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Address correspondence and reprint requests to Maciej Zdrojkowski, Department of Clinical Pnonoaudiology and Speech Therapy, Medical University of Białystok, ul. Szpitalna, 37, 15-295, Białystok, Poland
The aim of the study was to determine the individual variability of the severity of dysphonia in the population of older women and men using the initial perceptual voice assessment (GRBAS) and objective diagnosis of the clinical form of Presbyphonia with laryngeal visualization technique (High-Speed Digital Imaging [HSDI]) and acoustic voice analysis (Diagnoscope Specjalista).
Methods
The study included 302 elderly women and men. Application of perceptual GRBAS scale allowed to extract 230 subjects with voice disorders (Group I). Remaining 72 elderly subjects without the symptoms of dysphonia consisted Group II. Group III included 50 subjects with euphonic voice. In the assessment of dysphonia, visualization technique (HSDI) as well as acoustic method (Diagnoscope Specjalista). The observation of real vibration of vocal folds using HSDI technique and HS camera allowed to examine symmetricity (Shaw-Deliyski scale), periodicity and amplitude of vibration, Mucosal Wave (MW) morphology, Glottal Closure Type, and value of Open Quotient (OQ). Acoustic analysis allowed to assess value of Fundamental Frequency (F0), Maximum Phonation Time (MPT) as well as Jitter, Shimmer, Noise-to-Harmonics Ratio (NHR) parameters. Narrowband Spectrography was performed.
Results
HSDI technique allowed to register in elderly women with voice disorders a mild asymmetry and aperiodicity of vibrations, MW reduction, amplitude increase and glottal insufficiency in the posterior segment of glottis which indicated edematous changes in the larynx. In 90% of men in this group, moderate asymmetry and aperiodicity were observed as well as amplitude decrease, significant limitation of MW and glottal insufficiency in the middle segment of the glottis which indicated atrophic changes in the larynx. In remaining 10% of men, amplitude of vibration was increased which indicated the existence of hypofunctional dysphonia. Objective confirmation of glottal insufficiency in women with edematous changes was high value of OQ in posterior segment of the glottis registered with HSDI technique. In men with larynx atrophy, the value of OQ was the highest in the middle segment of the glottis. Glottal insufficiency, especially in the middle segment, coexisted with the increase of NHR parameter observed in acoustic examination and with numerous nonharmonic components in the scope of high frequencies revealed in narrowband spectrography, especially in men with larynx atrophy. What is more, in men, the increase of F0 and reduction of MPT was registered. In women with edematous changes of the larynx, acoustic analysis revealed decrease of F0 value, increase of Jitter, Shimmer, NHR as well as reduction of MPT. Narrowband sopectrography revealed not only harmonic components but also nonharmonics in the range of low, medium, and high frequencies.
Conclusions
The course of Presbyphonia varies individually in the elderly. In many subjects, the process of aging does not influence the quality of voice. Crucial importance in the diagnosis of Presbyphonia is assigned to High-Speed Digital Imaging technique which confirms the existence of edematous changes in the larynx in women as well as atrophy and hypofunctional dysphonia in men. The acoustic examination of voice confirmed the individual variability of the severity of Presbyphonia in the elderly depending on the clinical form of dysphonia determined by the gender of the diagnosed person.
In many individuals, old age has no influence on voice, in other, it causes severe disorders called Presbyphonia, Vox senium, Presbylarynx, etc. The incidence rate of voice disorders over the age of 60 is estimated for 12–30, even 35%.
Presbyphonia may be observed in the form of functional or organic disorders, caused by morphological changes within the laryngeal structures. Functional voice disorders in the elderly may also have psychogenic origin (Phononeurosis) associated with social isolation and loneliness.
The application of High-Speed camera (HS), acoustic analysis and Voice Handicap Index (VHI) questionnaire in diagnosis of voice disorders in elderly men.
This feeling is completely unjustified, according to the fact that elderly persons have great capital of valuable life and professional experience, the use of which is in the social interest.
Voice disorders in the elderly result from the existence of changes in the larynx. The literature on the subject describes numerous morphological and functional changes in this age group.
The application of High-Speed camera (HS), acoustic analysis and Voice Handicap Index (VHI) questionnaire in diagnosis of voice disorders in elderly men.
