Anterior-Posterior and Medial Compression of the

Supraglottis: Signs of Nonorganic Dysphonia

or Normal Postures?
*Alison Behrman, Linda D. Dahl, Allan L. Abramson, and Harm K. Schutte
New York, New Hyde Park, and Bronx, New York and Groningen, The Netherlands

Summary: Two vocal tract postures commonly identified as hallmarks of

nonorganic dysphonia are anteriorposterior and medial compression of the
supraglottis. However, insufficient data exist to support their diagnostic utility.
The purpose of this study was to compare these two postures in patients with
nonorganic dysphonia and normal controls using interval data derived from
quantitative measures of videostroboscopic images obtained with an oral
endoscope. Retrospectively, 40 patients with nonorganic dysphonia and 40
normal controls were selected. Relative anteriorposterior compression (LOAP)
was calculated as the laryngeal outlet (LO) (the view of the true vocal
folds during phonation) normalized to the anteriorposterior dimension in
pixels. Relative ventricular fold medial compression (LOW) was calculated as
the laryngeal outlet normalized to the medial dimension in pixels. Results were
as follows: (1) LOAP was significantly greater for the dysphonic group, (2)
the range of LOAP values between the two groups overlapped considerably,
(3) no significant difference was found between groups for LOw, (4) the
correlation between LOAP and LOW within each subject yielded r values
of 0.71 and 0.67 for the nonorganic dysphonia and normal control groups,
respectively. It is concluded that medial compression of the ventricular folds
can be a normal laryngeal posture, and that although anteriorposterior
compression is present in greater degree in dysphonics, it is sufficiently common
in normals to question its utility as a diagnostic sign of phonatory dysfunction.
Key Words: Muscle tension dysphoniaFunctional dysphoniaNonorganic
dysphoniaVideostroboscopy.

Address correspondence and reprint requests to Alison Behrman, PhD, Department of Otolaryngology, The New York Eye
and Ear Infirmary, 310 East 14th Street, New York, NY 10003.
E-mail: abehrman@nyee.com
Journal of Voice, Vol. 17, No. 3, pp. 403410
2003 The Voice Foundation
0892-1997/2003 $30.000
doi:10.1067/S0892-1997(03)00018-3

Accepted for publication November 13, 2002.

An earlier version of this paper was presented at the Combined Otolaryngologic Spring Meeting (COSM), May 12, 2002,
Boca Raton, FL.
From the *Center for the Voice, The New York Eye and Ear
Infirmary, New York; Schein Voice and Laryngeal Center, Long
Island Jewish Medical Center, New Hyde Park, New York;
Albert Einstein College of Medicine, Montefiore Medical
Center, Department of Otolaryngology, Bronx, New York; Groningen Voice Research Lab (H.K.S.), Groningen, The Netherlands.

403

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ALISON BEHRMAN ET AL
INTRODUCTION

Nonorganic dysphonia is predominantly a diagnosis of exclusion in which voice production is impaired without discernable morphologic or
neurological abnormalities of the larynx. Diagnosis
is confounded by a lack of uniform terminology.
Labels include functional dysphonia,13 muscle
misuse dysphonia,4 muscle tension dysphonia,14
and psychogenic dysphonia.5 The nomenclature is
derived from a complexity of diagnostic classifications that are based primarily on endoscopic signs of
glottic and supraglottic postures.15 Other diagnostic
signs are also frequently included, such as specific vocal qualities, voice use patterns, or psychogenic factors. However, many of these diagnostic
features overlap more than one category, adding additional complexity to classification. Cooccurring organic lesions are often included, either
as a precipitating cause of the functional component2
or as a reactive inflammatory response,14 further
confounding application of these classification systems to diagnosis.
Two vocal tract postures commonly identified as
diagnostic hallmarks of nonorganic dysphonia are
anteriorposterior compression of the supraglottis
and medial compression of the ventricular folds.
These postures define the two types of primary
muscle tension dysphonia proposed by Rosen and
Murry,3 two of the six types of muscle misuse disorder identified by Morrison and Rammage,4 three of
the six features of vocal hyperfunction identified by
Van Lawrence,6 and the main types of supraglottic
laryngeal postures of muscle tension dysphonia described by Koufman and Blalock.2 Despite the apparent widespread acceptance of these postures as
endoscopic signs of vocal dysfunction, there is little
empirical data to support their diagnostic utility.
Sama et al7 assessed prevalence of the six features
of functional dysphonia as defined by Morrison and
Rammage5 and the six features of hyperfunction
defined by Van Lawrence6 in 51 subjects found to
have functional (nonorganic) dysphonia and 52
normal controls. Categorical data were obtained
from qualitative judgments of the fiber-optic examinations. No feature had significantly greater prevalence in the dysphonic group as compared to the
normals. Stager et al8 also obtained categorical data
Journal of Voice, Vol. 17, No. 3, 2003

from qualitative assessment of supraglottal activity.

