oreo MD Consuit - Print Previewer Use of this cont LARYNGEAL MANIPULATION satis subject to the Terms and Conditions Otolaryngologic Clinics of North America - Volume 33, Issue 5 (October 2000) - Copyright © 2000 W. B. Saunders Company OF: 10.1016180030.666 805%42970261-9 VOICE DISORDERS AND PHONOSURGERY IT LARYNGEAL MANIPULATION, John Stephen Rubin 1 > + MD, FRCS Jacob Lieberman « s DO, MA ‘Tom M. Harris « FRCS Voice Disorders Unit, Royal National Throat, Nose, and Ear Hospital (SR) Institute of Laryngology and Otology, University of London, London, England (JSR) > Department of Otolaryngology, Albert Binstein College of Medicine, Bronx, New York (ISR) « The Voice Research Laboratory, Queen Mary's Hospital, Sidcup Kent (JL) + British School of Osteopathy, London, England (JL) « Bar, Nose, and Throat Departsnent, University Hospital, Lewisham, England (TMH) ‘This work was presented at the First Laryngology Study Group, 101st Annual Meeting, AAOHNS, Physical Therapy and Laryngeal Manipulation for the Treatment of Voice Disorders, September 1998, Address reprint requests to John Stephen Rubin, MD, FRCS 15 Smith Close London SEI6 IPB England The larynxis an intrusion into the pharynxthat has many functions, including airway protection, serving as a pressure valve, and phonation. Airway protection is the larynx’s most critical function. The larynxis a complex sphincter designed to protect, the lower airway from food particles, fluids, and saliva. The intrinsic muscles tilt the epiglottis and medially compress and adduct the true and ventricular vocal folds with each swallow. The extrinsic muscles elevate the larynxup under the glottis, and back of the tongue, The larynxalso has a phylogenetic survival function as a pressure valve. In this capacity, the larynxcloses off the airway to prevent ingress or egress of air, thereby allowing sudden increases in intrathoracic and intra-abdominal pressures to occur. This function permits activities such as forceful micturition, defecation, and weight lifting. (25 Phonation, which can be regarded as controlled laryngeal closure, is also anguably important for survival. Phylogenetically, phonation is a more recently developed activity. The capacity to produce highly complex phonatory behavior seems to be limited to human beings. It has been related by Laitman et al 2») to the lowering ofthe laryngeal complex fromthe basicranium. Phonation is primarily produced by the intrinsic laryngeal muscles related to the arytenoid cartilages, by the medial portion (vocalis) of the thyroarytenoid muscle, and by the cricothyroid muscle and joint. 25 ‘This article discusses the potential role of laryngeal manipulation from the standpoint of anatomy and physiology. Indications for examination, basic and advanced manipulation, treatment outcome, and current hypotheses for the underlying mechanisms involved are presented, méconsultm-i csinet esivebsitalvowprevewprining=truekURL=htpisAlimconsut mi. csinelesldaslartcletbody401975774-Ajorg%eaDetinics%k2... 44oreo MD Consuit - Print Previewer ‘The role ofthe osteopath is almost as central as that of the speech and language pathologist in the authors' maltidisciplinary voice team. The speech and language pathologist is the primary provider of vocal rehabilitation, As the understanding of the role of posture in Voice production has increased, so has the likelihood that the osteopath will become involved in the early rehabilitative management of a patient. The osteopath is also frequently called on to assist in the diagnosis. A copy of the revised Lieberman protocol used in the osteopathic evaluation is provided in the Appendix BIOMECHANICS OF THE LARYNX More than 30 years ago Hast published his landmark study on the physiology ofthe cricothyroid muscle, but the biomechanics of the larynxare still poorly understood. Research has been scant, with more emphasis on laryngeal mucosa than on gesture, The biomechanics of the laryngeal muscles and skeleton link the inherent properties of laryngeal tissues to the gestures that control phonation. Numerous investigators have cortelated prolonged mechanical misuse and abuse with laryngeal dysfunction and vocal fold injury. Many patients have demonstrated marked improvement through nonspecific reductions in mechanical strain using voice therapy and other techniques. |») (16) 17) 26 The osteopath must consider the entire vocal tract, including the interactions between the voice source and the breathing apparatus below and the resonators above, Because of the limitations of space, however, this article primarily reviews the sound source, Further discussion of this entire area can be found in The Voice Clinic Handbook edited by T. Harts, S. Harris, J.S. Rubin, and D. M. Howard (London, Whur Publishers, 1998). The authors believe that it is overly simplistic to argue that any given phonatory behavior results froma single muscula activity (although such statements have been, and undoubtedly will continue, to be argued). The relative contraction of each ‘muscle is balanced by the activities of other muscles. The overall vector of contraction and joint axes determines the actual motion. «1s; This interrelationship is particularly important when discussing the various muscles (interarytenoid, lateral cricoarytenoid, and others) which are directly attached to the muscular process ofthe arytenoid cartilage and are involved in ‘medial positioning of the vocal fold. ‘The underlying joint supporting this movement, the cticoarytenoid joint, is essential for phonatory contro, as is the cricothyroid joint. These joints (together with the intrinsic laryngeal musculature) are crucial to the sound source. They are discussed in some detail because they are the biomechanical platform forall other aspects of phonation. The cricothyroid joint is a plane-synovial joint. The articular facets on the cricoid, which sit laterally near the junction of the arch and the body of the cricoid, articulate with corresponding facets on the inferior homs of the thyroid cartilage. The facets face dorsolaterally and slightly superiorly. They are often grossly asymmetric from one side to the other. A joint capsule and two ligaments stabilize the joint. 