The research in a large population of elderly people was inspired by the need to identify the most common aging-related changes in the larynx, taking into account the gender of subjects.
Initial perceptual assessment of voice indicating the presence of dysphonia should be objectively confirmed using laryngeal visualization methods or voice acoustic assessment. The absence of dysphonia features in the auditory examination is not synonymous with the absence of pathology within the larynx. Accurate diagnosis of Presbyphonia guarantees rapid implementation of therapy and greatly improves the prognoses.
OBJECTIVE
The aim of the study was to determine the individual variability of the severity of dysphonia in the population of older women and men using the initial perceptual voice assessment (GRBAS) and objective diagnosis of the clinical form of Presbyphonia with laryngeal visualization technique (High-Speed Digital Imaging [HSDI]) and acoustic voice analysis (Diagnoscope Specjalista).
MATERIAL AND METHODS
The study included a group of 302 subjects, age 65–75 years old, classified as elderly age according to WHO. The diagnosis of voice quality disorders was conducted at the Department of Clinical Phonoaudiology and Speech Therapy, Medical University of Białystok. After the diagnosis of the clinical form of Presbyphonia, patients were treated at the Phoniatric Outpatient Clinic, University Hospital in Białystok. The examined group consisted of subjects with no vocal overload, thyroid diseases, severe hearing disorders and psychogenic diseases.
Group I consisted of 230 subjects, age 65–75 with voice quality disorders. The average age was 71.2 years (SD 3.44). The group included 161 (70%) women and 69 (30%) men.
Group II included 72 subjects who did not report voice quality disorders, age 65–73 years. The average age was 68.7 years (SD 2.58). The group included 54 (75%) women and 18 (25%) men.
Group III (control group) consisted of 50 subjects with a physiological voice (euphonic voice), age 24–39 years. The average age was 31. The group included 30 (60%) women and 20 (40%) men. The subjects have no co-morbidities, were nonsmokers, without the professional voice overload.
Group I and II did not differ significantly in terms of age and gender.
In order to initially assess voice disorders, in all 3 groups, the perceptual GRBAS scale (according to the Japanese Society of Logopedics and Phoniatrics) was used, which determines: the grade of hoarseness – G, roughness – R, breathiness – B, asthenicity – A and voice strain – S. The severity of symptoms was determined on 0-3 scale, where 0 means physiological (euphonic) voice; 1 – slight; 2 – moderate; 3 – severe intensification of symptoms. The assessment was conducted by a specialist audiologist-phoniatrician with several decades of work experience.
In the visual assessment of vocal folds, the HSDI technique by Richard Wolf GmbH in the HRES ENDOCAM 5562 system was used. Images were recorded using High-Speed (HS) camera by Richard Wolf GmbH, registering vibration of vocal folds at a rate of 4000 frames per second. The HS camera mode allows to determine the parameters of the actual vibrations of vocal folds, while the High-Resolution mode allows for a precise visual assessment of the laryngeal structures, including the respiratory position of vocal folds. Rigid endoscope with 90° optics of the same producer was used in the study. The recorded 2-second sequences, due to availability of playback option, were analyzed for a period of 8.88 minutes, played back at the speed of 15 frames per second. The examination was performed during the phonation of vowel "i" pronounced in isolation and during breathing.
The symmetry, synchronicity and vibration amplitude were analyzed along with the morphology of Mucosal Wave (MW), Glottal Closure Type (GTs) and also the position of vocal folds during resting breathing was assessed visually.
The symmetry of Right (R) and Left (L) vocal fold vibration was diagnosed on the basis of the morphology of the actual vocal fold vibrations using the HS camera and the HSDI technique. Asymmetry was classified on the basis of the Shaw-Deliyski scale commonly used in clinical proceedings.
On a 5-point scale, a 1-point difference was total asymmetry; 2-severe; 3- moderate; 4-mild asymmetry of the mobility of vocal folds. Value of 5 points indicated the symmetry of the vibrations of both vocal folds. The asymmetry of vocal fold vibrations is the result of changes in muscle mass and tone, while the symmetry of vibrations is a reflex image of the mobility of the right (R) and left (L) vocal folds.
The MW morphology was classified as normal, limited, or increased.
The trajectory of movement of the right (R) and left (L) vocal fold was analyzed.
