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Presbylaryngis

a state-of-the-art review

Mallick, Ali Sameer; Garas, George; McGlashan, Julian

Current Opinion in Otolaryngology & Head and Neck Surgery: June 2019 - Volume 27 - Issue 3 - p 168–177
doi: 10.1097/MOO.0000000000000540
SPEECH THERAPY AND REHABILITATION: Edited by H. Fiona Robinson and Jo Patterson
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SDC

Purpose of review Presbylaryngis is the term used to describe changes in the larynx with ageing. It represents an increasingly common complaint as global populations continue to grow and get older. Presbylaryngis has a significantly negative impact on patients’ quality of life and their ability to participate in society. This article will review the relevant literature on the incidence, pathophysiology, clinical evaluation, and treatment modalities for presbylaryngis.

Recent findings The recently developed Ageing Voice Index (AVI) constitutes the first validated instrument for voice complaints specifically for the elderly. The evidence suggests that the bedrock of treating presbylaryngis centres on voice therapy. Thus, voice therapy should represent the primary treatment offered with surgery reserved for those failing to adequately respond. However, the comparative effectiveness of the different surgical interventions, namely injection laryngoplasty and thyroplasty, remains undetermined highlighting the need for larger, prospective, comparative studies.

Summary Presbylaryngis is characterized by specific changes at the microscopic level resulting in age-related vocal fold atrophy. However, its presence alone does not always result in symptomatic dysphonia and equally, presbyphonia is often multifactorial involving the lower respiratory tract in addition to the larynx. Thus, the role of a multidisciplinary voice clinic for presbylaryngis cannot be overstated.

Department of Otorhinolaryngology – Head and Neck Surgery, Nottingham University Hospitals NHS Trust, Queens Medical Centre Campus, Nottingham, United Kingdom

Correspondence to Julian McGlashan, MBBS, FRCS (Otol), FRCSLT (Hon), Department of Otorhinolaryngology – Head and Neck Surgery, Nottingham University Hospitals NHS Trust, Queens Medical Centre Campus, Nottingham, United Kingdom. Tel: +44 7713093368; e-mail: julian.mcglashan@nottingham.ac.uk

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INTRODUCTION

It is widely accepted that one of the most significant challenges that healthcare services face across the world is an unprecedented demand from an ageing population. With advances in medicine helping more people to live longer lives, the number of people over the age of 60 is expected to double by 2050 [1]. This is a result of people in low-income and middle-income countries surviving through childhood, childbirth, and from infectious diseases and in declining mortality rates in high-income countries [1]. Older people can contribute significantly to family life; their local communities; or more broadly to society in many ways but this requires good functional ability. If this is not maintained, living longer can lead to a poor quality of life and require more social and healthcare resources for support.

Within the United Kingdom, the cost of healthcare delivery appears to be rising almost exponentially with increasing age; it costs almost 3.5 times more to look after a 75-year-old and five times more to look after an 80-year-old, than it does for a thirty-year-old [2]. This of course reflects the fact that many elderly patients are more likely to suffer with chronic conditions than those who are younger. Dementia is one such condition, which is placing a significant burden on health and social care. Currently the National Health Service (NHS) spends around £26 billion annually on the condition [3]. In 2013, it was estimated that there were more than 800 000 people living in the United Kingdom with dementia with a projected increase in prevalence by almost 156% in the next 38 years [2]. It has been postulated that there is a significant link between social isolation and the risk of developing dementia. A recent meta-analysis has shown that poor social engagement indices were associated with an increased risk of developing dementia, and that good social engagement was moderately protective against dementia [4].

Communication for the elderly is one key element of maintaining functional ability. Impairment of hearing (presbyacusis) and voice production (presbyphonia) are two ends of the speech chain [5] (Fig. 1). Impairment of these two functions can impact significantly on the ability to communicate through both reduced auditory perception (of the listener and speaker) and the production of an intelligible voice. This can lead to social isolation from family and friends, which in turn, can lead to anxiety and depression [6].

FIGURE 1

FIGURE 1

Dysphonia is a particularly common complaint of elderly patients presenting to the Otorhinolaryngology – Head and Neck Surgery clinic, with an incidence between 12 and 35% [7,8]. With the exception of vocal nodules and polyps, most of the common benign and malignant structural lesions, neurological, inflammatory, and muscle tension imbalance problems that can cause dysphonia can also affect elderly patients [9]. In addition, however, they are also susceptible to developing dysphonia because of age-related changes of the laryngeal architecture. These changes affect the vocal folds at the microscopic level causing atrophy. These changes are often referred to as presbylaryngis whereas the change in the voice with age is known as presbyphonia.

