Journal of Voice Vol. 16, No. 3, pp.

333343 2002 The Voice Foundation

Extrinsic Laryngeal Muscular Tension in Patients with Voice Disorders

*Thana Angsuwarangsee and Murray Morrison
*Division of Otolaryngology and Department of Health Care and Epidemiology, University of British Columbia, Vancouver, Canada, and Department of Otolaryngology, Mahidol University, Bangkok, Thailand; Division of Otolaryngology, University of British Columbia, Vancouver, Canada

Summary: The objective of this study was to establish a standard clinical evaluation tool for assessment by palpation of extrinsic laryngeal muscular tension (ELMT) and investigate the relationship between ELMT and different voice disorder diagnosis categories, particularly muscle misuse dysphonia (MMD), and the presence or absence of gastroesophageal reflux (GER). A palpation technique and tension grading system for four separate muscle groups (suprahyoid, thyrohyoid, cricothyroid, and pharyngolaryngeal) were established. 465 patients, 65% female and 35% male, were assessed sequentially and ELMT results were analyzed in relation to diagnosis and reflux status. A strong relationship was found between thyrohyoid muscle tension and both GER and MMD (p 0.01). Thyrohyoid muscle tension is the only group that demonstrated a significant relationship with MMD. No significant difference in the ELMT scores was found between GER and non-GER patients, although a possible causal relationship was found between MMD type 3 and reflux. It is postulated that palpation of extrinsic laryngeal muscles can yield important information about internal laryngeal postures and diagnosis of muscle misuse voice disorders, particularly MMD type 3 (anteroposterior supraglottic compression). Integration of this technique into routine laryngeal examination can be a significant aid to diagnostic accuracy. Key Words: Muscular tension dysphoniaLaryngeal palpationVoice disorder diagnosis.

INTRODUCTION Patients with voice disorders are often classified into groups having organic and nonorganic dysphonia. Most organic causes are easy to identify by hisAccepted for publication December 10, 2001. Address correspondence and reprint requests to Dr. M.D. Morrison, Division of Otolaryngology, Vancouver General Hospital, 805 West 12th Ave., Vancouver BC Canada V5Z 1M9. Presented to the Collegium Medicorum Theatri (COMET) Aspen, CO, June 26, 1999. e-mail: mdmorrsn@interchange.ubc.ca

tory and laryngoscopic examination. Nonorganic, often termed functional, dysphonia is frequently the diagnosis made by most general otolaryngologists when there is no demonstrable organic lesion. Muscle misuse dysphonia (MMD) is probably the most common nonorganic cause of voice disorders diagnosed in most voice clinics today and may be the most common cause of chronic dysphonia experienced by humans. Up to 60% to 70% of patients in some voice clinics have been identified as having MMD.1 The diagnosis of MMD is based on case history of vocal misuse or abuse and the videostrobolaryngoscopic finding of normal vocal fold mucosa 333

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THANA ANGSUWARANGSEE AND MURRAY MORRISON duced pharyngeal muscle tension,5 it seems important to question whether or not the pharyngeal constrictor tension is palpably higher in reflux patients. OBJECTIVE The purpose of this study is to investigate the relationship between extrinsic laryngeal muscle tension (ELMT) and different diagnosis voice disorder categories, particularly muscle misuse dysphonia (MMD), and the relationship of gastroesophageal reflux (GER) to ELMT and the diagnosis of MMD. Hypotheses Null hypothesis Extrinsic laryngeal muscle tension (ELMT) patterns are the same in patients with muscle tension dysphonia (MMD) and non-MMD patients. There is no difference in extrinsic laryngeal muscle tension (ELMT) patterns in patients with and without gastroesophageal reflux. Alternative hypothesis Extrinsic laryngeal muscle tension (ELMT) patterns are not the same in patients with muscle tension dysphonia (MMD) and non-MMD patients. Extrinsic laryngeal muscle tension (ELMT) patterns are different in patients with gastroesophageal reflux disorders (GER) than those without GER. MATERIAL AND METHODS The study was conducted in the Pacific Voice Clinic at the Vancouver General Hospital during a 1-year period from January 1 to December 31, 1999. All new patients who fit inclusion-exclusion criteria (Figure 1) were included in the study. Voice evaluations began with an interview followed by vocal function evaluation, extrinsic laryngeal muscle tension (ELMT) palpation, standard otolaryngological examination, and videostrobolaryngoscopy. A grading system for four separate muscle groups around the larynx was established, based on the original work of Lieberman.3 Our severity scale is 0 to 3, with 0 indicating normal tone, 1 for mild, 2 for moderate, and 3 for severe increase in palpable muscle tension. Figure 2 describes the technique of palpation of the suprahyoid (S), thyrohyoid (T), cricothyroid (C) and pharyngolaryngeal (P) muscle groups. Figure 3 lists the criteria used to assign a tension severity grade to