The Open Quotient (OQ) value was assessed in the anterior, middle and posterior segment of the glottis. The numerical value of the OQ was determined, where 1 means the lack of glottal closure and 0 – complete glottal closure during phonation.
GTs was determined according to the guidelines of the Committee on Phoniatrics of the European Laryngological Society (ELS), where type A is rectangular glottal closure; B - hourglass; C - triangular; D - "V"-shaped and E – spindle-shaped. The analyses were conducted by a specialist in audiology-phoniatrics and a specialist in acoustics.
Acoustic assessment of voice was conducted during the phonation of vowel "a" twice in isolation and a continuous linguistic, phonematically balanced text: “Dziś jest ładna pogoda…” ("Today is nice weather..."). In the acoustic examination, the Diagnoscope Specjalista software by DiagNova Technologies was used. The analysis was conducted in an acoustically soundproofed room eliminating ambient noise. The recordings were made in the patient's standing position, using the SHURE SM86 microphone with a cardioid characteristic and an extended upper band at a distance of 10 cm from the patient's mouth.
The value of Fundamental Frequency (F0) of the laryngeal tone in men and women of both diagnosed groups was assessed. Jitter, Shimmer and Noise-to-Harmonics Ratio (NHR) parameters were analyzed collectively.
Narrowband spectrography was performed analyzing the presence of harmonics and nonharmonics indicating the existence of a noise component.
The value of Maximum Phonation Time (MPT) was assessed in women and men in diagnosed groups. The examination was conducted during phonation of the vowel "a", with physiological intensity, after taking a deep breath. The mean arithmetic value of 3 replicates was calculated. The respondents were instructed about the need to phonate as long as possible, until the voice breaks down, after the examiner had demonstrated the correct way of performing the test. The tests were conducted by a specialist in audiology-phoniatrics and a specialist in acoustics.
The project was approved by the Bioethics Committee of the Medical University of Bialystok No.R-I-002/77/2019. The diagnosed patients were informed about the benefits, burdens and potential complications of the endoscopic examination of the larynx and acoustic voice, and their course, giving written consent to the examination.
In the statistical analysis of the obtained values of OQ and the parameters F0, Jitter, Shimmer and NHR, one-way analysis of variance was used, where statistically significant values were established for P ≤ 0.05.
RESULTS
Perceptual voice assessment using GRBAS
In Group I, 150 (93%) women revealed the existence of hoarseness (G3), roughness of voice (R2), no breathiness (A0) and no voice strain (S0) - G3R2B1A0S0. In the remaining 11 (7%) women, apart from hoarseness (G3), roughness (R2), and the breathiness of voice (B1), asthenicity (A1) and voice strain (S1) were recorded - G3R2B1A1S1 (Figure 1).
Figure 1Evaluation of the parameters of voice disorders on the GRBAS scale in women and men in Group I.
In Group I, 62 (90%) men revealed hoarseness (G2), roughness (R2), breathiness (B3), asthenicity of voice (A3), and lack of voice strain (S0) - G2R2B3A3S0. In the remaining 7 (10%) men, hoarseness (G2), roughness (R1), breathiness (B2), voice asthenicity (A2), without features of voice strain (S0) - G2R1B2A2S0 were recorded (Figure 1).
In Group II, 48 (89%) women revealed slight hoarseness (G1), roughness (R1), without breathiness of voice (B0), asthenicity (A0) and voice strain (S0) - G1R1B0A0S0. Hoarseness (G0), roughness (R0), breathiness (B0), asthenicity (A0) and voice strain (S0) - G0R0B0A0S0 were not recorded in the remaining 6 (11%) women.
In Group II, in 15 (83%) men, hoarseness (G0), roughness (R0), breathiness (B0), asthenicity (A0) and voice strain (S0) - G0R0B0A0S0 were not recorded. In the remaining 3 (17%) men, hoarseness (G1), no roughness (R0), slight breathiness (B1), asthenicity (A1), and no voice strain (S0) were observed – G1R0B1A1S0.
In Group III, 30 (60%) women and 20 (40%) men revealed no signs of hoarseness (G0), roughness (R0), breathiness (B0), asthenicity (A0) or voice strain (S0) – G0R0B0A0S0.