6) The posterior ligament prevents spreading of the inferior homs of the thyroid; the lateral ligament limits but does not abolish posterior displacement of the thyroid over the cricoid. Rotation about a trans verse axis is possible with opening end closing of the cticoid arch in relation to the lower border of the thyroid cartilage. This movement is predominantly controlled by contraction of the vertical belly of the cricothyroid muscle. ‘On contraction, the cricothyroid muscle approximates the cricoid arch to the anterior inferior thyroid cartilage. In so doing, it increases the distance between the posterior ericoid (and thus the arytenoid) and the anterior thyroid cartilage, thereby stretching the vocal fold. Dickson and Maue-Dickson have found that in fresh cadavers this movement can increase the length of the vocal ligament up to 30%. (10) (1, Vocally, this stretching may cause a rise in the fundamental frequency and its comelate, pitch. In some patients, osteopaths also palpate an anterior-posterior movement of the cricoid in relation to the thyroid (J Lieberman, unpublished data). The authors postulate that this movement comes about through contraction of the oblique portion of the cricothyroid muscle. It is unclear whether this movement is pathologic (ic, caused by laxity of the ligaments). Its clear that this combined movement affords some mechanical advantage in changing the length of the vocal ligament, ‘The cricoarytenoid joint is a synovial, load-bearing, saddle-type joint. The posterior aspect of the upper cricoid has two elliptical facets, each measuring approximately 6 mmin adult men, along the length of the major axis. Fach facet slopes laterally downward and forward, The base ofeach arytenoid cartilage, on the inferior surface of its muscular process, has a corresponding facet that articulates with it. (5) 11 Two ligaments and a tight fibrous articular capsule affect the motion of the cricoarytenoid joint. The posterior cricoarytenoid ligament is contiguous with the joint, attaches to the superior rimof the cricoid lamina between the two cricoarytenoid facets, and extends anteriorly to the medial surface of the arytenoid cartilage. 1.0 1» Its primary function is probably preventing lateral dislocation of the arytenoid during forced abduction of the vocal folds. «1 i) ‘The anterior ligament of the ericoarytenoid joint, extending fromthe vocal process of the arytenoid to the thyroid cartilage, is the vocal ligament. (11 It maintains the positional integrity of the true vocal fold. Its anterior attachment to the thyroid méconsultn-i csinet esivebsitaliowprevewprining=truekURL=htpiisAlimconsul mi csineleslaslarticletbody401975774-Bjorg%aDelincs%k2... 24oreo MD Consuit - Print Previewer cartilage is known as Broyle's ligament. Itcan also be considered as an anterior check ligament for the arytenoid, capable of ‘medial and lateral motion depending on the vector of force applied to the arytenoid ‘The motion of the cricoarytenoid joint includes very limited sliding along the long, flat axis of the cricoid facet. This sliding is restricted to only a few millimeters, as shown by Dickson and Maue-Dickson in their work on fresh cadavers. (1) The primary motion, however, is rotation ( rocking) about the cticoarytenoid joint. 1) This rotational motion is quite fice, with the ligaments acting as guidewires. ‘The vocal ligament itselfis a condensation of the superior edge of the cricothyroid membrane (also called the triangular membrane). The superior border of the cricothyroid membrane is the vocal ligament; the anterior border is the anterior cricothyroid ligament; the inferior border is the superior rimof ericoid arch; the posterior border is the posterior end of vocal ligament, attaching to the vocal process and inferior fossa of the arytenoid cartilage. The body of this membrane is known as the conus elasticus and is the supporting structure for the deeper surface of the vocal fold below the vocal ligament. (11) (23) ‘The vocalis muscle, the medial fibers of the thyroarytenoid muscle, travels posteriorly with the vocal ligament forming the shelflike body of the true vocal fold. As described latcr, contraction causes bulking and shortening of the vocal fold and stiffening of the muscle and acts to help control pitch production. (251 LARYNGEAL MUSCLES In considering manipulation of the larynx, itis best to think of the intrinsic and extrinsic laryngeal muscles in terms of sphincteric activity and phonatory function. It must again be emphasized that phonation is a function not only of the sound source but also of the breathing mechanism and the resonators, ‘There are several definable laryngeal muscle groups: Intrinsic muscles that insert into the quadrangular membrane Intrinsic muscles that insert into the arytenoid cartilage Extrinsic muscles, such as the suprahyoid and strap muscles ‘The cricothyroid muscle Constrictor muscles Muscles that insert into the quadrangular membrane (¢.g., the aryepiglotticus, the thyroepiglotticus, and others) have a significant survival function. With each swallow these muscles help close the epiglottis over the vocal folds, diverting food into the piriform sinuses and away from the airway. These muscles act in synchrony in a vegetative fashion under reflexogenic control. 