ARTICLE IN PRESS

An evaluation of short-term treatment outcomes of

Cricothyroid Visor Maneuver: A proof-of-concept Pilot Study
*,†Ali Dehqan, and ‡Kirrie J. Ballard, *yZahedan, Iran, and zLidcombe, Australia

Summary: Introduction. Muscle tension dysphonia (MTD) is used as a clinical and diagnostic descriptive
label for a diverse range of vocal fold behaviors caused by increased tension of the (para) laryngeal musculature.
These increased tension can occur in the cricothyroid muscle and in the ‘‘visor’’ mechanism, contributing to voice
problems. The main goal of this study is to determine whether a new method, the cricothyroid visor maneuver
(CVM), is an effective method for improving quality and other aspects of the MTD patients' voices.
Method(s). Eighty-eight adult female patients participated in this quasiexperimental study. One group consisted
of 30 MTD patients (mean age 28.7 § 4.95 years) for whom manual circumlaryngeal therapy (MCT) was pro-
vided. The other group consisted of 30 MTD patients (mean age 28.9 § 5.1 years) who received CVM. Also, 28
adult females with MTD (mean age 28.60 § 4.56 years), who were on the clinic’s waiting list, served as a control
group and did not receive any treatment. Treatment was provided in a single 30-minute session. Pre- and post-
treatment audio recordings of sustained vowels, selected sentences, and connected speech samples were submitted
to auditory-perceptual and acoustical analysis to assess the short-term effects of the two treatment programs.
Also, perceptions of patients’ about their voice quality before and after therapy were assessed by visual analogue
scale.
Results. Perceptually, Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) ratings improved in all
patients with both treatment methods. Acoustically, with CVM, harmonic-to-noise ratio and Cepstral Peak
Prominence increased and perturbation (jitter and shimmer) measures decreased and there was not significant
change in MCT and control groups. Visual analogue scale showed that feelings of patients improved after ther-
apy in both treatment methods, with higher scores for patients receiving CVM in comparison to the MCT
method.
Discussion. These results suggest that CVM can be an effective method for voice rehabilitation in patients with
MTD and manipulation of Cricothyroid muscle and ‘‘visor’’ mechanism can lead to marked voice improvement.
Keywords: Cricothyroid visor maneuver (CVM)−Manual circumlaryngeal therapy (MCT)−Visor−Acoustic
analysis−Mmuscle tension dysphonia.

INTRODUCTION in secondary MTD, the tension and dysphonia are a

Muscle tension dysphonia (MTD) is used as a clinical and
diagnostic descriptive label for a diverse range of vocal fold
behaviors caused by increased tension of the (para) laryn-
geal musculature.1 MTD is one of the frequent complaints
at voice clinics and between 10%−40% of the patients at a
voice clinic have MTD2 Psychological, social, or physiologi-
cal problems play the main role in the development of
MTD.3 The intrinsic and extrinsic laryngeal muscles are
responsive to emotional triggers and can easily become
hypercontracted.3 Van Houtte et al1 described MTD as a
pathological condition in which an excessive tension of the
paralaryngeal musculature, caused by a diverse number of
etiological factors, leads to a disturbed voice.
There are two types of MTD based on etiology. In pri-
mary MTD the excessive tension occurs in the absence of
known structural or dynamic alterations in the larynx and,
Accepted for publication September 23, 2019.
From the *Cellular and Molecular Research Center, Zahedan University of Medi-
cal Sciences, Zahedan, Iran; yDepartment of Speech therapy, School of Rehabilita-
tion, Zahedan University of Medical Sciences, Zahedan, Iran; and the zFaculty of
Health Sciences, University of Sydney, Lidcombe, New South Wales, Australia.
Address correspondence and reprint requests to Ali Dehqan, Cellular and Molecu-
lar Research Center, Zahedan University of Medical Sciences, Zahedan, Iran.
