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Glottic characteristics of presbylarynx: Relation with vocal complaint and vocal

fold mucosal alterations

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 Glottic Characteristics and Voice Complaint
in the Elderly

*Paulo Pontes, †Alcione Brasolotto, and ‡Mara Behlau

São Paulo, Brazil

Summary: This study evaluated the relationship between voice complaint

and deviant vocal fold status with special regard to presbylarynx, in patients
aged more than 60 years, with pharyngeal-laryngeal complaint. The material
consisted of clinical histories and images obtained by laryngoscopies from
protocols from the Larynx Institute—INLAR, São Paulo, Brazil, of 210 pa-
tients, 88 men and 122 women, aged more than 60 years, who had sought
otorhinolaryngologic treatment. Indicative glottic characteristics of the presby-
larynx, such as vocal fold bowing, prominence of vocal processes, and spindle-
shaped glottic chink, were analyzed. The increase in mass, leukoplakia, and
other vocal fold alterations, distinct from these two, grouped as miscellaneous,
as well as the presence or absence of voice complaint were also analyzed.
Vocal fold bowing, prominence of vocal processes, and spindle-shaped glottic
chink showed a strong correlation among each other. The presence of presbylar-
ynx was accompanied by less voice complaint than the presence of vocal fold
mucosa alterations, which in turn are more common where an absence of
presbylarynx exists.
Key Words: Voice—Aging—Vocal fold.

INTRODUCTION ture and the functions of the larynx deteriorate with

Aging produces physiological changes that can
alter the voice. Strong evidence exists that the struc-
Accepted for publication September 20, 2004.
From the *Department of Otorhinolaryngology, Universidade
Federal De São Paulo and Instituto da Laringe, São Paulo;
†the Department of Speech Pathology and Audiology, Facul-
dade de Odontologia de Bauru, Universidade de São Paulo, São
Paulo, Brazil; ‡and the Department of Speech Pathology and
Audiology, Universidade Federal de São Paulo and Centro de
Estudos da Voz, São Paulo.
Address correspondence and reprint requests to Alcione Bra-
solotto, Department of Speech Pathology and Audiology, Facul-
dade de Odontologia de Bauru, Universidade de Sao Paulo,
Alamed Octavio Pinheiro Brisolla, 9-75, Bauru, Sao Paulo CEP:
17012-901, Brazil. E-mail: alcionebra@uol.com.br
Journal of Voice, Vol. 19, No. 1, pp. 84–94
0892-1997/$30.00
쑕 2005 The Voice Foundation
doi:10.1016/j.jvoice.2004.09.002
age. Studies with laryngoscopic methods have re-
vealed morphologic changes in the vocal folds of
the elderly, related to the vocal quality of the subject.
Vocal fold bowing and atrophy, besides the presence
of sulci and fat degeneration, are characteristics
commonly found in the larynx of elderly men. The
occurrence of vocal fold bowing plus prominence of
vocal processes results in the glottic configuration
called the “arrow point.”1,2 In older women, the
same laryngeal configuration takes place, however,
with a high incidence of edema.3 Men present a
higher percentage of vocal fold atrophy than do
women, characterized by vocal fold bowing, ventri-
cle visibility, or prominence of vocal processes con-
tours; vocal fold edema is found in a greater
percentage of women than in men.1 Senile bowing
is also attributed to connective tissue loss and muscle
atrophy, which produces a vocal fold approximation