7) 18) Muscles which attach to the muscular process of the arytenoid (¢g., the lateral cricoarytenoid, interarytenoid, posterior ericoarytenoid, and others) function to position the vocal folds. Again, these muscles have an important survival function, medially positioning (addueting) the vocal folds, and thereby sealing off the upper airway, or allowing periodic opening of the aperture (abducting) for inspiration, During swallowing, these muscles bring about adduction and thickening of the vocal folds on a reflexogenic basis, thereby protecting the lower airway fomaspiration of food particles and liquid. ‘The suprahyoid miscles (¢g., the geniohyoid, hyoglossus, stylohyoid, and others) elevate the laryngeal complex upward and forward with each swallow, thereby protecting the airway. The strap muscles are also involved in raising and lowering the thyroid cartilage in relation to the hyoid bone and, to a lesser extent, the cricoid cartilage. The thyrohyoid muscle elevates the thyroid cartilage and narrows the thyrohyoid space. The stemothyroid and stemohyoid muscles lower the larynx, helping reset the mechanismafter swallowing. (7) 20) The cricothyroid muscle has a special role in closing the ericothyroid space (called the ericothyroid visor by Hams 0s) 16) and Lieberman (15) ).In so doing, the cricothyroid muscle stretches the vocal ligament, increases tension within the various layers of the true vocal fold, and thereby contributes to pitch raising. 1») 2. 271 Contraction of the vocalis muscle shortens and increases the bulk of the true vocal fold, contributing to pitch lowering, at least during soft phonation, 9) 3) ja» Of course other aerodynamic and neuromuscular factors are also involved in pitch control. ‘The cricothyroid visor, the mechanism which controls the excursion of the anterior cricothyroid ligament, is one of the critical areas in the larynxin voice disorders and for laryngeal manipulation. Many patients come to the authors’ clinic with the visor locked in a closed position; or with a limited range of motion, Haris postulates that this limited range of motion results from chronic shortening caused by chronic misuse of the cricothyroid muscle (e-g., the habitual use of too high a pitch for the speaking voice). 1s) In another group of voice patients, the thyrohyoid membrane is found to be held or guarded, often in association with méconsultn-i sine esivebsitalvowprevewprining=truekURL=htpisAlimconsul mi csineleslaslarticletbody401975774-Bjorg%eaDelincs%k2... 44oreo MD Consuit - Print Previewer tendemess or with asymmetry of the hyoid complexas determined by palpation. This condition may also be related to chronic ‘muscular shortening. (15) The authors have found that this phenomenon is often associated with unresolved emotional issues. a1) The locked thyrohyoid mechanism reduces the range of movement and thus reduces dynamic range. The constrictor muscles are described separately although the middle and superior constrictor museles might also be considered suprahyoid muscles, The constrictor muscles attach to their counterparts by a thin but tough midline band of fibrous tissue (raphe) in front of the prevertebral fascia of the spine. This attachment provides posterosuperior anchorage for the pharynxand the larynx, 2 and these muscles seemto exert a powerful posterior and superior influence upon the larynx, ‘The cervical spine and all the posterior muscles attaching to the spine or to the ligamentum nuchae are of critical importance to the osteopath. The reader is referred to standard texts of anatomy for further information, It is simplistic and incorrect to believe that any one muscle works by itself, in the larynxor elsewhere. Several muscles work together for many activities. In the larynx, as elsewhere, muscles probably work like a series of pulleys, the resultant moment ‘of action being zero at any given laryngeal position, In other words, the net vector of force of the muscles, pulling synchronously, leads to stability, 1s INDICATIONS FOR LARYNGEAL MANIPULATION Laryngeal manipulation is indicated in patients in whoma musculoskeletal problem exists in the larynx (Laryngeal manipulation is contraindicated in patients with underlying laryngeal or thyroid neoplasms). The musculoskeletal issues (¢.g., poor posture with hyperlordosis of the neck, chronic overactivity and shortening of the cricothyroid muscles with a locked cricothyroid visor, a habitually low-held or high-held larynx) may be the primary cause ofthe dysphonia, The dysphonia may also be secondary, as a protective gesture, Patients with secondary musculoskeletal problems include those with reflux, those with @ high-held larynxand thyrohyoid narrowing caused by ansiely or unresolved emotional issues, and those with chronic ‘muscular hyperfunction caused by compensatory vocalization resulting froma laryngeal cyst, sulcus, or other lesion, Many of these conditions should be routinely treated initially or primarily by @ speech and language pathologist who has @ specialized interest in voice and, ideally, extra training in counseling. Treatment always follows a careful history and physical ‘@amination by a referring otolaryngologist. In the patients with secondary hyperfunction, the underlying cause should be identified and treated appropriately. Nonetheless, manipulation is useful in treating many voice disorders, It can be used when speech therapy has failed, in conjunction with speech therapy, or as the primary treatment, Manipulation can achieve rapid improvement, with some improvement usually noted after the first session. The warning here, much as with speech therapy, is that the patient must adopt the new pattem of musculoskeletal positioning ifthe improvement is to be long lasting and this process may require several sessions Characteristic symptoms described by patients whom the authors refer for laryngeal manipulation include pain, tendemess. loss of vocal range, difficulties in the passaggio, loss of vocal stamina, dryness, or excessive catarrh. Other symptoms might include difficulties in swallowing or globus-type feelings just above the stemum, tightness at the tongue base, or non-specific EXAMINATION Examination is performed both in static and dynamic modes. It involves a general examination of posture, head and neck positioning, breathing apparatus, and an examination of the larynx. The laryngeal examination includes evaluation ofthe resting muscle and joint tone, ease of mobility, and range of motion. RESTING MUSCLE AND JOINT TONE, Ifitis accepted that a failure to relaxa muscle following an activity constitutes hyperfunctional muscular behavior and that voice production (and swallowing) requires repeated complex muscular activity, then itis not surprising that the laryngeal and perilaryngeal misculature is at risk for hyperfunction. The osteopathic examination should specifically look for and identify tight, tender, or contracted muscles. The postural muscles, including the trapezius and the righting muscles attaching to the posterior spine and ligamentum nuchae, and the stemocleidomastoid muscles are all at risk for hyperfunctional behavior. The suspensory (perilaryngeal) muscles can similarly be found to be in a chronically contracted, shortened state. méconsultn-i csinet esivebsitaliowprevewprining=truekURL=htipisAlimconsul mi. csinelesdaslartcletbody401975774-Ajorg%eaDelinics%k2... 