Journal of Voice, Vol. &&, No. &&, pp. &&−&&
0892-1997
© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2019.09.016
response to damaged tissue.4 The treatment of MTD has
two main approaches, direct and indirect. The indirect
approach includes education about vocal function, commu-
nication, and vocal health, as well as counseling regarding
stress management and relaxation. Direct therapy consists
of specific exercises to control and coordinate the different
aspects of voice production, based on a broad multidimen-
sional evaluation.5
A method of rehabilitation for MTD was described in the
1990s as perilaryngeal manipulation.6 Mathieson (2009)
declares that the first purpose of manual therapies in the
perilaryngeal and laryngeal area is to relax the excessively
tense musculature, which inhibits normal phonatory func-
tion.7 Aronson reported that in cases of vocal hyperfunction
resulting from musculoskeletal tension, the larynx and
hyoid bone are elevated. The outstanding feature in individ-
uals with MTD is elevation of the larynx and hyoid bone;
although, this is not always true based on clinical observa-
tions. As Roy and Ferguson have reported, elevation of the
larynx can result from extrinsic laryngeal muscle tension8
and this, consequently, can raise the larynx and affect the
way in which the vocal folds vibrate.9,10 These authors also
make reference to the fact that vertical laryngeal position
can be presumed to influence phonatory function by altering
control over the length, tension, and stiffness of the vocal
 ARTICLE IN PRESS
2 Journal of Voice, Vol. &&, No. &&, 2019
folds, thus contributing to the disturbance of voice qual-
ity.11,12 Overall, it can be deduced that strategies directed to
relaxing the excessively tense perilaryngeal musculature
might improve glottal source function.7
There are several different approaches to laryngeal
manipulation13−15 and evidence of its positive results,
regardless of the type of manipulation used, particularly for
primary MTD cases.4,16 The aims of the direct approaches
is to reposition the larynx, relax (para) laryngeal and cervi-
cal musculature, promote respiratory control, efficient glot-
tal closure, and resonance equilibrium, reduce voice
symptoms, improve articulation, and relax (para)laryngeal
musculature.17,18 The most common manual therapy techni-
ques are manual circumlaryngeal therapy (MCT)13 and
laryngeal manual therapy.15
One of the key points that has not received sufficient
attention in common manual therapy techniques is the Cri-
cothyroid visor mechanism. This mechanism is of critical
importance to normal laryngeal function.19 Lieberman
noted: “The Cricothyroid visor mechanism is of critical
importance to normal laryngeal function, yet it has a rela-
tively small range of movement and the Cricothyroid
muscles operating about the two joints are relatively small.
Little has been written about the resting position of the Cri-
cothyroid joint,20 but it is reasonable to assume that the
joint is likely to “rest” somewhere in the mid-range between
maximum opening and closure. Clinically in patients pre-
senting with endstage hyperkinetic dysphonia there is a high
incidence of a habitually closed Cricothyroid visor . . . clini-
cally, the cricothyroid visor may not only show a reduced
range of movement but can also lock in any position about
its main axis of movement.” This closed position can result
from the laryngeal elevation during phonation that leads to
high vocal pitch, and postural problems in MTD20 and this
justifies use of EMG recordings in future studies.21−23 The
main goal of this study is manipulation of the Cricothyroid
visor in combination with the MCT method, to determine
whether this combined approach achieves a greater change
in quality and other aspects of the patients with MTD voices
compared with MCT alone.
METHODS
Design
The study was a single-blind randomized quasiexperimental
trial with participants assigned to one of two intervention
conditions, ensuring the groups were matched on age and
duration of the disorder.
Participants
Eighty-eight adult female patients, who had been referred to
the speech therapy clinic in a major metropolitan hospital in
Iran, participated in this quasiexperimental study. Adult
females were chosen due to the higher percentage of voice
problems for women than for men.24 A consecutive sam-
pling method was used. Patients who were referred from the
Ear, Nose and Throat ward and were diagnosed as primary
MTD participated in the study. Participants were between
18 and 40 years old. All of patients’ first language was Farsi.