84
 VOICE COMPLAINT IN THE ELDERLY
deficit.4 Results of studies on histologic aspects of
vocal folds in elderly subjects point to modifications
in vocal fold layers that are related to the character-
istics previously mentioned. Reduction in vocal fold
mucosa thickness is frequently described.5 The
changes in the elastic fibers of the superficial layer
of the vocal fold lamina propria are related to vocal
aging,6 with more significant changes found in men
than in women: The superficial layer of the lamina
propria becomes thicker and more edematous in men
and women; however, the intermediary layer of
the lamina propria becomes thinner in men, and the
deeper layer becomes thicker in men, with forma-
tions of fibroses; with regard to the muscle portion,
muscle fiber atrophy takes place.7 The viscoelastic-
ity of the vocal fold mucosa can change normal
phonation standards, and this change could explain
a vocal aging component.8 Histologic changes and
ossification occur earlier in men,9 and women pres-
ent more thickened vocal fold coping than do men,
with the degree of these alterations varying from
person to person.10 Studies reveal electromyo-
graphic ranges of the thyroarytenoid muscle as re-
duced in the elderly, considering that activity levels
of this muscle may contribute to the hypophonic
characteristics of the vocal disorder.11,12
During phonation another factor adds to the pre-
vious ones in elderly patients: Incomplete vocal
closing is a common finding in elderly patient evalu-
ations.1,13–15 The wheezing of the elderly voice is
often associated with atrophy and vocal fold bowing,
which is caused by changes in the elastic fibers and
collagens of the lamina proprias; however, they may
also be related to cricoarytenoid articulation alter-
ations.9,16,17 Other authors considered that cricoary-
tenoid articulation changes do not have an important
role in vocal senescence.18 Incomplete glottic clos-
ing in the elderly is also associated with vocal fold
vocal ligament modifications, which are frequent at
this age.19 The phase of vocal fold closing may
present alterations associated with aging, which
may be related to a situation involving glottic closing
insufficiency.20 A videostroboscopic evaluation
study in 46 patients with presbylarynx and 20 young
subjects observed that vocal fold bowing does not
predict glottic cleft extension, which suggests that
other changes probably contribute to incomplete
85
glottic closing, and therefore, bowing is not suffi-
cient to identify presbylarynx.21
Physiologic age may not correspond exactly to
chronologic age. Although the stereotypical voice
of the elderly is weak and trembling, in reality, this
is not a general rule. With improvements in health
and longevity, vocal deterioration can be minimized
or delayed, with those people having professional
vocal training seeming to have less evident vocal de-
terioration. We know that laryngeal aging varies
from person to person, and the endogenous and ex-
ogenous factors that participate in this result are not
totally clear. One of the factors that may interfere
in this individuality is the professional voice.22–25
Other research relates differences in vocal aging
characteristics to health conditions.26–32
Studies in the voice area are more directed toward
disorders than toward normal voice production, and
although we have some knowledge on the normal
aging process, the limit between the physiologic pro-
cess and the disease interference in voice produc-
tion by the elderly is still not well defined.33–36
Various authors point out the importance in differ-
entiating aging characteristics from pathologic con-
ditions to which the elderly are subject.35–40
However, this differentiation is difficult to do, most
especially because of the heterogeneity of the
healthy elderly person and the influence of intrasub-
ject and intersubject variability in research.36,41–43
At what point only laryngeal aging is responsible
for vocal alterations is not known, and whether
the probable vocal alterations, caused only from
aging, are noticed by the elderly to the point of
bothering them. Difficulty exists in isolating the
variables in studies on vocal aging. Even when con-
ducting a longitudinal study, not all factors that inter-
fere in aging can be identified or eliminated from
the sample.44
Vocal changes, when they occur, can produce
communication difficulties for the elderly and prob-
lems with their self-images, because the voice has
a strong personal identity meaning. Therefore, the
possibility exists of the elderly man developing la-
ryngeal behavior with phonation who tries to com-
