Auris Nasus Larynx 37 (2010) 461464

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Clinical analysis of presbylarynxVocal fold

atrophy in elderly individuals
Shingo Takano a,b,*, Miwako Kimura d, Takaharu Nito b, Hiroshi Imagawa b,
Ken-Ichi Sakakibara c, Niro Tayama b,d
a
Department of Otorhinolaryngology, Takeda General Hospital, Fukushima, Japan
b
Department of Otorhinolaryngology-Head & Neck Surgery, University of Tokyo, Tokyo, Japan
c
Department of Communication Disorder, Health Sciences University of Hokkaido, Hokkaido, Japan
d
Ear-Nose-Throat Department, International Medical Center of Japan, Tokyo, Japan
Received 19 May 2009; accepted 30 November 2009
Available online 28 December 2009

Abstract

Objective: The proportion of elderly Japanese is increasing significantly and aging society greatly influences the medical services. The number
of elderly patients who visited out Voice Outpatient Clinic has been increasing in recent years. The aim of the present study was to analyze the
trend in the number of patients with aging-related vocal fold atrophy, and to assess the characteristics of senile change of vocal function.
Methods: A retrospective review of the 19992005 medical records of patients aged 65 years was conducted, and patients with
presbylarynx were analyzed. We evaluated age, sex, occupation, maximal phonation time (MPT), and mean airflow rate (MFR) during
comfortable phonation to assess the physiological characteristics of senile change of vocal function. We compared MFR of presbylarynx with
those of normal elderly person.
Results: The number of patients aged 65 who visited our clinic in the 7-year study period was 361, and 72 (20%) were diagnosed with vocal
fold atrophy. They included 47 (65%) men and 25 (35%) women, with a mean age of 71 years (range, 6589). Among these patients, 27 (38%)
were still employed at the time of consultation, while 17 (24%) were retired, at least 26 jobs required voice skills; and 15 patients (21%) were
involved in singing and recitation of poems. MPT correlated negatively with age, while MFR correlated positively with age.
Conclusion: The number of elderly patient with vocal fold atrophy increased gradually almost every year. The male patients account for 65%.
Thirty-three percent of patient of the present study with presbylarynx were still in the workforce. MFR correlated positively and significantly
with age. MFR was higher in presbylarynx than normal elderly person.
# 2009 Elsevier Ireland Ltd. All rights reserved.

Keywords: Presbylarynx vocal fold atrophy; Maximal phonation time (MPT); Mean airflow rate (MFR); Aging society

1. Introduction in 2004, the percentage will rise to 30% of Japans

Mainly in the developed countries, the society is aging
significantly in the late twentieth and the early twenty-first
century. Especially in Japan, the average life expectancy is
the longest in the world, and the percentage of elderly person
(65 and over) in 2005 was the highest (20%, equal to Italy).
Furthermore, according to UN. World Population Prospects
* Corresponding author at: Department of Otolaryngology, Takeda Gen-
eral Hospital, 3-27 Yamaga-machi, Aizuwakamatsu, Fukushima 965-8585,
Japan. Tel.: +81 242 27 5511; fax: +81 242 27 5670.
E-mail address: shingo7@pop06.odn.ne.jp (S. Takano).
population by 2030. The population pyramid by Annual
Report on the Aging Society in 2005 shows that will reverse
in 2050, i.e., the elderly population is increasing while the
younger population is decreasing at an incredible pace.
At the Department of Oto-rhino-laryngology and Head &
Neck Surgery, the University of Tokyo Hospital (Tokyo,
Japan), the number of elderly patients who visit the Voice
Outpatient Clinic has been increasing in recent years. The
proportion of patients aged 65 and over has been increasing in
the last 20 years. For example, this rate was 30% of the entire
patients in 2005, compared with 20% in 2000, 13% in 1995,
and 9% in 1985 (Fig. 1). These patients suffer from various

0385-8146/$ see front matter # 2009 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.anl.2009.11.013
462 S. Takano et al. / Auris Nasus Larynx 37 (2010) 461464

Fig. 2. Changes in the number and proportion of elderly patients with

Fig. 1. Changes in the number and proportion of elderly patients with
phonatory disorders in the last 7 years.
phonatory disorders.