One group consisted of 30 MTD-1 patients (mean age 28.7
§ 4.95 years) for whom MCT was provided. The other
group consisted of 30 MTD-1 patients (mean age 28.9 § 5.1
years) who received MCT plus Cricothyroid visor maneuver
(CVM). Also, 28 adult females with MTD (mean age 28.60
§ 4.56 years), who were on the clinic’s waiting list, served as
a control group, and did not receive any treatment.
Although assignment to CVM/MCT (intervention condi-
tions) in the original 60 cases was randomized; the control
group were collected at a different time. Therefore, their
assignment to the control group was not randomized.
The diagnostic inclusion criteria for primary MTD were:
(a) a voice disturbance, tension, fatigue, and pain in the
absence of any visible mucosal disease or structural pathol-
ogy; (b) no neurological pathology, specifically vocal fold
paresis, paralysis, or motor speech disturbance; (c) no previ-
ous laryngeal surgery; (d) no coexisting upper respiratory
infection symptoms at the time of examination. Two laryngol-
ogists in the Ear, Nose, and Throat ward of the Hospital per-
formed routine examinations of the larynx using both indirect
laryngoscopy and laryngostroboscopy. The patients were
asked to sustain the vowel /i/ for better visualization of the lar-
ynx. The minimum duration of dysphonia was 6 months prior
to the diagnostic session (mean 8.20 § 1.66 months).
Treatment protocol
All patients in the MCT and CVM groups were treated by
one speech pathologist and were blinded to which method
was being used for them. MCT was undertaken according
to the description of Aronson3,5 and explained in steps (a, b,
c, d, e and g) below, and CVM was conducted as explained
in (a) to (g) below.
(a) The hyoid bone was encircled with the thumb and
index finger, which were worked posteriorly until the tips of
the major horns were felt; (b) light pressure was exerted
with the fingers in a circular motion over the horns of the
hyoid bone; (c) the procedure was repeated beginning from
the thyroid notch and working posteriorly; (d) the posterior
borders of the thyroid cartilage just medial to the sternoclei-
domastoid muscles were located and the procedure was
repeated; (e) with the fingers over the superior borders of
the thyroid cartilage, the larynx was worked downward,
and moved laterally at times; (f) with the thumbs of both
hands over both sides of the visor as shown in Figure 1, the
structure was pulled away from the both sides for opening
of the visor. The patient was asked to produce the vowel /a/
in a high pitched voice for activating the Cricothyroid mus-
cle (g) the larynx was worked downward; the patient was
also asked to hum or prolong vowels and any changes in
vocal quality were noted. Improvement in the voice
production of the patients was immediately reinforced by
repositioning the larynx by the clinician. The improved
voice was progressively shaped from vowels and words
 ARTICLE IN PRESS
Ali Dehqan and Kirrie J. Ballard An evaluation of short-term treatment outcomes of Cricothyroid Visor Maneuver: A 3
FIGURE 1. Manipulation of cricothyroid visor.
(usually automatic serial speech, ie, counting, stating the
days of the week) to short phrases to sentences, and finally
to conversation.
Assessment of outcome variables
The two treatment groups were tested.
Acoustic analysis
Using tokens of sustained vowels may be preferred over reg-
ular speech in vocal acoustic assessment25 and thus they
were used here. After instruction and several test trials, the
participants were instructed to phonate 10 stable /^a/ vow-
els26 continuously for as long as possible, using habitual
vocal pitch and loudness and constant quality, with about 5
seconds between tokens. Patients were audio-recorded using
a microphone (ECM-717 electret condenser microphone;
Sony Corporation, Minato, Tokyo, Japan; frequency
response 100−15,000 Hz) positioned approximately 10 cm
from the mouth. All recordings were made in a quiet, acous-
tically treated room. The room noise level was determined
by a sound level meter (model: CEL-450, product of Casella
CEL, Regent House, Kempston, Bedford, UK) with room
noise measured as Min LA: 28.0 dB and Min LC: 40.8 dB.