Otorhinolaryngologists – Head and Neck Surgeons and Speech and Language Therapists have a key role in the assessment and treatment of presbylaryngis. The purpose of this review is to review the current understanding of age-related dysphonia and the management options for these patients.

Box 1

Box 1

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PATHOPHYSIOLOGY

When considering age-related dysphonia, it is important to clarify terminology from the outset. Presbylaryngis generally refers to the structural changes that occur in the aged larynx, whilst presbyphonia refers to the symptomatic dysphonia that this can cause. However, it must be recognized that the presence of presbylaryngis alone does not necessarily lead to the development of presbyphonia. A recent study comparing elderly patients with dysphonia versus those who had no vocal complaints, found an almost equal prevalence of presbylaryngis in both groups [10▪▪]. This highlights the complex and multifactorial nature of this clinical problem and the need to consider the whole of the speech chain when assessing an elderly patient with a voice problem. The clinician must consider disease affecting all areas involved in phonation, which includes the lower respiratory tract, the larynx and the vocal tract.

The thoracic cavity plays an important role in facilitating respiratory effort and generating subglottic pressure to enable the vocal folds to vibrate. Degenerative musculoskeletal changes can impact lung function. For example, the elderly is more prone to developing kyphosis because of narrowing of intervertebral disc spaces [11], which subsequently decreases the space between ribs, thus reducing intrathoracic volume [12]. This decrease in inter-rib space may also shorten the intercostal muscles and change the angle of orientation of their muscle fibres, which will negatively affect chest wall compliance [13].

The diaphragm is the most important inspiratory muscle and is also susceptible to age-related changes. In early studies, it was suggested that Maximal Inspiratory Pressure (MIP), an index of diaphragmatic strength, is inversely proportional to age [14]. Moreover, rather than having a linear relationship, the decline in MIP above the age of 65 seems to occur in an exponential fashion [15]. This may be as a result of degenerative changes in the neuromuscular junction, or because of the general effects of sarcopenia that affects the elderly. It is, therefore, clearly apparent, that even before one considers the changes that occur within the laryngeal framework, age-related changes of the thoracic cavity alone can significantly diminish the ultimate power source of the voice. In addition, recent computational modeling work in glottal insufficiency (not restricted to presbylaryngis), indicates that compensatory strategies may help to alleviate the undesirable associated voice changes, but at the cost of hyperfunctional laryngeal and respiratory muscle activities, which may result in vocal fatigue [16▪▪].

Given that the larynx is primarily a musculoskeletal organ, it follows that the general age-related degeneration of the musculoskeletal system that affects the human body will also affect the larynx. Early studies of presbylaryngis reported a general loss of slow twitch (type I) and fast twitch (type II) muscle fibres, accompanied by changes to the connective tissue architecture [17]. Furthermore, a decrease in capillary blood flow and decline in capillary surface area severely hampers oxygen and metabolite delivery to muscles [18]. The thyroarytenoid muscle being the principle muscle involved in voice production is also prone to numerous age-related changes secondary to metabolic, hormonal, and neural changes. Studies in rats have suggested that although there is no loss of nerve fibres to the thyroarytenoid muscle, there is disruption of their myelin architecture [6]. It has also been demonstrated that changes in the neuromuscular junction of the thyroarytenoid muscle in presbylaryngis resemble those seen with denervation, including reductions in the axon terminal area [19]. Finally, mutational changes in mitochondrial deoxyribonucleic acid (DNA) can lead to overproduction of dysfunctional mitochondrial units, which may have a detrimental effect on contractility of the thyroarytenoid muscle [20].

One would assume that these changes would result in loss of muscle volume, and although this has been demonstrated on histological examination of laryngeal specimens from elderly patients [21], a recent MRI study examining the thyroarytenoid muscle in patients with presbylaryngis has shown no significant volumetric difference compared with that in the larynx of younger adults [22]. Whilst in most skeletal muscle sarcopenia seems to equally affect type I and II fibres, the pattern of degeneration within the thyroarytenoid muscle is a matter of debate. Some have suggested only loss of type I fibres [23], whilst others conclude that the loss predominantly affects the type II fibres [24]. Other studies have suggested that a compensatory hypertrophy in remaining muscle fibres accompanies the aforementioned loss, which may explain the macroscopic observation of preserved muscle bulk in the thyroarytenoid muscle in the presbylaryngis [24,25].

