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Helping seniors find their voice
VOICE disorders are fairly common and in the vast majority of cases - self-limiting. They are seen in all age groups and caused by a variety of factors including overuse, abuse, infection, laryngopharyngeal reflux (LPR) and cancer. There is, however, an increasing trend in the first world of age-related voice deterioration which is becoming more prevalent given the increased life expectancy. The aim of this review is to provide the reader with an understanding of the physiological changes that occur with ageing to the voice box, the effects this has on the quality of life of the patient vis-a-vis phonation (voicing) primarily and the medical management of the ageing voice (presbyphonia).
Our voice box (larynx) consists of a rigid framework (thyroid and cricoid cartilages) housing a set of muscles and ligaments and these are supplied by nerves and blood vessels. These structures change with time in varying ways and rates. The cartilages can become harder with calcium deposition (ossification) but this however does not change the voice. It is the ageing process physiologically that does so.
As we age, our bodies tend to lose muscle bulk partly due to reduced need and also due to reduced hormonal/neurological stimuli. In the ageing male, testosterone levels begin to taper around the 50s/60s with reduced muscle bulk in the voice box more so than in women where the hormone is less prevalent.
Consequently, the male voice begins to rise in pitch and may become more feeble. The female voice generally remains the same or very slightly lowers its pitch due to reduced tone of the vocal folds (cords) and relaxation creates a deeper voice with greater difficulty to "stretch" the vocal folds.
The ensuing processes can result in "bowing" of the vocal folds which can appear as a breathy voice. The mucous glands that moisten the vocal folds begin to reduce in number and size (atrophy) leaving the vocal folds drier. The vibratory surface from which air escapes becomes less supple creating a less efficient sound. Laryngopharyngeal reflux (LPR) also affects this age group and the stomach acid irritates the lining of the larynx. Finally, the most important part of the vibrating fold, its "cover" is a very delicate structure composed of flattened cells over a jelly-like layer called the superficial lamina propria (SLP). This gelatinous layer has elastic fibres, collagen and water. The density of this SLP becomes higher with ageing, and less pliable with time, causing it to stiffen - affecting our ageing voice.
Ageing also affects cardiorespiratory function. The elderly can be prone to conditions such as heart failure, chronic bronchitis (in smokers) and pneumonia. A weaker lung results in reduced air expulsion and weakening of the voice. Chronic cough and throat clearance can also affect the voice.Neurological diseases such as Parkinson's disease, stroke and tumours in the brain, neck or lungs also affect the voice.
Smoking and alcohol
Elderly patients who smoke or have smoked and drink alcohol are also prone to voice problems. Chronic irritation and inflammation in women smokers can result in swelling of the SLP and concomitant hoarseness to an extent that the pitch can resemble a males.
Chronic smoking with or without alcohol consumption can potentially cause the cells to transform into cancerous cells with patients having a 38-fold increased risk. Hoarseness in the elderly who have or continue to smoke and drink heavily is a serious symptom and should be seen urgently by an ENT surgeon.
Management of the ageing voice
Elderly patients do not always complain of voice deterioration. Sudden deterioration is more alarming and requires investigation if the patient does not improve within a fortnight. Gradual deterioration is less likely to worry but may require investigation if the symptoms begin to worsen - such as hoarseness, breathiness, vocal fatigue, pitch breaks and/or weakness.
A thorough history including the patient's drug history (inhalers, diuretics, blood pressure tablets), previous surgery (thydgfroid, neck, chest) and medical history (low thyroid level, neurological conditions, chest disease) should be sought and documented.
Examination of the ears, nose and throat followed by a special examination using rigid or flexible laryngoscopes help evaluate the voice box in detail. Hearing tests can be helpful in many cases as deafness is common and often associated with voice abuse. Nasal conditions such as allergy and chronic rhinosinusitis can increase the backflow of mucus irritating the throat and resulting in a chronic tendency to clear the throat and/or cough.
The "gold" standard for voice evaluation using endoscopes is a videolaryngostroboscopy (VLS). This examination is performed usually without any need for anaesthesia, takes a few minutes at most and allows for visualisation of the movement of the vocal folds and their mucosal wave. Current technology has improved to an extent that the digital camera is at the tip of the flexible scope with high-definition image capture.
Patients who have voice disorders (dysphonia) benefit from a multi-disciplinary voice clinic. This includes an ENT surgeon who has a special interest in voice (laryngologist) and a speech and language therapist (SALT). Together, they provide a holistic assessment and appraisal of the voice disorder with complementary roles in diagnosing and treating patients with dysphonia.
The vast majority of patients with age-related voice disorders benefit from optimisation of their voice using voice exercises and also changes to their lifestyle which may be contributing to their problem. Issues with diet (oily, spicy, coffee, tea and irregular eating times) physical exercise (cardiovascular function), hearing loss and medical disorders (hypothyroidism) are jointly dealt with.
Where there is only a need to help with conversational voice, SALT is often adequate. There are however patients who seek help especially when they are still working and use their voices professionally. Amateur singing in choirs, bands and other such activities which are hobbies dear to some patients can be affected too. Social isolation as a result of this is becoming an increasingly important problem. Together with deafness, many patients with presbyphonia may develop depression and even dementia.
Speech therapists provide a range of rehabilitative exercises for patients seeking an improvement to their ageing voice. These exercises combine evidence-based therapies with achievable outcomes that are tailored individually to each patient. Subjective and objective voice assessment tools with or without acoustic analysis of patient's voices are utilised in the voice laboratory. Typically, patients benefit from 6-12 sessions each lasting 30 to 60 minutes.
Surgical intervention for the ageing voice is rarely recommended in isolation. Most patients benefit from SALT before and after surgery. The aim of surgery in the ageing larynx, assuming that there are no other vocal fold pathologies (nodule, polyps, cysts) is to provide a better bulk to the atrophy of the folds.
This involves injecting bio-compatible materials either in the office setting with the patient awake or in the operating theatre under a general anaesthetic (see images 1 and 2).
Surgery does not however restore the loss of the SLP and the pliability of the folds does not improve. It does however help improve voice quality and amplification.
Presbyphonia affects between 12 per cent and 47 per cent of the population. Its impact on the quality of life of our elderly is high but early identification and intervention has been shown to be helpful in reversing what is viewed as a "normal" part of life. As clinicians, it is imperative that we view ageing as natural but provide our elderly with a quality of life that allows them to enjoy their golden era to the fullest.
This series is produced on alternate Saturdays in collaboration with Singapore Medical Specialists Centre.