pensate the high-pitched and unstable voice, just
as the elderly woman may try to avoid a deep,
sometimes virile voice.45
Journal of Voice, Vol. 19, No. 1, 2005
86 PAULO PONTES ET AL
It is important to know how to differentiate those
alterations that are related to structural and physio-
logic changes, a part of the aging process, from
the alterations associated with other disorders that
are more common in the elderly, but not necessarily
a part of the physiologic process of aging. This
differentiation could aid in the definition of preven-
tive and rehabilitation measures concerning vocal
alterations in this population.
The objective of this study was to evaluate the
relationship of voice complaint with vocal fold
mucosa alterations, considering those alterations re-
lated to presbylarynx, in patients aged more than 60
years, with pharyngeal-laryngeal complaint.
METHOD
The material analyzed consisted of 210 clinical
protocols, which includes clinical history and video-
tape of images obtained with laryngoscopes at the
Larynx Institute—INLAR from patients who sought
otorhinolaryngological treatment with pharyngeal-
laryngeal complaint, with the exception of the cancer
and paralysis cases. The complaints varied from
alterations in vocal quality, vocal fatigue, globus, a
squeezing sensation, phlegm, cough, reflux percep-
tion, choking, alterations in sensitivity (pain, burn-
ing, itching, dryness, pruritus), and posterior catarrh.
The average age of subjects was 67.4 years, and the
SD was at 5.94 years. The minimum age was 60
years, and the maximum age was 89 years. Of these
subjects, 88 were men aged 60 to 89 years, with an
average of 67.7 years, and 122 were women aged
60 to 86 years, with an average of 67.2 years.
For the obtaining of images, two procedures were
used, the videolaryngoscope with a rigid optic fiber or
the nasolaryngoscope with a flexible optic fiber. The
latter procedure was used on 29 subjects who
presented impediments in conducting the video
laryngoscope.
The instruments used for conducting the laryn-
goscope were a Maschida model LY-C30 rigid
telescope and a Maschida 3.1-caliber nasolaryngo-
scope; Stryker model ORTHOBEAM II 150 watt
xenon light source (Stryker Corporation, Kalama-
zoo, MI); Toshiba IK-C30 CCD system camera (Tos-
hiba Corporation, Tokyo, Japan); Panasonic model
AG-1730 videocassette (Panasonic Corporation,
Journal of Voice, Vol. 19, No. 1, 2005
Tokyo, Japan); Sony model KV-1311CR monitor
(Sony Corporation, Tokyo, Japan); TDK magnetic
tape (TDK USA Corporation, Garden City, NY).
The taped images were analyzed at normal speed,
in slow motion, and in pause mode, according to
the needs of the evaluation.
From the images obtained from laryngoscopes,
we analyzed parameters related to the glottic region
and that in this study were grouped into glottic
characteristics and vocal fold mucosa alterations.
The glottic characteristics were identified by glot-
tis modifications, in abduction as well as adduction,
such as (1) vocal fold bowing: during inhalation, the
free edge of the vocal fold assumes a bowed position,
bilaterally; (2) prominence of vocal processes:
during adduction or abduction, the arytenoid carti-
lage of the vocal process becomes more prominent
than the free edge of the membranous portion of
the vocal fold, bilaterally; (3) membranous spindle-
shaped glottic chink: characterized by the incom-
plete closing of the spindle-shaped vocal folds,
limited only to the membranous portion of the vocal
folds, with contact between the vocal processes of
the arytenoid cartilages. The vocal fold mucosa al-
terations considered include (1) increase in vocal fold
mass: diffuse increase in vocal fold mucosa, suggests
the presence of edema and that does not acquire
specific forms, such as polyps, cysts, and granulo-
mas; (2) vocal fold leukoplakia: white area, imped-
ing normal epithelial transparency and that are
stable, not changing with laryngeal movements
such as throat clearing, coughing, and phonation;
(3) vocal folds with the presence of circumscrip-
tive inflammatory processes, cysts, and minor
structural alterations. This set was denominated
miscellaneous.
The origin of these alterations was not considered
in this study because the focus is in relation to vocal
complaint with laryngeal characteristics, with the
presence of presbylarynx-type alterations or any
other alteration in vocal fold mucosa, such as edema,
that may be caused by several factors, from hor-
monal alterations to tobacco smoking, gastroesopha-
geal reflux, and allergies.
From the patient histories, information as to the
presence or absence of voice complaint was ex-