They used both flexible and oral endoscopy in three
subject groups; patients with nodules (n 12), functional (nonorganic) dysphonia (n 11), and normals
(n 10). The authors found that differences
across groups for anteriorposterior compression
were statistically significant but the posture was
prevalent in all groups (74% of controls, 78% of
nodules group, and 92% of nonorganic group). Similarly, differences across groups for medial compression of the ventricular folds were statistically
significant, but again this posture was prevalent in
all groups (45% of controls, 68% of nodules group,
and 80% of nonorganic group). The prevalence of
both postures across all groups may be of greater
clinical diagnostic significance than the statistical
significance of group differences. Group size was
small, however, necessitating caution in the interpretation of these findings. In addition, the controls
were patients under evaluation for allergy-related or
reflux pharyngeal symptoms, and so those subjects
may not have been truly representative of normals.
In a more recent study, Stager et al9 used quantitative measures of supraglottal postures derived from
endoscopic images obtained with a flexible nasal
endoscope during sustained vowel phonation and
speech in 12 healthy controls, 6 patients with
nodules, and 6 patients with nonorganic vocal fatigue. No significant differences were found in
degree of medial compression of the ventricular
folds across groups for sustained vowel phonation
or during speech. The authors did find a statistically
significant greater degree of anteriorposterior compression in both dysphonic groups compared with
normals.
The data from these studies provide sufficient
preliminary evidence of the prevalence and degree
of anteriorposterior and medial compression in normals to question their diagnostic utility as signs of
nonorganic dysphonia. Therefore, additional studies
of larger samples of normals appear justified. Quantification of these postures provides interval rather
than ordinal data, facilitating assessment of relative
degree of supraglottal activity and possibly increasing the objectivity of the assessment. Therefore, the
use of quantitative measures to assess the prevalence of these supraglottal postures appears warranted. Deriving relative distance measures from

ANTERIOR-POSTERIOR AND MEDIAL COMPRESSION OF THE SUPRAGLOTTIS

endoscopic images does require some subjective decision-making about structural boundaries, making
sharp definition of the images important. Therefore,
using images obtained with a rigid oral endoscope
may increase the accuracy of the quantitative measures, as compared to images obtained from a fiberoptic endoscope. The purpose of this study was to
assess relative degree of anteriorposterior and
medial compression of the supraglottis in a group
of normal controls compared with individuals with
nonorganic dysphonia by deriving quantitative measures from endoscopic images obtained with a rigid
oral endoscope. This study was performed in compliance with the guidelines set forth by the Institutional Review Board of the North Shore-Long Island
Jewish Health System.

MATERIALS AND METHODS

Subjects
This retrospective study was conducted by selecting subjects from two separate database sources.
The nonorganic dysphonia patient group was selected from the database of the Schein Voice and
Laryngeal Center of the Department of Otolaryngology and Communicative Disorders at the Long
Island Jewish Medical Center. At the time of review,
the database contained information on approximately 700 patients who had undergone laryngeal
videostroboscopic examinations at the Center. Patients were identified from this database who had
presented with dysphonia at the time of the evaluation with an absence of laryngeal pathology (including neuromuscular, pulmonary and connective tissue
diseases, and vocal fold mucosal lesions) and for
whom no specific organic etiology of the dysphonia
was found. Seventy-seven patients were identified,
composing a heterogenous group of individuals with
respect to potential factors contributing to the dysphonia. That is, a variety of factors that could precipitate or maintain a voice disorder were reported by
some of these patients, including history of prior
upper respiratory infection, psychogenic stress associated with local terrorist events of 9/11/2002, or
substantial occupational vocal demands, for example. However, none of these patients demonstrated
any organic factors (including laryngopharyngeal

