# Biography of Muscle Tension Dysphonia: A Scoping Review
## 4 Discussion
### Treatment  
Treatment approaches can be classified as indirect (vocal education) or direct interventions. Intervention usually involves a combination of direct and indirect treatment approaches for successful outcomes and begins by addressing vocal hygiene [87]. The patient must understand that his or her voice is a combination of multiple factors, including possible psychological influences. Vocal education includes a series of general measures (environmental, behavioral, and related to vocal use) that seek to modify and avoid possible factors that are related to altered vocal behavior. Some examples would be talking as little as possible in an environment where there is a lot of background noise, avoiding shouting, trying not to whisper, or using good breathing techniques [1]. Direct approaches to voice therapy aim at modifying the physiology of the vocal mechanism through symptomatic vocal therapy or the physiological principles of vocal therapy [87]. Physiological voice therapy programs strive to balance the three subsystems of voice production (respiration, phonation, and resonance) rather than working directly on isolated voice symptoms [88]. They include techniques such as the Accent Method, Conversation Training Therapy (CTT), Expiratory Muscle Strength Training (EMST), Lee Silverman Voice Treatment (LSVT), Manual Circumularyngeal Techniques, Phonation Resistance Training Exercises (PhoRTE), Resonant Voice Therapy (RVT), Stretch and Flow Phonation, and Vocal Function Exercises (VFEs). As previously shown, results with many of these techniques have been published for the treatment of MTD. The RVT deserves a special mention for being one of the most widely used. The goal of RVT is to produce the most powerful and \"clean\" voice possible with the least effort and impact between the vocal folds to minimize the likelihood of injury and maximize the likelihood of vocal health [87]. It attempts to have patients produce an oral voice localized to the anterior alveolar ridge or adjacent facial plates [89], which is derived from the principles of a semi-occluded vocal tract [90]. Semi-occlusion occurs at the ends of the resonant cavities, which reduces unnecessary pressure at the vocal fold level [87]. One of the exercises included in this program is humming, used as a treatment for MTD with improvements in supraglottic compression and EGG parameters [47; 91]. Within the manual laryngeal techniques (first described in 1993) [92], there are also many different maneuvers described. MCT was developed by Aronson and Roy and Leeper [93], and it is based on the application of pressure, massage, to different points of the larynx. It starts with a circular compression on the hyoid bone, the thyrohyoid space, and the posterior borders of the thyroid cartilage. Lastly, the whole larynx is moved down and laterally. During the technique, the patient vocalizes sustained vowels or hums so that changes in vocal quality can be tracked [92]. The objective of MCT is to reduce the increased tension and muscular contraction, especially around the hio-laryngeal musculature [52; 54; 92; 94]. The LMT proposed by Mathieson (MLMT) consists of rotational massage, kneading, and stretching of the perilaryngeal muscles (sternocleidomastoid muscles). Although these muscles are not directly related to laryngeal function, patients frequently complain of stiffness and tenderness in them in association with their voice disorders [95]. The cricothyroid visor maneuver (CVM) was proposed by Dehqan et al. [96] based on the findings of Harris and Lieberman [97], who reported that abnormal patterns of muscle activity can develop in the cricothyroid muscle and visor mechanism, which may contribute to voice problems, and manipulation of this muscle and articulation can lead to remarkable improvement in the voice. A lower range of action of the cricothyroid visor has also been identified in patients with MTD, probably associated with a reduced efficiency of cricothyroid muscle activity.