The voice quality in prebysphonia is conditioned by morphological changes in the vocal folds mucosa. The studies including light microscopy and transmission electron microscopy (TEM) revealed changes within the basal membrane epithelium and the stroma of the vocal folds mucosa. Age-related changes in thickness of the epithelium and direction of the basal membrane, increased number of collagenous fibres (C) and fibroblasts and chronic inflammatory process in the stroma were found. Vacuolated and keratinised epithelial cells, enlarged extracellular spaces and numerous blood vessels confirm the edematous form of prebysphonia. Thinned epithelium with signs of hyalinization, inflammatory infiltrations in the stroma with numerous collagenous fibres and small number of blood vessels indicate atrophy of the vocal folds mucosa. Edematous and atrophic changes in the vocal folds mucosa are most frequently reported form of prebysphonia

Andrzejewska, Anna

Kosztyla-Hojna, Bozena

Rogowski, Marek

Rutkowski, Ryszard

English

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IntroductionAgeing of a human being is a biological process andan unpreventable fate [17]. The senile age is relatedto a decreased efficiency of the organism [5,8,15,18].The voice organ, as well as other elements of thehuman body, is submitted to the ageing process,which begins around the age of 60 and takes an indi-vidual course [15]. The voice disturbances in the eld-erly are named the senile voice, vox senium or pre-bysphonia. According to many authors prebysphoniais conditioned by involutional changes in CNSaccompanied by endocrine, pulmonary and anatomi-cal changes in the larynx and throat mucosa[1,15,19,20]. According to Bennett, Klajman andMorrison et al. [2,3,9,13] larynx changes in the senileage should be termed as the polypomatous degenera-tion or atrophy. Pruszewicz [14,15] claims that thesenile hypokinematic dysphonia is caused by adecreased tension in the vocal folds which results ina hourglass-shaped phonatic insufficiency of the glot-tis due to a decreased tension of the vocal and thearytenoideus transversus muscles. The vocal foldsoedema is known as  the polypoid degeneration or theReinke's edema. The condition is a particular varietyof the chronic inflammation of the larynx whichdevelops on the glottis level [4,12,19,20]. The etiolo-gy of the Reinke's edema arise from accumulation ofa fluid in the supraepithelial space due to permeabil-ity of the blood vessels and formation of an exudate[4,10,11]. The most frequent incidence of the diseaseis in the IV decade of life and does not affect youngpeople. According to Abrams, Pruszewicz andZalesska-Krêcicka [1,15,19,20] a frequent larynxpathology in the elderly is a degenerative larynxinflammation which is accompanied by atrophy ofthe tunica muscularis, metaplasia of the epithelium,atrophy of the connective tissue and the glandular tis-sue. Morphological transformation in the larynxresults in disturbances of the voice quality and manysubjective complaints in the elderly.The aim of this study was a morphological assess-ment of the vocal folds mucosa in the elderly coexist-ing hypoharynx cancer with the use of lightmicroscopy and transmission electron microscopy.FOLIA HISTOCHEMICAET CYTOBIOLOGICAVol. 45, No. 3, 2007pp. 221-227Morphological aspect of voice disturbances of aged persons coexisting hypopharynx cancerBo¿ena Koszty³a-Hojna1, Anna Andrzejewska2, Ryszard Rutkowski3and Marek Rogowski 1Departments of: 1Otolaryngology, 2Clinical Pathomorphology, and 3Respiratory Diagnostics and Bronchofiberoscopy, Medical University of Bialystok, Poland Abstract: The voice quality in prebysphonia is conditioned by morphological changes in the vocal folds mucosa. Thestudies including light microscopy and transmission electron microscopy (TEM) revealed changes within the basal mem-brane epithelium and the stroma of the vocal folds mucosa. Age-related changes in thickness of the epithelium and direc-tion of the basal membrane, increased number of collagenous fibres (C) and fibroblasts and chronic inflammatory processin the stroma were found. Vacuolated and keratinised epithelial cells, enlarged