and movement, usually with some specific abnormal laryngeal posture.2 Videostrobolaryngoscopy is essential in distinguishing MMD from subtle vocal fold lesions such as sulcus vocalis or submucosal scarring. Treatment options for MMD consist of voice therapy, psychotherapy, manual therapy, and treatment of associated disorders. Voice therapy is the main therapy for MMD, but manual therapy, if done correctly, can accelerate improvement and shorten the course of therapy.3 Identifying specific extrinsic laryngeal muscle groups with abnormally high tension and applying manual therapy to that specific group of muscles may reduce the number of visits for this therapy. Treatment of associated causes or aggravating factors such as gastroesophageal reflux disorders (GER) is also an essential part of the treatment plan. Rationale for extrinsic laryngeal muscle palpation in evaluation of voice disorders There is little doubt that the external laryngeal muscles contribute significantly to voice production. In the course of more than 100 years of research a number of theoretical explanations for the role of the extrinsic muscles and other external mechanisms in phonatory function have emerged. This topic was reviewed by Vilkman et al in 1996.4 However, to the best of our knowledge there have been no systematic grading criteria established for clinical application, perhaps due to a lack of clinical data relating extrinsic laryngeal muscle tension (ELMT) to the diagnosis in voice disorders. If there are unique patterns of ELMT in different categories of voice disorders, measuring it will be a useful clinical tool. The voice clinician will find ELMT helpful in the diagnosis of MMD and speech-language pathologists, singing teachers, and the patients themselves can use ELMT for monitoring clinical improvement, and as biofeedback during therapy exercises. Gastroesophageal reflux (GER) is a known cause and aggravating factor of laryngeal and voice disorders,5 and we feel that this is possibly due in part to reflux-generated tense intrinsic and extrinsic laryngeal musculature. Patients assessed in our clinic are given a primary diagnosis, and often a secondary diagnosis is assigned as well. All patients with proven or strongly suspected GER are listed as having reflux as the secondary diagnosis. Since esophageal stimulation is shown to produce a reflex laryngeal contraction,6 and globus sensation is thought to be due to reflux-inJournal of Voice, Vol. 16, No. 3, 2002

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Inclusion Criteria 1. New with voice disorders patients 2. Age 12 years old or older 3. Male, female, and transgender Exclusion Criteria 1. Airway-compromised patients 2. Extensive scarring of anterior cervical skin and soft tissue around the larynx from any causes (e.g. surgery, radiation therapy, trauma) 3. Abnormal laryngeal framework from congenital or acquired causes (e.g., laryngeal trauma, laryngeal framework surgery) 4. History of laryngospasm, stridor, or airway compromise initiated by manipulation of the larynx or adjacent structure 5. Tracheotomized or laryngectomized patients 6. Cervical pathology that precludes complete evaluation of ELMT by the palpation techniques, e.g., mass lesion around the larynx 7. Neurological conditions that preclude proper ELMT palpation examination e.g. abnormal cervical posture, uncontrollable spontaneous head and neck movement, unable to vocalize as instructed 8. Patient is not cooperative or is under emotional distress 9. Short, fatty neck: unable to identify laryngeal landmarks FIGURE 1. Patient selection criteria.