44oreo MD Consuit - Print Previewer GENERAL POSTURE Posture may contribute to dysphonia when it affects the position of the larynx or the breathing mechanism, Posture has been recognized to be important in voice production and vocal technique for 50 years, 2) but there has been very little research as to which aspect of posture directly affects voicing. Vilkman (2) recently investigated the possible effects of laryngeal position and pullon the suspensory muscles on the fundamental frequency of the voice The authors consider the following conditions as true posture-related dysphonias. (2) L. Spinal conditions that affect breathing, including conditions such as scoliosis and ankylosing spondylitis that affect rib mobility and spinal symmetry 2. Habitual posture that results in spinal asymmetry which may affect the position of the larynx, for example, rotation of the torso in relation to the lumbar and cervical spine, rotation of the cervical spine in relation to the thoracic spine, and forward translation of the head with relation to the cervical spine. The second of these conditions will pull the larynx away fromthe midline through attachment of the inferior suspensory muscles; the third will do so through attachment of the superior suspensory muscles Posture is observed from five views: anterior-posterior, both laterals, posterior-anterior and vertical (from above). The anterior- posterior observation may reveal deformities of the rib cage. The posterior-anterior view may reveal spinal curves, deviation fromthe midline, or shoulders held at different levels. The lateral views may reveal swaying fromthe midline, either anteriorly ‘or posteriorly froman imaginary center of gravity. The vertical view is particularly important, because it may reveal rotation of the Corso in relation (o a fixed pelvis (in a normal person the larynx, because of ils inferior attachments, moves with the (or80). HEAD AND NECK POSITIONING Head position affects the initial resting length of the suspensory muscles and so directly affects the mechanismof voice production (Table 1) (Table Not Available TABLE 1 -- HEAD POSITION (Not Available) From Harris T, Harris S, Rubin JS, et al (eds): The Voice Clinic Handbook. London, Whurr Publishers, 1998; with permission. Anteriorposterir displacement, as caused by a hyperiondotie segment of the neck (sometimes called a cervicodorsal shelf) ‘will cause the head to be habitually held forward. (23) A hyperlordotic cervical curve may intrude into the laryngeal space, thereby causing some of the symptom. It may cause a forward position of the cricoid in relation to the thyroid, thereby stretching the ericothyroid muscle. In general, such displacement changes the anatomical relationships ofthe laryngeal structures to both the power source and the resonators. Head tilt and side-bending ofthe cervical spine may also interfere with functional symmetry of the suspensory muscles. The vocal tract on the dropped side may be compressed. The patient may maintain the head tilted to one side, often with one shoulder higher than the other. This posture is often seen in singing teachers who work froma piano. BREATHING APPARATUS Although the breathing apparatus is an integral aspect of the osteopathic examination, it is beyond the scope of this article. LARYNGEAL EXAMINATION ‘The relative level of the larynxin the neck should be assessed, méconsult-i csinet esivebsitaliowprevewprining=truekURL=htip2isAlimconsu mi. csinelesdaslarticletbody401975774-Bjorg%aDelincs%k2... 54oreo MD Consuit - Print Previewer ‘The suprahyoid and floor of the mouth musculature should be palpated. The superior suspensory muscles consist ofthe stylohyoid, geniohyoid, hyoglossus, and mylohyoid muscle and the anterior and posterior bellies of the digastric muscles. Excessively tight suprahyoid musculature in association with a high-held larynx signifies marked muscular hyperactivity that ‘may occur in association with unresolved emotional issues (2) (e-g.,as commonly found in mutational dysphonias). The inferior suspensory miscles—the stemothyroid, stemohyoid, and omohyoid muscles--should be palpated. These muscles are long and have thin bellies, so they are difficult to assess by direct palpation. Their quality can be inferred by assessing the resting level of the larynxand by stretching the larynxupward and laterally (see later discussion). The examiner should check for an extremely low-held, or anchored, larynx. Koufian has classified one such pattem of speaking-voice abuse associated with a low-held larynxas the Bogart-Bacalll syndrome, because the patient speaks with a very low-pitched fundamental frequency. (14) 1 ‘When the thyrohyoid space is palpated, a space should be detected between the thyroid cartilage and the hyoid bone. The ‘©aminer should be alert to asymmetry of the hyoid bone and its attached musculature and to tendemess or shortening of the stylohyoid muscle and the posterior belly of the digastric muscle. The position of the hyoid in relation to the spinal column is also very important. In palpating the cricothyroid visor, the examiner should check (1) the position of the anterior cricoid arch, (2) that there is adequate space at rest between the cricoid and