voice disorders, but patients with presbylarynx, age-related women. Fig. 3 shows changes in the number of patients with
dysphonia, visiting the clinic may have been increasing vocal fold atrophy and recurrent nerve paralysis (RNP) in
recently. The aim of the present retrospective study was to the last 7 years. Although the number of total elderly patient
characterize patients who present with presbylarynx, aging- and RNP patient varied during this period, those with
related vocal fold atrophy, to analyze the trend in the number presbylarynx increased gradually almost every year.
of patients with presbylarynx, and to assess the characteristics Among these patients, 27 (38%) were employed at the time
of senile change of vocal function. of consultation, 23 men and 4 women, while 28 (39%) patients
were retired, 24 men and 4 women. At least 26 jobs required
voice use (e.g., school or kindergarten teacher, manager or
2. Materials and methods executive of a company). The voice complaint greatly
influenced the singing capability of the patients. Fifteen
A retrospective review was conducted of patients aged 65 (21%) patients participated in hobby groups of singing and
years who underwent video laryngeal stroboscopy for poetry, and the occupation of 5 patients were related to
dysphonia at Voice Outpatient Clinic between 1999 and singing, e.g., chorus instructor and member of a choir.
2005. The medical records of patients who were diagnosed The mean MPT was 17 s (range, 3.934.5 s). MPT
with presbylarynx were obtained and their data analyzed. correlated negatively and significantly with age (P < 0.05,
Presbylarynx was diagnosed by several otorhinolaryngolo- Fig. 4). The mean MFR was 224 ml/s (range, 49.3837 s).
gists with subspeciality in voice treatment. The patients aged MFR correlated positively and significantly with age
65 years who had vocal fold bowing and incomplete closure (P < 0.05, Fig. 5).
in stroboscopic images were diagnosed with presbylarynx.
Patients with chronic laryngeal diseases such as recurrent
nerve paralysis, sulcus vocalis, vocal fold polyp, and laryngeal 4. Discussion
tumor were excluded. The maximum phonation time (MPT)
was calculated for the entire group. The mean airflow rate Vocal fold problems are common among the elderly.
(MFR) in comfortable phonation was measured by using Many patients suffered from various phonation disorders
Phonatory Function Analyzer PS-77E: Nagasima Medical associated with age-related changes in the vocal folds.
Instruments Co., to assess the physiological characteristics of Aging is associated with changes in voice quality including
voice of elderly people. Correlations between MPT and age breathiness, weakness, tremulousness, hoarseness, inability
and MFR were examined by linear regression analysis. to sustain phonation, and inadequate loudness level. These
changes in sound quality are thought to be the result of
Table 1
3. Results
Age distribution of patients with presbylarynx.
Age Patients of presbylarynx
The medical records of 361 patient aged 65 years who
visited Voice Outpatient Clinic over a 7-year period were Male Female Total
collected. The numbers of total and 65 patient varied 6569 16 12 28
during this period, but the rate of elderly patient increased 7074 13 7 20
7579 16 4 20
gradually almost every year (Fig. 2). Among the patient aged 8084 1 1 2
65 years, 72 (20%) were diagnosed with vocal fold 8590 1 1 2
atrophy. The median age of the group was 71 years (range,
Total 47 25 72
6589, Table 1). They included 47 (65%) men and 25 (35%)
 S. Takano et al. / Auris Nasus Larynx 37 (2010) 461464 463