405

reflux disease or any apparent mucosal inflammatory

process) at the time of the evaluation.
From the selected 77 patients, video examinations
were included in this study only if the patient had
been able to tolerate the oral endoscope for a full
evaluation without apparent discomfort. This included complete view of the abducted vocal folds
(including anterior commissure) during quiet breathing, and two trials each of phonation at self-selected
comfortable pitch and loudness, glissade (low to
high pitch), and soft to loud voice. It was hypothesized that patients who could participate in a full
endoscopic evaluation would be sufficiently comfortable with the presence of the oral endoscope such
that supraglottal squeezing associated with gagging
would be minimized. Of the 77 patients, 40 (17 men
and 23 women) had full videostroboscopic evaluations and were included in the study. Ages ranged
from 22 to 56 years with a median age of 48. All
patients reported dysphonia at the time of the evaluation, and all patients were perceived to be dysphonic
by the evaluation team. All stroboscopic examinations of these patients had been performed by the
second author using the Kay Elemetrics RLS System
(Kay Elemetrics, Lincoln Park, NJ) with a 70 oral
endoscope and saved onto SVHS videotape or in
digital video files on DVD.
A control group of 40 healthy voiced individuals
was selected from a database of 139 laryngeal videostroboscopic examinations performed by Harm
Schutte, MD, in the Groningen Voice Research Lab
in Groningen, the Netherlands. There were 20 men
and 20 women with ages ranging from 17 to 60
years and a median of 38. These data had been
obtained as part of an earlier study of normal phonatory characteristics.10 The video database was reviewed starting at the beginning, and the first 20
men and 20 women who were 60 years of age or
below were selected for inclusion into the study.
The laryngeal examinations in the database were
performed with a Wolf 90 rigid endoscope (model
4450.57) (Knittlingen, Germany) and a Bruel & Kjaer
4914 Rhino-Larynx Stroboscope (Naerum, Denmark) and recorded on a Sony Betamax video recorder SL-C9 ES PAL (Tokyo, Japan).
Selection of Images
Two frames were selected from each video recording of the dysphonic subjects; one each from
Journal of Voice, Vol. 17, No. 3, 2003

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ALISON BEHRMAN ET AL

FIGURE 1. Measurement in pixels of the anteriorposterior

dimension (AP) of the visible true vocal folds during phonation.

FIGURE 2. Measurement in pixels of the width dimension

(W) of the visible true vocal folds during phonation.

the two trials of sustained phonation of /i/ (as in

heat) at self-selected comfortable pitch and loudness. Each frame showed maximal glottal closure
in which the laryngeal outlet (LO) (arytenoid cartilages, interarytenoid mucosa, petiole of the epiglottis, ventricular folds) was visualized. All images
were at least 1 second after phonation onset, similar
to the methods of Stager et al9, to avoid potential
medial compression associated with the articulatory
gesture of phonation onset. The images selected were
representative of the majority of cycles observed
during the examination at comfortable pitch in appearance of glottal closure and positioning of supraglottal structures. The selection of two frames, one
from each of two trials, was chosen to help ensure that
the selected images were reliable representations of
the subjects supraglottal posture during the examination. Two frames were also selected from each of
the control subjects video recordings, using similar
criteria. The controls videos often had more than
two trials of sustained phonation at comfortable
speaking pitch and loudness. In those cases, two
images were selected from different phonatory trials
that appeared representative of all trials for that subject. All images were then converted to TIFF or
JPEG digital format and transferred to an IBM-compatible computer for analysis. All image enhancement and measurements were performed using

SigmaScan software (SPSS Scientific Corporation,

Chicago, IL). Using the histogram capabilities of
this software, files were converted to grayscale and
maximally contrasted to better define borders and
anatomic landmarks.11 Tracing functions were then
used for measurements, all of which were made
in pixels.

