Aging Clin Exp Res (2014) 26:1–5
DOI 10.1007/s40520-013-0143-5
REVIEW
Aging voice: presbyphonia
Regina Helena Garcia Martins • Tatiana Maria Gonçalvez
Adriana Bueno Benito Pessin • Anete Branco
Received: 5 May 2013 / Accepted: 5 September 2013 / Published online: 26 September 2013
Ó Springer International Publishing Switzerland 2013
Abstract Presbyphonia is a physiological process of
aging voice that includes morphological changes in the
coverage mucosa, muscle, and cartilage. We revised the
morphological, endoscopic, and vocal acoustic changes
that occur in presbyphonia and discussed some treatments
proposed to minimize glottal incompetence and improve
vocal performance of the elderly.
Keywords Presbyphonia
Voice
Elderly

Dysphonia
Aging
Introduction
Senility process does not spare the laryngeal structures, and
the sequence of physiological events related to voice aging
is named presbyphonia, which includes morphological
changes in its coverage mucosa, as well as muscle, carti-
laginous, neurological, and functional alterations [1, 2]. We
reviewed the main research manuscripts available at the
databases Medline, PubMed, EMBASE, Lilacs, SciELO,
and Cochrane, which address presbyphonia, considering
R. H. G. Martins
T. M. Gonçalvez

A. B. B. Pessin
A. Branco
Department of Otorhinolaryngology, Botucatu Medical School,
São Paulo State University, Botucatu, São Paulo, Brazil
R. H. G. Martins (&)
Disciplina de Otorrinolaringologia, Departamento de
Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e
Pescoço, Faculdade de Medicina de Botucatu, São Paulo
State University, Distrito de Rubião Junior s/n, Botucatu,
São Paulo 18618-970, Brazil
e-mail: rmartins@fmb.unesp.br
•
clinical, physiopathological, histopathological, vocal ana-
lysis, and treatment aspects.
Physiopathology of the vocal production and structural
characteristics of the larynx in the aged
The pathophysiology of vocal production involves three
systems: respiratory, vibrator, and resonator. In the respi-
ratory system, the expiratory air is produced from the lungs
and passes between the vocal folds making them vibrate.
Diseases that compromise the vital lung capacity, reduce
the intensity of the voice. The vibrator system corresponds
to the structure of the vocal folds and the resonator system
to the supraglottic, the hypopharynx, the nasopharynx, and
the oral cavity. Thus, vocal production depends on the
pulmonary aerodynamic mechanism, myoelastic structures
of the larynx, laryngeal mucosal wave, and resonance
channel [3]. Optimal voice (euphonia) is the result of a
well-controlled air flow produced by the pulmonary sys-
tem, a regular mucosal wave along the entire vocal fold and
a proper resonance of the vocal tract.
The pioneer studies of Hirano introduced the concept of
body-cover to the structure of the vocal fold and the tri-
laminar configuration of the lamina propria, dividing it
into superficial, intermediate, and deep layers [4]. Epi-
thelial structures are related to the cover while the vocal
muscle is related to the body and both of them have a
dissociate participation during the muco-ondulatory
movement [5]. The larynx undergoes a continuous process
of growth and differentiation from birth to the adult age.
The structures of the lamina propria gradually differenti-
ate, even though an outline of vocal ligament can be
recognized already at birth [6]. However, the true tri-
laminar configuration of the lamina propria can only be
noticed from adolescence.
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Among the compounds of the lamina propria are fibro- Videolaryngostroboscopic findings
blasts, elastic and collagen fibers, glycoproteins, hyaluronic
acid, proteoglycans, glucosamines, and rare capillaries. Videolaryngoscopy of the presbyphonia reveals vocal folds
Hyaluronic acid, an important compound of the extracel- bowed and with marked concavity of its free edge due to
lular matrix, is responsible for the local regulation of the atrophy of the vocal muscle (Figs. 1, 2). The video-
water content, reducing the impact of phonotrauma [7]. laryngostroboscopy shows aperiodicity of the glottic cycle,
The intermediate layer of the lamina propria is rich in decrease in the glottic wave amplitude, and reduced phase
elastic fibers and the deep layer, in collagen fibers. Colla- of glottic closure. Sulter et al. [18] assessed 214 video-
gen fibers are responsible for maintaining the tension and stroboscopies of aged people and noted that the vocal folds
the stretching of vocal folds, while elastic fibers play the were thicker, vertically longer and laterally denser with
role of rapidly correcting the organ when the latter is less muco-ondulatory movement amplitude in men, relative
exposed to deformities [8]. Type-I collagen is distributed to women. Glottic closure was more complete in men than
over the superficial layer, close to the basal membrane (thin in women.