Recordings and analyses were carried out using PRAAT
software version 6.0.55 (Phonetic Sciences, University of
Amsterdam, Amsterdam, the Netherlands) installed on a
laptop computer (ASUSK43SJ; ASUSTeK Computer Inc.,
Taipei, Taiwan). The measures acquired from PRAAT
included jitter (%), shimmer (%), HNR (dB), and smoothed
cepstral peak prominence (ie, CPPS). CPPS was calculated
as the distance between the first rahmonic’s peak and the
point with equal quefrency on the regression line through
the smoothed cepstrum.27 A mid-3-second segment of each
vowel prolongation was subjected to the acoustic analyses.
Perceptual analysis
Auditory perceptual evaluation of each patient’s voice was
performed using the Consensus Auditory-Perceptual Evalu-
ation of Voice (CAPE-V). The CAPE-V is a subjective
measurement tool of perceived voice qualities. Vocal rough-
ness, breathiness, strain, pitch, loudness, and overall sever-
ity are rated during several tasks, including general
conversation, vowel prolongation, and sentence reading. A
score of 0 represents a normal voice and 100 a severely devi-
ant voice. Ratings are recorded on a 100 mm line as a visual
analog scale for each parameter. The scores were judged
together as a whole and rated as severely deviant, moder-
ately deviant, mildly deviant, and normal.28 The overall
severity was used for comparison across the two testing
points. The blind ratings were performed on recorded vow-
els and 1-minute samples of recorded sentences and sponta-
neous speech, by two speech language pathologists with
more than 10 years’ experience performing voice therapy.
The first recording was made before starting treatment dur-
ing the first session of therapy as a pretreatment sample.
Post therapy voice samples were recorded immediately after
the therapy session in one session. The duration of the ses-
sion was 50−60 minutes. Because patients had to frequently
travel long distances at considerable personal expense for
voice assessment and treatment, regularly scheduled follow-
up visits at predetermined intervals were difficult. Therefore,
post treatment recordings were done immediately after ter-
mination of the therapy session.
Participant self-ratings
Visual analogue scales (VAS) are used for measuring many
subjective characteristics that cannot be measured easily by
instruments; such as feeling of patients about their disor-
ders.29,30 In a VAS system, a 100 mm horizontal line is used
to represent a spectrum: one end showing the worst feeling
and the other end showing the best condition. On this 100-
mm line, patients place a cross at the point corresponding to
their feelings and the distance from zero up to that crossing
point is measured by using a millimeter tape measure. For
obtaining sufficient sensitivity, hundredths divisions are
used.31 Using VAS without grading and marking the
100 mm line is more sensitive that when the graded line is
used.32
Therefore, to perform self-assessment, individuals were
asked to mark a point on the line according to how they
classified their quality of voice, from worst quality at the left
end to best quality at the right end. This evaluation was
done once before and once after therapy.
Statistical analysis
Data were analyzed with the statistical software IBM SPSS
24.0 for Windows (SPSS Corp, Chicago, IL). The Kolmo-
gorov−Smirnov test was used to assess normality of distri-
butions. Acoustic data were found to be normally
distributed. Repeated measures ANOVA was used to evalu-
ate the main effects of group (MCT, CVM) and time (pre,
post) and their interaction. A paired samples t test was con-
ducted to compare the effects of therapies on acoustical
parameters at the two times, before starting therapy and
immediately after termination of the therapies. One way
 ARTICLE IN PRESS
4 Journal of Voice, Vol. &&, No. &&, 2019

ANOVA was used for comparing mean differences of both However, the interaction of group by time again was signifi-
therapy methods. To minimize Type 1 error, the Bonferroni cant (F (1, 85) = 146.25, P < 0.001, E2 = 0.77). Posthoc test-
correction was used. This correction reduces chances of false ing showed no change in CPPS for the MCT and control
positive findings by testing each individual hypothesis at a groups but a significant increase for the CVM group (see
significance level of a/m. The current study has 5 compari- Tables 1 and 2).
sons so a = 0.05/5; a = 0.01 was the threshold used for statis-
tical significance. Intrarater reliability was calculated by
Perceptual analysis
Kappa coefficient agreement for the six CAPE-V features.
