However, explaining a patient's presenting complaint purely on the basis of these endoscopic findings might be somewhat premature. Crawley et al.[10▪▪] examined the endoscopic findings of patients presenting with ‘pathologic presbyphonia’ and compared these with elderly patients who had no voice complaints. Both groups possessed the cardinal endoscopic signs associated with presbylaryngis, with no significant difference between the two groups [10▪▪]. Whilst the authors of this study admit that their control population was not necessarily representative of all people aged above 74, the findings nevertheless do highlight the multifaceted nature of this problem.
At this point, it is important to emphasize that adequate airflow from the respiratory system is also a key ingredient for a satisfactory voice, and thus clinical evaluation should ideally include an assessment of this. The mean phonation time (MPT) is a useful and simple tool that can easily be used in the clinic. MPT involves producing a sustained phonation of a vowel sound /ɑ/vowel (as in bar) for as long as possible and the time recorded. The best of three attempts is used as the final measure . It provides a useful insight into the interaction between the respiratory system and the larynx, specifically the interplay between aerodynamic forces from the lower respiratory tract and glottal elasticity. Several studies have reported a trend for MPT to reduce with age [44–46]. A study by Vaca et al. made an attempt to tease out the relative impact of age-related laryngeal and respiratory changes in patients with presbyphonia. They included patients with a decreased MPT, and assessed laryngeal function qualitatively through stroboscopy, and respiratory function quantitatively through spirometry. They found that the patients with the most severe vocal deficits had concomitant impairment of their respiratory and laryngeal function, when compared with patients with impairments of one of these systems. This, therefore, highlights the need to make a thorough assessment of respiratory function in the presbyphonia patient, as ameliorating lung function with chest physiotherapy and bronchodilator therapy may potentially complement any treatment prescribed to the patient within the Otorhinolaryngology – Head and Neck Surgery clinic.
Objective voice assessment allows baseline measures of severity of the patient's dysphonia and potentially their response to treatment. However, the fundamental weakness of subjective and objective testing is that they only measure impairment and parameters of the voice at one point in time and does not reflect the impact of the vocal disability on the patient's QoL. A number of validated QoL indices do exist to measure the patient's perception of their voice complaint, including the Voice Handicap Index (VHI) , and its shorter version, VHI-10 , as well as the voice-related QoL tool (V-RQOL) . These tools have also been adapted for use in the paediatric population [55–57], however, there appears to be a lack of a validated instrument specifically for the elderly population. To address this apparent need, Etter et al.[58▪▪] have recently developed the Ageing Voice Index (AVI). Following engagement with patients, they initially identified six themes that concerned patients most about their voice; the ability to be understood by others, feeling hindered because of their voice, the energy and effort required to phonate, dissatisfaction with the sound of their voice, the emotional impact of their deficit, and the impact their voice had on preventing them from partaking in activities they enjoy. This resulted in the development of a 23-item questionnaire, which they subsequently measured against the V-RQOL, demonstrating its reliability as a dedicated tool for use in elderly patients presenting to the voice clinic.
As with any voice disorder, the decision to treat is largely determined by the patient's perception of their perceived impairment, limitation in activity and participation restriction [35,59]. This is best assessed in a multidisciplinary team (MDT) voice clinic, involving both Otorhinolaryngologists – Head and Neck Surgeons and Speech and Language Therapists with an interest in voice disorders. Patients may only require reassurance that there is no serious cause for their dysphonia, advice in the form of indirect voice therapy  or referral to another appropriate specialty such as respiratory medicine. For those that request interventional treatment, the choice is between techniques involving advice about coping strategies, direct voice therapy, and/or surgical medialization procedures .
With an ever-increasing ageing population, the demand for improvements in all aspects of QoL and functional ability, including vocal function, is likely to increase. Impaired vocal function can result in loss of self-esteem, social isolation, and may contribute to the development of dementia in an already vulnerable patient group. Although important advances have been made in understanding the underlying pathophysiology of presbylaryngis, it seems that structural changes to the larynx do not account for the whole clinical picture. There is increasing evidence of the link between laryngeal and lung function and a systematic approach to consider and rule out neurological and other structural causes of vocal fold bowing. A multidisciplinary approach in assessing patients presenting with presbyphonia is essential in determining the optimal treatment strategy. Although many patients may just require reassurance and an explanation of their dysphonia and can manage their condition, others require treatment. Direct and indirect voice therapy should constitute the primary treatment modality offered to presbylaryngis patients with surgical intervention reserved for those patients that fail to respond adequately to it. With a lack of good quality data in the form of randomized controlled trials, the choice of surgery at present depends on patient's vocal demands, their comorbidities, and the experience of the surgeon in treating this condition.
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