anatomical and functional changes of the larynx associated

Fig. 3. Changes in the number of patients with vocal fold atrophy and
recurrent nerve paralysis (RNP) in the last 7 years.
Fig. 4. Correlation between age and MPT for patients with presbylarynx.
Fig. 5. Correlation between age and MFR for patients with presbylarynx.
with the aging process [13]. The incidence of vocal fold
atrophy identified in the present study (20%) is similar to
that reported by Lundy et al. [4] (19%) but is higher than the
4% reported by Woo et al. [5].
Presbylarynges is typically a diagnosis of exclusion made
in the absence of other laryngeal diseases in elderly patients
with weak, breathy, or hoarse voice [1,5]. Vocal fold bowing,
atrophy and incomplete vocal fold closure are common
findings in the larynx of elderly patients [2,3,6]. Senile
bowing is also attributed to connective tissue loss and
muscle atrophy, which produces vocal fold deficit. Changes
in extracellular matrices of the superficial layer of the vocal
fold lamina propria, such as elastic and collagenous fibers,
are related to vocal aging [2,79]. These changes are related
to vocal fold vibration.
The proportion of patients aged 65 and over has been
increasing in the last 20 years; 9% in 1985, 13% in 1995,
20% in 2000, and 30% in 2005 (Fig. 1). According to UN,
World Population Prospects in 2004, the percentage of
elderly person (65 and over) in each years were 11% in 1985,
15% in 1995, 17% in 2000, and 20% in 2005. The rates of
elderly patients and elderly population were almost equal
from 1985 to 2000, but the rate of elderly patient showed
marked increase more than that of elderly population. The
number of elderly patients has increased in the last two
decades, but in the limitation of the last 7 years, this number
has fluctuated. Although the number has changed during this
period, the number of cases with vocal fold atrophy has
increased almost every year (Fig. 3).
These data suggest that the rise in the number of
presbylarynx will parallel the increase in the proportion of
elderly people. Furthermore, in the era of the Aging Society,
elderly people are actively involved at their work or hobby, and
that could entail increased demand for improvement of their
voice. The age of forced retirement in Japan is 6065 years.
Therefore, the fact that 38% of patient of the present study with
presbylarynx were still in the workforce is remarkable.
It is reported that MFR is an objective parameter of voice
function [10,11] and has correlation with degree of vocal
fold bowing [12]. In this report, the mean value of MFR was
224 ml/s, 254.3 ml/s in men and 166.1 in women (Table 2).
According to previous reports, the mean values of MFR
of normal elderly males and females (age, 7079 years) were

Table 2
MFR (comparison between presbylarynx patients and normal elderly person, aged 6069 years and aged 70 years).
Author n Mean Mean S.D. Mean + S.D. P (Students t-test)
MFR male
Makiyama et al. [12] (60 2 age < 70) 27 166.4 130.8 202 P < 0.001
Makiyama et al. [12] (age 3 70) 29 169.5 139.5 199.5 P < 0001
Takano 47 254.3 123 385.6
MFR male
Makiyama et al. [12] (60 2 age < 70) 28 139.6 108.5 170.7 P > 0.05
Makiyama et al. [12] (age 3 70) 26 133.2 108.2 158.2 P < 0.05
Takanu 25 166.1 102.5 229.7
464 S. Takano et al. / Auris Nasus Larynx 37 (2010) 461464
Table 3
MFR (male and female with presbylarynx).
Sex n Mean
MFR male vs. female
Male 47 254.3
Female 25 166.1
169.5 and 133.2 ml/s, respectively, and those data of age 60
69 years were 166.4 and 139.6 ml/s, respectively (Table 2)
[12]. There was significant difference in MFR between
normal elderly persons and patients with presbylarynx,
excluding one report of female age 6069 years (unpaired
Students t-test, Table 2). Specifically, the MFR was higher
in presbylarynx than normal elderly person, especially in
men. In the past records, most of patients with presbylarynx
were men [2,3,6]. Equally, male patients accounted for 65%
of the total number of presbylarynges in this study.
Furthermore, there was statistical difference in MFR
between men and women, men have larger MFR than
women (unpaired Students t-test, Table 3). It is expected
that men tends to be more affected by age-related atrophic
change than women.
Our study showed that both MPT and MFR correlated with
age in patients with presbylarynx. It is anticipated that vocal
fold atrophy progresses with age and the number of elderly
people who will present with hoarseness will increase in the
future. MPT is an important parameter of vocal function
[10,11], but it is closely related to the ventilation or lung
volume [4,5]. Although incomplete vocal fold closure causes
shorter MPT, MPT itself may be inadequate for a parameter
that represents glottis closure. Evaluation of changes in vital
capacity associated with aging is needed for more accurate
analysis of vocal fold atrophy. On the other hand, MFR is an
objective voice measure of glottic closure. There is a tendency
that older patients with presbylarynx have severer symptom.
These glottic measures can help evaluate characteristics of
vocal fold atrophy. Further study is needed to access the
relation between aging and progress of presbylarynx.
5. Conclusion
The number of elderly patient with vocal fold atrophy
increased gradually almost every year. The male patients
account for 65%. Thirty-three percent of patient with
presbylarynx were still in the workforce. MFR was higher in
Mean S.D. Mean + S.D. P (Students t-test)
123 385.6 P < 0.05
102.5 229.7
presbylarynx than normal elderly person. MFR correlated
positively and significantly with age.
In the era of the Aging Society, a large number of elderly
people might require improvement of their voice. As the
number of patients with presbylarynx is increasing, medical
treatment of vocal fold atrophy should become more
important from now on. Further studies are needed to
characterize vocal fold atrophy in presbylarynx for accurate
diagnosis and proper treatment.
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