Review on Laryngeal Palpation Methods in Muscle

Tension Dysphonia: Validity and reliability issues

*Seyyedeh Maryam Khoddami, Noureddin Nakhostin Ansari, and Shohreh Jalaie, *yTehran, Iran
Summary: Background. Laryngeal palpation is a common clinical method for the assessment of neck and laryngeal
muscles in muscle tension dysphonia (MTD).
Objective. To review the available laryngeal palpation methods used in patients with MTD for the assessment, diagnosis, or document of treatment outcomes.
Study Design (Method). A systematic review of the literature concerning palpatory methods in MTD was conducted using the databases MEDLINE (PubMed), ScienceDirect, Scopus, Web of science, Web of knowledge and Cochrane
Library between July and October 2013. Relevant studies were identified by one reviewer based on screened titles/abstracts and full texts. Manual searching was also used to track the source literature.
Results. There were five main as well as miscellaneous palpation methods that were different according to target
anatomical structures, judgment or grading system, and using tasks. There were only a few scales available, and the
majority of the palpatory methods were qualitative. Most of the palpatory methods evaluate the tension at both static
and dynamic tasks. There was little information about the validity and reliability of the available methods.
Conclusion. The literature on the scientific evidence of muscle tension indicators perceived by laryngeal palpation in
MTD is scarce. Future studies should be conducted to investigate the validity and reliability of palpation methods.
Key Words: PalpationMuscle tension dysphoniaLarynxAssessmentValidityReliabilityReview.

INTRODUCTION
Muscle tension dysphonia (MTD) is referred to a functional
voice disorder in which there is an excessive tension in the
(para)laryngeal musculatures. This pathologic condition usually affects young to middle-aged females who use voice extensively.13 Morrison et al1 found 20% of their dysphonic patients
are diagnosed as MTD. The MTD has been classified into two
different categories: (1) primary and (2) secondary MTD. Primary MTD is diagnosed in the absence of known organic conditions affecting voice, without obvious psychogenic or
neurologic etiologies. However, secondary MTD accompanies
organic conditions and may be a reaction to them.4 Although
different synonym terms suggested in the literature to introduce
this pathologic condition, now the MTD has been accepted as
the most appropriate diagnostic label. Multiple abnormal psychological, medical, aerodynamic, perceptual-acoustic, and
musculoskeletal characteristics have been documented in
MTD3,5,6; so, assessment and diagnosis of MTD is based on
several key features.3 These features typically are explored
through case history, psychological evaluations, perceptualacoustic voice assessment, observation of the larynx and
palpation.
Authors state that excessive tension of the (para)laryngeal
muscles is a hallmark of MTD.2,3,5,7,8 Also, excessive or
atypical laryngeal activity was introduced as required criteria
for medical diagnosis in both types of MTD.4 Therefore, the
Accepted for publication September 16, 2014.
From the *Department of Speech Therapy, School of Rehabilitation, Tehran University
of Medical Sciences, Tehran, Iran; and the yDepartment of Physiotherapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran.
Address correspondence and reprint requests to Shohreh Jalaie, Department of Physiotherapy, School of Rehabilitation, Tehran University of Medical Sciences, Enghelab Ave,
Pitch-e-shemiran, Tehran 11489, Iran. E-mail: Jalaeish@sina.tums.ac.ir
Journal of Voice, Vol. -, No. -, pp. 1-10
0892-1997/$36.00
2015 The Voice Foundation
http://dx.doi.org/10.1016/j.jvoice.2014.09.023

assessment of laryngeal muscular tension may be an important

part in the diagnosis of voice disorders, particularly MTD.915
Muscular tension can be assessed using several instrumental
and noninstrumental methods.16 Palpation is a noninstrumental
technique to document any visible or palpable tensions around
the larynx observed especially in the extrinsic laryngeal muscles. However, the underlying cases of excessive tension in
(para)laryngeal area in MTD have not been fully understood.17
The extrinsic and intrinsic laryngeal muscle groups both play a
role during phonation.9,1315 The intrinsic laryngeal muscles
provide motion and tension of the vocal folds.13 Free movement
of the intrinsic laryngeal muscles depends on stable and natural
position of the larynx provided by the extrinsic laryngeal muscles. In the presence of MTD, the tension of extrinsic musculature and thereby position of the larynx may be altered.
Subsequently, the movement of cartilaginous structures of the
larynx may be disturbed affecting the tension of intrinsic
musculature.13
Assessment of the extrinsic and the intrinsic laryngeal muscles using reliable and valid method is essential to diagnose the
MTD and to record treatment outcomes. The palpation method
used routinely in the speech therapy clinics provides useful information about the degree of laryngeal muscles tension, pain,
focal tenderness, tightness, laryngeal high position, decreased
laryngeal spaces, and abnormal displacement of cartilages during rest and/or phonation.9,10,15,18 Therefore, laryngeal
palpation can facilitate clinical decision-making process in
MTD.15,18
There are several laryngeal palpation methods in MTD used
in the clinic and investigations. Although some of palpation
methods have been introduced or discussed in the tutorial or review articles,10,11,13,18 there is no review article to include all
the palpation methods. The aims of the article are (1) to
characterize all available laryngeal palpation methods used
for the assessment of neck and laryngeal muscle tension in