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each. The criteria for the diagnosis of muscle misuse dysphonia (MMD) and gastroesophageal reflux (GER) are summarized in Figure 4. Patients with borderline clinical GER were further investigated by 24-hour ambulatory pH monitoring test. A double-blinded method was used to compare interrater differences in ELMT assessment. Fifty-seven patients in succession were evaluated by two otolaryngologists (the authors) during a 30-day period. One examiner evaluated the patient in the clinic during the routine sequence, and the other before the patient entered the clinic. Intrarater reliability was checked by evaluation of EMLT before and after the clinic visit by the laryngologist not doing the routine assessment. All immediate adverse reactions to the palpation were recorded. Delayed adverse reactions were to be reported by phone. We included only new patients in the study to prevent possible bias from knowing the previously assigned diagnosis. The palpation of ELMT was done

after the history to avoid possible adverse effects such as laryngospasm, and before videolaryngoscopy to avoid possible alteration of ELMT from that procedure. The diagnoses were made by consensus of voice clinic team members to avoid examiner diagnostic bias from knowing the ELMT result. Informed consent Since the palpation of ELMT is a safe procedure and part of our routine clinical evaluation in the Pacific Voice Clinic, there is no need for informed consent from the patients. However, all patients were informed about the palpation before the examination and were told to inform the examiner if they felt uncomfortable or wanted the palpation terminated. Biostatistical analysis methods The relationship between ELMT palpation scores and the diagnosis were analyzed as follows:
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Suprahyoid muscles (S) Midline upward palpation in submental space with middle finger Observe : 1. tension at rest 2. contraction during low-pitched /a/ follow by high-pitch /u/ phonation Thyrohyoid muscles (T) Palpate both thyrohyoid spaces with the thumb and forefinger Observe : 1. tension at rest 2. contraction during connected speech (count 1 to 5), and with an easy hum

Cricothyroid muscles (C) Feel the cricothyroid space in midline with tip of the index finger Observe : 1. position of the cricoid arch relative to the thyroid cartilage 2. size of the space at rest 3. closing and opening of the space during high-ptiched and low-pitched phonation

Pharyngo-laryngeal muscles (inferior constrictor) (P) Rotate the larynx, hook posterior edge of thyroid cartilage with index finger and draw forward, feel the posterior aspect of the cricoid cartilage with middle and ring finger Observe : 1. tension in pharyngeal muscles 2. associated arytenoid movement and posterior cricoarytenoid (PCA) muscle contraction during sniffing Important note: Laryngeal palpation should be done before any intraoral or laryngoscopic examination to avoid changes in muscle tension due to the manipulation. Some tenderness may be found in these muscle groups, and should be noted. Examination is best done from the side, with the head, neck, and shoulders in a neutral position. FIGURE 2. Technique of palpation.

1. The Mann-Whitney U nonparametric test was used to compare ELMT scores between MMD and non-MMD, and between GER and nonGER patients. 2. Logistic regression methods were used to identify explanatory variables that significantly affected the following outcome variables:
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The diagnosis of muscle misuse dysphonia (MMD) or nonmuscle misuse dysphonia (non-MMD). The diagnosis of gastroesophageal reflux (GER) disorder or non-GER. 3. The Wilcoxon signed ranks nonparametric test was used to compare ELMT scores between

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Suprahyoid muscles (S) 0 = soft at rest, may slightly contract on phonation 1 = soft at rest, mild low-pitch and moderate high-pitch contraction 2 = some tension at rest, tense with jaw protrusion on phonation 3 = tense all the time, maximally tight on phonation

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Thyrohyoid muscles (T) 0 = no muscular contraction at rest, mild on phonation 1 = soft thyrohyoid space at rest, some contraction on phonation 2 = tense, narrow thyrohyoid space at rest, moderate contraction on phonation 3 = very tense with closed thyrohyoid space all the time

Cricothyroid muscles (C) 0 = normal cricothyroid space and phonatory movement 1 = narrowing of cricothyroid space at rest, some movement on phonation 2 = anterior displacement of cricoid cartilage with narrowing of cricothyroid space at rest, closing of the space on phonation 3 = closed cricothyroid space all the time

