This article is a follow-up to our recent presentation at the Pan American Vocology Association Symposium in 2025, Mexico City (Verdolini Abbott and Guzman, 2025). The term muscle tension dysphonia was first introduced by Aronson (1980) and later popularized by Morrison and Rammage (1983) to describe a series of conditions negatively impacting voice due to presumed muscle hyperactivation. Cogent arguments were made largely on the basis of clinical observations. Since that time, of particular interest has been so-called “primary muscle tension dysphonia” (pMTD), a diagnostic entity involving voice disruptions without identifiable organic cause and reported to constitute large proportions of diagnoses in voice clinics worldwide. Chief complaints may include dysphonia, odynophonia, or debilitating vocal fatigue. A variety of approaches have been taken to describing the laryngeal correlates, most of which have suggested some degree of atypical postural or dynamic laryngeal presentations. Despite its ubiquity, serious problems exist with this nomenclature. The problems are not merely academic.

A first problem is that dysphonia—understood as an auditory-perceptual alteration in voice quality—is not always present in patients diagnosed with pMTD. In these patients, the main clinical complaints are typically vocal fatigue, effort to phonate, discomfort, or regional pain associated with phonation, in particular laryngeal and pharyngeal rather than auditorily-perceived dysphonia itself. Hence, it is unclear why the condition should be called a type of “dysphonia” at all. Several studies have reported that pMTD participants have lower Cepstral peak prominence (CPP) values but on average are within normal range (Shembel et al., 2023; Toles, 2024; McDowell et al., 2022). Even though pMTD patients do not always have a perceptually dysphonic voice, they present a significantly higher degree of self-perceived phonatory effort and vocal tract discomfort than healthy controls (Shembel et al., 2023; Morrison et al., 2023; Toles et al., 2024; McDowell et al., 2022). In fact, increased effort is a hallmark symptom of pMTD. No correlation, positive or negative, has been reported between any acoustic variables, including those associated with voice quality and self-perceived phonatory effort (Toles et al., 2024, Shembel et al., 2023). A multivariate clustering of 15 acoustic and aerodynamic metrics of voice failed to distinguish pMTD vs control participants (Shembel et al., 2021). In another study, no significant differences were found between patients diagnosed with pMTD and normal controls in any aerodynamic parameters (Psub, mean flow, peak flow, expiratory flow duration, total expiratory volume). Groups differed only for significantly more symptoms (vocal effort, vocal fatigue, and vocal tract discomfort scores) in the pMTD group (Shembel et al., 2025). Therefore, pMTD may be more sensory in nature than previously thought. The heightened sensory perception of vocal effort, vocal fatigue, vocal tract discomfort, and pain, despite similar acoustics, aerodynamics, and importantly also extrinsic laryngeal muscle tension patterns to those of typical speakers (see below) suggests that individuals with pMTD experience voice production differently (Shembel et al., 2023). Consequently, these clinical characteristics may indicate that the disorder is primarily related to an abnormal somatosensory processes — especially higher-order ones involving attention and valence attribution — rather than to intrinsic laryngeal muscle tension or laryngeal hyperfunction.

Second, and more gravely, systematic studies using a range of technologies have failed to identify evidence of elevated muscle “tension” in extrinsic laryngeal musculature in phonation for individuals diagnosed with pMTD compared to healthy controls (Crocker, 2024; Han, 2023; Hogue, 2023; McDowell, 2025; Morrison, 2024; Shembel, 2023; Smeltzer 2023; Toles, 2024). Thus, the characterization of this condition as involving “muscle tension” is misleading at best and dishonest at worst, obscuring effective treatment approaches targeting the root cause of the complaints. In a recent study aimed at assessing extrinsic laryngeal muscle (ELM) tension using shear wave elastography, results showed increase in ELM activation from rest to voicing in all participants, but no differences between those diagnosed with pMTD and healthy controls (Shembel et al., 2023). Despite the lack of differences in extrinsic muscle tension, voice users with pMTD reported significantly greater levels of vocal effort and vocal tract discomfort. Correlations between increased ELM tension and increased sensory experiences of vocal effort and vocal tract discomfort were also weak (Shembel et al., 2023). These findings and previous works assessing the ELMs using different exploration methods (e.g., electromyography and palpation), do not support the validity of ELM tension as a clinical indicator of pMTD (Hocevar-Boltezar et al, 1998; Van Houtte et al., 2013; Stepp et al., 2011; Hirano,1969; Khoddami et al., 2015 Spencer, 2015). Previous findings also do not support the theory that common symptoms of vocal effort, vocal fatigue, vocal tract discomfort, and odynophonia that patients with pMTD report are the result of ELM tension (Shembel et al., 2023; Morrison et al., 2023). Of course, these studies alone do not exclude the possibility that there are differences in intrinsic laryngeal muscle activation in pMTD. However, to date, we are not aware of any evidence demonstrating this.