2
MTD and (2) to compare them in terms of target anatomical
structures, criteria for judgment/grading, assessment tasks,
validity, and reliability.
METHOD
A systematic review of literature related to laryngeal palpation
methods in MTD was undertaken. We performed a computerized search using the databases MEDLINE (PubMed), ScienceDirect, Scopus, ISI, Web of knowledge, And Cochrane Library
from 1980 to 2013. The search terms used were assess,*
evaluat*,diagnos,* muscle tension dysphonia, muscle
misuse dysphonia, functional dysphonia, functional voice
disorder, nonorganic dysphonia, nonorganic voice disorder, and vocal hyperfunction for each database. Manual
searching was also used to track the source literature. The articles in which the palpatory methods were used as a tool for the
assessment and diagnosis of dysphonic patients or treatment
outcome were included. The relevant tutorial and review articles also were included.
RESULTS
We found five main laryngeal palpatory methods.1013,18,19 In
nearly all methods, the client is at the sitting position, the
examiner is on the one side, the client head is in a neutral
position, and the thumb and middle (or index) finger of the
other hand are used for palpation.11,18 The degree of
examiner hand force should be equal to the pressure required
to cause the thumbnail tip to blanch against a firm surface.10
We found similarities and differences among the palpation
methods particularly according to the target structures, criteria
for judgment or grading, and assessment tasks. There were no
sufficient data about validity and reliability of palpation
methods. In the following, we characterize the available palpation methods.
The laryngeal palpation method of Aronson
This method at first was introduced in 1990 by Aronson for the
clinical assessment of voice disorders.12 In this method, the
laryngeal critical sites are the major horns of the hyoid bone,
the superior cornu of the thyroid cartilage, and the thyrohyoid
space. The clinician tests tension signs by encircling the larynx
with the thumb and middle (or index) finger (C-shape) at
rest.11,12
The criteria defined in the Aronson method to determine the
presence of musculoskeletal tension are (1) pain in response to
pressure on the larynx and hyoid bone; (2) elevation of the larynx and hyoid bone (diminished width of the thyrohyoid
space); (3) resistance of the larynx to displacement; and (4)
voice improvement while lowering the larynx.12 This method
is a qualitative tool with no rating scale. There are no studies
on the validity and reliability of the Aronson method (Table 1).
The laryngeal palpation method of Roy et al
Roy et al2023 documented effectiveness of laryngeal manual
therapy by palpation. They recommended muscle tension