Pharyngolaryngeal muscles (inferior constrictor) (P) 0 = soft, easy to rotate the larynx for 90 and palpate posterior cricoarytenoid (PCA) muscle and arytenoid movement on sniffing 1 = slightly tense, cannot palpate PCA muscle movement on sniffing 2 = moderately tense, difficult to rotate the larynx but still can palpate the posterior edge of thyroid cartilage 3 = very tense, cannot rotate the larynx at all FIGURE 3. Criteria for extralaryngeal muscular tension grading system.

Diagnostic criteria for MMD Absence of organic lesion or cause of dysphonia History of vocal misuse or abuse Demonstration of typical laryngoscopic pattern of MMD Diagnostic criteria for GERD History of GERD symptom(s) Chronic inflammation of the posterior part of the larynx demonstrated by videostrobolaryngoscopy Positive result of 24-hour pH monitoring test FIGURE 4. Diagnostic criteria.

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THANA ANGSUWARANGSEE AND MURRAY MORRISON examiners (interrater) and pre-examination and postexamination scores (intrarater). RESULTS (49.6%) of them had GER compared to 105 (32.4 %) of the non-MMD patients. Thirty-four patients were excluded according to the exclusion criteria and these are summarized in Table 2. STATISTICAL ANALYSES Nonparametric tests The Mann-Whitney U test was used to study the relationship between muscle tension scores in the four groups and the diagnosis groups (non-MMD and MMD) as well as the relationship to GER. The results shown in Table 3 indicate a strong relationship between thyrohyoid muscle tension, GER, and MMD (p 0.01). Subgroup analysis, separating MMD into MMD3 and other MMD, and comparing these to the non-MMD, showed that the thyrohyoid muscle tension and GER were significantly different only between MMD3 and non-MMD.

In 1999, 1135 patients visited the Pacific Voice Clinic and 499 of these were new patients. Four hundred sixty-five patients, 303 (65%) female and 162 (35%) male, were included in the study. Transgender patients were assigned their birth gender for this study. Age ranged from 13 to 98 years (mean = 44.8, median = 44, SD = 17.3). Primary diagnoses were categorized into two main groups, muscle misuse dysphonia (MMD) and nonmuscle misuse dysphonia (non-MMD). All 19 subcategories of both groups are summarized in Table 1, including the number and percentage of cases with GER. There were 175 (37.6%) patients with a clinical diagnosis of GER. Of the 141 patients with the diagnosis of MMD, 70

TABLE 1. Primary Diagnosis Categories

Primary Diagnosis Muscle misuse dysphonia Muscle misuse type 1 Muscle misuse type 2 Muscle misuse type 3 Muscle misuse type 4 Muscle misuse type 5 Muscle misusenonspecific Non-muscle misuse dysphonia Congenital sulcus and cyst Functional miscellaneous* Irritable larynx syndrome Chronic laryngitis and granuloma Laryngeal trauma Normal Organic miscellaneous Vocal fold paralysis Spasmodic dysphonia Tumor Vocal nodule Vocal polyp Neurological disorders Total No. of Cases 141 14 19 70 8 5 25 324 9 16 40 53 18 13 16 35 25 19 37 14 29 465 Percent 30.3 3.0 4.1 15.1 1.7 1.1 5.4 69.7 1.9 3.4 8.6 11.4 3.9 2.8 3.4 7.5 5.4 4.1 8.0 3.0 6.2 100.0 No. of GER 70 8 9 41 1 0 11 105 2 2 22 36 5 3 1 9 4 0 14 3 4 175 % of GER 49.65 57.14 47.37 58.57 12.50 0.00 44.00 32.41 22.22 12.50 55.00 67.92 27.78 23.08 6.25 25.71 16.00 0.00 37.84 21.43 13.79 37.63

