The Aging

Edward J. Damrose, MD, FACS Lecture Goals Assistant Professor Chief, Division of • Understand the of the voice box () Department of Otolaryngology/ Head & Surgery • Understand the development of the human larynx • Understand several basic concepts in the production of the • Describe the changes that occur to the aging larynx • Understand the impact of neurological on the aging larynx

The Larynx: The Voice Box The : Basic Anatomy

• Throat contains one common chamber that divides into two – Larynx (voice box) – (food passage) • Air moves through the larynx • Food and liquid move through the pharynx into the

The Voice Box: The Larynx The Complex Larynx

• producing • 8 • • 9 muscles • • 2 true • Coughing • 2 false (extra) vocal cords • Lifting • 2 major motor • Quality of Life • 2 major sensory nerves

1 Cartilages Cricoid and Arytenoids

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Vocal Intrinsic Musculature

• Abductors • Adductors • Tensors

Laryngeal Nerves: Recurrent and Intrinsic Musculature Superior

2 Normal Functions Vocal Cord = Vocal Fold

• Closing (speaking) • Opening (breathing) • High pitch () • Low pitch • Whisper •

Mechanism of Mechanism of Phonation

• Inhalation of air • Exhalation increases subglottic pressure until vocal folds • Glottic closure displace laterally

Mechanism of Phonation The : Resonance

Vocal folds return to midline • Everything above the – Decrease in subglottic pressure vocal cords to the – Elastic forces in vocal fold • Concentrates harmonics – Bernoulli effect of airflow • Resonance • Variable/adjustable

3 Vocal Cords/Vocal Tract

Why we sound the way we sound • Larynx develops from two branchial arches (air pressure) – 4th supraglottis + – 6th /subglottis Brain Larynx  Hearing + Vocal tract (, , palate)

4 Differences between infants and adults

Infants Adults flat Pointed Arytenoids large Proportionately smaller CT membrane slit Space furled Paddle configuration

Presbyphonia: Stereotypic Aged Voice Vocal fold: Atrophy

• High pitched • Mucosa thins • Breathy • Atrophy of the • Hoarse • Edema within the lamina • Soft propria in females • Tremulous

5 Cartilage: Ossification Muscle: Atrophy

• Loss of muscle mass • Dennervation • Strap muscles of neck

. atrophy and sag

Decreased Capacity: Decreased Neurologic Flow • Upper motor neuron disease • Parkinson’s disease • Amyotrophic lateral sclerosis

6 Secretions: Thicken Overall Impression

• Decreased mucous • Larynx descends (neck looks sagged) production • Voice pitch higher in men • Thickened mucous • Voice pitch lower in women • Decreased • and globus • Breathy • Hoarse • Vocal folds appear bowed

Vocal Cord Paralysis Vocal Cord Paralysis • Occasionally caused by a tumor somewhere in the neck • Injury to one or both of • Patient may be unaware until the vocal cord nerves the vocal cord becomes • Often following an paralyzed infection • Need to perform a scan in • Painless order to rule this out • Symptoms vary

Reincke’s Edema Reinke’s Edema

• Classically occurs in smokers • Typically both sides but may be one-sided • Looks like a • Benign • Hoarse, husky voice • Must stop or will recur

7 (White patch) of the Larynx

• May be precancerous • 10,000-12,000 new cases per year • Typically seen in smokers • Most common site in • Can be mistaken for fungal infections • 4200 deaths per year from • Surgical removal is the treatment of choice • Need to followup regularly and re-biopsy if it comes back

Cancer Cancer

• Laryngeal cancer the most • Can occur on one vocal common cancer of the cord head and neck area • Can get a good estimate • Least common cause of of the true extent in the hoarseness operating room • Difficulty swallowing • Coughing up blood • Sore throat • Ear pain

Cancer Treatment

• Can involve both vocal • What components of speech mechanism are cords involved? • Presbyphonia? • Removal of part of tongue, palate? • Stroke with neurological injury? • Removal of lung or treatment for ?

8 Treatment Hearing

• • Assess hearing • Lee Silverman Voice Therapy (LSVT) • Patient may be embarased to discuss • Particularly helpful in Parkinson’s disease • May be dismissed by patient as minor factor • Goal of therapy is to make the person loud • Consider audiogram/hearing aids • Intense therapy given over several weeks

Therapy Surgery

• Growth factors? • Goal is the restoration of glottic competence • ? • Variety of methods • ? • Often voicing becomes easier, more efficient while the voice itself may not change very much

Surgery

• Preop • Postop

9 10 11 Direct Materials - Fat • Fat • General anesthesia – Excellent viscoelastic • Jet ventilation properties • Spontaneous – Temporary vs. permanent • Microlaryngeal tube 5.0 – Injecting complete cells • Paralysis with attached fibrovascular support probably critical to • Outpatient survival

Collagen Acellular dermis

• Acellular human dermis • Collagen (Zyplast, (Cymetra) Cosmoplast) – Need to reconstitute in office – Recommendation for skin – Requires 10-15 minutes testing up to 4 weeks prior to injection – Reconstitution product “lumpy”, increases difficulty of injection – $250.00 per cc – Results last clinically 6 – 9 – No skin testing required months with Cosmoplast ($350.00/cc) – Long term effects of “biointegration” unknown – Persists up to 3-6 months – $400.00 per cc – Less endurance with each subsequent injection?

Calcium hydroxylapatite Calcium hydroxylapatite

• Calcium hydroxylapatite • Calcium hydroxylapatite – White paste – easy to – Expensive - $500.00/cc visualize – Exact long term benefit – Particle size 75 to 125 remains to be seen microns vs. 25 to 45 – Extrusion of material at microns injection site – Calcium spherules may be – Degree of reabsorption replaced by fibrous tissue undetermined ingrowth, preserving augmentation

12 Summary Summary

• Larynx is a complex organ, and the vocal fold • Presbyphonia due to many factors: itself is layered – Calcification of cartilage • Voice is not a property of laryngeal function – Muscle atrophy alone – much more goes into voice production – Loss of lamina propria than vocal fold vibration – Thinning of mucosa • Consider the person as a whole when assessing a – Thickening/drying of secretions voice problem

Summary

• Treatment geared to situation at hand – Hearing aids – Voice therapy – Injection laryngoplasty – Thyroplasty

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