The Aging Voice From Clinical Symptoms to Biological Realities

1
The Aging VoiceFrom Clinical Symptoms to
Biological Realities

• Lisa B. Thomas, Doctoral Candidate
• Joseph C. Stemple, Ph.D.
• University of Kentucky

2
Voice The Delicate Balance
Resonance
Changes can perturb the system result in an
altered voice signal.
Mild changes in each subsystem with age.
Phonation
Respiration
3
Voice Changes with Aging

• Presbyphonia
• Prevalence
• One of primary etiologies of voice concerns in
  the elderly (treatment-seeking population)
• Prevalence in general population of aging adults
  unknown
• Preliminary studies suggest prevalence may
  approach 30 of those over age 65 (Roy et al.,
  2007)

4
Presbyphonia

• Auditory Perceptual Changes
• Altered Pitch - Gender Differences
• Hoarseness
• Breathiness
• Strain
• Slowed rate

5
Presbyphonia

• Visual Perceptual Changes
• Bowing of vocal fold edge
• Atrophy
• Spindle-shaped gap
• Prominence of vocal processes
• Discoloration
• Edema (female)

6
Presbyphonia

• Acoustic Changes
• Increased Fo in males
• Decreased Fo in females
• Decreased SPL
• Increased Noise to Harmonics Ratio
• Inconclusive findings on changes in jitter and
  shimmer

• Aerodynamic Changes
• Few studies
• Suggest maintenance of mean airflow rate
• Changes in LAR vary
• May be gender differences

7
Impact

• Changes often of sufficient magnitude to be
  recognized by others
• Changes may negatively influence a listeners
  perception of an aged speaker
• Impact on functional use of voice and ultimately
  quality of life

8
What Underlies Presbyphonia?

• Changes at multiple levels
• Subglottic Respiratory Tract
• Supraglottal Vocal tract
• Laryngeal / Glottal

9
What underlies presbyphonia? Factors external to
the larynx

• Subglottic Respiratory Tract
• Calcif. of costal cartilages
• Respiratory muscles infiltrated by conn. tissue
• Decreased chest wall compliance tissue recoil
• Decreased vital capacity
• Increased residual volume

• Supraglottic Tract
• Endocranial space increases
• Tongue atrophies
• Muscles of the pharynx (vocal tract) weaken
• Larynx drops in the neck

10
What underlies presbyphonia?Laryngeal Factors

• Changes at each major layer
• Epithelium
• Lamina Propria
• Muscle

11
Epithelium

• Slight change in thickness
• Discoloration
• Yellowish, Grayish
• Effect on phonation minimal

12
Lamina Propria Review
13
Lamina Propria Change with Age

• LPS
• Change in layer thickness (increase/decrease)
• Fibrous proteins more complex course altered
  properties
• Reduced elasticity
• LPI
• Less thick (gt prominent in males) Change in
  contour
• Fibrous proteins (elastin) loose elasticity
• Layer stiffens
• LPD
• Fibrous proteins (collagen) more dense
  multidirectional course
• Layer becomes more fibrous

14
Lamina Propria Mechanisms of Change

• Metabolic and enzymatic changes
• Proteins destroyed at a slower rate slower
  turnover
• Older proteins with altered properties remain
• Fibroblast activity levels change

15
Laryngeal Muscle Biology Overview
16
Morphological Changes TA
Change in muscle cell leading to changes in
overall muscle structure function
17
Mechanisms of Muscle Change

• Primary mechanisms of cellular change with age
• Neurologic
• Metabolic
• Hormonal
• Physical Activity

18
Neurologic Mechanisms of Change
19
Metabolic Mechanisms of Change
20
Hormonal Mechanisms of Change
May see shift in the anabolic-catabolic hormone
balance in later life.
21
Muscle Change Summary

• TA remodels with age
• Muscle atrophy
• Fiber loss
• Increase in glycolytic metabolism
• Increase in mitochondrial abnormalities
• In animal models, above changes alter the
  muscles contractile properties toward a slower,
  weaker, and less fatigue-resistant profile.

22
Muscle Change Summary

• Likely due to changes in the peripheral nerve
  supply, decreased vascular support, systemic
  hormonal changes, and stochastic damage.
• Appropriateness of behavioral treatments for
  reversing the TAs changes has not been
  documented

23
Current Treatments

• Surgical
• Vocal Fold Augmentation or Medialization
• Belafsky et al. (2004)
• Ford Bless (1986)
• Ford (2004)
• Isshiki et al., (1996)
• Effective in short-term. Long-term information
  limited.