tracted. Voice complaint is understood as any refer-
ence to vocal quality change.
 VOICE COMPLAINT IN THE ELDERLY
For the quantitative study of the characteristics
analyzed that were presented by the 210 subjects aged
60 to 89 years, a comparison was conducted between
the subjects who presented and who did not present
bilateral vocal fold bowing; and among those who
presented bowing, the men were compared with
the women. The same groupings were made for those
subjects who presented and who did not present
membranous spindle-shaped chink and prominence
of vocal processes. The chi-square was the statistical
test used, whereas the significance level was consid-
ered to be 5%. We also used the Fisher exact test
for those situations in which we could not use the
previous test, with the result considered significant
when P ⬍ .05.
This study was submitted and approved by the
Ethics Committee of the Universidade Federal de
São Paulo.
RESULTS AND DISCUSSION
The presbylarynx glottic characteristics found in
the laryngeal images of the 210 subjects aged more
than 60 years and the vocal fold mucosa alterations
were analyzed for the presence or absence of voice
complaint. These characteristics were also analyzed,
taking into consideration the results found in the
groups of men and women as proposed in one of
the models to guide research on vocal aging, pro-
posed by Hollien.46
The studies on the laryngeal characteristics of
the elderly indicate that the presence of vocal fold
bowing and the prominence of vocal processes are
indications of laryngeal aging and are more evident in
men. In our study, the percentage of vocal fold
bowing was 23.8%, and of prominence of vocal
processes was 29.5%, as shown in Table 1. In other
studies,1,45,47 presbylarynx aspects were found for
vocal fold bowing and prominence of vocal pro-
cesses at much higher percentages than in our study;
however, the average age of the subjects whose
larynxes were examined in the cited works was
higher than that of this study. Furthermore, the sub-
jects whose larynxes were analyzed in our study are
subjects who sought otorhinolaryngologic treatment
with pharyngeal–laryngeal complaint and, in some
cases, with laryngeal conditions such as vocal fold
mucosa alterations that may have also contributed to
87
the reduction in the percentage of vocal fold bowing
cases. In a study on vocal fold bowing cases, of
the only 12 cases without an associated lesion, 9
were elderly.48
One important point is to understand the concept
of vocal fold bowing and membranous spindle-
shaped glottic chink. In this study, we considered
vocal fold bowing to exist when a bowed position
occurred at the free edge of the vocal fold during
inhalation (Figure 1), whereas the membranous
spindle-shaped chink is relative to glottic closing
during phonation (Figure 2), which is the type of
glottic closing expected for the age range. Although
young women present a greater incidence of poste-
rior chink, elderly women present more anterior
spindle-shaped chink.49 The incidence of incomplete
glottic closing in previous studies1,13,14 point to
higher percentages than do those found in our study.
The average ages of the participants in said studies
were higher than in ours.
Because this study was rendered uniform without
stroboscope analysis, we must consider that, in some
cases, the reference to the presence of an incom-
plete closing of the vocal folds could represent short-
ened closed time periods in the vibratory cycle,
which gives us the impression of a chink during
laryngoscopy. However, both situations can be re-
lated to the aging process, where glottis insufficiency
is of particular importance.
The presence of membranous spindle-shaped
chink occurred at higher percentages than bowing
and prominence of vocal processes (Table 1), al-
though in all statistical analyses, a strong correlation
was observed among the three characteristics of pre-
sbylarynx highlighted in this study: vocal fold
bowing, prominence of vocal processes, and mem-
branous spindle-shaped chink (Tables 2–4). The
strong correlation among the three characteristics of
presbylarynx was probably because bowing oc-
curred as a result of vocal fold layer atrophy with
a reduction of tissue. As a result, the vocal process
becomes more exposed, and consequently, when
making the approach for phonation, the vocal folds
maintain insufficient coaptation, conserving bow-
ing’s spindle shape. Other changes can contribute
to incomplete glottic closing, where only vocal fold
bowing cannot predict glottic chink extension.21
Journal of Voice, Vol. 19, No. 1, 2005
88 PAULO PONTES ET AL