Journal of Voice, Vol. -, No. -, 2015

should be assessed not only at rest but also during voicing

attempts.11
At first, the Roy et al method was used by Roy and Leeper20
as a judgment based on laryngeal elevation (narrowing of the
thyrohyoid space) and pain during palpation. This method has
been used in the literature with modifications between 1996
and 1998.10,21,22 In the modified Roy et al method, muscle
tension is judged according to focal tenderness, muscle
nodularity, laryngeal pain, laryngeal elevation, and horizontal
laryngeal mobility. Furthermore, tension in the medial
submental regions during rest, modal pitch, and high
phonation needs to be detected.10 Finally, the examination of
anterior border of the sternocleidomastoid (SCM) muscles at
rest has been suggested to be included in the modified Roy
et al method.11
The laryngeal palpation method of Roy et al has no grading
system to rate the muscle tension and has not been evaluated for
reliability and validity (Table 1).
The laryngeal palpation method of Morrison
The Morrison method was suggested in 1997. This is a qualitative method in which clinician documents tenderness, tightness,
closed spaces, and restricted mobility of the larynx. These signs
can be observed in different functional areas like the suprahyoid
region, the thyrohyoid muscles and space, the cricothyroid
space, the inferior constrictor, and lateral laryngeal gutters.
Tightness of the inferior constrictor and freedom of the lateral
laryngeal gutters can be assessed while the larynx has rotated.
Any displacement of the cricoid cartilage is also documented.18
The method of Morrison18 is not restricted to rest but palpatory findings are compared between rest and voicing tasks. The
original Morrison palpation method does not grade the severity
of tension (Table 1) but Morrison et al presented a four-point
scale to rate muscular tension in 1999. The authors palpated
only four muscle groups including the suprahyoid, the thyrohyoid, the cricothyroid, and the pharyngeal constrictor muscles24 (Table 2). There are no data about the validity and
reliability of the Morrison palpation method.
The laryngeal palpation method of Lieberman
This method was first introduced by Lieberman in 1998.25 It is a
comprehensive qualitative method that includes many structures in the head, neck, and body.13,25,26 In this method, the
laryngeal palpation is similar to that of the Morrison
method18 and the modified Roy et al method10,11 but internal
laryngeal structures (the arytenoid cartilages, the posterior
cricoarytenoid muscles, and the interarytenoid muscles) are
also evaluated. As well, laryngeal structures are palpated for
position, tone, symmetry, and tenderness at rest and during
swallowing and speech tasks13,25,26 (Table 1).
Angsuwarangsee and Morrison developed a grading system
based on the original work of Lieberman. In this system, only
four muscle groups including the suprahyoid, the thyrohyoid,
the cricothyroid, and the pharyngolaryngeal muscles are
palpated at rest, phonation, and connected speech, then tension
severity are graded using a four-point scale16 (Table 2).

Authors
Aronson

Participants
12

Roy and
Leeper20
Roy et al22

Roy and
Bless10

Rubin
et al13

Target
Structures

The method of Hyoid bone; laryngeal

Aronson
region; thyroid cartilage;
thyrohyoid space
Hyoid bone; laryngeal
The original
17 patients with
region; thyrohyoid space
method of
functional
Roy et al
dysphonia
150 patients with The method of Hyoid bone; suprahyoid/
Roy et al with submental area; thyroid
MTD and
cartilage; thyrohyoid
some
spasmodic
modifications space;
dysphonia
sternocleidomastoid
(MTD category:
muscles
not reported)
The method
Thyroid cartilage
26 professional
suprahyoid muscles;
voice users with of Morrison
thyrohyoid muscles
voice problems
and space; cricothyroid
(12 normal
muscles and space;
larynx, 10
cricoid cartilage inferior
prenodule/
constrictor; lateral
nodule, 3 red
laryngeal gutters
appearing
larynx, 1
sulcus vocalis)
25 patients with
The method of Hyoid bone; suprahyoid/
functional
Roy et al with submental area; thyroid
cartilage; thyrohyoid
dysphonia
some
modifications space

The method of Hyoid bone; superior and

Lieberman
inferior suspensory
muscles; thyroid
cartilage; cricothyroid
muscles and space;
cricoid cartilage;
constrictor muscles;
arytenoid cartilages;
posterior cricoarytenoid
muscles; interarytenoid
muscles;

Main Criteria
for Judgment

Assessment
Tasks

Reliability
Validity

Inter-Rater Intra-Rater

Not reported

Not
Not
reported reported

Not reported

Not
Not
reported reported

Not reported

Not
Not
reported reported

Not reported

Not
Not
reported reported

Rest;
Not reported
Tenderness;
phonation
hypertonocity;
laryngeal elevation:
laryngeal pain;
laryngeal lateral
mobility
Not reported
Tenderness; tightness; Rest;
swallowing;
cricoid
speech
displacement;
singing
laryngeal
excursion; closed
spaces; laryngeal
lateral mobility

Not
Not
reported reported

Rest;
Laryngeal elevation;
phonation
laryngeal pain;
laryngeal resistance
Rest;
Laryngeal elevation;
phonation
closed space;
laryngeal pain
Rest;
Laryngeal elevation;
phonation
laryngeal pain;
focal nodularity

Rest;
Tenderness;
phonation
tightness; cricoid
displacement;
laryngeal excursion;
closed spaces

Laryngeal Palpation Methods in MTD

Morrison18

Palpation
Method

Seyyedeh Maryam Khoddami, et al

TABLE 1.
Characteristics of Descriptive Laryngeal Palpation Methods

Not
Not
reported reported

(Continued )

TABLE 1.
(Continued )

