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Advancing age produces physiologic changes that may alter voice. Some of these changes are inevitable; others may be avoidable or reversible. In addition, many treatable medical conditions may cause voice changes similar to those of aging. It is essential that all voice care providers be familiar with the expected changes of aging, and be alert to reversible conditions that may adversely affect phonation and be mistaken for presbyphonia.

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New insights into the anatomy and physiology of phonation, along with technological advances in voice assessment and quantification, have led to dramatic improvements in medical voice care. Techniques to prevent vocal fold scar have been among the most important, especially scarring and hoarseness associated with voice surgery. Nevertheless, dysphonia due to vocal fold scar is still encountered all too frequently. Although it is not generally possible to restore such injured voices to normal, patients with scar-induced dysphonia can usually be helped. Voice improvement is optimized through a team approach. Treatment may include sophisticated voice therapy and vocal fold surgery. Although experience with collagen injection has been encouraging in selected cases (particularly in those involving limited areas of vocal fold scar), there is no consistently successful surgical technique. Attempts to treat massive vocal fold scar, such as may be seen following vocal fold stripping, have been particularly unsuccessful. This paper reports preliminary experience with the implantation of autologous fat into the vibratory margin of the vocal fold of patients with severe, extensive scarring. Using this technique, it appears possible to recreate a mucosal wave and improve voice quality. Additional research is needed.

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Strobovideolaryngoscopy has proven essential to accurate diagnosis of voice disorders. Clinical interpretation of stroboscopic images usually follows a standard assessment protocol. Features analyzed typically include symmetry of amplitude, symmetry of phase, regularity of periodicity, amplitudes and wave forms of individual vocal folds, presence or absence of adynamic segments, and other features. Speed and smoothness of abduction and adduction are also assessed. In order for stroboscopic data to be used meaningfully in a clinical setting, it is essential for the laryngologist to recognize the range of normal variability of these parameters. This may be particularly important when trying to establish diagnoses for subtle voice disorders in professional voice users. This study investigates strobovideolaryngoscopic findings in a population of normal professional singers without voice complaints. "Abnormal" strobovideolaryngoscopic findings occur in this asymptomatic population of "volunteers." These abnormalities might have been misinterpreted as causing voice complaints if seen for the first time when the singer sought medical care for a voice problem. Physicians must be aware of the range of laryngeal behavior that may be found among normal subjects and must be cautious when interpreting strobovideolaryngoscopic findings. This study also highlights the importance of obtaining "normal" baseline strobovideolaryngoscopic evaluations on professional voice users. The review of strobovideolaryngoscopy performed upon 65 healthy, asymptomatic professional singers revealed an incidence of 58% "abnormal" findings as six clinical entities.

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The single-photon-emission computed tomography (SPECT) scan enables clinicians to probe dynamic and metabolic changes in brain tissue through measurement of regional cerebral blood flow (rCBF). Diagnostic benefits of the SPECT scan in clinical neurology have been demonstrated. SPECT scanning has been shown to be more sensitive than morphologic imaging techniques [magnetic resonance imaging (MRI) and computed tomography (CT)] in many conditions. However, the use of the scan in assessing neurotologic complaints remains inadequately investigated. Few studies have explored the value of SPECT in establishing the causes of dizziness, hearing loss, and tinnitus. We studied SPECT along with MRI, CT scan, electroencephalogram (EEG), and other evaluations in patients with these neurotologic complaints, SPECT abnormalities were more frequent and prominent than those visualized by other imaging modalities. Overall, 78% of SPECT scans revealed abnormalities. Abnormalities were found in 46% of MRIs, 40% of CTs, and 29% of EEGs. The disparity between SPECT scanning and other procedures was also seen once patients were divided by their chief complaints. This study illustrates the sensitivity of SPECT scanning in evaluating neurotologic complaints and highlights the need for additional research into the importance of SPECT scanning in comprehensive neurotologic evaluation.

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Superior laryngeal nerve paresis and paralysis are relatively common but often difficult to diagnose with certainty. They are most commonly caused by viral infections, though other etiologies must be considered. A thorough history and physical examination, including strobovideolaryngoscopy and laryngeal electromyography, are needed for definitive diagnosis. It is essential to establish the diagnosis accurately to differentiate an apparent superior laryngeal nerve paresis from other conditions, such as myasthenia gravis. Laryngeal electromyography is used to confirm clinical impressions, as a guide for therapy, and as one measure of recovery. In our experience, accurate and early diagnosis assure the best phonatory outcome by directing therapy that will prevent or eliminate compensatory vocal abuses, which may themselves lead to even more serious vocal injury.

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Vocal fold surgical technique has advanced substantially because of increased knowledge regarding anatomy and physiology of phonation and because of technological improvements. However, many new techniques have been based on anecdote and "common sense," largely because there is no good experimental model for vocal fold surgery since the human is the only species with a vocal ligament. Consequently, our earlier pronouncements require careful reexamination especially as new research adds to our fund of knowledge. Review of the principles and results of laryngeal microflap surgery suggests that there may be important shortcomings in the technique. A new mini-microflap technique appears better, as does limited mucosal resection. This is a preliminary report, and further investigation is needed.

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Radiation therapy is effective in the treatment of various tumors of the head and neck. Clinical practice and published literature reveal contradictory opinions regarding the incidence, type, severity, and time of onset of hearing loss as a complication of radiation therapy. Review of animal and human studies highlights the paucity of scientifically defensible information. The available literature appears to support the contention that otitis media and sensorineural hearing loss can occur as complications during, or shortly following radiation therapy. However, there is little or no convincing evidence to support the notion that hearing loss developing several years following radiation is causally related to radiation therapy. Additional research is needed.

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