24
Current Treatments

• Behavioral
• Exercise shown to enhance muscle in limb skeletal
  muscle
• Uncertain of effect on laryngeal muscle
• Proposed
• Vocal Function Exercises
• Laryngeal strengthening exercise
• Studies showing treatment effectiveness with
  presbyphonia not available

25
Current Treatment Summary

• Limited number of treatment options available
• Limited research supporting the use of current
  methods
• Area ripe for study as population ages

26
Future Directions in Treatment

• Molecular Biology / Tissue Engineering
• Ongoing research into restoring lamina propria in
  cases of VF scar
• Can similar approaches be applied to the aged VF?
• Fibroblasts / Myoblasts
• Can we stimulate fibroblasts to restore the LP?
• Can we learn from limb muscle studies on
  myoblasts to facilitate muscle growth and
  counteract age-related atrophy?

27
Future Directions in Treatment

• Medical / Hormonal
• Hormones known to influence muscle
• Can we control the anabolic-catabolic forces
  medically to preserve VF muscle?
• Risk vs Benefit?

28
Future Directions in Treatment

• Surgical
• Demonstrate the long-term efficacy of current
  procedures (augmentation, medialization)
• Consider application of new approaches, new
  injectables

29
Future Directions in Treatment

• Behavioral
• Efficacy studies on application of behavioral
  approaches in elderly population
• Determine mechanism by which exercise results in
  functional change.
• Need objective means of measuring the effect of
  therapies on laryngeal biology
• Muscle biopsy?
• Myoblast / fibroblast activity

30
Future Directions

• Linking the basic and clinical sciences to
  enhance treatment options for the aging voice
• Dilemma of animal vs. human models of aging
• Realize that the future of voice care for the
  elderly (and other populations) may involve the
  SLP, ENT, and basic scientist

31
Selected References

• Andreatta, R. D., Mann, E. A., Poletto, C. J.,
  Ludlow, C. L. (2002). Mucosal afferents mediate
  laryngeal adductor responses in the cat. J Appl
  Physiol, 93(5), 1622-1629.
• Bach, A. C., Lederer, F. L., Dinolt, R. (1941).
  Senile changes in the laryngeal musculature.
  Arch of Otolaryngology, 34, 47-56.
• Belafsky, P.C., Postma, G.N. (2004) Vocal fold
  augmentation with calcium hydoxylapatite.
  Otolaryngology Head and Neck Surgery, 131,
  351-354.
• Bendiksen, F. S., Dahl, H. A., Teig, E. (1981).
  Innervation pattern of different types of muscle
  fibres in the human thyroarytenoid muscle. Acta
  Otolaryngol, 91(5-6), 391-397.
• Brandon, C. A., Rosen, C., Georgelis, G., Horton,
  M. J., Mooney, M. P., Sciote, J. J. (2003).
  Staining of human thyroarytenoid muscle with
  myosin antibodies reveals some unique extrafusal
  fibers, but no muscle spindles. J Voice, 17(2),
  245-254.
• Connor, N. P., Suzuki, T., Lee, K., Sewall, G.
  K., Heisey, D. M. (2002). Neuromuscular
  junction changes in aged rat thyroarytenoid
  muscle. Ann Otol Rhinol Laryngol, 111(7 Pt 1),
  579-586.
• Ford, C. (2004). Voice restoration in
  presbyphonia. Archives of Otolaryngology Head
  and Neck Surgery, 130, 1117.

32
Selected References

• Ford, C.N., Bless, D.M. (1986). Clinical
  experience with injectable collagen for vocal
  fold augmentation. Laryngoscope, 96, 863-868.
• Goding, G. S., Jr., Al-Sharif, K. I., McLoon,
  L. K. (2005). Myonuclear addition to uninjured
  laryngeal myofibers in adult rabbits. Ann Otol
  Rhinol Laryngol, 114(7), 552-557.
• Hartman, D. E. (1979). The perceptual identity
  and characteristics of aging in normal male
  adult speakers. J Commun Disord, 12(1), 53-61.
• Hartman, D. E., Danahuer, J. L. (1976).
  Perceptual features of speech for males in four
  perceived age decades. J Acoust Soc Am, 59(3),
  713-715.
• Hinrichsen, C., Dulhunty, A. (1982). The
  contractile properties, histochemistry,
  ultrastructure and electrophysiology of the
  cricothyroid and posterior cricoarytenoid
  muscles in the rat. J Muscle Res Cell Motil,
  3(2), 169-190.
• Hirano, M., Kurita, S., Nakashima, T. (1983).
  Growth, development, and aging of human vocal
  folds. In D. M. Bless J. H. Abbs (Eds.), Vocal
  Fold Physiology Contemporary Research and
  Clinical Issues (pp. 22-43). San Diego
  College-Hill.