Authors

Participants

Palpation
Method

Target
Structures

sternocleidomastoid
muscles
Van Lierde 4 patients with
the other
Hyoid bone
et al31
primary MTD
palpation
geniohyoid muscles;
methods
sternohyoid muscles;
stylohyoid muscles;
thyrohyoid muscles;
cricothyroid muscles
and space;
cricopharyngeus
muscles; masseter
muscles; trapezius
muscles;
sternocleidomastoid
muscles
Kooijman 25 teachers with The method of Hyoid bone; geniohyoid
et al9
persistent voice
Lieberman
muscles; thyroid
complaints
cartilage; thyrohyoid
(MTD category:
muscles; cricothyroid
not reported)
muscles trapezius
muscles;
sternocleidomastoid
muscles
Roy11

The other
palpation
methods

Assessment
Tasks

Rest
Hypertonicity; pain;
high position of
hyoid and shoulder;
closed space

Tensed or not

Reliability
Validity

Inter-Rater Intra-Rater

Not reported

Not
Not
reported reported

Not
Not
Rest; yawning The higher
reported reported
the score
and
associated with
phonating
at high pitch the higher the
score of the
just for t
voice handicap
hyrohyoid
and the worse
muscles
voice quality in
teachers
Rest;
Not reported
Not
Not
phonation
reported reported

Hyoid bone; suprahyoid/ Tenderness;

hypertonicity;
submental area; thyroid
laryngeal elevation:
cartilage; thyrohyoid
laryngeal pain;
space;
laryngeal lateral
sternocleidomastoid
mobility
muscles
High position of hyoid Rest;
Aural region;
phonation
and shoulders;
temporomandibular
hypertonicity;
joint; hyoid bone;
pain; laryngeal
sternohyoid muscles;
elevation; closed
thyrohyoid muscles;
space
cricothyroid muscles
and space; trapezius
muscles;
sternocleidomastoid
muscles

Not reported

Not
Not
reported reported

Journal of Voice, Vol. -, No. -, 2015

Van Lierde 10 patients with

et al32
primary MTD

The modified
method of
Roy et al

Main Criteria
for Judgment

Izadi and
Salehi33

40 teachers with The method of Hyoid bone; geniohyoid

Lieberman
muscles; suprahyoid
chronic
muscles; pharyngeal
diseases of
constrictor muscles;
the voice organ
thyroid cartilage;
thyrohyoid space;
cricothyroid muscle,
space and joint;
sternocleidomastoid
muscles
The other
Hyoid bone; geniohyoid
39 patients with
palpation
muscles group; thyroid
MTD (30
methods
cartilage; thyrohyoid
primary MTD,
space
8 vocal fold
nodule, 1 polyp)

the other
palpation
methods

(Para)laryngeal muscles;
thyrohyoid space

Rest;
phonation

Not reported

A or B: A, pulled-up
hyoid position;
B, pulled-down
hyoid position

Vocal task
(counting)

Tightness; laryngeal
rise; focal
tenderness; closed
space

Rest;
phonation

Not
Not
Hyperfunction
reported reported
in the
supralaryngeal
area more
associated
with roughness
in MTD patients
who showed
pulled-up hyoid
pattern
Not reported
Not
Not
reported reported

Note: The original terms used by authors in the literatures have been included to introduce the participants in the patients group.
Abbreviation: MTD, muscle tension dysphonia.

Not
Not
reported reported

Laryngeal Palpation Methods in MTD

Van Houtte 18 patients with

et al17
primary MTD

Tonus; tenderness;
size and symmetry
of spaces

Seyyedeh Maryam Khoddami, et al

Marszalek
et al27

TABLE 2.
Characteristics of Laryngeal Palpation Grading Systems

Authors

Participants

Palpation
Method

Target Structures

Redenbaugh 7 normal and 7

The other palpation Suprahyoid muscles;
and Reich30
patients with
methods
infrahyoid muscles
MTD (2 vocal
fold nodules, 3
contact ulcer, 2
laryngitis)
Morrison
39 patients with The method
Suprahyoid muscles;
et al24
primary MTD
of Morrison
thyrohyoid muscles;
cricothyroid muscles;
pharyngeal constrictor
muscles
Angsuwar465 dysphonic
The method of
Suprahyoid muscles;
angsee and
patients (141
Lieberman
thyrohyoid muscles;
Morrison15
muscle misuse
cricothyroid muscles;
dysphonia &
pharyngolaryngeal
324 nonmuscle
muscles
misuse
dysphonia)
Mathieson
10 patients with The method of
Hyoid bone;
et al19
primary MTD
Mathieson et al
supralaryngeal
area; thyroid cartilage;
sternocleidomastoid
muscles