Intrarater reliability was relatively high, with a Kappa coef-
The correlation between the raters in the CAPE-V scores
ficient agreement ranging from 0.74 to 0.91 across the six
was calculated by a Spearman correlation coefficient.
CAPE-V features. For the control group, the subjective
CAPE-V ratings did not change. For MCT, the subjective
RESULTS CAPE-V ratings changed in all patients (P < 0.01). In over-
all severity before treatment, six patients had severe devia-
Acoustic analysis
tion (r = 0.78, P < 0.01). After completion of the treatment,
Repeated measures ANOVA for jitter revealed a highly sig-
Spearman correlations between two raters showed that of
nificant main effect of time (F (1,85) = 7.46, P = .008,
those patients, three changed to moderate (r = 0.78, P <
E2 = .081), but not group (F (1,85) = 2.08, P = .131,
0.01), one to mild (r = 0.86, P < 0.01), and two to normal
E2 = .013). However, the interaction of group by time was
(r = 0.81, P < 0.01). The other 24 patients were moderately
significant (F (1,58) = 4.727, P = .01, E2 = .01). Posthoc test-
deviant pretreatment (r = 0.86, P < 0.01), of which 11
ing showed no change in jitter for the MCT and control
changed to mild (r = 0.83, P < 0.01) and 13 to normal
groups but a significant decrease for the CVM group (see
(r = 0.78, P < 0.01). Also, CVM showed changes of the sub-
Tables 1 and 2).
jective CAPE-V ratings in all patients (P < 0.01). In overall
The analysis for shimmer showed a highly significant
severity before treatment, eight patients had severe devia-
main effect of time (F (1, 85) = 37.04, P < .001, E2 = .304),
tion (r = 0.85, P < 0.01). After completion of the treatment,
but not group (F (1,85) = 0.594, P = .554, E2 = 3.16). How-
Spearman correlations between two raters showed that of
ever, the interaction of group by time was significant (F
those patients, two changed to moderate (r = 0.90, P <
(1,85) = 11.42, P < 0.001, E2 = .212). Posthoc testing showed
0.01), two to mild (r = 0.88, P < 0.01), and four to normal
no change in shimmer for the MCT and control groups but
(r = 0.87, P < 0.01). The other 22 patients were moderately
a significant decrease for the CVM group (see Tables 1
deviant pretreatment (r = 0.88, P < 0.01), of which eight
and 2).
changed to mild (r = 0.83, P < 0.01) and 14 to normal
Similar to jitter and shimmer, the analysis for HNR
(r = 0.91, P < 0.01).
showed a significant main effect of time (F (1,85) = 6.004,
For rating of CAPE-V, 0 was perceived as normal voice
P = .016, E2 = .066), but not group (F (1,85) = 0.007,
and scores of 1−25 mm as MI (Mildly Deviant), 25−50 mm
P = .99, E2 = .07). However, the interaction of group by
(Moderately Deviant) and more than 50 mm was judged as
time again was significant (F (1, 85) = 4.78, P = .01,
SE (Severely Deviant).
E2 = .10). Posthoc testing showed no change in HNR for the
MCT and control groups but a significant increase for the
CVM group (see Tables 1 and 2). Participant self-ratings
Finally, the analysis for CPPS showed a significant main Repeated measures ANOVA for VAS revealed a significant
effect of time (F (1, 85) = 152.19, P < .001, E2 = 0.64), but main effect of time (F (1, 85) = 1058.48, P < 0.001,
not group (F (1, 85) = 51.41, P < 0.001, E2 = 278.71). E2 = 0.93), but not group (F (1, 85) = 270.52, P < 0.001,

TABLE 1.