extracellular spaces and numerous bloodvessels confirm the edematous form of prebysphonia. Thinned epithelium with signs of hyalinization, inflammatory infil-trations in the stroma with numerous collagenous fibres and small number of blood vessels indicate atrophy of the vocalfolds mucosa. Edematous and atrophic changes in the vocal folds mucosa are most frequently reported form of prebys-phonia. Key words: Prebysphonia - Vox senium - Vocal folds atrophy - Larynx edema - Hypopharynx cancer - Dysphonia - VoicequalityCorrespondence: B. Kosztyla-Hojna, Dept. of Otolaryngology,Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276 Bialystok, Poland; tel.: (+4885) 7468627, fax.: (+4885)7468697, e-mail: otol@amb.edu.plMaterials and methodsThe study samples for morphological studies were collectedfrom the intermembranous part of the vocal folds mucosa. Thecontrol group consisted of 20 persons aged 35-38 (average 36)with a prevalence of women (60%). All specimens were collect-ed during autopsy. In the group of the elderly 50 specimens wereanalyzed. The age span was 67-74 years (mean age 68.5) years.The group of 34 (68%) patients with the cancer of hypopharynx(piriform sinus carcinoma) at the age from 65 to 72 years oldwas included in the study. Epidemiological aspects were the cri-teria for selecting the patients. Only 4 (12%) patients weresmokers, and 6 (18%) patients were exposed to plant pesticides.In the group there were 15 (44%) female and 19 (56%) malepatients. In the study material 68% (n=34) specimens were col-lected as a result of the total laryngectomy due to the recessuspiriformis carcinoma. The specimens were compared with theautopsy material obtained from 16 (39%) dead persons withoutoncologic anamnesis at the age from 65 to 74. In this group therewere 13 (81%) women and 3 (19%) men and 2 (12%) of themwere smokers.For light microscopy, the study material was fixed in 10%formaldehyde solution and subsequently dehydrated in the ascend-ing alcohol row. The specimens were mounted in paraffin blocks,dissected and H+E stained. For TEM, the vocal folds mucosa sam-ples were fixed in 2.5% glutaric aldehyde in kakodylate buffer,pH=7.4 for 4 hrs, postfixed in 1% OsO4 for 2 hrs and subsequent-ly mounted in Epon 812. Half-thin specimens were stained withmethylene blue and preliminarily evaluated with the use of lightmicroscopy. Ultrathin specimens were cut on the Reichert Ultra-cuts microtome, contrasted with lead citrate and uranyl acetate andfinally analysed with the use of the transmission electron micro-scope Opton 900 PC. ResultsIn the control material the light microscopy studiesrevealed the multilayer flat epithelium alongside thevocal fold, with the multistratified ciliated epitheliumin the area of the ventricle of larynx (Fig. 1)In the analysed material the smooth surface of themucosa, the keratinising paraepidermoid epitheliumwith enlarged blood vessels and infiltrations from plas-ma cells and lymphocytes under the epithelium wereobserved (Fig. 2)In other specimens the thinned paraepidermoidepithelium and partly the multistratified epitheliumwere found. Under the epithelium small number ofplasma cells and lymphocytes were observed (Fig. 3)In the control group TEM specimens revealed themultilayer flat epithelium with folds in the basal mem-brane, blood vessels, numerous pericytes (P) andscanty collagenous fibres (C) in the stroma (Fig. 4).In the analysed material signs of the epithelial cellsdestruction with an increased vacuolisation andenlarged intercellular spaces were found. In the stromaa large number of blood vessels, fibroblasts (F) withthe signs of vacuolisation, collagenous fibres (C) andinflammatory cells were found. In branches of thefibroblasts (F) enlarged cisterns of the granular endo-plasmic reticulum were evident. The folds of theepithelial basal membrane were less pronounced than222 B. Koszty³a-Hojna et al.Table 1. Clinical characteristics of the morphological material.Table 2. Clinical diagnostics of the base of morphological material in analysed group.223Voice disturbances of aged personsFig. 