thyroid, and (3) that there is adequate excursion of the cricothyroid mechanism as the patient goes from vocal fiy to head range. The cricothyroid mechanism has relatively little range of motion, and the cricothyroid muscles are relatively small. Its possible, however, to assess the quality and range of cricoid movement in relationship to the thyroid (or vice versa), 's) and the ability to move this joint freely is critical for changes in pitch. For ‘example, a superior laryngeal palsy that prevents active motion of one joint will have a profoundly deleterious effect on the vocal tensioning mechanism, reducing the dynamic range. EASE OF MOBILITY Ease of mobility is determined by active maneuvers, performed by the osteopath to assess mobility of the laryngeal structures and thereby to infer the status of the muscles attached to these structures. The larynxshould be moved from side to side. Noml bony crepitus should be observed. Lateral laryngeal movement is defined as the amount of lateral displacement of the larynxaway from the midline as the practitioner grasps the thyroid cartilage and moves the larynx laterally, The practitioner ‘evaluates the quality of the lateral shift looking for unilateral or bilateral anchoring. Fromthis observation the practitioner ‘obtains much information about the status ofthe strap muscles and the constrictors (in particular the middle and inferior). In some instances the larynxmay seem to be impacted against the anterior vertebral cohurm, By stretching the larynx upward and laterally, the practitioner can make inferences about the status of the inferior suspensory ‘muscles, Similarly, lifting the larynxanteriorly and rotating it laterally away from the midline can indicate the quality of the constrictor muscles. This maneuver uncovers and stretches the inferior constrictor muscle on one side, which can then be palpated behind the cricoid and the posterior border of the thyroid cartilage. ‘The status of the superior suspensory muscles can be inferred fromthe status of the hyoid bone, Relaxed suprahyoid muscles should allow the hyoid bone to drop approximately onc half inch below the angle of the mandible, Tendemess, especially with lateral movement of the hyoid bone, indicates contraction and shortening of the superior suspensory muscles. (21) This area, however, is typically exposed to a considerable amount of inflammatory adenitis during episodes of acute tonsilitis in childhood, and such exposure alone can be sufficient to cause asymmetry. Tendemess in the strap, stemoclcidomastoid, or associated muscles should also be noted. In examining the hyoid bone and its attachments, the examiner should also be aware of the proximity of the carotid body and sinus. Energetic or inadvertent manipulation in this area could cause a rapid drop in blood pressure or pulse rate and in elderly patients could loosen atheromatous plaques. INTERNAL LARYNGEAL EXAMINATION In persons with long, thin necks, the arytenoid cartilages and the cricoarytenoid joints can be palpated by an experienced practitioner. Similarly, the posterior ericoarytenoid muscles and interarytenoid muscles can be palpated and compared for tendemess and hypertonicity. These maneuvers require considerable skill and may be very uncomfortable for the patient. ‘Thus they are outside ofthe scope of this article. méconsultn-i csinet esivebsitaliowprevewprining=truekURL=htpisAlimconsul mi. csinelesdaslartcletbody401975774-Bjorg%eaDelincs%k2... 614oreo MD Consuit - Print Previewer BASIC LARYNGEAL MANIPULATION General In soft-tissue damage caused by repetitive injury, the muscles will be chronically shortened, they may be fibrotic or scarred, and they will be tender to touch. By working on the muscles and associated joints, the osteopath attempts to stretch scar contractures, lengthen the muscle belly, increase blood flow to it, and improve joint mobility. The practitioner also hopes to improve blood flow into and fromthe damaged muscle and facilitate lymphatic drainage. ‘The process of manipulating soft tissue includes 1. Identifying the indicated muscle or structure to be manipulated 2. Stabilizing the tissue against a known, more fixed structure (e.g., the mandibular symphysis, hyoid bone, cricoid cartilage, or other structure) 3. Passive stretching, in which the osteopath holds the two structures (¢g., the cricoid and thyroid cartilages) apart for a period ofttime under gentle stretch 4, Dynamic stretch, in which the osteopath holds or manipulates structures and the patient assists by phonatory means (eg. sighing while the ericothytoid visor is being stretched) Muscle kneading 6. Working beyond guarding (the patient tres to relaxbut will always guard at a certain point; the osteopath may need to stabilize the joint or soft tissue in a position that prevents or circumvents this guarding to allow tissues to retum to a noma position) The goal of treatment is to improve joint mobility, restore symmetry to muscle function and, most important, to make the pationt aware of habitual abnormal postural pattems. As previously noted, this last aimis the critical one, because unless the patient adopts new musculoskeletal pattems he or she will revert to the previous pattem, and the treatment willbe a failure. INITIAL MANIPULATION General ‘The patient lies supine. The osteopath cradles the patient's head at the suboccipital groove/nuchal region and palpates the posterior neck looking for evidence of a cervicodorsal shelf or any specific area of muscular spasm. The osteopath then presses down on cach shoulder to stretch the trapezius muscle and extend the cervical spine. Any focal areas of spasmare identified and stretched to relaxthe affected muscle, increase blood flow, and break the spasm. (2) ‘Typical areas of spasm include the insertion of the trapezius muscle into the nuchal process and into the scapula and the insertion ofthe paraspinous muscles into the cervical spine. The splenius, scalene, and the stemocleidomastoid muscles are individually palpated and stretched