The Aging Voice

Aging of voice is an unseen issue perceived by sounding ‘old’. This involves a widespread change throughout the upper and lower airway mainly affected by the change in anatomy and physiology of vocal fold/cord. Thinning of laryngeal mucosa, atrophy of vocal muscles, reduced movement of cricoarytenoid joint, reduced lung volume and capacities; reduced movement of tongue, jaw as well systemic conditions may all affect the normal voice in older ages. Higher pitch voice in men, lower pitch voice in women, ‘thin’ voice, vocal fatigue, difficulty in being heard in noisy situations, tremor or shakiness in the voice are common changes found in old people. Various pathological conditions of larynx may cause voice change similar to aging voice. This can be differentiated endoscopically by an experienced Otolaryngologist. Avoidance of smoking, shouting, gastric reflux, resting the throat during a cold attack are simple measures that can delay aging process of our voice. ‘Voice related quality of life index’ is a quick & easy measurement of voice quality based on changes in last two weeks. Voice therapy and phonosurgery with injectable materials in vocal fold can improve the voice in advanced age.

The respiratory system changes from young adulthood to old age. In lung tissue, loss of elasticity is the most significant change while other changes include stiffening of the thorax and weakening of respiratory muscles. These changes alter lung volumes and respiratory mechanics. While total lung volume remains unchanged in the elderly, vital capacity decreases and residual volume increases. Maximum expiratory flow rate declines and lung pressure decreased. The larynx also undergoes age related anatomic changes during adulthood. Many of the changes are more extensive in males, including ossification and calcification of laryngeal cartilages, atrophy and degeneration of intrinsic muscles, restricted movement of CA (cricoarytenoid) joint, degeneration of mucosal glands, lamina propria and conus elasticus. In elderly males, changes in the CA joint may affect function by lessening vocal fold approximation during phonation. Dryness of epithelium causes stiffening of vocal cord cover leading to instability of vocal fold vibration and raise fundamental frequency (F 0 ) in elderly men. Changes in the supralaryngeal system include a process of "symmetrical enlargement" of the craniofacial skeleton (3-5%) from young adulthood to old age. Atrophy of facial, masticatory and pharyngeal muscles is reported in the elderly along with lowering of the larynx in the neck. Degenerative changes in the temporomandibular joint, thinning/ loss of elasticity of oral mucosa, declining salivary function, loss of tongue strength, and tooth loss -all affects the speech. 2 Furthermore, the older population are often exposed to a wide array of environmental and medicinal irritants that compound the problem, particularly in the case of long term tobacco smoking (indirect factors). 3 Older patients may also suffer from medical conditions that can affect vocal quality, such as carcinoma, vocal cord palsy, Parkinson's disease, amyotrophic lateral sclerosis, benign essential tremor, diabetes and other endocrine dysfunctions. The frequent occurrence of depression with SNHL can lead to a hyperfunctional voice and muscle tension dysphonia (MTD). 4,5,6,7 Common Changes in the voice as we age: • Higher pitch voice in men, lower pitch voice in women Under normal circumstances, the edge of the vocal fold stretches in a straight line between its attachments from thyroid cartilage to arytenoid cartilages in back of the larynx. Atrophy of the vocal fold muscle and thinning of the superficial vibratory tissues generally causes the edge to take on a scalloped appearance (Fig -1). 9 During voicing, the vocal fold edges do not come together in the middle because they have lost bulk. This produces a gap between the vocal folds in the shape of a spindle. This spindle-shaped gap has been accepted among otolaryngologists as the definitive sign of age-related voice change ( Fig.-3). In addition, the vocal folds are thinner and less plump. The cartilages are more starkly outlined, in particular, the vocal processes of the arytenoid cartilages may stand out, mistaken for a mass, like a polyp or a cyst (Fig -2).  Individuals should be aware that there are other reasons for such a gap, and also that the gap alone is not the whole problem underlying age-related voice changes. 10

How to minimize effect of aging on voice?
Couple of ways to minimize the changes that causes with growing older - SING LOUD: Reading a paper loudly for 10 -15 minutes, 2-3 times a day, as well as singing with the radio/ in the shower is good ways to preserve voice. Voice of the professional singers take longer to age, as they keep their laryngeal muscles strong.

What Can Be Done About Age-Related Voice Change?
Someone bothered with aging voice can take action today. By answering a short series of questions (Voice-Related Quality of Life quiz) available on the American Academy of Otolaryngologist web site, quality of voice can be assessed. 12 Answers should be based upon average voice quality over the past 2 weeks or so. Finally, should voice therapy alone prove unsatisfactory, vocal fold injection may be considered. The principle of this treatment is to restore the lost bulk of vocal fold muscle, and thereby improve the closure of the vocal folds stronger and less effortful. However, injection does not remedy all the changes occurred in the vibratory tissues of the larynx. So a "perfect" voice may not be produced by such a procedure. In addition, most vocal fold injectable materials are temporary; absorbed over a certain period of time.
Individuals should speak to their Otolaryngologist regarding the advisability of the procedure. 13

Conclusion:
In aged vocal folds, dense collagen deposition takes place and hyaluronic acid decreases in the lamina propria. Hirano, et al 14 reported an in vitro study using animal model where fibroblasts were harvested from young and aged rat vocal folds and cultured with or without hepatocyte growth factor and /or basic fibroblast growth factor at different concentration. Subsequently, the production of hyaluronic acid and collagen type I was examined in the supernatant culture media using ELISA. They found that aged fibroblast produced less hyaluronic acid than younger fibroblasts. When aged & younger fibroblast were cultured with basic fibroblast growth factor, hyaluronic acid production increased and collagen type I production decreased regardless of the concentration, whereas the effects of hepatocytes growth factor was also associated with stimulation of growth of aged fibroblasts. They concluded that basic fibroblast growth factor, may have therapeutic potential in restoration of aged vocal fold. 15