Presbyphonia

Author Credentials 

George S. Goding, Jr., MD
Professor, Department of Otolaryngology
Hennepin county Medical Center, University of Minnesota
Minneapolis, MN

Module Summary

Presbyphonia is a change in the voice resulting from physiological changes related to aging. These changes involve the entire person but particularly include changes related to the laryngeal structures. In the majority of elderly people with vocal symptoms the cause is multifactorial and specific laryngeal lesions should be pursued. Metabolic, autoimmune and neurologic diseases are more common in the elderly and should be ruled out as well. Patients present with several characteristic symptoms that include vocal weakness, reduced projection, changes in pitch and vocal fatigue. Characteristic findings on laryngoscopy include a persistent glottic gap usually associated with vocal fold bowing and prominence of the vocal processes. Treatment typically begins with speech therapy but may involve vocal fold injection and/or thyroplasty.

Module Learning Objectives 
  1. Describe the effects of age on the voice.
  2. Explain the pathophysiology of aged larynx.
  3. Describe the role of voice therapy in managing presbyphonia.
  4. Cite the potential surgical interventions in patients with presbyphonia.

Anatomy

Learning Objectives 

Understand the anatomy of the larynx.

References 
  1. See OTOSource Module LARYNGEAL ANATOMY AND EMBRYOLOGY

Pathogenesis

Learning Objectives 
  1. Describe the effects of age on the larynx
    1. Ossification of laryngeal cartilage
      1. Increases with age
    2. Joints
      1. Thinning of articular cartilages, degeneration of tendon attachments
    3. Vocal fold structure
      1. Vocal fold becomes thinner with age and less pliable.
    4. Muscular
      1. Decreased myofibrils and slower metabolism
    5. Non muscular
      1. Decreased elastic fibers, reduced hyaluronic acid, increased collagen
  2. Describe effects of age on pulmonary function
    1. Decreased maximal expiratory flow.
    2. Flow limitation at higher lung volumes (results in higher resting lung volumes).
    3. Inspiratory flow maintained
  3. Describe effects of menopause on the larynx and voice
    1. Symptoms: throat dryness, loss of upper range, change in timbre, reduced stability.
    2. Laryngeal changes: muscular and mucosal atrophy, Vocal fold edema, higher viscous mucosa.
  4. Describe effects of age on psychomotor performance and fine control of the voice.
    1. There is a deterioration of fine motor control in normal aging across different response modalities.
References 
  1. Martins RHG, Goncalvez TM, Pessin ABB, Anete Branco . Aging voice: presbyphonia. Aging Clin Exp Res. 2014;26:1–5.
  2. Kuhn MA. Histological changes in vocal fold growth and aging. Curr Opin Otolaryngol Head Neck Surg. 2014;22:460–465.
  3. Johns III MM, Arviso LC, Ramadan F. Challenges and Opportunities in the Management of the Aging Voice. Otolaryngol Head Neck Surg. 2011;145(1) 1–6.
  4. Zeleznik J. Normative aging of the respiratory system. Clin Geriatr Med. 2003;19:1-18.
  5. Vaca M, Mora E, and Cobeta I. The Aging Voice: Influence of Respiratory and Laryngeal Changes. Otolaryngol Head Neck Surg. 2015;153:409–413.
  6. D’haeseleer E, Depypere H, Claeys S, Van Borsel J, Van Lierde K. The menopause and the female larynx, clinical aspects and therapeutic options: A literature review. Maturitas 2009;64:27–32.
  7. Bilodeau-Mercure M; Kirouac V; Langlois N; Ouellet C; Gasse I; Tremblay P. Movement sequencing in normal aging: speech, oro-facial, and finger movements. Age. 2015; 37:9813-
  8. Bilodeau-Mercure M, Tremblay P. Age Differences in Sequential Speech Production: Articulatory and Physiological Factors. Journal of the American Geriatrics Society. 2016;64:e177-e182, 2016

Incidence

Learning Objectives 
  1. Know the incidence of Presbyphonia in the general population
    1. 20% of patients older than 65 years reported dysphonia of any kind.
  2. Quality of life issues
    1. Weakening of voice resulting in increased effort, increased fatigue and avoidance of social situations
References 
  1. Golub JS, Chen PH, Otto KJ, Hapner E, Johns MM III. Prevalence of perceived dysphonia in a geriatric population. J Am Geriatr Soc. 2006; 54: 1736-1739.
  2. Roy N, Stemple J, Merrill RM, Thomas L. Epidemiology of voice disorders in the elderly: preliminary findings. Laryngoscope. 2007; 117: 628-633.
  3. Costa HO, Matias C. Vocal impact on quality of life of elderly female subjects. Braz J Otorhinolaryngol. 2005;71:172-178.