16 patients
with MTD (11
primary MTD
and 5 vocal
fold nodules)

1. The method
of Lieberman
2. The method
of Mathieson
et al

1. Like Angsuwarangsee
and Morrison
(2002)
2. Like Mathieson
et al (2005)

Assessment
Tasks

Reliability
Validity

Inter-Rater

Intra-Rater

A 5-point scale based

on the muscle tension

Rest;
phonation;
reading

Moderately high
correlations
between sEMG
and palpation

Not
reported

Not
reported

Ordinal scale (0 to 3) 0:
normal tone; 1: mild
tension;
2: moderate tension;
3: severe tension
Ordinal scale (0 to 3) 0:
normal tone; 1: mild
tension; 2: moderate
tension; 3: severe
tension

Not reported

Not reported

Not
reported

Not
reported

Rest; phonation

Correlation
between
thyrohyoid
tension and
MMD3

Good
Good except
except
for the
for the
pharyngopharyngolaryngeal
muscles
laryngeal
muscles

Ordinal scale (1 to 5)
1: minimal; 5:
maximum muscle
resistance nominal
scale for larynx
position A: high
held; B: neutral;
C: lowered; D: forced
lowered

Rest

Not reported

Not
reported

1. Like Angsuwarangsee
and Morrison
(2002)
2. Like Mathieson
et al (2005)

1 and 2. low
1. Rest;
phonation correlation
between
2. Rest

palpation and
sEMG; no
association
between
position of the
larynx and
changes in the
third formant;
not sensitive to
one voice
therapy session

1. Low
2. Low

Not
reported

1. Not
reported
2. Not
reported

Journal of Voice, Vol. -, No. -, 2015

Stepp et al28

Main Criteria
for Judgment

Note: The original terms used by authors in the literatures have been included to introduce the participants in the patients group.
Abbreviations: LE, laryngeal elevation; LMTPE, laryngeal manual therapy palpatory evaluation; MMD3, muscle misuse dysphonia (type 3); MTD, muscle tension dysphonia; sEMG, surface
electromyography.

Lowell
et al29

10 normal and
10 patients
with primary
MTD

The method of
Mathieson et al

Like Mathieson et al
(2005)

Like Mathieson
et al (2005). But
high-held laryngeal
position high
score

Rest

Low to moderate
correlation for
LMTPE total
score and
radiographic
findings; no
correlation
between
laryngeal
position
score and
radiographic
findings

Not
reported

Not
reported

Seyyedeh Maryam Khoddami, et al

Laryngeal Palpation Methods in MTD

Kooijman et al9 evaluated muscular tension and body posture

using the Liebermans method based on a qualitative judgment.
The authors included the trapezius muscles for evaluation. They
assessed all structures only at rest but the thyrohyoid muscles
and position of the thyroid cartilage which were assessed in
both rest and during function (ie, yawn and phonation)
(Table 1).
Marszalek et al performed palpation according to the Liebermans method before and after osteopathic myofascial techniques. They included a few anatomical structures for the
assessment compared with the original Lieberman method.
Although the structures are assessed only at rest, the cricothyroid apparatus are examined both at rest and phonation. They
used no specific grading system for assessing the tenderness,
tonus, and size of the spaces27 (Table 1).
There are a few data available about the validity and reliability of the Lieberman method. Stepp et al who evaluated
the Angsuwarangsee and Morrison scale before and after voice
therapy reported that the correlation between this grading system and surface electromyography (sEMG) is generally low
(rPearson near zero or even negative).28 Inter-rater and intrarater reliability of the Angsuwarangsee and Morrison scale
were good except for the pharyngolaryngeal muscles.16 However, Stepp et al28 found a low inter-rater reliability for this scale
(rPearson 0/20/6, P > 0.05 for all assessments except for the
cricothyroid and pharyngolaryngeal assessments).
The laryngeal palpation method of Mathieson et al
Mathieson et al developed a palpatory rating system to document the outcomes of laryngeal manual therapy in MTD. In
this system, degree of muscle resistance and laryngeal height
are graded at rest. The resistance of the SCM muscles and the
supralaryngeal area as well as the laryngeal resistance to lateral
pressure are rated using a 15 scale. The height of the larynx in
the vocal tract is also assessed using a four-point nominal scale
(Table 2). For the assessment, the examiner stands behind the
client and palpates the target structures with both hands.19 In
2012, Lowell et al29 used scoring system and modified it with
the high score representing the high laryngeal position.
There is no enough information about validity and reliability
of the Mathieson et al method. Stepp et al evaluated palpation
method of Mathieson et al by using sEMG and acoustic recordings before and after voice therapy. The authors found correlation between this method, and sEMG was generally low
(rPearson near zero or even negative), and there was no association between the third formant frequency changes and
changes in laryngeal position as a subscale of the Mathieson
et al method (P > 0.05).28 The inter-rater reliability of this system also was low (rPearson 0/30/5, P > 0.05) when the muscle
resistance assessed; the results of kappa analysis used to assess
larynx position showed moderately low values, with nonsignificant P values to assess the likelihood of kappa > 0.28 Lowell
et al, who determined radiographic measures of hyoid position,
laryngeal position, and hyolaryngeal space during phonation in
patients with MTD and normal speakers, investigated correlation between these radiographic measures and the palpatory
method of Mathieson et al. They observed no correlation

