The Aging Voice Edward J. Damrose, MD, FACS Lecture Goals Assistant Professor Chief, Division of Laryngology • Understand the anatomy of the voice box (larynx) Department of Otolaryngology/ Head & Neck Surgery • Understand the development of the human larynx • Understand several basic concepts in the production of the human voice • Describe the changes that occur to the aging larynx • Understand the impact of neurological disease on the aging larynx The Larynx: The Voice Box The Throat: Basic Anatomy • Throat contains one common chamber that divides into two – Larynx (voice box) – Pharynx (food passage) • Air moves through the larynx • Food and liquid move through the pharynx into the esophagus The Voice Box: The Larynx The Complex Larynx • Speech producing organ • 8 cartilages • Swallowing • 9 muscles • Breathing • 2 true vocal cords • Coughing • 2 false (extra) vocal cords • Lifting • 2 major motor nerves • Quality of Life • 2 major sensory nerves 1 Cartilages Cricoid and Arytenoids . Vocal Ligament 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 (falsetto) • Low pitch • Whisper • Cough Mechanism of Phonation Mechanism of Phonation • Inhalation of air • Exhalation increases subglottic pressure until vocal folds • Glottic closure displace laterally Mechanism of Phonation The Vocal Tract: Resonance Vocal folds return to midline • Everything above the – Decrease in subglottic pressure vocal cords to the lips – 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 Lungs (air pressure) – 4th supraglottis + – 6th glottis/subglottis Brain Larynx Hearing + Vocal tract (tongue, mouth, palate) 4 Differences between infants and adults Infants Adults Thyroid cartilage flat Pointed Arytenoids large Proportionately smaller CT membrane slit Space Epiglottis furled Paddle configuration Presbyphonia: Stereotypic Aged Voice Vocal fold: Atrophy • High pitched • Mucosa thins • Breathy • Atrophy of the lamina propria • 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 Lung 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 saliva • Phlegm 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 polyp • Benign • Hoarse, husky voice • Must stop smoking or will recur 7 Leukoplakia (White patch) Cancer of the Larynx • May be precancerous • 10,000-12,000 new cases per year • Typically seen in smokers • Most common site in head and neck cancer • Can be mistaken for fungal infections • 4200 deaths per year from laryngeal cancer • 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 lung cancer? 8 Treatment Hearing • Voice therapy • 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 • Estrogen? • Variety of methods • Testosterone? • Often voicing becomes easier, more efficient while the voice itself may not change very much Surgery • Preop • Postop 9 10 11 Direct Laryngoscopy 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 13.