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Extrinsic laryngeal muscular tension in patients with voice disorders

Authors: Thana Angsuwarangsee and Murray Morrison
Date: Sept. 2002
From: Journal of Voice(Vol. 16, Issue 3)
Publisher: Elsevier, Inc.
Document Type: Clinical report
Length: 3,364 words
Lexile Measure: 1720L

Full Text:

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 [less than or
equal to] 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 dysphonia--Laryngeal palpation--Voice 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 history 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 videostrobo-laryngoscopic finding of normal vocal fold mucosa 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-induced 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

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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 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

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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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1. The Mann-Whitney U nonparametric test was used to compare ELMT scores between MMD and non-MMD, and between GER and non-GER patients.

2. Logistic regression methods were used to identify explanatory variables that significantly affected the following outcome variables:

* 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 examiners (interrater) and pre-examination and postexamination
scores (intrarater).

RESULTS

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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 (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

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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 [less than
or equal to] 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.

Logistic regression

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

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.

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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.

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.

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DISCUSSION

Since Morrison et al coined the term muscle tension dysphonia (MTD) in 1983, (7) some changes have 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 1-6 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.

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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 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
[less than or equal to] 0.01). But subgroup analysis showed that the thyrohyoid muscle tension and GER were significantly different only between MMD3 and
non-MMD 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 relationship 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

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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.

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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 non-GER 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-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.

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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 xvi-xvii.

2. Morrison MD, Rammage LA. Muscle misuse voice disorders: description and classification. Acta Otolaryngol 1993;113:428-434.

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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 Hand-book. London: Whurr; 1998:91-138.

4. Vilkman E, Sonninen A, Hurme P. Korkko P. External laryngeal frame function in voice production revisited: a review. J Voice. 1996;10:78-92.

6. Gill C, Morrison MD. Esophagolaryngeal reflex in a porcine animal model. J Otolaryng. 1997;27:76-80.

5. Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD). Laryngoscope. 1991;101 (supp53):1-78.

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, 2001:28-35.

9. Harris T, Lieberman J. The cricothyroid mechanism, its relation to vocal fatigue and vocal dysfunction. Voice Forum. 1993;2:89-96.

*Thana Angsuwarangsee and [dagger]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; [dagger]Division of Otolaryngology, University of British Columbia, Vancouver, Canada

Accepted 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

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.

Suprahyoid muscles (S)

* Midline upward palpation in submental space with middle finger
Observe: 1. tension at rest
2. contraction during
low-pitched [TEXT NOT REPRODUCIBLE IN ASCII] follow by
high-pitch [TEXT NOT REPRODUCIBLE IN ASCII]
phonation

Thyrohyoid muscles (T)

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* 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.

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

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[degrees] 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.

TABLE 1. Primary Diagnosis Categories

No. of No. of
Primary Diagnosis Cases Percent GER % of GER

Muscle misuse dysphonia 141 30.3 70 49.65

Muscle misuse type 1 14 3.0 8 57.14
Muscle misuse type 2 19 4.1 9 47.37
Muscle misuse type 3 70 15.1 41 58.57
Muscle misuse type 4 8 1.7 1 12.50
Muscle misuse type 5 5 1.1 0 0.00
Muscle misuse--nonspecific 25 5.4 11 44.00

Non-muscle misuse dysphonia 324 69.7 105 32.41

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Congenital sulcus and cyst 9 1.9 2 22.22

Functional miscellaneous* 16 3.4 2 12.50
Irritable larynx syndrome 40 8.6 22 55.00
Chronic laryngitis and granuloma 53 11.4 36 67.92
Laryngeal trauma 18 3.9 5 27.78
Normal 13 2.8 3 23.08
Organic miscellaneous[dagger] 16 3.4 1 6.25
Vocal fold paralysis 35 7.5 9 25.71
Spasmodic dysphonia 25 5.4 4 16.00
Tumor 19 4.1 0 0.00
Vocal nodule 37 8.0 14 37.84
Vocal polyp 14 3.0 3 21.43
Neurological disorders 29 6.2 4 13.79

Total 465 100.0 175 37.63

[dagger]Organic miscellaneous includes subglottic stenosis and

cricopharyngeal muscle spasm.
*Functional miscellaneous includes articulation disorders,
temporomandibular joint disorder, senile atrophic bowing, and gender
dysphoria.

TABLE 2. Excluded Cases

Exclusion Criteria Number of Cases

Airway-compromised patients 3
Neck scarring from surgery, radiation therapy, or 5
trauma
Age less than 12 years old 1
History of laryngospasm, stridor, or airway compromise 3
Tracheotomized patients 2
Cervical pathology: mass lesion around the larynx 1
Neurological conditions that preclude ELMT assessment 8
Patients who were not cooperative or who were under 10
emotional distress
Short, fatty neck: unable to identify laryngeal 1
landmarks
Total 34

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

Comparing Test
Groups (n) statistics Age Sex Suprahyoid Thyrohyoid

Non-MM (324) Z -4.421 -5.525 -1.026 -4.708

vs
MM (141) Asymp. Sig. 0.000* 0.000* 0.305 0.000*
(two-tailed)
Non-MM (324) Z -4.035 -4.243 -.054 -5.901
vs
MM3 (70) Asymp. Sig. 0.000* 0.000* 0.957 0.000*
(two-tailed)
Non-MM (324) Z -2.757 -4.078 -1.515 -1.338
Vs
Other-MM (71) Asymp. Sig. 0.006* 0.000* 0.130 0.181
(two-tailed)
Other-MM (71) Z -.897 -.190 -1.124 -3.927
vs
MM3 (70) Asymp. Sig. 0.370 0.849 0.261 0.000*
(two-tailed)
GERD (290) Z -1.068 -3.204 -1.603 -2.928
vs.
non-GERD (175) Asymp. Sig. 0.286 0.001* 0.109* 0.003*
(two-tailed)

