Hoarseness in the Elderly - A Simplified ENT Guide

What is Hoarseness?

Why Does the Elderly Voice Change? - Presbylaryngis

What happens to the larynx with age:

What this looks like on laryngoscopy:

• Bowing of the vocal fold edges
• Incomplete glottic closure
• Vocal fold appears yellowish or grayish and atrophic
• "Arrowhead configuration" at the glottis (prominence of the vocal process)

What the voice sounds like:

• In men (over age 50): voice rises in pitch - sounds thin, high, and reedy
• In women: fundamental frequency drops with age - voice becomes lower and rougher; worsens further after menopause due to oestrogen loss and laryngeal descent

Full Causes of Hoarseness in the Elderly

ACUTE (days to 2 weeks)

CHRONIC (> 3-4 weeks - needs ENT referral)

Clinical Evaluation - Step by Step

1. History

• When did it start? Sudden or gradual?
• Duration: acute (<2 weeks) or chronic (>3-4 weeks)?
• Getting better, worse, or fluctuating?
• Smoking and alcohol history (strong association with laryngeal cancer)
• Any dysphagia, odynophagia, hemoptysis? (Red flags for malignancy)
• GERD symptoms (heartburn, morning sour taste)
• Medications (ACE inhibitors cause chronic cough/throat clearing that mimics laryngitis; inhaled steroids cause fungal laryngitis)
• Previous surgery, intubation, radiotherapy to neck/chest
• Neurological symptoms

• Hoarseness > 3-4 weeks
• Hemoptysis + hoarseness = malignancy until proven otherwise
• Progressive dysphagia
• Weight loss
• Neck mass

2. Voice Assessment (GRBAS Scale)

• G - Grade (overall severity)
• R - Roughness
• B - Breathiness
• A - Asthenia (weakness)
• S - Strain

• Normal: >10 seconds
• Abnormal: ≤10 seconds
• Disabling: ≤5 seconds

3. Laryngeal Examination

• Indirect mirror examination is generally inadequate - use endoscopy
• Flexible transnasal laryngoscopy - well tolerated, preferred in elderly
• Rigid laryngoscopy with stroboscopy - gold standard for assessing vocal fold vibration (mucosal wave)
• Video recording allows detailed assessment and comparison over time

Management

A. Presbylaryngis (Age-related Hoarseness)

• Many patients just need reassurance after excluding malignancy
• Explain what presbylaryngis is - voice change is part of normal ageing

• Goals: build up laryngeal musculature and improve vocal control
• Vocal function exercises
• Accent method - useful for vocal fold atrophy and muscle tension dysphonias
• Voice hygiene education

• Injection into the vocal fold to bulk it up and improve glottic closure
• Materials used:
  • Calcium hydroxylapatite - good long-term results
  • Fat - less predictable results
  • Hyaluronic acid
• Can be done under local anaesthesia - suitable for elderly patients

• Framework surgery to medialise the vocal fold
• Modified bilateral thyroplasties used for presbylaryngis
• Reserved for cases failing injection and voice therapy

B. Acute Laryngitis

• Vocal rest - reduce voice use (total rest rarely needed)
• Hydration - keep vocal folds moist
• Avoid drying antihistamines (makes things worse)
• Cough suppressants
• Mucolytics
• Decongestant for nasal obstruction
• PPI/H2 blockers if reflux suspected
• Antibiotics only if bacterial cause confirmed
• Steroids only for urgent professional voice need (performance etc.)
• Resolves in 1-2 weeks

C. GERD/LPR-related Hoarseness

• Proton pump inhibitors (e.g. omeprazole 20-40 mg daily)
• Dietary modification: avoid acidic foods, caffeine, alcohol, large meals before bed
• Elevate head of bed
• Avoid lying down for 2-3 hours after eating
• Trial of treatment for 2-3 months before formal pH/impedance testing

D. Vocal Cord Paralysis

• Identify and treat the underlying cause first (rule out lung/thyroid/oesophageal cancer)
• Left-sided palsy requires urgent imaging of chest/neck
• Voice therapy - compensatory techniques
• Injection medialization - early augmentation if aspiration is a concern
• Thyroplasty type I - for permanent paralysis
• Arytenoid adduction - for large posterior glottic gap

E. Laryngeal Cancer

• Urgent ENT referral and biopsy
• Early glottic cancer (T1-T2): radiotherapy or laser microsurgery - both have excellent results
• Advanced disease: chemoradiotherapy or total laryngectomy
• Key point: Hoarseness is the EARLIEST and most important symptom of glottic cancer - this is why early referral matters

F. Hypothyroidism-related Hoarseness

• Bilateral oedematous, mobile (not fixed) vocal folds = suspect hypothyroidism
• Check TSH
• Hoarseness almost invariably resolves with thyroid hormone replacement alone

G. Spasmodic Dysphonia

• Responds poorly to voice therapy
• Botulinum toxin injection into the larynx (endoscopic or external) is the treatment of choice - weakens hyperactive muscles, effective for several months
• Repeat injections required; response may decrease over time

Summary Flowchart (Simplified)

HOARSENESS IN ELDERLY
         |
    Duration?
   /          \
< 3 weeks    > 3-4 weeks
   |               |
Conservative    ENT REFERRAL
management       urgently
(vocal rest,        |
hydration,      Laryngoscopy
PPI if reflux)      |
                    |
         ┌──────────┼────────────────┐
         |          |                |
    Normal      Vocal fold       Lesion/
    folds       bowing/atrophy   paralysis/mass
         |          |                |
  Consider      PRESBYLARYNGIS   Biopsy/Imaging
  functional    Voice therapy    Rule out cancer
  /systemic     Injection
  causes        Thyroplasty

Quick Reference - When to Urgently Refer