Visualization of the larynx using HSDI
In Group I, in 150 (93%) women, asymmetry of vocal folds vibrations classified as moderate (3 points) according to the Shaw-Deliyski scale, aperiodicity of vibrations, MW reduction, increase in the amplitude of vocal folds vibrations were registered. The lack of glottal closure was also observed, especially in the posterior segment. During resting breathing, vocal folds were in a physiological respiratory position.
The OQ value was on average 0.23 in the anterior; 0.1 – in the middle and 0.89 – in the posterior segment of the glottis (Table 1).
Table 1OQ Values in Three Diagnosed Groups in the Anterior, Middle, and Posterior Segment of Glottis
The analysis of vocal folds trajectory showed irregularity and aperiodicity of the right R (Right) and Left L (Left) vocal fold vibrations.
The kymographic examination indicated asymmetry and aperiodicity of vocal folds vibrations.
GTs was classified as B (according to ELS) (Figure 2).
Figure 2Results of kymographic examination in the diagnosed groups of patients (HSDI and DKG; own source): (A) in a 68-year-old woman with laryngeal edema; (B) in a 71-year-old man with hypofunctional dysphonia; (C) in a 65-year-old man with vocal fold atrophy; (D) in a 32-year-old woman with a euphonic voice.
In the remaining 11 (7%) women, vibration asymmetry classified as severe (2 points) according to the Shaw-Deliyski scale, aperiodicity of vibrations, limitation of the MW and an increase in the amplitude of vibrations of the vocal folds were recorded. During resting breathing, vocal folds were in a physiological respiratory position.
The lack of glottal closure in the posterior segment was observed. The average OQ value in the anterior segment was 0.25, 0.15 – in the middle and 0.96 in the posterior segment (Table 1).
The analysis of vocal folds trajectory showed the irregularity and aperiodicity of the right (R) and left (L) vocal fold vibrations.
Kymographic examination revealed asymmetry and aperiodicity of vocal folds vibrations (Figure 2).
The GTs was classified as B (according to ELS) (Figure 3).
Figure 3Morphological image of the larynx in the diagnosed groups of patients (HSDI; own source: (A) in a 68-year-old woman with laryngeal edema; (B) in a 71-year-old man with hypofunctional dysphonia; (C) in a 65-year-old man with vocal fold atrophy; (D) in a 32-year-old woman with a euphonic voice.
The results of the laryngeal visualization parameters indicated the existence of edema changes in the larynx in the group of diagnosed women with voice quality disorders.
In Group I, 62 (90%) men showed asymmetry of vocal folds vibrations classified as average (3 points) according to the Shaw-Deliyski scale, aperiodicity of vibrations, clear reduction of the MW, decrease of vibration amplitude and lack of glottal closure, especially in middle segment. During resting breathing, vocal folds were in a physiological respiratory position.
The OQ value in the anterior segment was 0.13 on average; in the middle – 0.75; in posterior – 0.4 (Table 1).
The trajectory of movement of the right (R) and left (L) vocal fold indicated the existence of asymmetry and aperiodicity of vibrations.
The kymographic examination confirmed the asymmetry, aperiodicity and lack of glottal closure during phonation (Figure 2).
The type of glottal closure was classified as E (according to ELS) (Figure 3).
The results of the laryngeal visualization parameters indicated the existence of vocal folds atrophy in the group of diagnosed men.
In the remaining 7 (10%) men, asymmetry of vocal folds vibrations classified as severe (2 points) according to the Shaw-Deliyski scale, aperiodicity of vibrations, presence of MW, increased amplitude of vibrations and lack of glottal closure, especially in the middle segment, were recorded. During resting breathing, vocal folds were in a physiological respiratory position.
The mean OQ value in the anterior segment was 0.14; middle – 0.71; posterior – 0.6 (Table 1).
The trajectory of the movement of right (R) and left (L) vocal fold indicated cyclic asymmetry and aperiodicity of vibrations.
The kymographic examination confirmed the asymmetry and aperiodicity of vibrations as well as the periodical lack of glottal closure (Figure 2).
The type of glottal closure was classified as E (according to ELS) (Figure 3).
The values of visualization parameters indicated the existence of hypofunctional dysphonia in the group of men with voice disorders.
In Group II, 48 (89%) women had asymmetry of vocal folds vibrations classified as moderate (4 points) according to the Shaw-Deliyski scale, periodicity of vibrations, physiological MW with regular amplitude of vibrations. During resting breathing vocal folds were in a physiological respiratory position.