Journal of Voice, Vol. 17, No. 3, 2003

Measurements
Quantification of the relative degree of anteriorposterior and medial compression of the supraglottis was achieved as follows. The anterior to
posterior distance was measured midline between
the vocal folds from anterior commissure or petiole
of the epiglottis to the interarytenoid mucosa in
pixels, and this distance was denoted AP (Figure 1).
To capture the medial compression of the ventricular
folds, the medial distance was measured as the width
of the true folds at their mid-membranous point from
the medial-most point of each ventricular fold in
pixels, and this width distance was denoted W
(Figure 2). All measures derived from endoscopic
images must be relative quantities normalized to
some known constant or to another quantity measured from the same image, primarily due to the
unknown and variable distance of the endoscope tip
to the larynx. Both the AP and W distances were
normalized to the LO, a measure recently described

ANTERIOR-POSTERIOR AND MEDIAL COMPRESSION OF THE SUPRAGLOTTIS

by Bloch and Behrman,11 defined as the area above
the glottis bounded by the petiole of the epiglottis
anteriorly, arytenoids posteriorly, and the ventricular
folds laterally (Figure 3). This measure represents
the view of the true vocal folds during phonation,
which can often appear to be reduced in the presence
of supraglottal compression.6
To obtain a numeric pixel value representing relative anteriorposterior compression, the LO measure
was normalized to the AP distance (LOAP) of the
same image by LO/AP2 100. In this way, a smaller
AP distance yields a larger LOAP, and therefore,
the greater the anteriorposterior compression, the
greater the value of LOAP. To obtain a numeric pixel
value representing medial compression, the LO measure was normalized to the W distance (LOW) of
the same image by LO/W2 100. In this way, a
smaller W distance yields a larger LOW, and therefore, the greater the medial squeeze of the ventricular
folds, the greater the value of LOW.
In order to determine whether differences in endoscope angle (70 for the dysphonic patients and
90 for the normal controls) affected LOAP or LOW,
measures from five volunteers with normal voices
and no laryngeal pathology were derived from
images obtained with both a 70 and 90 endoscopes.
These two sets of measures were compared using a
two-tailed paired t-test. No statistically significant
differences were found.
Statistical Analyses
Descriptive statistics were calculated for each of
the measures, including means and standard deviations. Assessment of paired differences between the
two images within each subject was performed
using a two-tailed paired t-test with a significance
level of p 0.05. Group differences for the two
vocal tract posture measures were assessed using
one-way analysis of variance (ANOVA) (p 0.05).
Assessment of the relatedness between the two measures within each individual was assessed using the
Pearson product-moment correlation coefficient.
Statistical analyses were performed using Systat version 7.0 (SPSS Corporation).
RESULTS
Differences between the two images for each subject in both the normal controls and the dysphonic

407

FIGURE 3. Measurement in pixels of the laryngeal outlet (LO)

during phonation.

patients were not statistically significant for either

LOAP (p 0.18) or LOW (p 0.23). This suggested
that the measures of anteriorposterior and medial
compression were reliably measured for each individual. Therefore, the first image from each subject
was arbitrarily selected for further analysis.
LOAP was significantly greater for the group of
patients with nonorganic dysphonia (p 0.001).
That is, on average, the degree of anteriorposterior
compression was greater for the dysphonia patients
than for the normal controls. However, the range of
LOAP values between the two groups overlapped
considerably in the lower values (Figure 4). No significant difference was found between groups for
LOw (p 0.05) (Figure 5). That is, on average, the
degree of medial compression for the dysphonia
patients was no greater (or lesser) than for the normal
controls. No gender difference was found for
either measure.
Assessment of the correlation between the values
of LOAP and LOW within each subject yielded r
values of 0.71 for the nonorganic dysphonia group
and 0.67 for the normal controls. The strength of
the association, given by r2, indicates that only 50%
of the variation in LOAP is explained by LOW in the
nonorganic dysphonia group, with the remaining
50% due to one or more unexplained variables. Similarly, only approximately 45% of the variation in
Journal of Voice, Vol. 17, No. 3, 2003

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ALISON BEHRMAN ET AL

FIGURE 4. Calculation of the LO normalized to the anterior

posterior dimension, where NLOAP LO area/AP2 100, such
that greater values correspond to greater anteriorposterior compression. The boundary of the box closest to zero indicates the
25th percentile, and the boundary farthest from zero indicates
the 75th percentile. Whiskers above and below the box indicate
the 90th and 10th percentiles. The horizontal line within the box
marks the median. Symbols lying outside the box represent
outlying data points. Differences between the groups are, on
average, statistically significant ( p 0.001).