Organic miscellaneous includes subglottic stenosis and cricopharyngeal muscle spasm. *Functional miscellaneous includes articulation disorders, temporomandibular joint disorder, senile atrophic bowing, and gender dysphoria.
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TABLE 2. Excluded Cases
Exclusion Criteria Airway-compromised patients Neck scarring from surgery, radiation therapy, or trauma Age less than 12 years old History of laryngospasm, stridor, or airway compromise Tracheotomized patients Cervical pathology: mass lesion around the larynx Neurological conditions that preclude ELMT assessment Patients who were not cooperative or who were under emotional distress Short, fatty neck: unable to identify laryngeal landmarks Total Number of Cases 3 5 1 3 2 1 8 10 1 34

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TABLE 3. Nonparametric Tests (Test Statistics: Mann-Whitney U Test)

Comparing Groups (n) Non-MM (324) vs MM (141) Non-MM (324) vs MM3 (70) Non-MM (324) Vs Other-MM (71) Other-MM (71) vs MM3 (70) GERD (290) vs. non-GERD (175) Test statistics Z Asymp. Sig. (two-tailed) Z Asymp. Sig. (two-tailed) Z Asymp. Sig. (two-tailed) Z Asymp. Sig. (two-tailed) Z Asymp. Sig. (two-tailed) Age -4.421 0.000* -4.035 0.000* -2.757 0.006* -.897 0.370 -1.068 0.286 Sex -5.525 0.000* -4.243 0.000* -4.078 0.000* -.190 0.849 -3.204 0.001* Suprahyoid -1.026 0.305 -.054 0.957 -1.515 0.130 -1.124 0.261 -1.603 0.109* Thyrohyoid -4.708 0.000* -5.901 0.000* -1.338 0.181 -3.927 0.000* -2.928 0.003* Cricothyroid -2.808 0.005* -2.172 0.030* -2.126 0.034* -.009 0.993 -2.849 0.004* Pharyngolaryngeus -2.118 0.034* -2.276 0.023* -.984 0.325 -1.007 0.314 -1.897 0.058 GERD -3.523 0.000* -4.105 0.000* -1.358 0.174 -2.097 0.036*

*p < 0.05. Abbreviations: Non-MM, non-muscle misuse dysphonia; MM, muscle misuse dysphonia; MM3, muscle misuse dysphonia type 3; other-MM, muscle misuse dysphonia except MMD3; GERD, gastroesophageal reflux disorders; (n) = number of patients in the group

Logistic regression Logistic regression was used to identify the explanatory variables of interest (ELMT scores) that significantly affect the outcome variables of inter-

est (diagnosis of MMD and GER) while controlling for age and sex. The analysis results of the significant variables in each model are summarized in Table 4.
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TABLE 4. Logistic Regression Results
Model Likelihood Ratio (degree freedom) (Significance) 76.017 (7) (0.0000) 84.376 (7) (0.0000) 28.345 (7) (0.0002) 30.891 (7) (0.0001) 23.095 (6) (0.0008)

Comparing Groups in the model(n) Non-MM (324) vs MM (141) Non-MM (324) vs MM3 (70) Non-MM (324) vs Other-MM (71) Other-MM (71) vs MM3 (70) GERD (290) vs. non-GERD (175)` *p < 0.05.

Significant Explanatory Variables* Variables Age Sex T GERD Age Sex T GERD Age Sex S T GERD Age Sex B -0.0224 -1.2254 0.6594 0.5622 -0.0235 -1.3910 1.4680 0.8964 -0.0217 -1.1106 -0.5253 1.5850 0.7830 0.0112 -0.7283 Wald 9.9672 19.4819 13.3284 6.2020 5.4247 12.0651 26.5443 8.4386 6.3150 9.8908 5.0259 18.9107 4.0790 3.4038 10.4620 Sig. 0.0016 0.0000 0.0003 0.0128 0.0199 0.0005 0.0000 0.0037 0.0120 0.0017 0.0250 0.0000 0.0434 0.0650 0.0012 Exp (B) 0.9779 0.2937 1.9337 1.7545 0.9768 0.2488 4.3403 2.4508 0.9785 0.3293 0.5914 4.8759 2.1880 1.0112 0.4827

Abbreviations: Non-MM, non-muscle misuse dysphonia; MM, muscle misuse dysphonia; MM3, muscle misuse dysphonia type 3; other-MM, muscle misuse dysphonia except MM3; S, Suprahyoid; T, Thyrohyoid; GERD, gastroesophageal reflux disorders; (n), number of patients in the group; classification cut-off value = 0.5; B, estimated logit coefficient; Wald = [B/S.E.]2; Sig., significant level of the coefficient; Exp (B), odds ratio of the individual coefficient.