The mean OQ value in the anterior segment was 0.44; middle – 0.53, posterior – 0.39 (Table 1).
The trajectory of the right (R) and left (L) vocal fold movements indicated symmetry and periodicity of the vibrations.
The kymographic examination confirmed the symmetry and periodicity of vocal folds vibrations as well as complete glottal closure (Figure 2).
In the remaining 6 (11%) women, symmetry and periodicity of vocal folds vibrations, normal MW and vibration amplitude were observed. The mean OQ value in the anterior segment was 0.38; middle – 0.49, posterior – 0.69 (Table 1).
The trajectory of vocal folds movements and the kymographic examination confirmed the symmetry and periodicity of vocal folds vibrations.
Complete glottal closure was recorded.
In Group II, 15 (83%) men were diagnosed with mild vibration asymmetry (4 points) on the Shaw-Deliyski scale, periodicity of vibrations, physiological MW and normal amplitude of vibrations. During resting breathing, vocal folds were in a physiological respiratory position.
The mean OQ value in the anterior segment was 0.12, the middle – 0.11 and in the posterior – 0.15 (Table 1).
The GTs was classified as physiological (Figure 3).
In Group II, 3 (17%) men showed symmetry and periodicity of vibrations, reduction of the MW and reduction of the amplitude of vibrations. The mean OQ in the anterior segment was 0.45; middle – 0.65; posterior – 0.58 (Table 1).
The kymography and trajectory of vocal folds movement confirmed symmetry, periodicity and glottal closure as physiological (Figure 2).
In Group III, 30 (60%) women and 20 (40%) men showed vibration symmetry (5 points) on the Shaw-Deliyski scale, periodicity of vibrations, and physiological MW with the normal amplitude of vibrations. During resting breathing, vocal folds were in a physiological respiratory position.
The anterior OQ value in women was 0.51; in the middle – 0.61; in the posterior segment – 0.48 (Table 1).
In men, the mean OQ value in the anterior segment was 0.45; middle – 0.56 and posterior – 0.52 (Table 1).
The trajectory of movement of the right (R) and left (L) vocal fold in women and men confirmed the symmetry and periodicity of vibrations, as was the kymographic examination (Figure 2).
Acoustic analysis using Diagnoscope Specialista f. DiagNova technologies
In Group I, 161 (100%) women had the mean F0 value of 127 Hz; in 62 (90%) men with atrophy it was 216 Hz and in 7 (10%) men with hypofunctional dysphonia – 225 Hz (Table 2).
Table 2Statistical Analysis of F0 Values in Diagnosed Groups
In the group of women, a statistically significant increase in the value of the Jitter parameter was recorded to 4.3 (P < 0.001), and to a lesser extent Shimmer – 11.7 (P < 0.004) and NHR – 10.7 (P < 0.003) parameters. In the group of men with atrophy, a significant increase in the values of Shimmer – 16.9 (P < 0.001) and NHR – 16.2 (P < 0.001) parameters was observed, in the lesser extent the Jitter parameter values – 1.2 (P < 0.05). In men with hypofunctional dysphonia, average values of acoustic parameters were: Shimmer – 17.1 (P < 0.01), NHR – 14.5 (P < 0.01), Jitter – 1.7 (P < 0.01) (Table 3, Table 4, Table 5).
Table 3Statistical Analysis of Jitter Values in Three Diagnosed Groups
The average value of MPT in women with larynx edema was 11 seconds, in men with atrophy – 13 seconds, with hypofunctional dysphonia – 17 seconds, average value – 15 seconds (Figure 4).
Figure 4Maximum Phonation Time (MPT) values in three diagnosed groups.
The narrowband spectrography, in the group of women, indicated the existence of numerous nonharmonic components in the low, medium and high frequencies range.
In the group of men, the presence of nonharmonic components were recorded, especially in the high frequencies range (Figure 5).
Figure 5Narrowband spectrograms in the diagnosed groups of patients (own source): (A) in a 71-year-old woman with laryngeal edema; (B) in a 65-year-old man with hypofunctional dysphonia; (C) in a 72-year-old man with vocal fold atrophy; (D) in a 35-year-old woman with a euphonic voice.
In Group II, 54 (100%) women had the mean value of F0 196 Hz; in 18 (100%) men 130 Hz (Table 2).
