We all age, as our bodies unfailingly tell us. Muscles weaken, joints stiffen, hair thins, skin sags-the external signs are evident, albeit somewhat delayed and distorted in the increasing penchant toward masking time through cosmetics. But internal signs are also telling. Hearing dims, vision alters, and the voice takes on a different pitch and tone as the larynx gets older. All these natural and inevitable changes are the stuff of life, but fortunately there is a growing recognition within the health care profession that many of the alterations that come with age can be addressed to improve quality of life, and that age itself should not be used as the reason to dismiss the concerns of people who are experiencing life’s alterations.
For otolaryngologists who deal with older patients who come in with concerns over voice changes, a key factor to proper care, say experts in the field, is first and foremost to listen and be attentive to the patient without giving them, essentially, a diagnosis of age.
According to Stanley M. Shapshay, MD, Professor in the Division of Otolaryngology at Albany Medical College, who regularly sees and treats elderly patients with voice problems, otolaryngologists need to be mindful that voice problems in the elderly can indicate underlying medical conditions and-even if no other medical problems are found-treatments to improve the voice should be discussed with the patient. Don’t dismiss these patients, he said. They should be examined and treated with care because this [voice impairment] is a bona fide problem for these patients, adding that he often thinks his colleagues shrug this off as a sign of aging that an older person just has to accept.
Aging patients themselves may also not recognize the help available for them to improve voice impairments, and thereby often unnecessarily live with a diminished ability to communicate that leads to loss of confidence, credibility, and quality of life that accompanies such impairment. For Robert T. Sataloff, MD, Professor and Chairman of the Department of Otolaryngology-Head and Neck Surgery at Drexel University College of Medicine in Philadelphia, otolaryngologists therefore are also called to take the helm in educating society at large about age-related voice abnormalities, their impact on everyday social and professional activities, and the ways-some quite easy-that are available to improve the voice and quality of life in the older person.
Our society has tolerated abnormal voices and become insensitive to the fact that they can impair the quality of life, he said. We [otolaryngologists] should be diligent and help educate the public that they don’t have to put up with the vocal aspects of aging.
Changes in the Older Voice-Know the Cause
For many elderly patients who present with voice problems, presbyphonia, or aging of the larynx, accounts for a number of voice alterations, including poor vocal projection, shorter phonation duration, and changes in pitch and tone. For many of these people, the main culprit is glottic insufficiency, or the failure of the vocal folds to close solidly. However, because aging affects the whole body system, other changes that may alter breath support or pulmonary capacity, or induce neurologic deficits and tremor, may also be affecting an older person’s voice and indicate an underlying medical condition that needs correction.
The really important thing to remember is that there are multiple factors that impact the quality of voice in seniors, said Michael S. Benninger, MD, Chairman of the Head and Neck Institute at the Cleveland Clinic. It is not uncommon that seniors present to us where their primary initial complaint for progressive neurologic disease are voice-related. I’ve seen patients whose first evidence of Parkinson’s disease or ALS [amyotrophic lateral sclerosis] has been changes in their voice. Although he said that most patients will not have a serious disease, he emphasized that clinicians need to be diligent to make sure there is none.
Other medical conditions commonly found in older persons and that can affect the voice include hormonal changes, tumors, viruses, allergies, and gastroesophageal reflux disease (GERD).
Accurate diagnosis of the cause of vocal problems in the elderly is therefore the first critical step. Along with a thorough medical history, which includes medications and environmental factors (e.g., tobacco smoke) that can affect the voice, examination of the larynx to look at the vocal cords and to determine the degree of glottal incompetence is critical.
If an underlying medical condition is found, treatment of the condition is the next step. Simple measures such as better hydration or controlling the inflammatory changes associated with GERD or persistent posterior nasal drainage may be of help to many elderly patients with vocal changes, according to Dr. Shapshay.
For patients whose vocal changes are identified as presbyphonia, different therapeutic options are available, depending on the degree of vocal fold changes as well as the needs of the patient.
Treatment Options for Presbyphonia
The first and, for most patients, the only treatment needed for voice alterations due to the aging larynx will be voice therapy. Voice therapy is a common first treatment, said Nadine P. Connor, PhD, a speech pathologist and Assistant Professor at the University of Wisconsin in the Departments of Communicative Disorders and Surgery. The pro of voice therapy is that it is noninvasive; the con is that it can take time and home practice and the patient has to be cognitively able and motivated to perform the exercises.
As the third step in what Dr. Sataloff has termed voice lift therapy (the first two steps being a comprehensive evaluation and treatment of any identified medical condition), voice therapy includes techniques and exercises to restrengthen the power source of the voice, which includes medically supervised aerobic retraining of the respiratory, abdominal, and back muscle systems. In Dr. Sataloff’s practice, along with a speech pathologist, most patients also see a singing voice specialist even if they are not singers, and some eventually also see an acting voice specialist as well. Using singing training for a speaker is like using jogging or running for someone who wants to walk better, he said. It gives them training beyond anything they’ll need for daily speech, so even when they are talking in public they are nowhere near the limits of their ability.
According to Dr. Benninger, although compliance can be low, as it is for therapy for any chronic medical condition, he emphasized that for people who really need their voices, compliance is fairly good. In general, most people can be helped in six to eight sessions, but they may have to continue exercises on their own to maintain vocal quality. Although factors that influence compliance or adherence to treatment have not been well studied for voice therapy, said Dr. Connor, studies are currently under way to examine these factors and their contribution to the success of voice therapy.
Voice therapy usually is sufficient to improve glottic insufficiency for most patients; however, some people may need more invasive help to close a particularly large gap in the vocal folds or because of the failure of voice therapy to provide adequate improvement to meet the needs of the patient.
The fourth and final step in the voice lift therapy process, according to Dr. Sataloff’s schema, is surgery. There are several approaches to surgery, but the basic principle of all of them is to bring the vocal folds closer together, so that when people exert minimal effort, instead of having a gap and flabby partial closure, they have good, firm, redundant closure for a little effort, said Dr. Sataloff.
Two main surgical approaches are used to bring the vocal folds together: injection laryngoplasty or thyroplasty. The most common first approach used is injection therapy, in which filler such as collagen, fat, or hydroxyapatite is injected into the larynx to bulk up the vocal folds. Thyroplasty is often used to correct large vocal fold gaps, and consists of an implant placed through a small incision in the neck to compress the laryngeal tissues. According to Dr. Sataloff, it takes a great deal of skill and experience to determine when to use which approach.
If someone has vocal folds that are almost completely closed and just a little gap and flabbiness and a lack of resistance, then often injecting a little filler to bulk up the vocal folds is the ideal methodology, he said. Although, he said, a disadvantage of this approach is the frequent need to repeat the procedure several times to obtain permanent closure, he also emphasized the need at times to intentionally use only temporary fillers.
If you’re not sure how a filler will work or if the patient is not certain he or she wants it done, there are temporary substances that we can inject that are gone in anywhere from five weeks to six months, depending on what we choose to inject, he said, adding that temporary fillers are also good for patients with temporary vocal fold paralysis who cannot wait for their voice to recover on its own, such as radio announcers.
Thyroplasty, or external implants, he observed, is often reserved for people with large vocal fold gaps, although this approach too has complications, including shifting implants and, more rarely, infection or rejection.
©2008 The Triological Society