fibers), the deep layer and the macula flava; type-III col-
lagen is found all over the lamina propria (thin and thick Clinical characteristics of presbyphonia
fibers), while type-IV and type-V collagens (fibrous com-
pound) are distributed over the basal membrane and The degree of vocal deterioration in presbyphonia is related
endothelium of vessels. Elastin, an important compound of to individual susceptibilities such as physical and psycho-
the extracellular matrix of vocal folds, is found in maculas logical health, life habits, and racial and hereditary factors
flavas, superficial (very close to the basal membrane),
intermediate, and deep layers [9, 10].
Morphological studies of the senile larynx have sug-
gested that, besides the decrease in the quantity of elastic
fibers, there are morphological changes that compromise
their function, including the increase in amorphous sub-
stance, the decrease in myofibrils, and the changes in their
metabolism [11]. Ohno et al. [12, 13] attributed the fall in
the phonatory intensity of the aged to the reduced density
of the extracellular matrix, a result of increased collagen
and decreased hyaluronic acid. Ximenes et al. [14] con-
ducted a histomorphometric analysis of larynxes of aged
people and noted that both the thickness of the lamina
propria of vocal folds and the density of epithelial cells
were reduced, and such changes were more evident in men.
According to those authors, these findings may justify the
vocal pattern observed in presbyphonia. Fig. 1 Atrophic vocal folds and vocal apophysis prominent
With aging, there is an increase in the relationship
between the numbers of collagen and elastic fibers result-
ing in higher rigidity and consequently decreased vibratory
wave of the vocal folds [15]. In parallel, there is a decrease
in the concentration of hyaluronic acid and mucus-pro-
ducing glands, also reducing the viscosity of vocal folds
[11, 16]. All these structural changes unfavorably affect the
voice performance of the aged. In elderly women, the
fundamental frequency (f0) decreases and the vocal
symptoms become more frequent.
In addition to structural changes in the epithelium and in
the lamina propria, the senile larynx may undergo calcifi-
cation of hyaline laryngeal cartilages, atrophy of muscles,
including the vocal muscle and decreased transmission and
failure in the neuromuscular control. The latter changes
result in instability and vocal tremor, constituting a marked
characteristic of the voice of the elderly [3, 17]. Fig. 2 Atrophic and bowed vocal folds

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[3]. The most relevant vocal symptoms are vocal fatigue,
hoarseness, difficulty in singing and in voice projection,
cough, increased secretion in the airways, and decreased
vocal intensity [19]. Age-related vocal changes are so
marked that they easily reveal the age of the person to
whom we are talking to on the telephone, only by hearing
their voice. For voice professionals, the vocal changes that
occur in presbyphonia may culminate in early interruption
of professional activities, as is the case for teachers. It must
also be considered that a large number of aged people sing
in choirs and alterations in their vocal quality may limit
their performance, depriving them from moments of
relaxation and leisure [20].
Elderly singers frequently report reduction in their voice
range and vocal training has helped them to delay the vocal
deterioration of presbyphonia. Prakup [21] showed the
benefits of training the voice during the study of differ-
ences in the vocal acoustic measures (f0, jitter, intensity,
and shimmer) of older amateur singers (30 males and 30
females) and non-singers (30 males and 30 females). The
results of this study indicated that male and female singer
participants were perceived to be significantly younger
than male and female non-singers. Singers had less jitter
and greater intensity than non-singers.
Aging also evolves with a decrease in the production of
secretions. There is a decrease in salivary secretion and
mucous glands, and consequent thickening in the secretions
of the pharynx and the larynx, making the vocal folds less
lubricated and damaging the vibration of their mucosae. In
these cases, the ingestion of a large amount of liquid,
around eight glasses per day, is recommended to minimize
these symptoms [22].