In Group II, in women, Jitter parameter was on average 0.4, Shimmer – 4.8, NHR – 4.8. In Group II, in men, values of acoustic parameters were: Jitter – 0.3, Shimmer – 4.6, NHR – 4.8 (Table 3, Table 4, Table 5).
The average value of MPT in women was 21 seconds, in men – 20 seconds (Figure 4).
In narrowband spectrography, harmonic and a few nonharmonic components were recorded for all frequencies in women and for high frequencies in men (Figure 5).
In Group III, in 30 (60%) women, the mean value of F0 was 230 Hz; in 20 (40%) men 141 Hz (Table 2).
In women and men, the Jitter, Shimmer and NHR parameters were normative (Table 3, Table 4, Table 5).
The mean value of MPT in women was 25 seconds; in men 22 seconds (Figure 4).
In narrowband spectrography, the presence of harmonics in the low, medium and high frequencies was recorded (Figure 5).
DISCUSSION
The aging of human body is an inevitable process that affects many organs and systems, including voice organ. The epidemiology of voice disorders in old age indicates the existence of dysphonia in as much as 30% of the population.
Only 15%–20% of them seek medical help, while others treat voice disorders as part of the natural aging process. It should be emphasized that the rapidly growing population of the elderly will be associated with the need to extend the period of their professional activity. According to Rapoport et al
the absence of voice ailments does not always exclude pathological changes in the larynx. Endoscopic and stroboscopic examination of the larynx of subjects over 74 years of age confirmed the pathology in 87% of respondents with symptoms of dysphonia and in 85% of the group without voice quality disorders symptoms.
Larynx and voice organ are characterized by individual compensatory abilities, allowing for the maintenance of good voice quality with coexisting pathological changes within the vocal organ
. Co-morbidities, including diseases of the respiratory system (bronchitis, asthma bronchiale, COPD), GERD, thyroid diseases and rheumatoid diseases may deteriorate voice quality in Presbyphonia.
Smoking and alcohol consumption further deteriorate voice quality of the elderly. No comorbidities were observed in the group of diagnosed patients. They were nonsmokers and did not abuse alcohol, without professional overload of voice. According to Gugatchka et al, the most common complaints from the vocal organ in the elderly are: hoarseness, breathiness, decreased voice intensity, increased vocal effort, roughness and fatigue of the voice.
The application of High-Speed camera (HS), acoustic analysis and Voice Handicap Index (VHI) questionnaire in diagnosis of voice disorders in elderly men.
In Group I of the diagnosed patients, hoarseness (G3) and voice roughness (R2) in women as well as breathiness of voice (B3) and its weakness (A3) in men were most often recorded with the perceptual voice assessment.
The definition of Presbyphonia has not yet been established, and the speculum image of the larynx is nonspecific.
The cause of voice disorders in elderly people are morphological changes in the larynx which concern all layers of the lamina propria of the laryngeal mucosa and mainly consist in a reduction in the number of elastic fibers and an increase in collagen fibrils, especially within the superficial layer of the lamina propria. In addition, there is a reduction in the number of blood vessels in this layer and lesser folding of the basement membrane recorded in the ultramorphological evaluation using Transmission Electron Microscopy.
using the Transmission Electron Microscopy technique, registered an increase in the number of blood vessels, fibroblasts, collagen fibrils, inflammatory cells in the stroma, and a reduction in basement membrane folding in elderly patients, which indicated the presence of edema changes in the larynx. In men, in this age group, she described a significant increase in the number of collagen fibrils, fibroblasts with features of hydrocephalic degeneration, reduction of blood vessels with multiplication of their basal membranes, and slight folding of the basal epithelial membrane, which confirmed atrophy of the vocal folds. According to Gugatschka et al,
morphological changes in the area of lamina propria regard degeneration of elastic fibrils, especially in men, and the growth of collagen fibrils in both genders. The subject of the ongoing discussion is the differentiation of morphological changes in the larynx into pathological or physiological ones related to the aging process of the organism, as these boundaries are unclear.
Due to the lack of typical symptoms of voice disorders and the pathognomonic morphological image of the larynx, many diagnostic methods are used in the diagnosis of Presbyphonia.
How does our voice change as we age? A systematic review and meta-analysis of acoustic and perceptual voice data from healthy adults over 50 years of age.