8
between the radiographic findings and the laryngeal position
subscore (rSpearman 0.12, P 0.58), and the correlation
between the total score of Mathieson et al method and the
radiographic findings was low to moderate (rSpearman 0.51,
P 0.22 for radiographic hyoid position, rSpearman 0.52, P
0.01 for radiographic laryngeal position)29 (Table 2).
Other laryngeal palpation methods
There are a number of laryngeal palpation methods3033 that
have not been widely used in clinical settings or
investigations. These methods have not been evaluated for
validity and reliability measures.
Redenbaugh and Reich30 evaluated muscle tension of the
suprahyoid and the infrahyoid muscles using a palpatory
method to rate the tonicity at rest, vowel production, and
reading aloud with a five-point scale. The authors found a
moderately high correlation between the palpation score and
sEMG during function of the larynx (Table 1).
Van Lierde et al31,32 have used a qualitative clinical method
based on palpation. They documented the laryngeal elevation,
high position of the hyoid bone and shoulder, and closed
spaces in the larynx. Hypertonicity felt by the examiner and
pain during palpation reported by the patient are also
considered as muscle tension. Van Houtte et al17 used also a
qualitative palpatory method during rest and phonation as a
measure to diagnosis the MTD. The authors reported tightness
and tenderness of the (para)laryngeal muscles, laryngeal rise,
and decreased thyrohyoid space as clinical features of tension
(Table 1).
Izadi and Salehi developed a qualitative method based on the
direction of the hyoid pull. In this method, the thyrohyoid apparatus are palpated during counting task. According to this
method, there are two abnormal hyoid patterns in MTD
including pulled-up and pulled-down hyoid. Impalpable
superior border of the hyoid, the hyoid resistance against
displacement, and tight geniohyoid muscle group are the
main criteria for pulled-up hyoid pattern. Impalpable superior border of the thyroid cartilage and decreased the thyrohyoid
space are major indicative of pulled-down hyoid position.
They concluded that the hyperfunction in the supralaryngeal
area was more associated with roughness in MTD patients
who showed pulled-up hyoid33 (Table 1).
DISCUSSION
In this article, we attempted to review the available laryngeal
palpation methods in MTD. Palpation is an easy, direct, and
useful clinical method to measure muscular tension which
needs no equipment. It is a safe technique with no specific
side effects.16 Laryngeal palpation methods are subjective
and depend on the experience and skill of practitioner.
Excessive tension of the (para) laryngeal muscles can be
considered as a core feature in MTD,2,3,5,7,8 and clinicians are
willing to measure tension using available palpation methods
in both primary and secondary MTD. There are similarities
and differences among palpation methods based on the
criteria considered for diagnosing and measuring muscle