The voice is also influenced by emotional factors, and
feeding habits and vices. Smoking causes a chronic
inflammatory process and triggers a series of structural
changes that compromise both the epithelium and the
lamina propria of vocal folds, culminating in the estab-
lishment of permanent lesions such as Reinke’s edema,
leukoplakia, pachydermia, mucus thickening, and even
carcinoma.
Presbyphonia is a multifactorial phenomenon and other
comorbidities related to vocal change such as metabolic,
autoimmune, and neurological diseases should be investi-
gated. These diseases are more common in the elderly and
thus must be identified, diagnosed, and duly treated or
controlled for a successful vocal therapy. Disorders of the
thyroid gland may damage the voice both in hyperthy-
roidism and in hypothyroidism. In hyperthyroidism, there
may be dystonias, paradoxical movements, and laryngeal
tremors; in hypothyroidisms, there is edema of vocal folds
and the voice can become weak with decreased funda-
mental frequency and vocal range [23]. Among the auto-
immune diseases of the elderly, which may evolve with
3
dysphonia, are systemic lupus erythematosus, rheumatoid
arthritis, and Sjögren syndrome. In these diseases, dys-
phonia may affect 30–38 % of patients [24]. In rheumatoid
arthritis, bamboo nodes are in the mid third of vocal folds
like yellowish nodular lesions, compromising the vocal
performance. These laryngeal lesions are histologically
similar to subcutaneous rheumatoid nodules [25].
Some drugs can also damage vocal emission, such as the
negative effects of antihistamines, due to mucosal drying
and mucus thickness; the chronic cough caused by anti-
hypertensives, specially the angiotensin-converting
enzyme [26]; the dysphonia caused by chronic use of
inhaled corticosteroids, reported by 5–58 % of the asth-
matic patients, due to laryngeal injuries, myopathy,
inflammation, edema or moniliasis.
In addition, auditory changes are commonly observed
among the aged, which impairs the feedback of the voice
intensity control; programs for adaptation of individual
hearing aids have minimized such damages and improved
the life quality of this population. The aged also show tooth
loss which considerably interferes in the articulation,
impairing the speech intelligibility.
Auditory perceptual and acoustic characteristics
of presbyphonia
Auditory perceptual voice analysis shows decreased har-
monics and vocal range, tremor, reduced speech rate,
increased degree of breathiness, lack of pneumophonic
coordination, and reduced vocal intensity and maximal
phonation time. In some cases, there are variable degrees of
excessive nasal resonance.
The investigation of perceptual vocal characteristics is
usually carried out by speech therapists who adopt the
GRABASI scale for this purpose. In this scale, each letter
corresponds to one analyzed vocal parameter: overall grade
or severity (G), roughness of the voice (R), breathiness (B),
asthenia (A), strain (S), and instability (I). The degree of
intensity of each parameter is quantified as 0 (without
alteration), 1 (mild alteration), 2 (moderate alteration), and
3 (severe alteration). Gama et al. [27] analyzed the voices
of 103 aged people without vocal symptoms (aged between
60 and 100 years) by GRBASI scale and noted significant
changes in the vocal parameters for 44.66 % cases, espe-
cially concerning roughness, breathiness, and instability.
Asthenia and tension were the least affected parameters.
Computerized acoustic analyses have indicated a
decrease in the fundamental frequency of women and an
increase in that of men, as well as increased percentage of
jitter and shimmer [27, 28]. Gama et al. [27] evaluated the
acoustic measures of voice for 96 women aged between 60
and 103 years and found a significant and gradual reduc-
tion in f0 for aged women, from 193.81 Hz for 60 years to
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187.60 Hz for 80 years. For some women older than
80 years, those authors recorded f0 values close to 88 Hz.