Voice perception assessment using GRBAS scale was used as a preliminary criterion in selecting examined group. In 93% of women with voice disorders, in the perceptual assessment, increased hoarseness (G3) and voice roughness (R2) were recorded. Voice asthenicity (A3) and breathiness (B3) were observed in 90% of the diagnosed men. In 93% of women with voice disorders, in the perceptual assessment, increased hoarseness (G3) and voice roughness (R2) were recorded. Voice asthenicity (A3) and breathiness (B3) were observed in 90% of the diagnosed men. Martins et al,
How does our voice change as we age? A systematic review and meta-analysis of acoustic and perceptual voice data from healthy adults over 50 years of age.
in Presbyphonia, in addition to glottal insufficiency of various degrees, in the stroboscopic examination of the larynx, an abnormal amplitude of vibrations and disturbances in the periodicity of vibrations of vocal folds are observed. In the analyzed clinical material, the most common diagnoses were vocal folds edema in women, while men were diagnosed with vocal folds atrophy and hypofunctional dysphonia using the HSDI method.
The real vibrations of vocal folds, unlike the stroboscopic illusion, may only be assessed using HSDI technique. It allows the registration of vocal folds vibrations at a speed of 4000 frames per second with the HS camera. This technique also allows an objective assessment of glottal insufficiency in the anterior, middle and posterior segment of the glottis based on the OQ value. In the diagnosed group of elderly subjects, the HSDI technique was used to visualize the larynx, assess the symmetry, synchronicity and amplitude of vibrations, the morphology of the MW and the type of glottal closure (GTs). Yamauchi et al
used the stroboscopic method and the HSDI technique in the imaging assessment of the larynx of the elderly, confirming the particular usefulness of HSDI. In the group of women diagnosed with the HSDI, asymmetry, aperiodicity of vibrations, type B of glottal closure, limitation of MW and an increase in the amplitude of vibrations, which indicated the existence of edema changes in the larynx, were recorded. The OQ value in the posterior segment of the glottis was 0.89, confirming the most severe paresis in this segment of the glottis. In the group of men, apart from asymmetry, aperiodicity, and reduction of the vibration amplitude, a clear limitation of the MW and type E of glottal insufficiency were recorded.
The lack of glottal closure in the middle segment was confirmed by the value of OQ, on average equal to 0.75. The results of the parameters indicated the existence of vocal folds atrophy in the group of diagnosed men with voice disorders (Group I). Glottal insufficiency in men after the age of 75 was described by Rosow et al
basing on stroboscopic method, recognizing it as the "gold standard" in the diagnosis of vocal folds dysfunction. Glottal insufficiency, asymmetry of MW and tremors of vocal folds were also recorded in elderly patients by Kendall
using the stroboscopic technique of larynx visualization. The atrophy of vocal folds in the elderly was also confirmed in the studies by Martins et al.
In the group of diagnosed men with voice disorders (Group I), the lack of glottal closure in the middle segment, with asymmetry and aperiodicity of vibrations, and limitation of the MW coexisted with an increase in vibration amplitude in 10% of men. The increase in the amplitude of vibrations indicated the existence of hypofunctional dysphonia. Similar parameters for the assessment of vocal folds vibration in hypofunctional dysphonia were described by Pruszewicz
, glottal insufficiency is caused not only by a reduction in the mass of vocal muscles but also by a reduction in muscle strength and tension. Both, organic and functional changes within the laryngeal structures always deteriorate the quality of voice and cause dysphonia.
An important examination allowing the assessment of the severity of dysphonia is the acoustic analysis of voice.
An increase in the mass of the vocal folds causes a decrease in the F0 value, which was recorded in the group of diagnosed women with laryngeal edema changes (Group I). The mean value of F0 decreased statistically significantly and amounted to 127 Hz. Voice frequency decrease in elderly women was also described by Martins et al.