GER 24-hour pH monitoring result Of 39 patients with borderline clinical GER sent for 24-hour pH monitoring, 35 underwent the test and 24 (68.6 %) demonstrated significant pathological GER. Pearson correlation showed no significant correlation between any of the ELMT scores and DeMeester (GER standard test) scores. The ELMT scores showed no statistical difference between patients with positive and negative 24-hour pH monitoring tests. Tables 5, 6, and 7 present EMLT and GER results. Interrater reliability Double-blinded evaluation of ELMT was performed in 57 successive patients during a 30-day period. The results of paired sample Wilcoxon signed-ranks test showed significant difference (p < 0.05) in the pharyngolaryngeal muscle. There is no significant difference between examiners in other groups of ELMT scores. Table 6 presents data on interrater reliability.
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Intrarater reliability Since the examiner still may remember the first palpation scores while doing the second palpation it is probably better to interpret this result as pre and post videostrobolaryngoscopy ELMT changes, rather than as intrarater reliability. The pharyngolaryngeal muscle tension is the only score that shows a statistically significant difference between two examinations. Table 7 presents data on intrarater reliability. Adverse reactions No immediate or delayed adverse effect from the palpation was observed, recorded in the clinic, or reported by the patients during the study period. Most tolerated the palpation without complaint. DISCUSSION Since Morrison et al coined the term muscle tension dysphonia (MTD) in 1983,7 some changes have

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TABLE 5. EMLT and GER
Test statistics Mann-Whitney U Wilcoxon W Z Asymp. Sig. (two-tailed) Exact Sig. [2*(one-tailed Sig.)] Age 117.5 417.5 -0.515 0.606 0.612 Sex 98.50 398.50 -1.422 0.155 0.238 Suprahyoid 88.000 154.000 -1.634 0.102 0.123 Thyrohyoid 104.500 170.500 -1.040 0.298 0.334 Cricothyroid 130.500 196.500 -0.057 0.955 0.958 Pharyngolaryngeus 92.500 158.500 -1.470 0.142 0.163

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Grouping: Reflux vs nonreflux defined by 24-hour pH monitoring. There was no significant difference between the groups.

TABLE 6. Interrater Reliability (Test Statistics Wilcoxon Signed-Ranks Test)

S2 - S1 Z Asymp. Sig. (two-tailed) *Based on positive ranks. Based on negative ranks. S1,T1,C1,P1 = main examiners scores. S2,T2,C2,P2 = preclinical evaluation examiners scores -0.921* 0.357 T2 - T1 -0.349 0.727 C2 - C1 -0.474 0.636 P2 - P1 -2.232 0.026

TABLE 7. Intrarater Reliability (Wilcoxon Signed-Ranks Test)

S3 - S2 Z Asymp. Sig. (two-tailed)
ABased BThe

T3 - T2 0.000 B 1.000

C3 - C2 -1.000C 0.317

P3 - P2 -2.333c 0.020

-0.333A 0.739

on positive ranks. on negative ranks.

sum of negative ranks equals the sum of positive ranks.