33
Selected References

• Hirano, M., Kurita, S., Sakaguchi, S. (1989).
  Ageing of the vibratory tissue of human vocal
  folds. Acta Otolaryngol, 107(5-6), 428-433.
• Hirano, M., Sato, K., Nakashima, T. (2000).
  Fibroblasts in geriatric vocal fold mucosa. Acta
  Otolaryngol, 120(2), 336-340.
• Hoit, J. D., Hixon, T. J. (1987). Age and
  speech breathing. J Speech Hear Res, 30(3),
  351-366.
• Hoit, J. D., Hixon, T. J., Altman, M. E.,
  Morgan, W. J. (1989). Speech breathing in women.
  J Speech Hear Res, 32(2), 353-365.
• Holt, G. R., Aufdemorte, T. B., Sheridan, P. J.
  (1986). Estrogen receptor in the larynx of the
  aged baboon (Papio cynocephalus). Ann Otol
  Rhinol Laryngol, 95(6 Pt 1), 608-617.
• Honjo, I., Isshiki, N. (1980). Laryngoscopic
  and voice characteristics of aged persons. Arch
  Otolaryngol, 106(3), 149-150.
• Isshiki, N., Kojima, H., Shoji, K., Hirano, S.
  (1996). Vocal fold atrophy and its surgical
  treatment. Ann Oto Rhino Laryn, 105, 182-188.

34
Selected References

• Kersing, W. (1986). Vocal Musculature, Aging and
  Developmental Aspects. In J. A. Kirchner (Ed.),
  Vocal Fold Histopathology (pp. 11- 16). San
  Diego College-Hill Press.
• Konig, W. F., von Leden, H. (1961). The
  peripheral nervous system of the human larynx.
  Archives of Otolaryngology, 74, 45-55.
• Linville, S. E., Fisher, H. B. (1985). Acoustic
  characteristics of perceived versus actual vocal
  age in controlled phonation by adult females. J
  Acoust Soc Am, 78(1 Pt 1), 40-48.
• Lucas, C. A., Rughani, A., Hoh, J. F. (1995).
  Expression of extraocular myosin heavy chain in
  rabbit laryngeal muscle. J Muscle Res Cell
  Motil, 16(4), 368-378.
• Malmgren, L. T., Ringwood, M. A. (1988). Aging
  of the Recurrent Laryngeal Nerve An
  Ultrastructural Morphometric Study. In L. T.
  Malmgren (Ed.), Vocal Fold Physiology Voice
  Production, Mechanisms and Functions (Vol. 2,
  pp. 159-178). New York Raven Press.

35
Selected References

• Malmgren, L. T., Fisher, P. J., Bookman, L. M.,
  Uno, T. (1999). Age- related changes in muscle
  fiber types in the human thyroarytenoid muscle
  an immunohistochemical and stereological study
  using confocal laser scanning microscopy.
  Otolaryngol Head Neck Surg, 121(4), 441-451.
• Manaligod, J. M., Milam, M., Hill, S. A.,
  Sanders, T., Skaggs, J., Smith, R. J. (2000).
  Age-related mitochondrial DNA mutations in the
  human larynx. Laryngoscope, 110(12), 2123-2127.
• McMullen, C. A., Andrade, F. H. (2006).
  Contractile dysfunction and altered metabolic
  profile of the aging rat thyroarytenoid muscle. J
  Appl Physiol, 100(2), 602-608.
• Merati, A. L., Bodine, S. C., Bennett, T., Jung,
  H. H., Furuta, H., Ryan, A. F. (1996).
  Identification of a novel myosin heavy chain gene
  expressed in the rat larynx. Biochim Biophys
  Acta, 1306(2-3), 153- 159.
• Mortelliti, A. J., Malmgren, L. T., Gacek, R.
  R. (1990). Ultrastructural changes with age in
  the human superior laryngeal nerve. Arch
  Otolaryngol Head Neck Surg, 116(9), 1062-1069.