In the diagnosed men with vocal folds atrophy and hypofunctional dysphonia, an increase in the mean F0 value was observed, respectively to 216 Hz and 225 Hz. In diagnosed men with voice disorders, an increase in the mean F0 value to 217 Hz was recorded. Voice frequency increase in elderly men was also observed by Martins et al
in elderly men with hypofunctional dysphonia. In the elderly, apart from changes in the F0 value, the pathological values of other acoustic parameters, in particular Jitter, Shimmer and NHR, are recorded.
during acoustic assessment of voice, observed the narrowing of the vocal range, tremor and changes in the Jitter and Shimmer parameters in this age group. In the diagnosed group of subjects with Presbyphonia, an increase in the Jitter parameter was recorded especially in women with laryngeal edema, whose voice was hoarse (G3) and rough (R2) on the GRBAS scale classified as G3R2B0A0S0. In group I of men with vocal folds atrophy, a significant increase in the Shimmer parameter was recorded, which in the GRBAS assessment of voice confirmed the breathiness of voice (B3). The increase of Jitter and Shimmer parameters in the acoustic assessment were described by Mezzedimi et al
in patients with Presbyphonia in comparison to young subjects. In men with glottal insufficiency in the middle segment of the glottis, confirmed by a high value of the OQ, an increase in the NHR parameter and the F0 frequency were recorded. In this group of patients, numerous nonharmonic components were observed in narrowband spectrography, especially in the high frequencies range.
In the group of elderly women with edematous changes in the larynx and glottal insufficiency in the posterior segment of glottis, a decrease in the mean value of F0 to 127 Hz was recorded, which made the female voice similar to the male voice. In women with larynx edema (Group I), values of Jitter, Shimmer and NHR parameters were significantly higher, especially Jitter. The existence of nonharmonic components in the low, medium and high frequencies was recorded with the narrowband spectrography.
According to many authors, when assessing the severity of dysphonia, it is important to determine the MPT.
It is simple test which does not require advanced equipment and brings many crucial information regarding the severity of dysphonia. In the group of diagnosed women with Presbyphonia, MPT was reduced to an average value of 11 seconds; in men up to 15 seconds. In Group II, the average value of MPT was higher – 21 seconds in women and 20 seconds in men. Similar results of MPT in the elderly was recorded by Vaca et al.
reported reduction of MPT to 12 seconds in women and 15 seconds in men over 65. In Group II of the diagnosed patients, without voice disorders, despite the lack of a statistically significant difference in the values of Jitter, Shimmer, NHR parameters in the acoustic voice test compared to Group III - control, the visualization of the larynx using the HSDI technique showed mild vibration asymmetry in 89% of women and 83% of men and the reduction of the amplitude of vibrations in 17% of men in this group. This indicates the crucial importance of the HSDI technique in the diagnosis of the clinical form of Presbyphonia.
The increase of the population of elderly will undoubtedly result in extending the period of their professional activity. The fact that the subjective lack of voice disorders does not prove the absence of pathology of the voice organ indicates an urgent need for comprehensive diagnostics of voice organ in this age group.
Voice disorders in elderly people deteriorate their functioning in the realities of everyday life, limit verbal contact with the environment, cause negative emotional attitude, which deteriorate the quality of life.
Accurate diagnosis of the clinical form of Presbyphonia guarantees the rapid implementation of therapy and rehabilitation, preventing the progression of the disease. Conservative treatment of early diagnosed edema, atrophic and hypofunctional dysphonia, physiotherapy, phonatory and breathing exercises have a positive effect by improving phonation activity of the larynx and voice quality. Late diagnosis delays the implementation of therapy and rehabilitation, favoring the development of pathology of the voice organ and disease progression.
CONCLUSIONS
The course of Presbyphonia varies individually in the elderly. In many people, the aging process does not significantly affect voice quality. The HSDI visualization technique allows objective diagnosis of the clinical form of Presbyphonia, confirming the existence of laryngeal edema changes in women and the presence of laryngeal atrophy and hypofunctional dysphonia in men. The acoustic examination of voice indicates individual variability of the severity of voice disorders in the elderly, depending on the clinical form of dysphonia determined by the gender of the diagnosed person. The HSDI visualization technique is of key importance in the diagnosis of Presbyphonia, as the acoustic assessment of the voice does not allow for unequivocal confirmation or exclusion of pathological changes in the laryngeal structures.
References
Kendall K
Presbyphonia: a review.
Curr Opin Otolaryngol Head Neck Surg.2007; 15: 137-140
The application of High-Speed camera (HS), acoustic analysis and Voice Handicap Index (VHI) questionnaire in diagnosis of voice disorders in elderly men.
How does our voice change as we age? A systematic review and meta-analysis of acoustic and perceptual voice data from healthy adults over 50 years of age.
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