Journal of Voice, Vol. -, No. -, 2015

tension. The criteria considered in this review to compare

palpation methods were target anatomical structures, criteria
for judgment/grading, assessment tasks, validity, and reliability.
Patients with MTD usually report tenderness or pain
in laryngeal area and/or in reaction to pressure.11,12,25 In
addition, elevation of the larynx is a hallmark clinical feature
of MTD68,20,30,32; this clinical finding also confirmed by
a recent radiographic study.29 It follows that the assessment
of focal tenderness, tightness, nodularity, discomfort, and
pain in laryngeal areas, and laryngeal elevation are common
criteria to document muscle tension in all palpation methods.
However, the palpatory methods consider different criteria
for the laryngeal elevation. In the method of Aronson and
original version of the Roy et al method, narrowing or closing
of the thyrohyoid space has been suggested as laryngeal
elevation.12,20,21 Tightness of the thyrohyoid and/or
suprahyoid muscles were interpreted as laryngeal elevation
in the available methods particularly modified method of
Roy et al, the method of Morrison, and the Liebermans
method.10,11,13,18,22,23,25,26,31,32 Kooijman et al9 described the
hypertonicity of the genoihyoid and thyrohyoid muscles, high
position of the hyoid bone, and the thyroid cartilage altogether
as elevation of the larynx. In the method of Izadi and Salehi33
,however, the direction of the hyoid pull has been suggested
as the major indicative for palpation; the laryngeal elevation
is not assessed in this method. Unlike other methods, Mathieson
et al19 assesses the laryngeal elevation directly by placing the
fingers horizontally with the lowest finger at the level of the
clavicles; however, the study by Stepp et al28 showed the indicator provided by Mathieson et al cannot evaluate laryngeal
elevation reliably. With regard to the characterizations of the
methods of palpation, laryngeal elevation must be evaluated
for the presence of laryngeal muscle tension. There is no evidence available to support which palpatory criteria should be
applied when assessing laryngeal elevation. Future studies
need to focus on this aspect of palpation methods to determine
which criteria define best the laryngeal elevation.
There are differences between palpation methods according
to number and target anatomical structures. Main target laryngeal structures in most palpation methods are the hyoid bone,
the suprahyoid muscles, the thyrohyoid muscles, the thyrohyoid
space, the cricothyroid muscles, and the cricothyroid space
(Tables 1 and 2).
The main target laryngeal structures are assessed with
various criteria in the palpation methods. Pain, tenderness,
tightness, nodularity, and hypertonocity as well as laryngeal
resistance and decreased laryngeal spaces are the most popular criteria considered in laryngeal palpation methods. For the
hyoid bone, pain, or tenderness over the hyoid bone, vertical
position, and lateral mobility of the hyoid are major
criteria.913,1922,25,27,31,32 Izadi and Salehi33 only focused on
the hyoid pull direction as a main indicator. For the target
muscle groups, hypertonicity, tightness, nodularity, tenderness, and pain have been used as criteria.913,15,18,
2022,24,27,28,3032
However, Mathieson et al19 used the degree
of muscles resistance as the criteria for laryngeal muscle tension. In some methods, the laryngeal resistance to lateral

Seyyedeh Maryam Khoddami, et al

Laryngeal Palpation Methods in MTD

pressure or mobility has been considered as the main criterion.1013,18,19,21,22,25 For the thyrohyoid space and the
cricothyroid space, narrowing or closing is the major
criterion in most palpaory methods; however, the tightness
and hypertonocity of related muscles also are interpreted as
tension in these structures.13,15,18,20,25,27,28,31,32
There is no sufficient scientific evidence to suggest which
criteria are the best indicators for the document of tension in
laryngeal structures. A recent study to determine the differences
of hyoid position and hyolaryngeal space during phonation
between people with primary MTD compared with control
group using radiography found hyoid position are higher in
patients with MTD but there is similar hyolaryngeal space
between groups.29 To measure the muscle tension directly, the
factors of hypertonicity, tightness, nodularity, and tenderness
can be considered as the major criteria. There is the distinct
possibility that the same muscular actions in one muscle group
could result in a different outcome for a cartilage or bone structure, depending on the actions of another muscle group. Similarly, the position of a given cartilage or bone structure can be
accomplished with different muscular actions. It follows that
because of the interaction between muscles, cartilage, and
bone structures, the excessive tension in the (para)laryngeal
musculatures may alter the size of the thyrohyoid, the cricothyroid spaces, position or mobility of the hyoid bone, and cartilage structures in the larynx. Consequently, assessment of the
thyrohyoid, the cricothyroid spaces as well as position and
lateral mobility of the hyoid can be useful to measure tension
in the larynx.
Some palpation methods use additional indicators to measure
the tension. In the method of the Morrison, the cricoid displacement and tightness of the inferior constrictors consider as additional indicators.34 The Lieberman method proposed palpation
of internal laryngeal structures such as the arytenoid cartilages,
the cricoarytenoid joints, the posterior cricoarytenoid, and the
interarytenoid muscles.13 Some palpation methods focus on
the assessment of the SCM muscles as an additional indicator,
particularly in MTD.911,13,19,21,22,25,27,31,32 There are some
clinical findings to confirm why these additional indicators
suggested. The cricoid displacement can be interpreted as
cricothyroid muscles fatigue in MTD.34 In some patient with
MTD, the larynx tightly held by the inferior constrictors and
the lateral laryngeal channels are not accessible during rotation
of the larynx.18 However, Rubin et al13 emphasized the assessment of internal laryngeal structures may be uncomfortable for
the patients and must be used by experienced practitioners. The
SCMs are one of the important neck muscles involved in phonation.9 Hypertonicity of the SCMs is a common clinical finding
in voice disorders.7 It seems because of the relation between
musculoskeletal abnormalities and voice disorders,27 SCMs
should be assessed in laryngeal palpation methods.
The palpatory methods use a qualitative or grading system
for documenting tension. However, most of them are qualitative
methods and only rely on a presence or absence measure of tension (Table 1). There are only a few rating systems to grade
severity of muscle tension (Table 2). Qualitative methods
may be used for the assessment and diagnose of patients with