Patient Evaluation

Learning Objectives 
  1. Know common presenting symptoms:Weak or breathy voice, changes in pitch, decreased projection, reduced vocal stability.
  2. Findings on laryngoscopy
    1. Vocal fold bowing, vocal fold atrophy, prominence of the vocal processes, vocal fold edema (more common in women)
  3. Diagnosis of exclusion.
References 
  1. Gregory ND, Chandran S, Lurie D, Sataloff RT. Voice disorders in the elderly. J Voice 2012; 26:248–254
  2. Pontes P, Brasolotto A, Behlau M. Glottic characteristics and voice complaint in the elderly. J Voice. 2005;19(1):84-94.
  3. Pontes P, Yamasaki R, Behlau M. Morphological and functional aspects of the senile larynx. Folia Phoniatr Logop. 2006;58(3):151-158.
  4. Woo P, Casper J, Colton R, Brewer D. Dysphonia in the aging: physiology versus disease. Laryngoscope 1992;102: 139–144.
  5. Johns III MM, Arviso LC. and Ramadan F. Challenges and Opportunities in the Management of the Aging Voice. Otolaryngology–Head and Neck Surgery. 2011; 145(1) 1–6.

Measurement of Functional Status

Learning Objectives 

Speech therapy evaluation.

References 
  1. See specific module UNIT 4: LARYNGOLOGY, VOICE and SWALLOWING: VOCAL FUNCTION TESTS/LARYNGOLOGICAL EMG

Treatment

Learning Objectives 
  1. Speech therapy
    1. Understand the role and outcomes of speech therapy in presbyphonia.
References 
  1. Berg EE, Hapner E, Klein A, Johns MM III. Voice therapy improves quality of life in age-related dysphonia: a case-control study. J Voice. 2008; 22: 70-74.
  2. Ted Mau, MD, PhD; Barbara H. Jacobson, PhD; C. Gaelyn Garrett. Factors Associated With Voice Therapy Outcomes in the Treatment of Presbyphonia. Laryngoscope, 120:1181–1187, 2010.
  3. Jennifer M. Oates. Treatment of dysphonia in older people: the role of the speech therapist. Curr Opin Otolaryngol Head Neck Surg 2014, 22:477–486

Surgical Therapies

Learning Objectives 
  1. Understand role of vocal fold medialization
    1. Typically after poor response to trial of speech therapy. Medialization can improve glottic closure and reduce breathiness and vocal fatigue while increasing projection. Injection laryngoplasty and thyroplasty are options.
References 
  1. Joseph P. Bradley JP; Edie Hapner E; Johns III MM. What Is the Optimal Treatment for Presbyphonia?. Laryngoscope 2014, 2439-40.
  2. Johns III MM, Arviso LC,and Ramadan, F. Challenges and Opportunities in the Management of the Aging Voice. Otolaryngology– Head and Neck Surgery 145(1) 1–6, 2011
  3. Seino Y and Allen E. Treatment of aging vocal folds: surgical approaches. Curr Opin Otolaryngol Head Neck Surg 2014, 22:466–471
  4. See Also specific modules: UNIT 4: LARYNGOLOGY, VOICE and SWALLOWING: INJECTION LARYNGOPLASTY and FRAMWORK SURGERY.

Case Studies

  1. A 74 year old female presents with five-year history of breathy quality to her voice. She is a university professor, retired, but continues to lecture. Her voice begins to tire after 15 minutes and is unable to lecture more than one hour. She is only aware of this when she is lecturing, but others, especially husband who wears a hearing aid, are aware of weak voice quality and difficulty hearing her in areas with background noise. What additional history would you require? What would you expect to see on exam? What additional testing, if any, in needed? What would your initial treatment recommendations be?
  2. An 85-year-old man describes a gradual loss of voice but no difficulties with swallowing or airway. His history is negative for cerebrovascular accident or other neurologic disease. He is independent in activities of daily living. Examination showed vocal fold bowing. A trial of speech therapy by a qualified voice therapist has been completed with some improvement but he is interested to see what additional treatment can be offered. What, if anything, can you offer as further treatment?

Complications

Learning Objectives 

Know the differential diagnosis for conditions that can be mistaken for Presbyphonia.

References 
  1. Kendall, K Curr Opin Otolaryngol Head Neck Surg. 2007; 15:137–140. 2007
  2. Woo P, Casper J, Colton R, Brewer D. Dysphonia in the aging: physiology versus disease. Laryngoscope 1992; 102:139–144.
  3. Sanz L, Sistiaga JA, Lara AJ, Cuende E, Garcı´a-Alca´ntara F,Rivera T. The prevalence of dysphonia, its association with immunomediated diseases and correlation with biochemical markers. J Voice. 2012;26(2):148–153

Review

Review Questions 
  1. What are the most common presenting symptoms of presbyphonia?
  2. What are the common clinical findings associated with presbyphonia?
  3. How is the diagnosis of presbyphonia made?
  4. What are the treatment options for presbyphonia?
Resources 

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  1. Annual Meeting Webcast (AMW):