1. The vocal fold mucosa in the controlgroup (H+E, magnification ×180)Fig. 2. The vocal fold mucosa with infiltra-tions from mononuclear cells (H+E, magnifi-cation ×180)Fig. 3. Thinned epithelium of the vocal foldmucosa with  small number of plasmatic cellsand lymphocytes. (H+E, magnification ×180)224 B. Koszty³a-Hojna et al.Fig. 4. The vocal fold mucosa in the controlgroup. Fragment of the blood vessel. Numer-ous branches of pericytes (P) (TEM, magnifi-cation ×2700)Fig. 5. Signs of the epithelial cells destructionwith enhanced vacuolisation (TEM, magnifi-cation ×1800)Fig. 6. Enlarged intercellular spaces in theepithelium (arrows). Numerous collagenousfibres (C) in the stroma (TEM, magnification×1800)225Voice disturbances of aged personsFig. 7. Fibroblasts (F) and numerous collagenfibres (C). Enlarged cisterns of the granularreticulum in the branches of fibroblasts (TEM,magnification ×1800)Fig. 8. Very numerous collagenous fibres (C)in the stroma (TEM, magnification ×1800) Fig.  9. Signs of destruction and degenerationof fibroblasts with large fagosomes in the cyto-plasm. Numerous collagenous fibres (C). A blood vessel in the right upper corner (TEM,magnification ×1800)those in the control group (Fig. 5, 6 and 7) and in manyspecimens the stroma contained large numbers of col-lagenous fibres (C), inflammatory cells and fibroblastswith traits of the vacuolic degeneration. Scanty bloodvessels exhibited multiplications of the basal mem-branes (BM). The folds of the epithelial basal mem-brane were less pronounced than those in the controlgroup (Fig. 8 and 9) and in 18 (52%) patients with thepiriform sinus carcinoma we found coexistent oede-ma tic morphologic changes of vocal folds mucosa.In 16 (47%) patients atrophic changes were found.Oedema was found in 13 (39%) women and 5 (14%)men. Atrophy was found in 2 (6%) women and 14(41%) men. In the autopsy female material, edema was found in9 (56%) and atrophy was found in 4 (25%) women. Inmale autopsy material atrophic changes were found in2 (12.5%) men and edematic changes were found in 1(6%) cases. DiscussionAnalysis of specimens of the vocal folds mucosarevealed influence of ageing on the membrane mor-phology. All the patients were classified as being ofthe senile age according to the WHO classification.The group of patients with hypopharynx cancer wasthe selected group with possibly the least significantinfluence of irritating agents. With the use of lightmicroscopy differences with relation to the controlgroup were found, which included keratinisation ofthe epithelium, infiltrations from plasma cells andlymphocytes and numerous enlarged blood vessels.According to Bêtkowski, Rak, Zalesska-Krêcicka[4,6,19,20] keratinisation of the epithelium is charac-teristic for the Reinke's edema. In other specimensthe paraepidermoid epithelium and partly the multi-layer epithelium were thinned, moreover, signs ofhyalinization and infiltrations from plasma cells andlymphocytes were found. Similar morphologicchanges in patients with clinical signs of the senileatrophy, manifested by the flattened epithelium withinflammatory infiltrations in the stroma, weredescribed by Lehmann et al. [12]. Ultrastructuralstudies revealed significant differences in theanalysed groups. Signs of epithelial cells destructionwith enhanced vacuolisation and enlarged intercellu-lar spaces were found. Besides a large number of theblood vessels and the collagenous fibres, fibroblastswith signs of vacuolic degeneration were found in thestroma. In the branches of fibroblasts, enlarged cis-terns of the granular endoplasmic reticulum wereobserved. According to Rak [16] ultrastructuralchanges in the cell cytoplasm include the endoplas-mic reticulum, ribosomes and mitochondria. The vac-uolic degeneration suggests the vocal folds edema ofthe Reinke's type [16]. Similar morphologicalchanges in the vocal folds mucosa of patients withthe larynx edema were described by many authors[2,3,6,7,9,13]. The thinned epithelium, small foldingsof the basal membrane, numerous collagenous fibresand inflammation in the stroma confirmed the clini-cal form of the atrophy of the vocal folds mucosa.Similar morphological changes were described byHirano, Kurita et al. [6,7,10,11] in patients