LOAP of the normal control group is explained by

LOW, with the remaining 55% unexplained. Therefore, although the two vocal tract postures may
be considered moderately correlated in the statistical
sense, the strength of their association from a clinical interpretation leaves much that is unexplained.

DISCUSSION
The inconsistent nomenclature and lack of uniform diagnostic classification systems of nonorganic
dysphonia reflect an uncertain pathophysiology.
Morrison et al1 hypothesized that the underlying
mechanism of functional dysphonia is incomplete
relaxation of the posterior cricoarytenoid muscle,
which causes incomplete vocal fold adduction.
The authors indicate that this results in hyperfunction of thyroarytenoid as a compensatory mechanism
to achieve phonatory glottal closure. In a later publication, Morrison and Rammage4 represent functional dysphonia as the manifestation of excessive
activity of intrinsic and extrinsic laryngeal muscles
during phonation. Rosen and Murry3 posit that the
underlying mechanism may be the in-coordination
of respiratory effort with vocal fold position or
Journal of Voice, Vol. 17, No. 3, 2003

tension. Koufman and Blalock2 note that occult underlying disease may be present, such as glottal
incompetence, and therefore, the functional dysphonia may represent a maladaptive compensatory
strategy.
The presumption of muscle hyperfunction that
underlies these theoretical constructs of abnormal
laryngeal and vocal tract biomechanics cannot be
measured directly. Therefore, diagnosis must rely
on signs that are presumed manifestations of hyperfunction, such as anteriorposterior and medial compression of the supraglottis observed on endoscopic
evaluation. The data from this study add to the growing body of evidence79 that these laryngeal postures
may not be signs of phonatory dysfunction.
The finding of this study are consistent with both
of the Stager et al studies.8,9 Those studies sought to
distinguish between vocal tract postures associated
with dysphonia, termed static postures, and dynamic
postures, those that may be a normal articulatory
feature associated with connected speech. Their earlier study,8 using categorical, qualitative assessment,
demonstrated no task dependence (eg, sustained
vowel or speech) for anteriorposterior compression, whereas there were statistically significant differences among tasks by group for medial
compression of the ventricular folds. The authors
concluded that the medial compression of the ventricular folds appeared to be more of a dynamic
articulatory feature, whereas anteriorposterior
compression, a static posture across all tasks, might
be suggestive of dysfunction. In the subsequent
study of Stager et al,9 using interval data from quantitative measures, the authors found significantly
less anteriorposterior compression in the normal
controls, whereas no group differences were found
in degree of medial compression. The lack of a statistically significant difference between groups for
the LOw measure found in this study supports their
conclusion that medial compression is largely a
normal articulatory posture rather than one of dysfunction. Another finding from this study, significantly lesser degree of LOAP for the normal controls,
also supports their conclusion that anteriorposterior
compression may be abnormal. Further supporting
their conclusions is the finding in this study of a
lack of a robust correlation between the LOw and
LOAP measures, because a correlation between a

ANTERIOR-POSTERIOR AND MEDIAL COMPRESSION OF THE SUPRAGLOTTIS

normal (medial compression) and abnormal (anteriorposterior compression) posture would not be
expected.
One finding from this study that does not support
the conclusions of Stager et al8,9 is the significant
overlap in range of LOAP between the normal controls and the dysphonic subjects. Despite the fact
that, on average, there was a statistically significant difference between the two groups on this measure, the substantial overlap in values suggests that
anteriorposterior compression is not necessarily an
abnormal vocal tract posture. It has been noted
in some classically trained male singers that certain
vocal tract postures, including anteriorposterior
compression, are used in formant tuning, that is,
shaping the vocal tract to maximally resonate harmonic energy (personal communication, Donald G.
Miller and Harm K. Schutte, April 2001). Perhaps
anteriorposterior compression does not represent
equivalent geometries across all individuals, and the
posture may yield different acoustic outputs
depending on factors that are not readily apparent
from the endoscopic examination. Recently, Titze
addressed laryngeal postures that may contribute to
optimal harmonic power.12 Although the physiology
is incompletely understood, he hypothesized that it
may involve narrowing the epilaryngeal space along
the anteriorposterior axis without medial ventricular fold compression to increase vocal tract inertance. (Inertance is an acoustic property of the
accelerating or decelerating supraglottal air mass
that facilitates vocal fold vibration by causing the
oscillating supraglottal pressures to be in phase with
vocal fold velocity, thereby lowering the subglottal
pressure necessary to vibrate the folds.)
Three factors may have influenced the findings
of this study. First, adequate visualization of the
true vocal folds was a requirement for inclusion of
subjects in this study. This may have resulted in the
exclusion of patients with significant hyperfunctional behavior of the supraglottis, limiting the study
to those with a less severe disorder. Perhaps patients
with more severe nonorganic dysphonia demonstrate
anteriorposterior or medial compression of the supraglottis that is distinct in frequency or degree
from normals.
Secondly, the use of a rigid oral endoscope for all
examinations, rather than a flexible nasal endoscope,

