Figure 4: Laryngoscopy (abduction) of three subjects older than 65 years old.
Figure 5: Laryngoscopy (adduction) of three subjects older than 65 years old.
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 (Pessin et al., 2017). This is best assessed in a multidisciplinary team voice clinic involving both Otorhinolaryngologists – Head and Neck Surgeons and Speech and Language Therapists interested 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 (Carding et al., 1999), or referral to another appropriate specialty such as respiratory medicine.
The current treatment of presbyphonia involves voice therapy to improve pulmonary support for voicing and decrease laryngeal tension (Kendall, 2007). In cases that do not respond to therapy alone, surgical correction of vocal-fold bowing can be considered (Kendall, 2007). Surgery is more likely required in patients with more significant glottic gap and severe bowing (Kendall, 2007). However, the lack of uniformity in endoscopic signs associated with the aging process of the larynx turns difficult the comparison of outcomes and clinical experience reported in the literature. To date, treatment orientations are based on expert opinions, and there is no clear consensus on a treatment algorithm for presbyphonia, specifically who should undergo up-front augmentation or framework surgery as opposed to voice therapy.
6.1.9.1 - Speech Therapy
It is increasingly common for elderly people to seek speech therapy to preserve voice quality. In the United States of America, it is estimated that, in percentage terms, speech therapy attendance in the elderly will increase from 39 percent to 59 percent in 2050 (Zraick et al., 2007).
The effects of aging on the voice can be prevented before its installation if preventive measures of hygiene and vocal rehabilitation are applied. However, some of the changes in the voice of the elderly are related to changes associated with the natural aging process, so understanding the etiology, history, and objective of the patient for the intervention, in addition to their capacity for treatment, is fundamental for a successful intervention.
The intervention of speech therapy in the elderly allows minimizing the impact produced by biological aging because, despite the process of cartilage calcification and atrophy of the intrinsic muscles of the larynx, some vocal flexibility can be recovered with voice exercises. This work allows for an improvement in pneumophonoarticulatory coordination, maximum phonation time, and the reduction of laryngeal tension, with a clear contribution to improving communication in the elderly.
Vocal rehabilitation is a non-invasive approach and is considered the primary treatment for presbyphonia. A recent survey included laryngologist´s reported decision and
it was found that voice therapy was the most often reported first-line treatment, with 57% of respondents indicating the majority of their patients receive voice therapy initially (Sund et al., 2021).
The therapeutic process in the speech therapy consultation begins with the collection of anamnesis and characterization of the voice, in addition to evaluating the quality of life/voice relationship.
Voice analysis should include an audio-perceptive and acoustic voice assessment protocol. The evaluation of other parameters, such as speech-respiratory control, orofacial motricity, and vocal psychodynamics, is essential for a correct diagnosis and prognosis and the definition of the therapeutic program. Thus, the speech pathologist is responsible for identifying and eliminating voice abuse and misuse, teaching vocal hygiene, and developing an exercise program for the spoken voice that emphasizes appropriate breath and abdominal support, relaxation in the muscles of the head and neck, and appropriate use of resonance to optimize audibility.
For some authors, the treatment of voice problems in the elderly must go through an integrated and truly multidisciplinary approach that includes, in addition to speech therapy, aerobic training, singing training, and voice techniques with actors (Rubin et al., 2006).
Health information is essential for the elderly and should be considered in speech therapy interventions. Adequate and accurate information on the importance of moderate and regular physical activity, the best ways to practice it, stimulation of cognitive functions, hydration, and nutrition, to maintain active aging, particularly in the retirement phase.
Several studies have examined the effects of exercise programs on voice improvement in the elderly population. Early studies (Gorman et al., 2008; Berg et al., 2008) have shown that elderly patients undergoing voice therapy for presbyphonia experience significant improvements in their glottis closure, Maximum Phonation Time scores, and Voice related quality of life. Furthermore, it was demonstrated (Berg et al., 2008) a relationship between compliance and degree of improvement: those that were more compliant experienced more significant improvements with their voice.
More recently, intensive voice therapy has been measured in a randomized control trial, whereby patients received either intensive treatment involving four sessions per week for a month or conventional therapy, where patients received the same number of sessions but a frequency of two sessions per week. Both groups experienced improvements in their voice-related quality of life, but no significant difference was identified between them (Godoy et al., 2019). However, patients who underwent intensive therapy appeared to have a
considerable improvement after therapy compared to those undergoing conventional therapy. However, it remains unclear if these effects are maintained in the long term.
Voice therapy as the main treatment for presbyphonia contributes to:
- Reduce glottic and supraglottic hyperfunctional compensation.
- Stimulate the isochronic attack and develop better respiratory support at the same time.
- Improve air efficiency.
- Promote and adapt the speech rate.
- Stabilize the voice.
- Increase vocal range.
- Increase the ability of vocal projection.
In addition to these aspects, attention to postural issues is essential to guarantee the verticality of the larynx and release tensions and efforts caused by inadequate postures.
The speech therapist should always integrate the perceptual, acoustic, and psychological dimensions associated with the voice in his intervention.
In short, any approach in speech therapy associated with aging changes should consider optimizing vocal quality and phonoarticulatory dynamics. Correlated factors that may affect voice quality, such as presbycusis or adaptation to dental prostheses, must also be considered. Finally, addressing issues related to health education and some environmental factors is an integral part of speech therapy intervention in the care of the elderly.
6.1.9.2 - Medical Voice Therapy
Certain aspects of the aging process are relatively easy to control medically.