Comparing
Groups (n) Cricothyroid Pharyngolaryngeus GERD

Non-MM (324) -2.808 -2.118 -3.523

vs
MM (141) 0.005* 0.034* 0.000*

Non-MM (324) -2.172 -2.276 -4.105

vs
MM3 (70) 0.030* 0.023* 0.000*

Non-MM (324) -2.126 -.984 -1.358

Vs
Other-MM (71) 0.034* 0.325 0.174

Other-MM (71) -.009 -1.007 -2.097

vs
MM3 (70) 0.993 0.314 0.036*

GERD (290) -2.849 -1.897

vs.
non-GERD (175) 0.004* 0.058

*p < 0.05.
Abbreviations: Non-MM, non-muscle misuse dysphonia; MM, muscle misuse

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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

TABLE 4. Logistic Regression Results

Model Likelihood Ratio Significant Explanatory

Comparing Groups (degree freedom) Variables*
in the model(n) (Significance) Variables B Wald

Non-MM (324) 76.017 Age -0.0224 9.9672

vs (7) Sex -1.2254 19.4819
MM (141) (0.0000) T 0.6594 13.3284
GERD 0.5622 6.2020
Non-MM (324) 84.376 Age -0.0235 5.4247
vs (7) Sex -1.3910 12.0651
MM3 (70) (0.0000) T 1.4680 26.5443
GERD 0.8964 8.4386
Non-MM (324) 28.345 Age -0.0217 6.3150
vs (7) Sex -1.1106 9.8908
Other-MM (71) (0.0002)
Other-MM (71) 30.891 S -0.5253 5.0259
vs (7) T 1.5850 18.9107
MM3 (70) (0.0001) GERD 0.7830 4.0790
GERD (290) 23.095 Age 0.0112 3.4038
vs. (6) Sex -0.7283 10.4620
non-GERD(175) (0.0008)

Comparing Groups Significant Explanatory Variables*

in the model(n) Sig. Exp (B)

Non-MM (324) 0.0016 0.9779

vs 0.0000 0.2937
MM (141) 0.0003 1.9337
0.0128 1.7545
Non-MM (324) 0.0199 0.9768
vs 0.0005 0.2488
MM3 (70) 0.0000 4.3403
0.0037 2.4508
Non-MM (324) 0.0120 0.9785
vs 0.0017 0.3293
Other-MM (71)
Other-MM (71) 0.0250 0.5914
vs 0.0000 4.8759
MM3 (70) 0.0434 2.1880
GERD (290) 0.0650 1.0112
vs. 0.0012 0.4827
non-GERD (175)

*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 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.][.sup.2]; Sig., significant level of the coefficient; Exp
(B), "odds ratio" of the individual coefficient.

TABLE 5. EMLT and GER

Test statistics Age Sex Suprahyoid Thyrohyoid

Mann-Whitney U 117.5 98.50 88.000 104.500

Wilcoxon W 417.5 398.50 154.000 170.500
Z -0.515 -1.422 -1.634 -1.040
Asymp. Sig. 0.606 0.155 0.102 0.298
(two-tailed)
Exact Sig. 0.612 0.238 0.123 0.334
[2*(one-tailed Sig.)]

Test statistics Cricothyroid Pharyngolaryngeus

Mann-Whitney U 130.500 92.500

Wilcoxon W 196.500 158.500
Z -0.057 -1.470
Asymp. Sig. 0.955 0.142
(two-tailed)
Exact Sig. 0.958 0.163
[2*(one-tailed Sig.)]

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 T2 - T1 C2 - C1

Z -0.921* -0.349[dagger] -0.474[dagger]

Asymp. Sig. (two-tailed) 0.357 0.727 0.636

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P2 - P1

Z -2.232[dagger]
Asymp. Sig. (two-tailed) 0.026

*Based on positive ranks.

[dagger]Based on negative ranks.
S1,T1,C1,P1 = main examiner's scores. S2,T2,C2,P2 = preclinical
evaluation examiner's scores

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

S3 - S2 T3 - T2 C3 - C2 P3 - P2

Z -0.333 (A) 0.000 (B) -1.000 (C) -2.333 (c)

Asymp. Sig. (two-tailed) 0.739 1.000 0.317 0.020

(A) Based on positive ranks.

(B) The sum of negative ranks equals the sum of positive ranks.
(C) Based on negative ranks.

Angsuwarangsee, Thana^Morrison, Murray

Copyright: COPYRIGHT 2002 Elsevier, Inc.

http://www.elsevier.com.proxy.binghamton.edu/wps/find/homepage.cws_home
Source Citation (MLA 9th Edition)
Angsuwarangsee, Thana, and Murray Morrison. "Extrinsic laryngeal muscular tension in patients with voice disorders." Journal of Voice, vol. 16, no. 3, Sept.
2002, pp. 333+. Gale OneFile: Health and Medicine, link.gale.com/apps/doc/A158917901/HRCA?u=bingul&sid=bookmark-HRCA&xid=f41973b2. Accessed
6 Mar. 2023.

Gale Document Number: GALE|A158917901

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