CBased

been made to refine the classification. In 1993, we made a major change and began to use the term muscle misuse dysphonia (MMD) instead of MTD.2 We classified these nonorganic voice disorders into muscle misuse types 16 according to different laryngoscopic laryngeal postures. After using this new classification for some time, we found that there were some patients with muscle misuse disorders that did not fit well into any category so their disorder was termed nonspecific muscle misuse. We also observed that extralaryngeal muscle tension was more prominent in

people with some types of muscle misuse dysphonia than in patients with other voice disorder diagnoses. A diagnosis of muscle misuse voice disorder implies abnormal laryngeal posture, which may result from a variety of causes. For example, hyperlordosis of the cervical spine with an extended head and kyphotic hump in the upper thoracic vertebrae can cause poor laryngeal posture, increased vocal effort, and muscular tension in and around the larynx during phonation.8 If not corrected, habitual misuse of laryngeal muscles during phonation may slowly
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THANA ANGSUWARANGSEE AND MURRAY MORRISON tionship between them. The unique anteroposterior contraction observed in MMD3 might be a protective mechanism to shield the airway from acid reflux. From this point of view, longstanding GER might be the cause of MMD3, or in other words MMD3 might be one of the laryngeal manifestations of reflux. Gastroesophageal reflux (GER) is commonly associated with voice disorders. When gastric acid regurgitates through the esophagus into the laryngopharynx, airway protective mechanisms are triggered that result in closure of the glottis, increased salivation and swallowing, coughing or choking, and tightening of laryngopharyngeal constrictor muscles, especially the cricopharyngeus. Our previous porcine animal study demonstrated a direct reflex relationship between stimulation of the lower esophagus and thyroarytenoid muscle activity.6 Voice patients with reflux may have symptoms ranging from minor throat irritation, globus pharyngeus, frequent throat clearing, heartburn, chronic cough, morning hoarseness or sore throat, nocturnal choking, or episodic laryngospasm. Interestingly, comparison of reflux and nonreflux groups in the logistic model did not show a statistically significant difference in tension in any of the muscle groups (p > 0.05). A potential source of error is that not all patients had pH testing. Patients that seemed to have obvious laryngopharyngeal reflux by history and examination frequently did not undergo pH testing, but were treated empirically. Thus the patients studied might have been those in whom the diagnosis of reflux was equivical. While there was no interrater difference in tension ratings for the suprahyoid, thyrohyoid, and cricothyroid groups, the significant difference between examiners in the pharyngolaryngeal palpation scores might be the result of difficulty in this muscle palpation technique. It requires rotation of the larynx to feel the movement of the arytenoid cartilage or contraction of the posterior cricoarytenoid muscles. To accurately perform this palpation requires more practical experience than the other three muscle groups, which do not require manipulation of the larynx. Since the time between the two examinations is quite short, i.e., less than 1 hour, the intrarater reliability might not be valid due to examiner bias. The result of this comparison might better be interpreted as ELMT change after videostrobolaryngoscopy. Only the pharyngolaryngeal muscle tension showed significant change after the videostrobolaryngoscopy.

change the resting tone of laryngeal muscles so that they are persistently tense. In time, this may lead to distortion of the laryngeal skeletal complex and persistent closure of thyrohyoid or cricothyroid spaces, or anterior displacement of the cricoid cartilage relative to the thyroid cartilage.9 Vocal fold lesions such as vocal nodules, polyps, or sulcus vocalis may promote secondary laryngeal muscle misuse, making the voice sound worse than would be expected from the appearance of the lesion. Each of the four muscle groups evaluated in this study plays a specific role in determining external and internal laryngeal posture, at rest and during phonation. In our experience, high tension in the suprahyoid muscles, usually found in untrained performers, results in excessive elevation of the larynx. Contraction of the thyrohyoid muscles pulls the hyoid bone and thyroid cartilage together and, in severe cases, closes the thyrohyoid space. This consequently produces anteroposterior supraglottic contraction, a typical laryngoscopic posture found in muscle misuse dysphonia type 3 (MMD3). The cricothyroid muscles increase pitch by lengthening the vocal cord, and also help to stabilize the cricoid-thyroid architecture against the opposing pull of the thyroarytenoid muscles.9 Therefore tension in cricothyroid muscles will increase with thyroarytenoid muscle tension. If the tension persists for long enough, the oblique belly of the cricothyroid muscles may fatigue and relax, resulting in subluxation of the cricothyroid joints and palpable anterior displacement of the cricoid cartilage. As noted above, our study showed that, after controlling for age and sex, there is a strong relationship between thyrohyoid muscle tension, GER, and MMD (p 0.01). But subgroup analysis showed that the thyrohyoid muscle tension and GER were significantly different only between MMD3 and nonMMD patients. Muscle misuse dysphonia type 3 involves inappropriate anteroposterior contraction of the supraglottic larynx during voicing. The arytenoid area and epiglottis may be drawn almost together in this form of abnormal laryngeal posture. From an anatomical point of view, it makes sense that excess contraction of the thyrohyoid muscles and closure of the space between the hyoid bone and the thyroid cartilage would enhance this posture. The relationship of GER to MMD3 might imply a causal relaJournal of Voice, Vol. 16, No. 3, 2002

