The Aging Voice and Differentiating Diseases Laurie Kozlakowski

Introduction Voice quality of the aging voice and disease (cancer of the lanrynx) have similar characteristics They can both be described as hoarse, shaky, breathy, weak, and altered pitch Voice changes in the elderly are more likely to be influenced by disease rather than by physiologic aging Study done by Woo (1992) of 64 patients aged 65 and older found that only 11 had functional problems related to aging -the others had lesions, cancer, or inflammatory problems

Normal Changes in the Aging Voice Decrease in breath support -result in weakened voice -try to compensate by sphyncterically contracting their larynx during phonation, producing a strained quality- muscular tension dysphonia Laryngeal changes -ossification of laryngeal cartilages and joints may cause “bowing” of the vocal folds which is probably the most common benign pathology of the aging voice—visible with an endoscopic exam -loss of vocal fold massdecrease patients ability to bring the vocal folds together- weak, breathy voice

Young vs. Aged vocal folds Young (healthy)

Normal Changes Con’t Other changes… -changes in the cricoarytenoid due to aging may account for some of the pitch variability -men, beginning in the 60’s and each decade after-vocal cords become thin and atrophied resulting in a higher pitched conversational voice -women, pitch seems to get lower through life—vocal cords may become more polypoid after menapause due to estrogen deprivation which causes substantial changes in mucous membranes that line the vocal tract

Presbylaryngis age related structural changes of the vocal folds- may cause glottal gap during voice production Woo, “presbylaryngis is not a common disorder and should be a diagnosis of exclusion made only after careful medical and speech evaluation”

Aging in the Larynx Laryngeal Structure Nature of Aging Change Gender Differences Cartilages Ossification & calcification More extensive, earlier onset in males Cricoarytenoid joint General deterioration More evident in males Intrinsic muscles Atrophy In males- limited data in females Epithelium Thickening Progressive in males until 70, declines thereafter Progressive in females after 70 From Linville, Vocal Aging

Perceptual Age-related changes Male Female Determine age from voice sample X Classify into age groups Pitch changes Hoarseness Breathy Slow rate

Physiologic Age-related changes Male Female Vital capacities Smaller Lung pressures Lower Peak airflow rates Greater Leakage airflow rates

Acoustic Age-related changes Male Female Avg Fund Freq Higher Lower Fo variability Greater Freq Pertubation Fo range Smaller Avg Intensity level Variability of Intensity Intensity range Speaking rate Slower

Pathological Conditions Infections of viral, bacterial, or fungal origin Inflammatory autoimmune disease Neoplasms (benign or malignant) Vocal cord paralysis Thyroid function problems Functional and psychogenic disorders Patients who have undergone surgical procedures or emergent intubation will have pathological changes in larynx for weeks, months, or permanently

Diagnostic Clues Laryngeal or hypopharyngeal cancer is suggested by… -voice changes of recent onset (several weeks to months) -associated pain with phonation -associated pain or difficulty swallowing -presence of new neck mass These findings coupled with a significant past history of alcohol or tobacco use should alert the clinician of cancer-refer to otolaryngologist Polyp or granuloma -vocal fatigue and pitch changes

Normal vs. Cancerous Normal Cancer (beginning stage)

Early and Advanced Signs of Cancer Location of primary tumour Early Disease Advanced Disease Supraglottic Disturbance of Swallowing Hoarseness, dysphagia Glottic Hoarseness Airway obstruction Subglottic Mild haemoptysis Hoarseness, airway obstruction

Treatment Time- most useful in distinguishing benign from malignant etiologies of hoarseness -2 weeks of symptomatic treatment w/ voice rest and increased hydration will often allow infectious or inflammatory disorders to resolve without adversely affecting the prognosis if the cause of the hoarseness is a malignant neoplasm

Treatment Options for the Aging Voice Surgery Thyroplasty Injection Surgical correction Voice Therapy

Voice therapy should focus on… Improving overall physical fitness -maintain muscle function and coordination -helps vascular system -helps nervous system -improves respiratory system Counseling on good vocal hygeine Improving respiratory eficiency -decrease residual volume -increase vital capacity Increasing speed of speech Proper nutrition and weight control -good abdominal support=strong, less shaky voice

LSVT as Treatment (study) Used to evaluate changes associated with vocal aging before and after treatment Patients had hoarseness and reduced volume 16 sessions in a 1 month period Results: increased phonatory efficiency -increase in sound pressure level -improved vocal fold adduction -increased respiratory-laryngeal-vocal tract coordination

References Boone, D. & McFarlane, S. (2000). The voice and voice therapy. Boston: Allyn and Bacon. Ramig,L., Gray, S., Baker, K., Corbin-Lewis, K., Buder, E., Luschei, E., Coon, H., & Smith, M. (2001). A review, treatment data and familial and genetic perspectives. Folia Phoniatrica et Logopaedica, 252-65. Sataloff, R, Rosen, D., Hawkshaw, M., & Spiegel, J. (1997). The aging adult voice. Journal of Voice, 156-60. Sinard, R. & Hall, D. (1998). The aging voice: How to differentiate disease from normal changes. Geriatrics, 53(7), 76-79. http://www.sandgovoice.org/presby.html http://www.hopkinsmedicine.org/voice/index.html