with thevocal folds atrophy after the age of seventy. Accord-ing to many authors, morphological transformation ofthe vocal folds mucosa result in disturbances of thevoice quality in prebysphonia [6,7,15,19,20]. Morphologic analysis of the vocal folds mucosaindicates age - related differences not related withcoexistence of cancer hypopharynx. The vacuolicdegeneration of the epithelial cells with signs of ker-atinisation, enlarged intercellular spaces, fibroblastswith traits of vacuolic degeneration and bronches ofthem and enlarged cisterns of the granular endoplas-mic reticulum indicate the vocal fold edema in theelderly patients. Thinned epithelium with signs ofhyalinization, large number of collagenous fibers andscanty blood vessels with inflammation in the stromaindicate atrophy of the vocal folds mucosa in thesenile age. The folds of the epithelial basal membranewere less pronounced in elderly patients. Edenaticchanges of vocal folds are more common in elderlywomen however in elderly men atrophic ones aremore common. References[ 1] Rutkiewicz J. Treatment of old people and its versatility. In:Geriatrics. Rutkiewicz J (eds), Warszawa PZWL, 1979:114-116.[ 2] Böhme G, Hecker G. Gerontological studies on vocal foldsfunction. Folia Phoniatr, 1970;22:176-184.[ 3] Hollien H. Old voices - what do we really know about them?J Voice, 1987;1:2-16.[ 4] Pruszewicz A, Obrêbowski A. Hormon related dysphonia. In:Clinical phoniatrics. Pruszewicz A (eds), Warszawa PZWL,1992:110-128.[ 5] Tucker HM. New voice for old. J Voice, 1995;9:111-114.[ 6] Abrams WB, Beers MD, Berkow R. Geriatrics - textbook,Wroclaw Urban & Partner 1999:144-148.[ 7] Zalesska-Krêcicka M, Krêcicki T, Cyganek P. Quincke'soedema - clinical aspects. Otolaryngol Pol,  1993;47:154-158.[ 8] Zalesska-Krêcicka M, Krêcicki T, Jeleñ M. Atlas of laryngealdiseases. Wroclaw: Volumed, 1995:123-146.[ 9] Bennett S, Bishop S, Lumpkin S. Phonatory characteristicsassociated with bilateral diffuse polypoid degeneration.Laryngoscope, 1987;97:446-450.[10] Bennett S, Bishop S, Lumpkin S. Phonatory characteristics ofsevere polypoid degeneration. Laryngoscope 1989;99:525-531.[11] Klajman S. Histological structure of vocal folds depending onhuman age. Otolaryngol Pol, 1974;18:203-209.[12] Morrison MD, Gore-Hickman P. Voice disorders in the old-ery. J Otolaryngol, 1986;15:231-234.226 B. Koszty³a-Hojna et al.[13] Pruszewicz A, Obrêbowski A, Œwidziñski P, Demenko G,Wika I, Wojciechowska A. Uselulness of acoustic studies onthe differential diagnostic of organic and functional dyspho-nia. Acta Otolaryngol, 1991;111:414-419.[14] Bêtkowski A, Wêdrychowicz B. Quincke's oedema. Oto-laryngol Pol, 1992;46:225-227.[15] Lehmann W, Pidoux JM, Widmann JJ. In: Larynx.Microloaryngoscopy et Histopatology. Cadempino, Switter-land Inpharzam Medical Publications (eds), 1981:49-53.[16] Kurita S, Nagata K, Hirano M.  A comparative study of thelayer structure to the vocal fold. In: Vocal fold physiology.Bless DM, Abbs JH (eds), San Diego Collage-Hill Press,1983:78-85.[17] Kurita S, Nagata K, Hirano M. 1986. Comparative histologyof mammalian vocal folds. In: Vocal fold histopatology.Kirchner (eds), San Diego Collage-Hill Press, 1986:65-74.[18] Hirano M, Koike Y, Hirose K, Kasuya T.  Observation ofmucous membranae of human vocal cords under electronmicroscopy. J Otolaryngol Jpn.  1974;77:650-660.[19] Rak J. Histological, histochemical and micro-electronicstudiem on abnormal volva fold mucosa in Ouincke's oede-ma, polyps and papilloma. Otolaryngol Pol, 1984;38:359-363.[20] Hirano M, Yoshida T, Kurita S, Kiyokawa K, Sato K, TateishiO.  Anatomy and behaviour of the vocal process. In: Laryn-geal function in phonation and respiration. Baer T, Sasaki C,Harris K [Eds], Boston Collage-Hill Press, 1987;520-540.Submitted: 22 November, 2006Accepted after reviews: 13 April, 2007227Voice disturbances of aged persons

Morphological aspect of voice disturbances of aged persons coexisting hypopharynx cancer.

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Morphological aspect of voice disturbances of aged persons coexisting hypopharynx cancer.

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