409

FIGURE 5. Calculation of the LO normalized to the width

dimension, where NLOW LO area/W2 100, such that
greater values correspond to greater medial compression. The
range of values is greater for the dysphonic group, but on
average, differences between the two groups are not statistically
significant ( p 0.05).

may have influenced the findings of this study, both

in the limitation of phonatory task (sustained vowel
vs. speech) and the abnormal posture required for
the oral endoscopic view. It has been reported that
flexible endoscopy is necessary to accurately diagnose supraglottal hyperfunction.2 This was based on
the fact that in an earlier study,1 the presence of
anteriorposterior compression was not observed,
and this was attributed to the use of an oral endoscope. In the present study, the presence of anterior
posterior compression was found to be highly prevalent in dysphonic subjects, suggesting that a flexible
endoscope is not requisite for observation of this
laryngeal posture. Intuitively, it is easy to make the
assumption that the protruded tongue posture and
elevated larynx required with the oral endoscope
yield hyperfunctional supraglottal behaviors that
are examination artifacts. There is simply no empirical evidence to support that hypothesis. Mild but
easily tolerable discomfort from the nasal endoscope
could just as easily engender hyperfunction. If the
oral endoscope so easily disturbed normal laryngeal
function, then accurate assessment of the vibratory
amplitude of the mucosal wave would not be valid
using rigid stroboscopy, because excessive muscular
tension might similarly disrupt mucosal vibratory
behavior. However, it is possible that abnormal vocal
tract postures are present only during speech tasks,
requiring a fiberoptic endoscope for examination.
The third factor that may have influenced the
findings of this study is the possibility that the task
Journal of Voice, Vol. 17, No. 3, 2003

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ALISON BEHRMAN ET AL

was not sensitive to all types of nonorganic hyperfunction. Many patients exhibit hyperfunction in
most phonatory contexts. In those cases, anterior
posterior or medial compression of the suprgalottis
would likely be visualized during the endoscopic
task assessed in this study. Other patients, however,
may exhibit abnormal vocal tract postures only
under conditions of physiologic or linguistic stress
and not during routine endoscopic examination.
Therefore, it is possible that the prevalence of supraglottal postures associated with hyperfunction was
underestimated in the patient population due to the
nature of the task.

CONCLUSIONS
Much information is lost when the three-dimensional vocal tract is viewed through an endoscopic
image. As such, endoscopic assessment of laryngeal
and vocal tract postures reveals little about the underlying pathophysiology. The results of this study
demonstrate a significant presence of medial compression of the ventricular folds in normal voiced
individuals, as quantified by the LOw measure. Despite the greater range of values obtained for the
dysphonic group, the lack of significant group
differences and overlap in values between the two
groups implies that medial compression of the supraglottis is of limited clinical utility in the diagnosis
of nonorganic dysphonia. Anteriorposterior compression, as captured by the LOAP measure, was
found to occur in significantly greater degree in the
dysphonic group. Some overlap in this measure of
anteriorposterior compression was demonstrated
across groups, and therefore, this measure is of uncertain diagnostic utility relative to nonorganic dysphonia. The findings of this and other studies79
strongly suggest that some of the assumptions about
the nature (and, hence, diagnosis) of functional dysphonia may not be correct, and certainly additional
empirical data are needed. The pathophysiology and
clinical findings that are diagnostic of nonorganic

Journal of Voice, Vol. 17, No. 3, 2003

dysphonia remain uncertain. Therefore, caution

must be exercised in accepting conceptual frameworks and diagnostic categorizations of this
disorder.
Acknowledgments: The authors thank the anonymous
reviewers for their thoughtful commentary.

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