MTD; rating systems may be more appropriate for recording

treatment outcomes where subtle changes need to be identified.
Furthermore, although palpation methods that use a grading
system are based on the subjective judgment can provide the
clinicians with a quantitative measure to document objectively
the degree of the muscle tension.
Palpation methods are performed in two different tasks: static
and/or dynamic. The tasks are static when performed at the rest,
whereas dynamic tasks are referred to the tasks of yawning,
swallowing, phonation, or speech. Most of the methods
of palpation perform the test in both static and dynamic
tasks.1013,15,18,20,25,27,28,30,33 A few of methods, however, are
performed in only static or dynamic tasks.9,19,31,33 Yamasaki
et al analyzed anatomy and morphology of the vocal tract in
patients with vocal nodules compared with normal speakers
by means of magnetic resonance imaging at rest. The authors
showed that patients with vocal nodules may present a
constantly increased tension of the laryngeal muscles, even at
rest35; but in some patients with MTD, clinical findings demonstrated the larynx is contracted abnormally only during voicing.11,18,29 It follows that those laryngeal palpation methods
that included both static and dynamic tasks are preferred.
There are not sufficient information about the validity and
reliability of palpation methods (Tables 1 and 2). The
concurrent validity of palpation methods has been
investigated by using sEMG, third formant frequency, and
radiography. The data regarding concurrent validity of
palpation methods in MTD are conflicting.2830 Although
Redenbaugh and Reich30 reported a moderately high correlation between palpation and sEMG, Stepp et al found no correlation between sEMG and palpatory systems of
Angsuwarangsee and Morrison and Mathieson et al. The differences of results between these two studies on the correlation
between the sEMG and palpatory methods might be because
of the methodology, method of data collection, and demographic characteristics of participants.
The acoustic and radiographic findings did not confirm the
concurrent validity of the palpation methods of Angsuwarangsee and Morrison and Mathieson et al.28,29 However, a direct
positive relationship has been demonstrated between the
Lieberman tension score and voice quality and Voice
Handicap Index.9 There is a paucity of data to draw strong
conclusion about the concurrent validity of the palpation
methods. More investigations are then recommended to document the concurrent validity of the palpation methods.
There are only two studies which evaluated the reliability of
the palpation methods.15,28 Angsuwarangsee and Morrison15
showed good inter-rater and intra-rater reliability for the Lieberman method except for the pharyngolaryngeal muscle tension, and Stepp et al found a low inter-rater reliability for
both the Angsuwarangsee and Morrison and Mathieson et al
grading systems.28 The results indicated that the inter-rater
agreement of laryngeal height is not significantly higher than
that because of chance.28 The methods of statistical analysis
adopted, disagreement on the definition of laryngeal height,
and practical experience might be explaining the differences
between these two reliability studies. Further studies are

10
required to investigate the inter-rater and intra-rate reliability of
the available palpatory methods.
CONCLUSIONS
This review article characterized all available laryngeal palpation methods for the assessment of muscle tension in MTD.
There are similarities and differences among palpation methods
based on the target anatomical structures and criteria for the
assessment of tension. There is need to provide sufficient scientific evidence for documentation of muscle tension indicators
perceived by laryngeal palpation, particularly in patients with
MTD.
Majority of the palpatory methods describe muscle tension
qualitatively and evaluate tension both at static and dynamic
tasks. There are little studies on the validity and reliability of
palpation methods that is recommended to support by further
investigations in the future. Future studies also are needed to
consider MTD category (primary/secondary) in the study of
palpation methods.
Acknowledgments
The authors thank Dr. Lesley Mathieson for her helpful comments and suggestions on the manuscript.
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