TABLE 1. Occurrence of Voice Complaint, Presbylarynx Characteristics, and Vocal Fold Mucosa Alterations
in Women and Men, Among the Subjects Studied, With the Respective Percentages
Women (n ⴝ 122) Men (n ⴝ 88) Total (n ⴝ 210)
Data Frequency % Frequency % Frequency % c2
VC 74 60.7 60 68.2 134 63.8 1.25
VFB 24 19.7 26 29.5 50 23.8 2.75
PVP 33 27.1 29 33.0 62 29.5 0.86
MSC 45 36.9 34 38.6 79 37.6 0.6
VFMI 35 28.7 6 6.8 41 19.5 15.55*
VFL 4 3.3 11 12.5 15 7.1 6.55*
M 15 12.3 18 20.5 33 15.7 2.57

Abbreviations: VC, voice complaint; VFB, vocal fold bowing; PVP, prominence of vocal processes; MSC, membranous spindle-
shaped chink; VFMI, vocal fold mass increase; VFL, vocal fold leukoplakia; M, miscellaneous.
*Statistically significant.

TABLE 2. Comparison Among Subjects Who Presented and Who Did Not Present Vocal Fold Bowing as to the
Occurrence of Voice Complaint, Presbylarynx Characteristics, and Vocal Fold Mucosa Alterations, With the
Respective Percentages
Presence (n ⴝ 50) Absence (n ⴝ 160)
Data Frequency % Frequency % Statistics
VC 24 48 110 68.8 χ ⫽ 7.10*
2

PVP 37 74 25 15.6 χ2 ⫽ 62.39*

MSC 27 54 52 32.5 χ2 ⫽ 7.46*
VFMI 3 6 38 23.8 χ2 ⫽ 7.63*
VFL 1 2 14 8.6 P ⬎ .10
M 1 2 32 20.0 χ2 ⫽ 9.38*

Abbreviations: VC, voice complaint; VFB, vocal fold bowing; PVP, prominence of vocal processes; MSC, membranous spindle-
shaped chink; VFMI, vocal fold mass increase; VFL, vocal fold leukoplakia; M, miscellaneous.
*Statistically significant.

TABLE 3. Comparison Between Those Subjects Who Presented and Who Did Not Present Prominence of Vocal as
to the Occurrence of Voice Complaint, Presbylarynx Characteristics, and Vocal Fold Mucosa Alterations, With the
Respective Percentage
Presence (n ⴝ 62) Absence (n ⴝ 148)
Data Frequency % Frequency % Statistics

VC 39 62.9 95 64.2 χ ⫽ 0.03

2

VFB 37 59.7 13 8.8 χ2 ⫽ 63.3*

MSC 41 66.1 38 25.7 χ2 ⫽ 30.48*
VFMI 5 8.1 36 24.3 χ2 ⫽ 7.34*
VFL 2 3.2 13 8.8 P ⫽ .12
M 1 1.6 32 21.6 χ2 ⫽ 13.19*

Abbreviations: VC, voice complaint; VFB, vocal fold bowing; PVP, prominence of vocal processes; MSC, membranous spindle-
shaped chink; VFMI, vocal fold mass increase; VFL, vocal fold leukoplakia; M, miscellaneous.
*Statistically significant.

Journal of Voice, Vol. 19, No. 1, 2005

 VOICE COMPLAINT IN THE ELDERLY 89

TABLE 4. Comparison Between Subjects Who Presented and Who Did Not Present Membranous Spindle-Shaped
Chink, as to the Incidence of Voice Complaint, Presbylarynx Characteristics, and Vocal Fold Mucosa Alterations,
With the Respective Percentages
Presence (n ⴝ 79) Absence (n ⴝ 131)
Data Frequency % Frequency % Statistics
VC 52 65.5 82 62.6 χ2 ⫽ 0.22
VFB 27 34.1 23 17.6 χ2 ⫽ 7.50*
PVP 41 51.9 21 16.0 χ2 ⫽ 30.48*
VFMI 10 12.6 31 23.7 χ2 ⫽ 3.79(*)
VFL 3 3.8 12 9.2 χ2 ⫽ 2.14
M 17 21.5 16 12.2 χ2 ⫽ 3.23

Abbreviations: VC, voice complaint; VFB, vocal fold bowing; PVP, prominence of vocal processes; MSC, membranous spindle-
shaped chink; VFMI, vocal fold mass increase; VFL, vocal fold leukoplakia; M, miscellaneous.
*Statistically significant.