Third, there is no evidence supporting the medical diagnosis of pMTD by laryngoscopic examination, in which the presence of supraglottic hyperfunction (medial and anterior–posterior narrowing) is considered a key diagnostic feature and sometimes the only feature to diagnose pMTD in the presence of voice complaints without clear organic findings. Studies comparing supraglottal activity between participants with pMTD and normal controls have shown inconsistent results and do not suggest that this activity should be considered a critical sign or criterion in the diagnosis of pMTD (Sama et al., 2001; Morrison et al., 2024; Han et al., 2023; Shembel et al., 2023; Stager et al., 2000; Stager et al., 2001, Behrman et at., 2003, Toles et al., 2024; Shembel et al., 2025; McDowell et al., 2022). Laryngeal narrowing is common enough in vocally normal individuals to call into question its usefulness as a diagnostic sign of pMTD (Behrman et at., 2003) and it should not be considered necessarily as a maladaptive strategy in people with pMTD (Toles et al., 2024). Moreover, no correlation between laryngeal narrowing and vocal effort/vocal tract discomfort has been found in patients with pMTD (Shembel et al., 2023; Shembel et al., 2025). A recent scoping review on pMTD concluded that endoscopic visualization of the larynx is crucial for the diagnosis, but must be combined with the patient’s clinical history (Ferran et al., 2024). Therefore, the actual relevance of laryngeal narrowing as a visual negative indicator can be highly questioned. In fact, supraglottic narrowing has been attributed to a protective factor that positively impacts vocal fold oscillation and vocal fold adduction due to the greater source-filter interaction and higher vocal tract inertance (Titze and Story., 1997; Titze, 2006, Story et al., 2000). Aditionally, supraglottic narrowing has been demonstrated to be present in well trained vocally healthy professional voice users (Behrman et al., 2003; Sama et al., 2001; Stager et al., 2001; Yanagisawa et al., 1989; Pershall et al., 1987; Mayerhoff et al., 2013, Hermoso et al., 2023, Guzman et al., 2013, Guzman et al., 2015; Guzman et al., 2016; Saldias et al., 2019). Finally, evidence has shown that variables such as vocal intensity and fundamental frequency significatly affect the degree of supraglottic narrowing. In general, both anterior-posterior and medial narrowing (and even pharyngeal narrowing) increase with intensity and fundamental frequency. However, these variables are rarely controlled in clinical laryngeal examinations (Yanagisawa et al., 1989; Mayerhoff et al., 2013, Hermoso et al., 2023, Guzman et al., 2015; Guzman et al., 2016; Guzman et al., 2025).

Fourth, literature reviews indicate—and most clinicians agree (Verdolini, Rosen, & Branski, 2006)—that pMTD presents with heterogeneous manifestations, raising questions about whether it can be considered a clearly identifiable clinical entity under any designation (Desjardins et al., 2022). Furthermore, there is general agreement that pMTD is a multifactorial phenomenon arising from complex interactions among various factors (Verdolini, Rosen, & Branski, 2006). Much remains to be understood about how these factors interact and why they lead to pMTD in some individuals (Baker, 2008; Hillman et al., 2020; Oates & Winkworth, 2008). The heterogeneity of presentations, combined with the multifactorial nature of pMTD, often results in limited benefit from conventional therapies or poor long-term outcomes despite treatment (Van Lierde et al., 2007). This may be because traditional therapeutic approaches primarily target the overt manifestation of MTD—supposed abnormal activation of the (para)laryngeal musculature (Van Houtte et al., 2011)—but fail to address the underlying sensory and/or motor mechanisms contributing to vocal discomfort reported by patients.

The diagnosis of pMTD is not just an academic matter, but a clinical issue. Calling this condition pMTD implies a cause that is unsubstantiated, suggesting treatment approaches that are in turn unsubstantiated and potentially misguided. The term implies we know what is going on with these patients, but we do not. In the interest of clinical and academic integrity, perhaps when individuals present with voice complaints of unknown origin, we might more properly refer to them as having an “idiopathic voice disorder.” Of course, this terminology may create challenges for health insurance reimbursement. Accordingly, we are currently developing a proposal with other authors to identify a new term to replace the current label of primary muscle tension dysphonia (in progress).

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HOW TO CITE

Guzman, M. & Verdolini Abbott, K. (2026). Primary Muscle Tension Dysphonia: The Term has Got to Go. NCVS Insights Vol. 4(3) pp. 1–5.