EXTRINSIC LARYNGEAL MUSCULAR TENSION In our experience, there are no adverse effects of laryngeal palpation performed by qualified practitioners. Except for the pharyngolaryngeal palpation, our technique and scoring criteria are simple, and easy to learn. It provides another clinical tool for assessment of patients with voice disorders. In addition to helping the clinician form a diagnostic profile for each patient, the palpation skills naturally extend to laryngeal manipulation as an adjuvant to voice therapy. In some patients, the palpation of suprahyoid and thyrohyoid muscles can be used as biofeedback or as a self-monitoring tool during and after voice therapy. The disadvantages of this diagnostic tool are the subjective nature of the method and the limited ability to palpate some patients, such as those with a short fatty neck, previous trauma, surgery, or radiation. CONCLUSION This study showed that, based on our extrinsic laryngeal muscle tension (ELMT) palpation and grading criteria, thyrohyoid tension is the only muscle group that demonstrated a statistically significant relationship with muscle misuse dysphonia (MMD), specifically MMD type 3. No significant difference in the ELMT scores was found between GER and nonGER patients although it is postulated that a causal relationship was found between MMD3 and GER. Palpation of extrinsic laryngeal muscles can yield information about laryngeal posture at rest and during phonation. Integration of this examination technique into routine laryngeal examinations, particularly in patients with voice disorders, can help the clinician make a more accurate diagnosis and plan appropriate management. The palpation technique and grading system criteria used in our clinic are easy to use with good inter-

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rater reliability except for the pharyngolaryngeal muscle tension. The technique used to palpate this muscle group is more difficult than that of other muscle groups and might stimulate the muscle to increase tension after the first examination. Like other physical examinations, practice and experience, plus the use of standard criteria, can increase reliability among examiners. We encourage clinicians to add this palpation technique to their routine clinical practice, as further information gained through practice is crucial to refining and standardizing the palpation technique as a useful clinical tool. REFERENCES
1. Harris T, Harris S, Rubin JS, Howard DM. The Voice Clinic Handbook. London: Whurr; 1998: Preface xvixvii. 2. Morrison MD, Rammage LA. Muscle misuse voice disorders: description and classification. Acta Otolaryngol 1993; 113:428434. 3. Lieberman J. Principles and techniques of manual therapy: applications in the management of dysphonia. In: Harris T, Harris S, Rubin JS, Howard DM, eds. The Voice Clinic Handbook. London: Whurr; 1998: 91138. 4. Vilkman E, Sonninen A, Hurme P, Korkko P. External laryngeal frame function in voice production revisited: a review. J Voice. 1996;10:7892. 6. Gill C, Morrison MD. Esophagolaryngeal reflex in a porcine animal model. J Otolaryng. 1997; 27:7680. 5. Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD). Laryngoscope. 1991;101 (supp53):178. 7. Morrison MD, Rammage LA, Belisle G, Nichol H, Pullan B. Muscular tension dysphonia. J Otolaryngol. 1983;12:302 306. 8. Morrison MD, Rammage LA, Nichol H. Management of the Voice and Its Disorders. 2nd ed. San Diego, Calif: Singular, 2001:2835. 9. Harris T, Lieberman J. The cricothyroid mechanism, its relation to vocal fatigue and vocal dysfunction. Voice Forum. 1993;2:8996.

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