as necessary. Tightness, frequently occurring in the region of the stemoclavicular joint, is identified and addressed. Limitation of joint movement is addressed by direct joint articulation and by soft-tissue techniques applied to surrounding musculature. Suprahyoid/Hyoid/Floor of the Mouth Complex ‘The suprahyoid muscles, the floor of the mouth musculature, and the muscles inserting into the lesser and greater homs of the hyoid bone are palpated for tightness or tendemess. These large muscles should be stabilized individually for maximal effect of stretch. Ifnecessary, these muscles can be stretched to relieve pain and lowertthe larynx. If successfal, the patient will sense a longer larynx and swallow more easily. ‘The tissues between the angle of the jaw and the superior border of the hyoid bone are pushed downward and toward the contralateral side, gently stretching the suprahyoid muscles unilaterally. This technique is then applied to the opposite side. As the suprahyoid muscles relax, it becomes possible to palpate the superior surface of the hyoid bone, which can then be used as a leverto release tight musculature further. For dynamic stretching of this area, the practitioner presses down on the hyoid bone and asks the patient to try to swallow. The practioner resists the upward movement of the larynx initiated by the patient's attempt to comply. Thyrohyoid Membrane The thyrohyoid membrane is palpated. If the thyrohyoid membrane is foreshortened, the thyrohyoid muscle can be directly méconsultn-i csinet esivebsitalvowprevewprining=truekURL=htpisAlimconsu mi. csineleslaslarticletbody401975774-Bjorg%aDetincs%k2... 74oreo MD Consuit - Print Previewer palpated and can be stretched digitally by directly increasing the distance between the undersurface of the hyoid bone and. the upper surface of the thyroid cartilage. Cricothyroid Visor The cricothyroid visor is often held in a closed position, with the anterior cricoid cartilage and the lower border of the thyroid cartilage in close proximity and with a lack of excursion on pitch changes frommodal to head range. The clinical correlate is a tight, contracted cricothyroid muscle and loss of vocal dynamic range. The cricothyroid joint is the principal joint for the tensor mechanism of the larynx, and its function needs to be improved ifit is damaged or limited, The cricothyroid joint can be articulated directly. With the thumb of one hand, the practioner pulls down on the anterior aspect of the cricoid arch while stabilizing the thyroid cartilage at the level of insertion of the cricothyroid muscle with the thumb of the other hand. The practioner can then apply gentle pressure, gradually increasing the gap and thereby articulating the joint into the open position. Dynamic stretch can be applied in two ways: by having the patient inspire deeply, thus combining the opening effect of tracheal pull on the joint with the practitioner's own pressure, or by having the patient produce a low-pitched yawn and sigh ora vocal creak, both of which tend to open the cricothyroid joint. Ifthe maneuver is successful, the patient will typically notice a change in fundamental frequency, increased dynamic range, ‘and increased timbre in the voice. Larynx Held in an Abnormally Low Position A larynxheld in an abnormally low position is a common problem and was noted in 26% of Koufman's patients with functional voice problems, (1s) This problem must be differentiated froma chronically high-held rib cage, as seen, for example, in patients with severe emphysema or long-standing asthma. The correlates are tight stemohyoid and stemothyroid muscles and, to a lesser extent, tight omohyoid muscles. The lower border of the stemocleidomastoid muscle is also very tight. All these ‘muscles can be palpated directly and manipulated by soft-tissue stretching techniques, thereby lengthening the muscle bellies, breaking spasm, and allowing a more natural position of the larynx Ifsuccessful, the fundamental frequency of the voice will be raised, and the dynamic range and timbre will be increased, SUCCESSFUL OUTCOME AFTER LARYNGEAL MANIPULATION Immediately after laryngeal manipulation the authors have frequently noted a change in pitch, audible to patient and practitioner, increased resonance; increased ease of swallowing and a sense of openness; decreased hoarseness; decreased ‘wobble; and decreased pain and discomfort. ‘Over time, patients have reported increased stamina, vocal flexibility, and range; better negotiation of the passaggio; and shorter recovery time following laryngeal exertions, Often the laryngeal click associated with a marked discharge of mucus resolves as the need to clear the throat decreases. Many patients also acknowledge underlying emotional issues related to the pathologie laryngeal conditions. ADVANCED MANIPULATION Although an osteopath who is highly experienced in laryngeal manipulation may be able to work his or her hands around the larynxand manipulate the posterior cricoarytenoid muscle and the interarytenoids muscles, this procedure should not be undertaken by a less-experienced osteopath, ‘The authors have referred the few granuloma patients who fail initial management with antirefluxtherapy and speech therapy for such expert manipulation because they believe that one component of the problem leading to the development of granuloma may be abnormalities with the laryngeal set. The treatment plan involves direct relaxation and stretching ofthe homelateral cricothyroid muscle, the posterior cricoarytenoid muscle, the strap muscles, and the constrictor muscles as necessary, thereby resetting the laryngeal mechanism, These patients are also referred for concomitant psychologic evaluation, Harris suggests that chronic contracture may cause an imbalance between the posterior cricoarytenoid muscle and the vocalis, leading to muscular tension dysphonia Type Las described by Morrison. (15) Lieberman has begun addressing this problem by directly manipulating the posterior cricoarytenoid muscle (J