One cause of the greater incidence of spindle-
shaped glottic chink in comparison with other as-
pects of presbylarynx being analyzed may have been
caused by the presence of vocal fold alterations
included in the miscellaneous category that, al-
though low in percentage, may have contributed
to the total number of spindle-shaped chink ob-
served. To exemplify, we can cite the vocal fold sulcus
found in 6 subjects in this study, with this being an
alteration with frequent presence of vocal fold
bowing during phonation.47
One issue that stands out is whether the character-
istics that refer to the presbylarynx can be manifested
in a higher or lower degree in the various age groups;
this aspect was not contemplated in this study, but
we cannot eliminate the possibility of a greater con-
tribution in understanding the presbylarynx if studies
are carried out concerning the dynamics involved
in the aging process.
Many studies on vocal fold characteristics of the
elderly point to edema as a common finding predom-
inately in women.10 In our study, a marked difference
was found between men and women; with 122 of
the laryngeal images of women, 28.7% presented
an increase in vocal fold mass, and among the 88
laryngeal images of men, 6.8% presented an increase
in mass (Table 1). This occurrence of an increase in
vocal fold mass registered in our study includes
the cases of tunic mucosa volume increases that
characterize and do not characterize Reinke edema.
The studies on women’s larynx and voice changes
over time greatly explore the changes related to
menopause.50 The most notable moment of funda-
mental frequency reduction in the woman’s voice
occurs when the woman has completed meno-
pause.51 Studies on the elderly women’s voice
frequently associate edemas to the reduced funda-
mental frequency findings in comparison with
younger women.52–58 Some studies compare the fun-
damental frequency of women aged more than 60
years, and no differences are found in women beyond
that age.2,55,59.60 The association of the increase in
vocal fold volume with the female gender was nota-
ble in our study (Tables 1–4).
With the exception of Benjamin,52 who found no
difference between the fundamental frequency of
young men when compared with elderly men,
most literature on the topic indicates an eleva-
tion of the fundamental frequency in elderly
men.2,29,53,55,57,58,61,62
As can be observed in Table 2, a greater occur-
rence of vocal fold mass increase took place with the
absence of bowing than with the presence. Although
statistical analysis did not reveal significance in the
case of leukoplakia, probably because of the reduced
value of the absolute number, we can observe that
evidently a greater occurrence of said lesion took
place in the group without bowing than in the group
with bowing (Figure 3 and 4), or 14 to 1, respec-
tively. This fact may be caused by the reduced
contact provided by vocal fold bowing, thus reducing
the possibility of lesion by attrition. In the case of
mass increase, the edema that is present may fill in
the bowing space, thus tending to rectify the vocal

