypersensitivity questionnaire,7 and
acoustic and aerodynamic voice analysis for pre- and postther-
apy should be included. History of anxiety and depression is not
well documented in this retrospective study. Only 2 sub-jects
self-reported concurrent anxiety and stress. This should be
addressed in prospective studies, since the literature shows a
high correlation of paradoxical vocal fold motion and MTDa
with stress, anxiety, and depression.36,37 Comparison of treat-
ment outcomes is underway. A study comparing the medical
management of laryngeal inflammation to a group undergoing
voice therapy alone is underway to establish the utility of voice
therapy and to better elucidate the theory behind the
pathogenesis of MTDg.
Although the proposed diagnostic and therapeutic para-
digm needs to be better established through further research,
this study sets the foundation for a new way of thinking
about and caring for patients with functional dysphagia. Such
patients with evidence of laryngeal muscle tension appear to
benefit from therapy aimed at unloading muscle tension.
Factors contributing to the development of laryn-geal muscle
tension, such as esophageal disorders, need to be diagnosed
and treated in addition to the muscle tension. Awareness of
the role that laryngeal muscle tension appears to play in this
subset of patients may provide a treatment option for patients
who previously had no other option.
Conclusion
Our study suggests that laryngeal muscle tension may be a
commonly overlooked etiology underlying the majority of
our patients with idiopathic functional dysphagia. It is
essentially laryngeal muscle tension manifested as dyspha-
gia. Similar to MTDa, MTDg may be primary or secondary
(with an underlying or contributing cause). In either the pri-
mary or secondary form, the dominant component contribut-
ing to the dysphagia symptoms appears to be laryngeal
muscle tension. The apparent underlying etiology of this
disorder suggests the need for an individualized algorithm of
care targeting reduction of laryngeal irritation and laryn-geal
muscle tension. Prospective studies are recommended to
further elucidate the pathogenesis and treatment efficacy of
this potentially new clinical diagnosis. The treatment
algorithm may offer symptomatic relief for a group of
patients who previously had no treatment options.
Acknowledgments
The authors would like to thank David E. Rosow, MD,
Claudio Milstein, PhD, and the anonymous reviewers for
valuable comments and suggestions to improve the quality of
the paper.
Kang et al
Author Contributions
Christina H. Kang, created the study design, drafted the proposal,
obtained institutional review board approval, created all study doc-
uments, created electronic data registry, reviewed all collected data,
worked with statistician to obtain statistical analysis, drafted
manuscript; created all revisions; created final manuscript; accounta-ble
for all aspects of the work; Joseph G. Hentz, analysis and inter-pretation
of data, assisted with all revisions, final approval of the version to be
published; accountability for all aspects of the work; David G. Lott,
assisted with study design, assisted with institutional review board
proposal, assisted with interpretation of data, assisted with manuscript
writing and all revisions, final approval of the ver-sion to be published;
accountable for all aspects of the work.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.
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