Mean (M) and Standard Deviations (SD) of Jitter, Shimmer, Harmonics-to-Noise Ratio (HNR), Cepstral Peak Prominence
Smoothed (CPPS), and the Visual Analog Scale (VAS) Before and After a Single Dose of MCT or CVM, Compared Against
a No-treatment Control Group
MCT CVM Control
Pre M(SD) Post M(SD) P Pre M(SD) Post M(SD) P Pre M(SD) Post M(SD) P
Jitter (%) 1.14 (0.19) 1.13 (0.18) 0.18 1.10 (0.18) 1.05 (0.22) 0.007* 1.03 (0.16) 1.04 (0.16) 0.41
Shimmer (%) 6.77 (1.1) 6.75 (1.08) 0.04 6.47 (1.19) 6.42 (1.18) <0.0001* 6.55 (1.18) 6.54 (1.18) 0.18
HNR(dB) 14.64 (1.55) 14.67 (1.64) 0.78 14.56 (1.53) 14.85 (1.52) 0.001* 14.68 (1.5) 14.67 (1.5) 0.18
CPPS(dB) 10.48 (1.29) 10.56 (1.30) 0.08 10.81 (1.44) 15.25(1.35) <0.0001* 27.59(6.44 27.37(6.48 0.29
VAS 29.66 (10.26) 74.76 (6.94) <0.0001* 29.53 (6.82) 88.26 (6.38) <0.0001* 10.25 (1.16 10.24 (1.17 0.33
* P < 0.01.
Abbreviations: Pre, Pretreatment, Post, Post-treatment Tre Paired samples t test
 ARTICLE IN PRESS
Ali Dehqan and Kirrie J. Ballard An evaluation of short-term treatment outcomes of Cricothyroid Visor Maneuver: A 5
TABLE 2.
Mean Differences of Acoustic Parameters Before and After a Single Dose of the Therapies and Comparison of these Differ-
ences with a No-treatment Control Group
MCT(1) CVM(2)
Mean Differences SD Mean Differences
Jitter (%) 0.01 .04 0.05
Shimmer (%) 0.24 0.56 0.53
HNR (dB) 0.03 0.53 0.29
CPPS (dB) 0.071 0.24 4.43
VAS 45.10 13.21 58.73
* P < 0.01.
Abbreviations: HNR, Harmonics-to-Noise Ratio; CPPS, Cepstral.
Peak Prominence Smoothed; VAS, Visual Analog Scale; Independent samples t test.
E2 = 31898.86). However, the interaction of group by time
was significant (F (1, 85) = 276.44, P < 0.001, E2 = 0.87).
Posthoc testing showed that VAS scores decreased for
groups with intervention and there was not any significant
change for control group (see Table 1), but the average
amount change for participants was greater for those in the
CVM group (see Table 2).
DISCUSSION
The goal of the current study was to compare the immediate
effects of MCT versus MCT plus visor manipulation
(CVM) for patients with MTD. Acoustic and perceptual
analyses as well as participant’s self-ratings of their voice
were used to study vocal function before and after a single
treatment session. As the acoustic analysis showed, with the
MCT method there were no significant differences in jitter,
Shimmer, HNR, and CPPS. This finding is parallel with the
literature.4,13 On the other hand, there were significant
improvements in all of the acoustic measures before and
after therapy with CVM. This is the first time that manipu-
lation of visor with vocalization was used in combination of
MCT. A close crico-thyroid visor with decreased range of
motion of the crico-thyroid joint are both changes often
found in patients with MTD.19,33 Harris and Lieberman
concluded that abnormal patterns of muscular activity can
occur in the Cricothyroid muscle and in the ‘‘visor’’ mecha-
nism which contribute to voice problems, and manipulation
of this muscle and joint can lead to marked voice improve-
ment.19,34 Also, Lieberman identified a decreased range of
motion of the crico-thyroid visor in patients with MTD,
probably in association with decreased efficiency of crico-
thyroid muscle activity.18 Results from CVM are parallel
with the findings of Lieberman.19
In the current study, for increasing crico-thyroid activity,
phonation of high pitch sound along with crico-thyroid
visor manipulation was used. McCullough et al studied
treatment of laryngeal hyperfunction with flow phonation
and concluded that using high pitch lead to shifting the voic-
ing focus higher up in the oral-nasal cavities and improved
voice quality in patients with laryngeal hyperfunction.35
Control(3) Post Hoc Test
SD Mean Differences SD
0.09 0.002 0.01 2<3*
0.39 0.003 0.006 2<1, 2<3*
0.41 0.001 0.01 2>1, 2>3*