Treatment for presbyphonia
Vocal therapy
Voice rehabilitation in presbyphonia contemplates the
improvement in oral communication, with decreased
speech effort, fitting the vocal quality to the needs of the
aged. Vocal exercises have been proposed to favor the
glottic closure, increase the subglottic pressure and the
voice intensity, stabilize the vocal quality and the funda-
mental frequency, and provide a global improvement in the
speech functional system. Vocal therapy may improve
voice quality, maximal phonation time, pneumophonic
coordination, tension, articulation, velocity, intensity, res-
onance, pitch, and vocal attack, depending on the aim of
the rehabilitation [29].
Vocal therapy should start with exercises for respiratory
support, resonance control, and supraglottic hyperfunction
exercises to improve the approach of vocal folds [30].
Vocal education should include optimal vocal postures,
neuromuscular coordination, respiratory exercises, and
practice on resonant voice production. Most patients are
benefited by these vocal therapies. Failures in vocal reha-
bilitation are usually found in patients with important vocal
fold atrophy and those with systemic diseases. Mau et al.
[31] analyzed the results of vocal reeducation treatment of
67 patients older than 55 years and noted that 85 % of
these patients demonstrated improvement with voice ther-
apy. Patients with pronounced vocal fold atrophy presented
less improvement from voice therapy.
However, when surgery is necessary, the patients may
benefit from a postoperative voice therapy follow-up aimed
at maximizing the laryngeal function, maintaining an
adequate vocal quality and guiding patients in ceasing
habits that are harmful to the voice and adopting preventive
strategies.
Surgery
Several materials like teflon, collagen, hyaluronic acid, fat,
and geofoam have been employed for the correction of the
glottis incompetence; however, the ideal substance to be
injected inside the vocal folds is still under investigation.
These substances have been used in laryngeal scars and
vocal sulcus, inducing minor inflammatory response. Tef-
lon injection has shown limited results for the susceptibility
to granuloma formation. Fat injection has shown rapid
absorption and suggested not to be a good choice for
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long-term vocal restoration. Hyaluronic acid stimulates
connective tissue formation, presents a similar viscosity of
the vocal fold mucosa and can be useful [32]. Even though
new biomaterials have arisen and indications have been
improved, injectable materials require attention as to tol-
erance, location of the substance-receptor site, reabsorption
degree, and viscosity.
A frequently used and long-lasting technique for glottic
insufficiency is the graft of fascia or pre-fascia of the
temporal muscle; it is easy to obtain and accommodates in
the lamina propria, promoting little reabsorption over the
years [33].
Type-I thyroplasty is reserved for more severe cases of
glottic incompetence in which breathiness is very impor-
tant, as is the case for laryngeal paralysis. This technique
requires external cervical approach and introduction of
silicon mold into a window made in the thyroid cartilage
[34].
With the advance of knowledge of the microstructure of
vocal folds, fibroblast culture has been cited as a future and
promising method to treat glottic insufficiency; on the other
hand, current studies are still premature and do not include a
follow-up. In addition, the culture methods are not totally
standardized yet, especially concerning the culture time and
the grafting interval. Hirano et al. [35] described the first
technique for fibroblast implantation in humans; they
injected 10 lm culture in the left vocal fold, under topical
anesthesia. Based on videostroboscopy and acoustic and
aerodynamic parameters, after 3-month follow-up, those
authors noted that the vocal fold atrophy improved, the
glottic aperture disappeared and the acoustic and aerody-
namic parameters were normalized. The authors have a
special interest in studies involving fibroblasts because these
cells are essential compounds of the lamina propria and
responsible for the maintenance, development and repair of
the extracellular matrix. The metabolic activity of fibro-
blasts seems to decrease with aging, showing changes in
their cytoplasm organelles. The most evident alterations are
in the rough endoplasmic reticulum, responsible for the
synthesis and storage of proteins, and in the Golgi apparatus,
responsible for storing, processing and distributing proteins
and polysaccharides [12, 13]. Further studies are needed to
prove the benefits of these new therapeutic techniques for
the lamina propria repair by adopting these methods.
Conclusion
We revised the morphological, endoscopic, and vocal
acoustic changes that occur in the presbyphonia. We dis-
cussed some treatments that have been proposed to
improve vocal performance of the elderly.
Aging Clin Exp Res (2014) 26:1–5
Conflict of interest On behalf of all authors, the corresponding
author states that there is no conflict of interest.
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