Immunohistochemical studies of the presbylaryngis have demonstrated that with increasing age, there appears to be atrophy of the epithelium and lamina propria, a reduction in the hyaluronic acid and elastin content and an associated increased deposition of collagen [25–28]. Electron microscopy has also been used to further identify some of the structural changes that occur to the cytoarchitecture at a microscopic level. Scanning electron microscopy of the vocal folds has demonstrated that in the presbylaryngis, there appears to be more mucosal undulation and desquamation of cells with loss of tight junctions, when compared with controls. Furthermore, collagen networks exhibit a more disordered appearance on the epithelial layer, and within the lamina propria the collagen deposition appears to form a rigid and fibrous structure [29]. This irregular structure of the collagen within the lamina propria has also been demonstrated through transmission electron microscopy by the same researchers, which seems to occur alongside morphological changes to the fibroblasts within the lamina propria of the aged larynx [30▪].

The anatomical areas of the upper vocal tract are also prone to the musculoskeletal changes that occur with ageing. Atrophy of the pharyngeal muscles [31] and degenerative changes to the temporomandibular joints [32] can all affect articulation. Reduced saliva production because of atrophy of the salivary glands leading to xerostomia can also impact on voice production [33]. Finally, the nasal passages and network of paranasal sinuses, which act as resonators of voice are also prone to age-related changes [34].

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CLINICAL EVALUATION

A thorough understanding of the pathophysiology underpinning age-related voice disorders will underpin one's clinical assessment of elderly patients presenting to the Otorhinolaryngology – Head and Neck Surgery clinic. Presbyphonia is a multifactorial condition and assessment should focus on measuring the severity of the patient's complaint, contextualizing this within their general health and finally assessing the impact this has within their social activities [35].

It is well recognized that male voices increase in pitch with age whereas female voices reduce in pitch [36]. However, the most common presenting complaints among the elderly include hoarseness, voice tremor, reduced intensity, and a hampered ability to sing [37,38]. A recent study examining voice complaints in a cohort of 72 patients over the age of 60 found hoarseness to be the most common presenting complaint at 34.72%, followed by singing difficulties, phonatory effort, and vocal fatigue. The study also found that these symptoms appear to be more important amongst the cohort of patients aged between 60 and 75 years as opposed to those aged above 75. This possibly reflects the higher likelihood of patients within the former cohort to take part in social activities where their vocal deficiencies are more likely to be socially troublesome [39]. A further point to note is the number of studies in which singing difficulties are often cited by patients; thus, not only are patients troubled by the functional aspects of their voice problems, but for many, it also acts as a hindrance to a most enjoyable hobby with an associated negative impact on their QoL.

All patients undergoing clinical evaluation should undergo laryngoscopy, ideally including stroboscopy. Typical findings in the patient presenting with presbyphonia include vocal fold atrophy, bowed vocal folds resulting in incomplete glottic closure, and prominence of the vocal processes [39,40] (Fig. 2). The differential diagnoses of bowed vocal folds need to be excluded (Table 1). It must be remembered that voice problems are often multifactorial, that more than one cause of glottal insufficiency may be present or there may have been a degree of decompensation for long-term preexisting vocal problem.

FIGURE 2

FIGURE 2

Table 1

Table 1

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 [43]. 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.[47] 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.

GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) scale [48] and CAPE-V [49] allow auditory–perceptual judgements of voice quality to be made in a standardized way. Pretreatment values have shown mean (SD) values of 38 (±20.7) (n = 21) [50▪]. Despite the widespread interest in voice disorders of the elderly, there still appears to be a lack of a clear-cut definition of presbyphonia, which one could measure through objective testing. Mezzedimi et al.[51] have recently conducted a spectroacoustic study on 142 patients with presbyphonia using the Praat software package (Amsterdam, The Netherlands), and have demonstrated significantly higher values of jitter (frequency perturbation) and shimmer (amplitude perturbation), the degree of breathiness and variations in intensity of voice. These correlate with the endoscopic findings of incomplete glottic closure secondary to bowing of the vocal folds. An alternative indirect measure is to calculate the Contact Quotient (%) of the vocal folds during a vibratory cycle using electroglottography (EGG) [43] This measure has not been used widely in studies on presbylaryngis but shows promise as an indicator of glottal function and response to treatment (Figs. 3–5).

FIGURE 3

FIGURE 3

FIGURE 4

FIGURE 4

FIGURE 5

FIGURE 5

Computational modeling work in glottal insufficiency (not restricted to presbylaryngis), indicates that it would be predicted that patients would also demonstrate reduced harmonics to noise ratio, loss of the upper F0 range, limited speaking fundamental frequency range and restrictions in the lower limit of the vocal intensity range. However, in certain cases, stretching of the vocal folds improves closure and consequently vocal intensity but at the expense of an increase in the mean pitch of the voice.

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) [52], and its shorter version, VHI-10 [53], as well as the voice-related QoL tool (V-RQOL) [54]. 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.

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TREATMENT

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 [60] 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 [60].

