Bilateral true vocal fold atrophy.
A 52-year-old computer programmer and avocational baritone complained of having a weak voice; odynophonia; decreased range, resonance, and projection; and difficulty with his passagio with voice breaks. His voice difficulties began after having a total thyroidectomy for micropapillary thyroid cancer. He declined postoperative radioactive iodine therapy and was taking thyroid hormone replacement daily.
Strobovideolaryngoscopy revealed bilateral vocal fold atrophy, glottic insufficiency, right vocal fold paresis, and muscle tension dysphonia (MTD) (figure). Laryngeal electromyography confirmed mild right superior laryngeal nerve paresis and MTD (poor relaxation at rest). Laboratory testing revealed normal thyroid-stimulating hormone, triiodothyronine (T3), and free thyroxin (T4) levels.
The patient was diagnosed with presbylaryngis because his marked vocal fold atrophy could not be accounted for by the documented mild, unilateral superior laryngeal nerve paresis. Voice therapy was recommended, and he was able to return to singing in a choir after several sessions.
The most common cause of vocal fold atrophy is aging. However, treatable causes such as paresis, menopause, and thyroiditis, as well as neuromuscular junction disorders such as myasthenia gravis, must be ruled out before attributing apparent atrophy to presbylaryngis. (1) Presbylaryngis develops from degeneration and fatty infiltration of the thyroarytenoid muscle and overlying structures. These changes are characterized by increased glycolitic metabolism, muscle fiber loss, and fragmentation of submucosal elastic fibers. (2)
Patients may present with weak and breathy phonation, an abnormally high pitch, and voice fatigue. Occasionally, dysphagia and aspiration also can be present in the setting of a systemic neurologic disease or stroke. Findings on strobovideolaryngoscopy can include soft or incomplete glottic closure, decreased vocal fold tension with bowing and sagging, and prominence of the ventricles and maculae flava.
Voice therapy alone can restore adequate muscle function in many cases. If necessary, a variety of surgical corrective options are available, ranging from vocal fold augmentation with injectable fillers or thyroplasty to arytenoid repositioning procedures for selected patients with vocal fold paralysis. (3,4)
(1.) Sataloff RT. Professional Voice: The Science and Art of Clinical Care. 3rd ed. San Diego: Plural Publishing; 2005:507.
(2.) Thomas LB, Harrison AL, Stemple JC. Aging thyroarytenoid and limb skeletal muscle: Lessons in contrast. J Voice 2008;22(4):430-50.
(3.) Sulica L, Rosen CA, Postma GN, et al. Current practice in injection augmentation of the vocal folds: Indications, treatment principles, techniques, and complications. Laryngoscope 2010;120(2):319-25.
(4.) Franco RA, Andrus JG. Aerodynamic and acoustic characteristics of voice before and after adduction arytenopexy and medialization laryngoplasty with GORE-TEX in patients with unilateral vocal fold immobility. J Voice 2009;23(2):261-7.
From the Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia.
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|Title Annotation:||LARYNGOSCOPIC CLINIC|
|Author:||Bell, Jason; DeFatta, Rima A.; Sataloff, Robert T.|
|Publication:||Ear, Nose and Throat Journal|
|Article Type:||Case study|
|Date:||Apr 1, 2015|
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