Presbyphonia: Is Voice Therapy A Good Choice For Your Patient?

Decision making in the treatment of presbyphonia is daunting for the thoughtful clinician. Several clinical questions often arise:

• Is the atrophy of the vocal folds and the resulting glottal gap too large to make the patient a candidate for voice therapy?
• Is the patient too frail to benefit from therapy?
• What about those patients who have complaints of dysphagia?

These can be confusing decisions. With a few quick tips, we can demystify these questions and ensure confidence when determining candidacy for voice therapy.

What is the Best Treatment for Presbyphonia?

While evidence supports the use of voice therapy, injection laryngoplasty, and bilateral thyroplasty, no studies compare their treatment outcomes.¹ Most physicians recommend voice therapy first simply because it is the most conservative intervention.¹ But, is that the best way to determine appropriate treatment?

Probably not, but the evidence has yet to support a best therapy. In the meantime, these four parameters can guide us in determining who to see for voice therapy and who to refer back to the physician for other choices:

1. Glottal gap
2. Overall frailty
3. Accompanying swallowing problems
4. Cognition

Glottal Gap

If you are lucky enough to see an image of the vocal folds or be involved with the vocal fold imaging, you are steps ahead of the game in understanding the size of the glottal gap and the extent of vocal fold atrophy. In the best candidates for therapy, you will see a small glottal gap as evidenced by Mau, Jacobson & Garrett. They examined outcomes from voice therapy in 67 older adults diagnosed with presbyphonia. Patients with what they called “slit” closure experienced the best outcomes.²

Overall Frailty

Frailty is a “state of high vulnerability to negative health-related outcomes, such as falls, physical and cognitive decline, hospitalization, physical disability, and mortality.”³ It is common in aging and more common in people with multiple co-morbidities.

It’s important to note the link between frailty and loss of muscle mass (sarcopenia).⁴ People with more co-morbidities leading to frailty show poorer outcomes in therapy.²

Accompanying Swallowing Problems

Multiple factors cause dysphagia in the elderly.⁵ Significant dysphagia, as a result of aspiration, due to glottal incompetence in presbyphonia is rare, but, if present, I always defer for injection augmentation or bilateral thyroplasty.

With that being said, many presbyphonic patients complain of cough not associated with dysphagia and of increased difficulty swallowing in the presence of a normal swallow study. Recently Kang & Lott proposed the existence of a muscle tension dysphagia.⁶ My patients undergoing exuberant voice therapy using PhoRTE anecdotally remarked that it reduced their cough and improved their swallowing.⁷

Cognition

With aging comes changes in cognition and mood. The term “age-associated memory loss” is a new topic of interest and has a DSMV category.⁸ The ability to attend to treatment tasks and follow directions are important parameters in determining candidacy for therapy.⁹

Depression – more common in aging adults¹⁰ – impacts adherence to voice therapy. The short Geriatric Depression Scale can gauge if the patient will likely be successful in therapy.

The Right Fit

Voice therapy has the potential to help many of the people who come to our offices diagnosed with presbylaryngeus. Nonetheless, carefully deciding candidacy for therapy is paramount.