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.
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
1–6
Ó American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2016
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599816657013
http://otojournal.org
Received February 12, 2016; revised June 3, 2016; accepted June 8,
2016.
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
1
Department of Otorhinolaryngology–Head and Neck Surgery, Mayo Clinic
Arizona, Phoenix, Arizona, USA
2
Department 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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