The bedrock of treating presbyphonia centres around having a programme of effective voice therapy. A number of studies have examined the effects of exercise programmes on voice improvement in the elderly population. Early studies by Gorman et al.[61] and Berg et al.[62] have shown that elderly patients undergoing voice therapy for presbyphonia experience significant improvements in their glottis closure, MPT scores, and V-RQOL scores. Furthermore, Berg et al. demonstrated a relationship between compliance and degree of improvement: those that were more compliant experiencing greater improvements with their voice. More recently, Godoy et al.[63] have measured the effects of intensive voice therapy in a randomized control trial (RCT), whereby patients received either intensive therapy consisting of a total of 16 sessions of voice therapy involving four sessions per week for a month, or conventional therapy, where patients received the same number of sessions but at a frequency of two sessions per week. Both groups experienced improvements in their V-RQOL but no significant difference was identified between the groups. However, patients who underwent intensive therapy did appear to have a significant improvement in their degree of vocal fold bowing immediately after therapy when compared with those undergoing conventional therapy. However, it remains unclear if these effects are maintained in the long-term. One must also consider the burden of such therapies on the patients, in particular, the regular attendance to the hospital for frequent therapy sessions, which may be a barrier for many elderly patients who have multiple comorbidities.

In patients not responding adequately to voice therapy, surgical intervention may be considered, with the least invasive approach involving injection medialization. A range of materials have been used for this procedure, including autologous fat, calcium hydroxyapatite (CaHA), and synthetic hydrogels [50▪]. Injection medialization with fat requires a general anaesthetic but CaHA and hydrogels are increasingly being administered under local/ topical anaesthesia in an office-based setting. Calcium hydroxyapatite loaded within a hydrogel carrier has been reported to offer patients a long-term effect. Kwon et al.[64] have reported improvements in subjective and objective measures of voice 12 months postinjection with calcium hydroxyapatite injection in 17 patients who either failed voice therapy or declined it. However, a retrospective study examining 275 patients undergoing injection laryngoplasty for vocal fold atrophy found that only 56% of patients reported an improvement in their VHI-10 scores [65]. The limitations of injectable materials lie in the temporary nature of the effects, and the possibility of negligible improvement of the voice. This must be explained to patients to help them in their informed decision-making.

External laryngeal framework surgery in the form of a Type I thyroplasty offers a more permanent surgical option for patients with incomplete glottic closure secondary to presbylaryngis. Unilateral or bilateral procedures should be considered. A number of studies have looked at the effects of type I thyroplasty surgery in small cohorts of elderly patients with endoscopic findings of vocal fold atrophy, presumed to be related to their age, and in all studies, patients reported improvements in their QoL scores [66–69]. More recently, Allensworth et al.[50▪] have demonstrated significantly improved subjective and objective outcomes following bilateral medialization thyroplasty in presbylaryngis patients.

A limitation of most of the studies examining surgical treatments of presbyphonia lies in the small number of patients included within them and limited follow-up. Thus, at present, there is little clarity on determining, which patients would be more suitable for injection laryngoplasty versus thyroplasty, or indeed surgery versus voice therapy. In an attempt to address this particular conundrum, Sachs et al. [70] retrospectively examined the surgical treatment of 22 patients with presbyphonia, and found that 64% patients undergoing bilateral thyroplasty reported a significant posttreatment effect (V-RQOL >20 posttreatment) compared with 20% of patients undergoing injection laryngoplasty. Moreover, patients undergoing bilateral thyroplasty rated their postoperative voice as significantly closer to their best when compared with those undergoing injection laryngoplasty. However, yet again, whilst this study does seem to advocate thyroplasty as the gold-standard surgical option, it is still limited by its small patient cohort. A further limitation is the fact that the authors compared the V-RQOL scores of their patients undergoing thyroplasty with other studies [8,62] where patients only received voice therapy, though they also comment that patients in all the studies had similar pretreatment and posttreatment V-RQOL scores compared with their patients (undergoing thyroplasty). This further highlights the need for larger, prospective studies to assess the comparative effectiveness of voice therapy, and the various surgical treatments. Future techniques make benefit from tissue engineering approaches but are still in their infancy.

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CONCLUSION

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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Acknowledgements

We are grateful to H. Fiona Robinson, Senior Speech, Voice and Swallow Specialist for her continuous contribution to the Nottingham Voice Clinic.

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Financial support and sponsorship

None.

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Conflicts of interest

There are no conflicts of interest.

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REFERENCES AND RECOMMENDED READING

Papers of particular interest, published within the annual period of review, have been highlighted as:

  • ▪ of special interest
  • ▪▪ of outstanding interest
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Keywords:

laryngoplasty; presbylaryngis; presbyphonia; quality of life; thyroplasty; voice therapy

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