What is the optimal treatment for presbyphonia?

Demographics in America are beginning to shift toward an older population, with the number of patients aged 65 years or older numbering approximately 41.4 million in 2011, which represents an increase of 18% since 2000. Within the aging population, the incidence of vocal disorders is estimated to be between 12% and 35%. In a series reported by Davids et al., 25% of patients over age 65 years presenting with a voice complaint were found to have vocal fold atrophy (presbylarynges), where the hallmark physical signs are vocal fold bowing with an increased glottic gap and prominent vocal processes. The epithelial and lamina propria covering of the vocal folds begin to exhibit changes due to aging. In older adults, the collagen of the vocal folds lose their “wicker basket” type of organization, which leads to more disarrayed segments throughout all the layers of the lamina propria, and there is also a loss of hyaluronic acid and elastic fibers. With this loss of the viscoelastic properties and subsequent vocal fold thinning, along with thyroarytenoid muscle atrophy, this leads to the classic bowed membranous vocal fold. Physiologically, these anatomical changes to the vocal folds leads to incomplete glottal closure, air escape, changes in vocal fold tension, altered fundamental frequency, and decreased vocal endurance. Women’s voices will often become lower pitched initially and then gradually higher pitched and shrill, whereas older men’s voices will gradually become more high pitched as the vocal folds lengthen to try and achieve approximation.  The literature documents that voice therapy is a useful tool in the treatment of presbyphonia and improves voice-related quality of life. The goal of therapy is based on a causal model that suggests targeting the biological basis of the condition—degenerative respiratory and laryngeal changes—as a result of sarcopenia. Specifically, the voice therapy protocol should capitalize on high-intensity phonatory exercises to overload the respiratory and laryngeal system and improve vocal loudness, reduce vocal effort, and increase voice-related quality of life (VRQoL). In a small prospective, randomized, controlled trial, Ziegler et al. demonstrated that patients with vocal atrophy undergoing therapy—phonation resistance training exercise (PhoRTE) or vocal function exercise (VFE)—had a significantly improved VRQoL score preand post-therapy (88.5–95.0, P 5.049 for PhoRTE and 80.8–87.5, P 5.054 for VFE), whereas patients in the nonintervention group saw no improvement (87.5–91.5, P 5.70). Patients in the PhoRTE group exhibited a significant decrease in perceived phonatory effort, but not patients undergoing VFE or no therapy. Injection laryngoplasty (IL), initially developed for restoration of glottic competence in vocal fold paralysis, has also been increasingly used in treatment of the aging voice. A number of materials have been used over the years including Teflon, silicone, fat, Gelfoam, collagen, hyaluronic acid, carboxymethylcellulose, and calcium hydroxylapatite. Some of these are limited by safety or efficacy concerns, and some of them are not long lasting. With the growing use of in-office IL, the ease of use has made this technique more popular because of the ability to avoid general anesthesia in a sometimes already frail patient population. Davids et al. also examined changes in VRQoL scores for patients undergoing IL and demonstrated a significant improvement preand post-therapy (34.8 vs. 22, P<.0001). Due to a small sample size, however, the authors were unable to make any direct comparisons between patients undergoing voice therapy versus IL. Medialization thyroplasty (MT) remains as the otolaryngologist’s permanent technique for addressing the glottal insufficiency found in the aging larynx. In the same fashion as IL, the technique developed as a way to address the paralytic vocal fold and can use either Silastic or Gore-Tex implants. Postma et al. looked at the From the Emory Voice Center, Department of Otolaryngology/ Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, U.S.A. This work was performed at the Emory Voice Center in the Department of Otolaryngology/Head and Neck Surgery at the Emory School of Medicine in Atlanta, Georgia. This work was funded internally by the Emory Voice Center. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Joseph Bradley has worked as a consultant for Merz Aesthetics teaching a vocal fold injection laryngoplasty course. Send correspondence to Michael M. Johns, III, MD, Emory University School of Medicine, 550 Peachtree St. NE, 9th Floor, Suite 4400, Atlanta, GA 30308.