Journal of Voice, Vol. 19, No. 1, 2005

90 PAULO PONTES ET AL
TABLE 5. Voice Complaint Occurrence in Relation to Presbylarynx Characteristics, as to Gender
Women
Data Frequency
VFB (Women ⫽ 24/Men ⫽ 26) 7 29.0
PVP (Women ⫽ 32/Men ⫽ 29) 17
MSC (Women ⫽ 45/Men ⫽ 34) 29
Abbreviations: VFB, vocal fold bowing; PVP, prominence of vocal processes; MSC, membranous spindle-shaped chink.
*Statistically significant.
fold, and not making the bowed configuration evi-
dent (Figures 5 and 6). The probable hydration
conditions as a result of laryngeal mucosa gland
atrophy may predispose the vocal folds to greater
attrition,63,64 which in turn may increase the inci-
dence of lesions. Also, other vocal fold alterations
placed in the miscellaneous group occurred in sta-
tistically greater percentages among subjects with-
out vocal fold bowing.
Observing Table 4, we can ascertain that the oc-
currence of mass lesions is greater in the absence of
prominence of vocal processes than in the presence
of this presbylarynx characteristic. When groups
with and without membranous spindle-shaped chink
were compared, however, despite the observance of
a greater incidence of lesions in the absence of the
chink, it was not statistically significant, although
it is a strong tendency in the case of mass increase.
This result may have been because the spindle-shaped
chink presented a higher incidence than the vocal
fold bowing, thus being present in other situations
besides presbylarynx. Leukoplakia showed a strong
association with subjects of the male gender,
whereas vocal fold mass increase was associated with
subjects of the female gender. It is still necessary
to examine these changes in the elderly in more
detail, especially considering conditions such as gas-
troesophageal reflux, tobacco, and other factors that
attack vocal fold mucosa in the diverse age groups
and genders.
Although many factors may contribute to the inci-
dence of mucosa alterations, such as leukoplakia,4
from our results, we can observe that, in a way, the
presence of presbylarynx may protect the elderly
from vocal fold mucosa alterations, which seem to
cause more negative consequences than vocal aging.
Journal of Voice, Vol. 19, No. 1, 2005
Men
% Frequency % Statistics
17 65.3 χ2 ⫽ 6.56*
51.5 22 75.9 χ2 ⫽ 3.91*
64.4 23 67.6 χ2 ⫽ 0.08
Now analyzing the factors that related to the pres-
ence or absence of voice complaint, we can affirm
that the high percentage of voice complaint within the
studied group is justified because it was composed of
subjects with pharyngeal-laryngeal complaints who
had sought an otorhinolaryngologist. However, anal-
ysis results of the presence of voice complaint with
the vocal fold bowing characteristic, typical of pre-
sbylarynx, reveal greater incidence of voice com-
plaint in the absence of said characteristic than in
the presence. Contradictorily, vocal fold bowing is
cited as the greatest cause of hoarseness in the el-
derly, where it was also proven that subjects with
bowing presented higher jitter rates.34 In our study,
the greater occurrence of voice complaint in the
absence of bowing is probably because in the ab-
sence of vocal fold bowing, vocal fold mucosa alter-
ations occurred; the elderly presented statistically
more vocal fold mucosa alterations in the presence
of voice complaint than in its absence.
Two main types of vocal fold changes are associ-
ated with aging: vocal fold atrophy, associated with
the reduction in volume and elasticity of the vocal
folds, which is more evident in men, causing an
elevation in fundamental frequency; and polypoid
degeneration, more common in women, which causes
the deepening of the voice; although both types of
alterations may be present in both sexes, only men
with bowing and women with polypoid degenera-
tion complained about their voices.44 In our study,
we observed statistical relevance for men who pre-
sented more voice complaint in the presence of vocal
fold bowing than for women; when we analyzed
the 62 cases that presented prominence of vocal
processes, we found that men with prominence pre-
sented statistically more voice complaint than did
women (Table 5).
 VOICE COMPLAINT IN THE ELDERLY
FIGURE 1. Vocal folds bowing and prominence of vocal pro-
cesses during inhalation.
FIGURE 2. Spindle-shaped glotic chink.
Also, the presence of voice complaint depends
on the need persons have for their voice. It is ex-
pected that persons who begin to manifest some
voice change, when the same is used professionally,
and they need the voice in optimal conditions,
they will present a complaint.65
Although the occurrence of incomplete glottic
closing in the elderly takes place, no alterations in
airflow occur when compared with the youth.66
On the other hand, less laryngeal resistance was found
in the elderly than in the young adult.67 Airflow
reduction is found in various studies involving respi-
ratory and phonation measures in the elderly.58,68,69
91
FIGURE 3. Vocal fold leukoplakia—inhalation.
FIGURE 4. Vocal fold leukoplakia—phonation.
Nonrelevant voice complaint in the presence of
chink may also be caused by the slow installation
of chink in the elderly and the reduction in airflow,
thus not generating dysphonia, as in the youth.
Although we observe that a smaller incidence of
voice complaint occurred in the presence of vocal
fold bowing, the contrary occurred in the presence
of mass increase and leukoplakia.
In our study, we found no great incidence of
voice complaint related to presbylarynx. However,
we know that the stereotypical voice of the elderly
exists, which can be confirmed by the results of the
studies that investigate the judging of age by means
Journal of Voice, Vol. 19, No. 1, 2005
92 PAULO PONTES ET AL
FIGURE 5. Vocal fold mass increase—inhalation.
FIGURE 6. Vocal fold mass increase—phonation.
of auditory perception of the voices of the speakers. In
general, this estimation is accurate, although inter-
ference may occur from the age of the listeners.70
Various studies reinforce the presence of this stereo-
type, especially those that showed that the associa-
tion of voices with more advanced age groups was
related to the characteristics of greater vocal instabil-
ity.71–75 That listeners associate more disagreeable
voices with older speakers is what most reinforces
the stereotypical voice of the elderly.76
We can observe that the vocal fold lesions are
more present in the absence of the typical presbylar-
ynx image, and that the lesions result in much more
Journal of Voice, Vol. 19, No. 1, 2005
voice complaint than does presbylarynx. This result
is expected when studying a population from an
otorhinolaryngology clinic. However, the correla-
tion findings among the presbylarynx characteristics,
vocal fold mucosa alterations, and voice complaint
increased knowledge that may aid in understanding
the laryngeal and voice characteristics of the elderly.
Even when faced with so many difficulties to
conduct studies that clear up these differences be-
tween the aging process and the pathologic pro-
cesses, at times so subtle, each study that brings
new information aids in the comprehension of el-
derly voice manifestations and orients more effective
care to help this population have a better communi-
cation, whatever the need for the voice. The vocal
need and interest of the person interferes in treatment
conduct and voice improvement.77
CONCLUSIONS
The analysis of the glottic characteristics of the
210 laryngeal images of persons aged more than
60 years allowed us to conclude that the indicative
characteristics of presbylarynx such as prominence of
vocal processes, membranous spindle-shaped glottic
chink during phonation, and vocal fold bowing
during inhalation were not related to voice com-
plaint; vocal fold lesions were more common in the
absence of presbylarynx and were responsible for
voice complaint.
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