Lieberman, DO, unpublished results). méconsultm-i csinet esivebsitalvowprevewprining=truekURL=htipisAlimconsul mi. csineleslaslarticletbody401975774-Bjorg%eaDelincs%k2... a4oreo MD Consuit - Print Previewer Although the intrinsic laryngeal muscle groups can be accessed and treated directly, such advanced manipulations necessarily involve working on the posterior aspect of the larynx, which in tum must be palpated across the lateral pharyngeal wall. This manipulation requires a great deal of palpatory skill; it also requires sensitivity and skill to introduce the patient to these techniques. Because the larynxis critical to the airway and is a structure with significant reflexogenie activity, such manipulation should be undertaken only after much training, SUMMARY Laryngeal manipulation can be useful in treating voice disorders. The more one understands that musculoskeletal issues may be involved in voice disorders, the more reasons become evident for referring such paticnts for diagnostic investigation and ‘treatment by a physical therapist, The physical therapist mast participate actively in a multidisciplinary treatment of voice disorders so that he or she will be sensitive to the needs of the patient, ACKNOWLEDGMENT ‘The authors would particulary lke to recognize Tomand Sara Harts for their enormous work and innovations in this new field. They would also like to recognize Murray Morrison's many ground-breaking concepts and hard work inthis area References 1. Alipow-Haghighi F, Perlman AL, Titze IR: Tetanie response ofthe cricothyroid muscle, Ann Otol Rhinol Laryngol 100:626-631, 1991 Abstract 2.Alipour-Haphighi F, Titze IR, Perlman AL: Tetanie contraction in vocal fold muscle. Journal of Speech and Hearing Research 32:226-231, 1989) 5 Arnold GE: Physiology and pathology of the cricothyroid muscle. Laryngoscope 71:687-753, 1961 Citation 4 Baredes S Blitzer A, Krespi YP, etal: Snallowing disorders and aspiration. Jn Blitzer A, Brin ME, Sasaki CT, otal (eds): Neurologic Disorders of the Larynx. New York, Thieme Medical Publishers, 1992, pp 201-213 5 Blaugrund SM, Taira‘, Ishii N: Laryngeal manual compression in the evaluation of patients for laryngeal framework surgery. In Gaufin J, Hammarberg B (eds): Vocal Fold Physiology. London, Whusr and Co, 1991, pp 207-212 «6 Boileau Grant JC, Basmajian IV: Grant's Atlas of Anatomy, ed 7. Baltimore, Williams Wilkins, 1972 + .Broniatowski M, Sonies BC, Rubin JS et al: Current evaluation end treatment of patients with swallowing disorders. Otolaryngol Head Neck Surg 120:464-473, 1999 Abstract §.Choi HS, Berke GS, Ye M, etal: Function ofthe thyroarytenoid muscle in canine laryngeal model. Ann Otel Rhinol Laryngol 102:769-776, 1993. Abstract 9. Cooper DS, Partridge LD, Alipour-Haghighi F: Muscle energetics, vocal efficiency, and laryngeal biomechanics. Jn Titze IR (ed): Vocal Fold Physiology; Frontiers in Basie Science. San Diego, Singular Publishing Group, 1993, pp 37-92 10.Dickson D, Dickson W: Functional anatomy of the human larynx. Jn Proceedings of the Pennsylvania Academy of Ophthalmology, 1971, p 29 11 Dickson DR, Maue-Dickson W: Anatomical and Physiological Bases of Speech. Boston, Litle Brown and Company, 1982 12, Feldenkrais M: Body and Mature Behavior. New York, Intemational University, 1949) 13,Fujimura O: Body-cover theory of the vocal fold and its phonetic implications, In Stevens KN, Hirano M: Vocal Fold Physiology. Tokyo, University of Tokyo Press, 1981, pp 271-288 14, Gould WI, Rubin IS: Special considerations forthe professional voice user. Jn Rubin JS, Sataloff RT, Korovin G, etal (eds) Diagnosis and ‘Treatment of Voice Disorders, New York, Igako-Shoin Press, 1995, pp 424-435 15. Harris T: Laryngeal mechanisms in normal function and dysfunction. In Harris T, Harris S, Rubin JS, etal (eds): The Voice Clinic Handbook, London, Whurr Publishers, 1998, pp 64-90, méconsultn-i csinet esivebsitaliowprevewprining=truekURL=htipisAlimconsu mh. csinelesdaslartcletbody401975774-Bjorg%eaDelincs%k2... 4oreo MD Consuit - Print Previewer 16. Haris T, Lieberman J: The erieothyrotd mechanism, its relation hip to vocal fatigue and voeel dysfunction. J Voiee 2:89.96, 1993, 117. Hast MH; Mechanical properties ofthe ericothyroid muscle, Laryngoscope 76:537-548, 1966 14,Hellemans J, Age HO, Pelemans W, et al: Pharyngoesophageal swallowing disorders and the pharyngoesophageal sphincter. Med Clin North ‘Am 65:1149-1171, 1981 Citation 19,Koufiman J, Blalock O: Functional voice disorders. Otolaryngol Clin North Am 24:1059-1073, 1991 Abstract 20,Laitman JT, Noden DM, Van de Water TR: Formation of the larynx: From homeobox genes to critical periods. Jn Rubin JS, eta Korovin GS, et al (ede): Diagnosis and Treatment of Voice Disorders. New York, Igaku-Stoin Medical Publishers, 1995, pp 9-23, 21, Lieberman J: Principles and techniques of manval therapy’ Application in the management of dysphonie. Zn Harris T, Harris S, Rubin JS t al (ois): The Voice Clinic Handbook, London, Whurr Publishers, 1998, pp 91-138 2, Morrison MD, Rammege LA, Clles M, etal: Muscular tension dysphonia, J Otolaryngol 12:302-306, 1983 Abstract 25. Morrison M, Rammage L, Nichol, et al: The Management of Voice Disorders. San Diego, Singular Publishing Group, 1994 24.Rubin JS: Anatomy and physiology of swallow. In Rubin JS, Broniatovski M, Kelly J (eds): The Swallowing Handbook. San Diego, Singular Publishing Group, 2000, pp 1-20 25.Rubin JS: The structural anatomy of the larynx and supraglottic voeal tract: Are Clinic Handbook. London, Whurr Publishers, 1998, pp 15-33 In Uarris T, Hares S, Rubin JS, et al (eds): The Voice 26,Rubin JS, SatalofT RT: Voice: Ni Singular Publishing Group, 1997 horizons, In SatalofT RT (ed): Professional Voice: The Science and Act of Clinical Care, ed2. San Diego, 27.Titze IR, Durham PL: Passive mechanisms influencing fundamental frequency control. n Baer T, Sasaki C, Harris KS (eds): Laryngeal Function in Phonation and Respiration. San Diego, Callege-Hill Press, 1987, pp 304-319 28.Titze IR, Jiang J, Drucker DG: Preliminaries to the body-cover theory of pitch control. J Voiee 1:314-319, 1988 29,Nilkman B, Sonninen A, Hurme P, et al: External laryngeal frame function in voice production revisited: A review: J Voice 10:78-92, 1996 Abstract APPENDIX Lieberman's Protocol Revised Assessment of Posture and the Laryngeal Apparatus (Joints and Muscles) in Hyperfunctional Dysphonia This protocol is a nonexhaustive reference for the assessment of posture and the laryngeal apparatus. It is designed to accompany the instructional course on the detailed anatomy of the larynx, its palpatory assessment, and the assessment of posture-related aspects of voice dysfunction.ft can be used in multidiseiplinary voice clinics as part of the overall assessment of voice patients to provide a framework for practitioner agreement and research, TABLE -- POSTURE AND LARYNGEAL ACTIVITY (tick as appropriate) Observations | Sitting (while patient is providing history) Anterior neck compartment: SmoothL] mspicuous RtL]) ‘Conspicuous signs of increased muscular uO activity Level and position of thyroid Static (patient | Normal] | High) LowL] Deviated) lamina is silent); Dynamic (talking) Dislnine amachaid smote activites Ateant Deanant BT Deanane 141 maconsultm i csint esivebsitalvowprevewprining=truekURL=htpisAlimconsulim.csineleslaslartcletbody401975774-Bjorg%eaDelinics%.. 104ora ‘uluig UiuvHUI LHUscR: acuity in speech Skin crease asymmetry Head position in the sagittal plane Head gestures (head nodding in speech’swallowing Jaw movement (vertical and lateral plane) Standing (lateral view) Weight bearing (sagital plane, observed fromthe side) Spinal curve (exaggerated, hyperhypolordosis)| Rib cage Breathing patterns Head position (cervical translation) MD Consuit Print Previewer Tilt Asymmetric Lumbar ‘Thoracic Cervical, Flexibility Function Diaphragmatic Upper chest Chavicular Anterior Cervical thoracic hump “AUSCLULS Absent] AbsentL] Absent] Absent] Normal] Normal lordosisL] Nomal kyphosis] Normal lordosis Normal] Normal] Normll] AbsentL] Absent] Absent] Absent] Spinal curves: standing (anterior/posterior view) Lumbar-thoracic (including scoliosis) Scapular level Head level Spinal curves: standing (vertical axis) ‘Note: the normal larynx moves with the torso Torso rotation Pelvis rotation. Head rotation Normal] Normal] Normal] Normal] Normal] Normal] riesem ny Present RIL] Present RIL) Present RIL] Present Rt] Anterior swayL] Decreased lordosisL] Decreased kyphosis] Decreased lordosisC] Decreased] Raised] DecreasedL] PresentL] Present] Present] Present] Asymmetry Ri) Raised RI) Tit RO Clockwise] Clockwise] Clockwise] riesemt Ling Present Li) Present Lt) tui Present Lt] Posterior sway Oo Increased lordosisC] Increased kyphosis] Increased lordosis] Hed Paradoxicall] Increased] Increased] Cervical level Oo ‘Asymmetry Lt oO Raised Lt) Tit LO Counter- clockwiseL] Counter- clockwise] ‘Counter- méconsultn-i csinet esivebsitaliowprevewprining=truekURL=htipisAlimconsul mi. csineleslaslarticletbody401975774-Bjorg%aDetinics%.. 1044voara MO Const - Print Prevever clockwise] Palpation Cervical spinous processes Palpable Nol Yes Cervical level Oo Suboccipital musculature (above Tonus Normal] Increased RIL) Increased Lt 2) Oo Symmetry Normal] Increased RIL) Increased Lt Oo Tenderness No Increased RIL) Increased Lt Oo Cervical musculature (other) Tonus Normal] Increased RIL) Increased Lt Oo Symmetry Normal] Increased RIL) Increased Lt oO ‘Tenderness No Increased RIL] Increased Lt oO ‘Temporo-mandibular joint Movement | Normall] Asymmetry RL) Asymmetry Lt oO Opening Normal] Asymmetry RIL] Asymmetry Lt Oo ‘Tenderness No Increased RIL] Increased Lt oO Stemocleido-mastoid muscle Tonus Normal] Increased RIL] Increased Lt oO Symmetry | Normall] Increased RIL) Increased Lt oO ‘Tenderness Nol] Increased RIC] Increased Lt oO TABLE -- THE LARYNGEAL APPARATUS (tick as appropriate) Observation ‘Superior suspensory Tone Normal] LowD) High) muscles Laryngeal range of movement (in speech Normal] IncreasedL] Decreased] and swallowing) Inferior suspensory Tone Nomll] Asymmetric RID) | Asymmetric L110 muscles Palpation Palpate for position, tone, symmetry, tenderness in static (passivejand dynamic (swallowing, speech singing) Normal] High LowL] Hyoid | rmaconsultm-y csinet eivebsitaewbrevew?priningtrus& kaNIméconsult- sine esldaslariclebodyMO1S75774-Sjorg%Dclinics%.... 12114ones Geniohyoid: static Geniohyoid: dynamic Superior suspensory muscles: static Superior suspensory muscles: dynamic Inferior suspensory muscles: static Inferior suspensory muscles; dynamic Thyrohyhoid apparatus: static ‘Thyrohyoid apparatus Cricothyroid musclessstatic Cricothyroid visor (joint) Head neutralstatic Cricothyroid joint dynamic Constrictor muscles: (perform hateral shift test) Internal laryngeal structures (for experienced therapists only) Tone Tenderness Tone Tenderness Tone Tenderness Coronal: attitude hyoid to thyroid Size of gap Tenderness Symmetry :dynamic (movement) Tone Tenderness Resting state Anterior arch Changes with siren Changes with yawn Posterior glide of arch with pitch rise Mobility Tendemess Accessible Tenderness MD Consuit Print Previewer Normal] None] Normmill] Normal] NoneL] Normall] Normal] NoneL] Normal] Parallel) NoneL] NoneL] Normal] Normal] Normal] NoneL] Closed NoneL] No change] No change] No changeL] Absent] NoneL] No None AsymmetricL] Present] Asymmetric] Asymmetric Rt) RO Asymmetric Rt) Asymmetric Rt) RO Asymmetric RIO) Tuo Diminished RO) RO Asymmetric Rt] Rotation RC) Asymmetric Rt) RO Midposition openL PresentL] Closes] OpensL] Diminishes LJ Present RIL) Asymmetric Rt) RO ri Asymmetric LiL] uO Asymmetric LJ Asymmetric LJ uO Asymmetric Lt) Tit RO Diminished Li) uO Asymmetric Lt) Rotation L1) Asymmetric LJ uO Open Present LO) Asymmetric Lt] uO it mdconsult-i csinet esivebsitalvowprevewprining=truekURL=htpisAlimiconsuli mi. csineleslaslarticletbody401975774-Bjorg%eaDetinics%.. 194oreo MD Consult Print Previewer uO NoneL rO Movement Courtesy of J. 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