1.94 0.21 1.06 2>1, 2>3*
10.69 0.002 0.01 2>1>3*
Another justification for using the high pitch voice is due to
intrinsic muscle tension present in patients with MTD. Ben-
ninger and Murry mentioned that intrinsic muscles of the
larynx may also be postured in a maladaptive way. There-
fore, imbalance of muscles exists during phonation that
resulted to some postulated abnormal patterns. Some of
these patterns are: (a) thyroarytenoid muscle hyperfunction
(TA predominance pattern), (b) lack of engagement of the
cricothyroid muscle (crico-thyroid lock), and (c) isometric
muscle tension pattern (posterior chink).36 It is reasonable
to predict that manipulation of the crico-thyroid visor and
active phonation of a high pitch sound can stimulate more
activation of the cricothyroid muscle when crico-thyroid
lock is present. Freedom from this abnormal pattern sug-
gests a release of the muscle tension, as can be seen in the
results of acoustic measurements.
Findings from the perceptual assessment and VAS scores
further support the positive changes in voice following both
therapies. In general, it was observed that the severe and
moderate grades were significantly reduced in overall sever-
ity. In MCT, 15 patients obtained normal voice perception
and this value for CVM was 18 patients, with perceptual
analysis showing better findings for CVM. Thus, it is possi-
ble to infer that this change could be attributed to the thera-
pies approach applied in the current study. The therapies
led to stability in sound production and better voice presen-
tation.37 However, comparison of the two therapies in VAS
scores and acoustic analyses shows that the patients
obtained better voice quality with CVM in comparison to
MCT.
A posterior glottal chink can be seen more in females and
it is presumed this is due to increasing of posterior cricoary-
tenoid muscle activity.38 As shown in Figure 2 for the cur-
rent study, decreased posterior glottal chink was observed
after CVM. It can be inferred that manipulation of the
crico-thyroid visor can result in more relaxation in the lar-
ynx musculature and decreasing tension of posterior cri-
coarytenoid muscle, which help to close the glottal gap.
The current study had several limitations worth consider-
ing in future work. First, this study was done in a single ses-
sion and there are no data on whether the effects of the
 ARTICLE IN PRESS
6 Journal of Voice, Vol. &&, No. &&, 2019
FIGURE 2. Decreasing posterior glottic chink after CVM.
Abbreviations: CVM, cricothyroid visor maneuver.
treatment lasted beyond the session. Therefore, future stud-
ies could follow patients for a longer time to study mainte-
nance of the treatment effects beyond the clinic. Second, for
obtaining accurate understanding of the changes after ther-
apy, additional variables could be investigated such as the
cepstral spectral index of dysphonia and relative fundamen-
tal frequency. Third, a voice clinician experienced in manual
laryngeal techniques administered assessment and treatment
and, therefore, the results are confined to the clinician’s level
of experience, confidence, and expectations.
In summary, this study suggests that the CVM approach
provides clinicians with an effective method for voice reha-
bilitation in the patient with MTD with short-term positive
effects. The CVM therapy used in the study resulted in a
positive change in acoustic and perceptual-auditory aspects
of voice production and self-report of the patients. Changes
from prepost treatment exceeding those in groups receiving
MCT or the no treatment control. Longer-term intervention
studies are now required to determine the persistence of
these observed positive effects.
Acknowledgment
This project was supported by the research deputy in Zahe-
dan University of Medical Sciences (No.9076).
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