At menopause, women's estradiol levels drop, but the ovaries continue to secrete androgens. Therefore, the voice tends to become deeper (decreased fundamental frequency). These changes may be compensated for by hormone replacement therapy (Rubin et al. 2006). Drugs containing androgens should be avoided in this therapy, as they may lead to masculinization of the voice. The dose to be administered is a matter that has yet to be defined, and this dose should be controlled by estrogen levels before menopause.
On the other hand, it is necessary to consider the contraindications to replacement therapy, namely a history of breast cancer due to an increased incidence of this medication. The risk-benefit should be weighed together with the gynecologist.
Regarding thyroid function, both hyperthyroidism and hypothyroidism are challenging to diagnose in the elderly. Changes in thyroid function led to considerable changes in vocal quality, decreasing vocal range and intensity. Hence, the possibility of
thyroid dysfunction should be investigated with analysis to correct it and, thus, resolve the vocal alterations.
Adjuvant medical treatment directed at extraesophageal reflux, xerostomia, and depression may be necessary, as well as therapeutic adjustments to frequent polymedication in the geriatric age.
Systematically attacking the aging process in other body areas is more novel and controversial. However, appropriate exercise helps maintain muscle function and coordination and aids the functioning of the cardiovascular system, nervous system, and especially the respiratory system. Proper nutrition and weight control are also important.
6.1.9.3 - Surgical Voice Therapy
One must consider that for elderly patients with multiple comorbidities, regular attendance at the hospital for frequent voice therapy sessions may be a barrier. Surgical intervention may be considered in patients not responding adequately to voice therapy.
Even the best voice therapy is not sufficient in some patients to overcome presbyphonia. When vocal fold thinning or bowing causes failure of glottic closure, hyperfunction (muscular tension dysphonia) develops routinely as the patient tries to compensate for eliminating breathiness. This muscle hyperfunction is often responsible for voice fatigue and increased hoarseness. As voice therapy eliminates hyperfunction, breathiness becomes audible again. If the glottal incompetence is minimal, vocal exercises may increase muscle bulk enough to restore glottic closure. At the same time, the improved vocal technique will enhance audibility even if slight breathiness remains. However, when glottal incompetence is too great, surgery should be considered.
Some surgical procedures, namely thyroplasties or intrachordal injection of fat, hyaluronic acid, or calcium hydroxyapatite, improve glottic closure and, therefore, may be options in the management of presbyphonia (Phua et al., 2013). However, there is still little experience, and they remain second-line therapies, as they are invasive methods with a risk of associated complications (Zeitels et al., 2003; Mathison et al., 2009; Sulica et al., 2010).
Injection laryngoplasty
A range of materials has been used for this procedure, including autologous fat, calcium hydroxyapatite, and synthetic hydrogels (Allensworth et al., 2019).
Teflon injections were abandoned due to foreign body reactions and the appearance of granulomas.
Mikaelian et al. (1991) initially described fat injection into the larynx. Sataloff (Calhoun et al., 2006) reports excellent results with fat injection, especially when the need for minimal medialization. In cases with an accentuated glottic cleft, thyroplasty should be performed alone or associated with fat injection.
Fat injections are also of interest in cases of low laryngeal resistance, in cases where there is no glottic gap, but there is a glottic leak when using the voice at high intensity.
It is important to note that fat needs to be injected in excess of about 30 percent to counterbalance the expected resorption (Rosen & Simpson, 2008). At the end of the procedure, the vocal fold should be convex. The patient in the immediate postoperative period will have dysphonia, and the outcome should not be good if the patient has a normal voice quality in the immediate postoperative period.
Injection medialization with fat requires a general anesthetic, but the other materials are increasingly being administered under local/topical anesthesia in an office-based setting.
Kwon et al. (Kwon et al., 2010) have reported improvements in subjective and objective voice measures 12 months post-injection 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 Voice Handicap Index scores (Gartner-Schmidt & Rosen, 2011). The limitations of injectable materials lie in the negligible improvement of the voice, which must be explained to patients to help them in their informed decision-making.
Thyroplasty
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 presbylarynx. Type I thyroplasty described in 1975 by Isshiki, is an excellent method for medialization and correction of glottic incompetence. It has recently been demonstrated that subjective and objective outcomes have significantly improved after bilateral medialization thyroplasty in patients with presbylarynx (Allensworth et al., 2019).
Type IV thyroplasty, or cricothyroid approximation, increases vocal fold tension, increasing fundamental frequency. The thyroid and cricoid cartilages are approximated using a Nylon 3.0 suture (Olias, 2004). This surgery was initially described for patients who intend to change the male-female sex, but it is indicated for women with excessive vocal masculinization.
A limitation of most of the studies examining surgical treatments of presbyphonia lies in the small number of patients included in them and limited follow-up. Thus, there is little clarity on determining which patients would be more suitable for injection laryngoplasty versus thyroplasty or surgery versus voice therapy (Mallick et al., 2019).
6.1.9.4 - Future Perspectives
With the advance in the knowledge of the microstructure of vocal folds, fibroblast culture has been cited as a future and promising method to treat glottic insufficiency; on the other hand, current studies are still premature and do not include a follow-up. In addition, the culture methods are not standardized yet, especially concerning the culture time and the grafting interval. Hirano et al. described the first technique for fibroblast implantation in humans (Hirano et al., 2009). After a 3-month follow-up, those authors noted that the vocal fold atrophy improved, the glottic aperture disappeared, and the acoustic and aerodynamic parameters were normalized. The authors are particularly interested in studies involving fibroblasts because these cells are essential compounds of the lamina propria and are responsible for maintaining, developing, and repairing the extracellular matrix. The metabolic activity of fibroblasts seems to decrease with aging, showing changes in their cytoplasm organelles. Further studies are needed to prove the benefits of these new therapeutic techniques for lamina propria repair.