36
Selected References

• Newman, S. R., Butler, J., Hammond, E. H.,
  Gray, S. D. (2000). Preliminary report on
  hormone receptors in the human vocal fold. J
  Voice, 14(1), 72-81.
• Perie, S., Agbulut, O., St Guily, J. L.,
  Butler-Browne, G. S. (2000). Myosin heavy chain
  expression in human laryngeal muscle fibers. A
  biochemical study. Ann Otol Rhinol Laryngol,
  109(2), 216-220.
• Perie, S., St Guily, J. L., Callard, P.,
  Sebille, A. (1997). Innervation of adult human
  laryngeal muscle fibers. J Neurol Sci, 149(1),
  81-86.
• Ptacek, P. H., Sander, E. K. (1966). Age
  recognition from voice. J Speech Hear Res, 9(2),
  273-277.
• Pawlak, A.S., Hammond, T., Hammond, E., Gray,
  S.D. (1996). Immunocytochemical study of
  proteoglycans in vocal folds. Annals of Otology,
  Rhinology, and Laryngology, 105, 6-11.
• Rodeno, M. T., Sanchez-Fernandez, J. M.,
  Rivera-Pomar, J. M. (1993). Histochemical and
  morphometrical ageing changes in human vocal
  cord muscles. Acta Otolaryngol, 113(3), 445-449.

37
Selected References

• Rosenberg, S. I., Malmgren, L. T., Woo, P.
  (1989). Age-related changes in the internal
  branch of the rat superior laryngeal nerve. Arch
  Otolaryngol Head Neck Surg, 115(1), 78-86.
• Rossi, G., Cortesina, G. (1965). Multi-motor
  end-plate muscle fibers in the human vocalis
  muscle. Nature, 206, 629-630.
• Roy, N., Stemple, J.C., Merrill, R., Thomas,
  L.B. (2004). Epidemiology of voice disorders in
  the elderly Preliminary findings. Laryngoscope,
  117, 1-6.
• Rubinstein, N. A., Kelly, A. M. (2004). The
  Diversity of Muscle Fiber Types and Its Origin
  during Development. In A. C. Engel C.
  Franzini-Armstrong (Eds.), Myology (3rd ed.,
  Vol. 1, pp. 87- 108). New York McGraw-Hill.
• Ryan, E. B., Capadano, H. L., 3rd. (1978). Age
  perceptions and evaluative reactions toward
  adult speakers. J Gerontol, 33(1), 98-102.
• Ryan, W. J., Burk, K. W. (1974). Perceptual and
  acoustic correlates of aging in the speech of
  males. J Commun Disord, 7(2), 181-192.

38
Selected References

• Sanders, I., Han, Y., Wang, J., Biller, H.
  (1998). Muscle spindles are concentrated in the
  superior vocalis subcompartment of the human
  thyroarytenoid muscle. J Voice, 12(1), 7-16.
• Sato, T., Tauchi, H. (1982). Age changes in
  human vocal muscle. Mech Ageing Dev, 18(1),
  67-74.
• Schiaffino, S., Reggiani, C. (1996). Molecular
  diversity of myofibrillar proteins gene
  regulation and functional significance. Physiol
  Rev, 76(2), 371-423.
• Sciote, J. J., Morris, T. J., Brandon, C. A.,
  Horton, M. J., Rosen, C. (2002). Unloaded
  shortening velocity and myosin heavy chain
  variations in human laryngeal muscle fibers. Ann
  Otol Rhinol Laryngol, 111(2), 120-127.
• Segre, R. (1971). Senescence of the Voice. The
  Eye, Ear, Nose and Throat Monthly, 50, 223-227.

39
Selected References

• Shinners, M. J., Goding, G. S., McLoon, L. K.
  (2006). Effect of recurrent laryngeal nerve
  section on the laryngeal muscles of adult
  rabbits. Otolaryngol Head Neck Surg, 134(3),
  413-418.
• Shiotani, A., Flint, P. W. (1998). Expression
  of extraocular-superfast- myosin heavy chain in
  rat laryngeal muscles. Neuroreport, 9(16),
  3639-3642.
• Shiotani, A., Westra, W. H., Flint, P. W.
  (1999). Myosin heavy chain composition in human
  laryngeal muscles. Laryngoscope, 109(9),
  1521-1524.
• Shipp, T., Hollien, H. (1969). Perception of
  the aging male voice. J Speech Hear Res, 12(4),
  703-710.
• Smith E, Verdolini K, Gray S, et al. Effect of
  voice disorders on quality of life. Journal of
  Medical Speech-Language Pathology. December
  19964(4)223-244.
• Yamamoto, Y., Tanaka, S., Tsubone, H., Atoji, Y.,
  Suzuki, Y. (2003). Age-related changes in
  sensory and secretomotor nerve endings in the
  larynx of F344/N rat. Arch Gerontol Geriatr,
  36(2), 173-183.