When our voices changed as we became older, it was mostly a welcome sign we were becoming adults.  But as we grow older, still more changes occur in our voices, and sometimes in ways that may make communication challenging. These changes may be signs of a condition called presbyphonia.

What is Presbyphonia?

As we age, we lose muscle mass, our mucous membranes thin and become drier, and we lose some of the coordination that we had in younger years. Some of these changes are due to physical inactivity.

Similar changes occur in the larynx and vocal cords, also called vocal folds, due in part to vocal inactivity that impact our ability to speak and be heard. The symptoms of presbyphonia include:

• Reduced volume and projection of your voice
• Reduced vocal endurance, meaning more fatigue or hoarseness when talking
• Difficulty being heard in noisy situations, such as dining out
• Scratchiness or roughness in your voice
• Breathiness or weakness in your voice
• A higher-pitched voice among men
• A lower-pitched voice among women
• Tremor or shakiness in your voice

According to one recent study, approximately one in three adults ages 60 and older in the United States have one or more of these difficulties, and it can have a significant negative impact on every aspect of our lives.

Olivia Boddicker, MA, CCC-SLP

“We tend to underestimate how important our voice is until we can’t rely on it anymore. Changes in our voice make it difficult for us to do the things we love, such as reading to our grandchildren, socializing with friends, or singing with a choir,” says Olivia Boddicker, MA, CCC-SLP, a voice-specialized speech language pathologist at the Grabscheid Voice and Swallowing Center of Mount Sinai.

“The changes related to presbyphonia are not necessarily dangerous, but they can affect our sense of identity and self-confidence, making it difficult to hold employment or socialize.”

How Presbyphonia is Diagnosed

Although these changes in the voice may be age related, they could be symptoms of a more serious issue. For that reason, it is important to consult a laryngologist and voice-specialized speech language pathologist to determine what is going on, rule out other causes, and start to address the problem.

The laryngologist will typically perform a complete examination of your head and neck, along with a specialized examination of the vocal cords/folds called stroboscopy.  This is a simple test in which a small device called a laryngoscope is inserted in the mouth or nose to examine the larynx and assess the appearance, mobility, and vibrations of the vocal cord/folds. If the laryngologist sees that the vocal cords/folds are thin, stiffened, or have a gap between them when they close, the diagnosis is typically presbyphonia.

During evaluation, the speech language pathologist will also perform a stimulability test to see how much effort it takes for the vocal cords/folds to create different sounds. This test will help determine the best approach to treatment.

Treatments for Presbyphonia

After reviewing the stroboscopy exam with the laryngologist and speech language pathologist, patients can decide whether behavioral intervention or surgical intervention is appropriate. In many cases, behavioral intervention through voice therapy is one of the first recommendations for treating presbyphonia because it is non-invasive and proven to be effective in increasing voice-related quality of life.

Voice therapy for presbyphonia focuses on increasing projection, vocal endurance, and improving stability of the voice. Techniques and programs such as vocal function exercises, phonation resistance training exercises, and respiratory muscle strength training are designed to coordinate the muscles of breathing and the muscles in the voice box, resulting in the best voice with the least amount of effort.

This strength and conditioning through daily exercise is similar to physical therapy, though instead of lifting weights, you make sounds. One example is holding out “ah” at high pitches and low pitches to work the different muscles of the vocal cords/folds and larynx.

However it is not always so simple, as no one-size-fits-all program exists for every person experiencing age-related changes to the voice.

“It is important to work with a voice-specialized speech pathologist if you are diagnosed with presbyphonia because they can give you personalized insights on how to work with your voice and make improvements in a way that is sustainable,” Ms. Boddicker says.

In some patients, however, vocal coordination and strength training are not enough to restore the voice to acceptable levels.  If vocal difficulties after attempted behavioral therapy continue to be a source of social withdrawal and significantly reduce the patient’s quality of life, then consideration should be given to surgical techniques to bulk up the vocal cords/folds.

Bulking up the vocal cords/folds through surgery, does not usually restore the voice completely, but usually increases the patient’s vocal volume and reduces their effort to produce that voice.  This allows the patients to be heard so that they may continue to interact and remain social, says Mark Courey, MD, Professor of Otolaryngology-Head and Neck Surgery, and Director of the Grabscheid Voice and Swallowing Center.

The vocal cords/folds can be bulked up either by injecting fat or by implanting plastic or Gore-Tex strips beneath them to partially push them into a better position for talking so the patient does not need to work so hard.

Use It or Lose It

Perhaps the best approach to presbyphonia is a preventative one. Just as we exercise to keep our muscles strong and responsive, it is important to find opportunities to keep using our voices so that our larynx and vocal cords/folds do not weaken and make it difficult to speak. This can be challenging for older adults if there are fewer opportunities for daily interactions.

“Look for opportunities to increase your voice use through the day,” Ms. Boddicker says. “Read aloud to yourself, sing around the house for fun, call a couple of friends each day, or stay connected in your community. All these activities can help keep your voice more youthful.”

Ultimately, if you are experiencing any age-related voice changes that are making it hard to communicate or be heard, it is important to have an exam so that you know what is going on and can take action to protect and even restore a more youthful quality to your voice.

To make an appointment for your voice, call 212-241-9425 or email  entpatientservices@mountsinai.org. For initial consults, you will need an appointment with both a laryngologist and a speech language pathologist.

For decades, there was no community transmission of polio in the United States. Though still rare, polio is back in the news.

The New York State Department of Health recently reported a case in Rockland County, and then the virus was found in the New York City sewer system.

For those with young children, the news about polio may be of special concern. Polio is highly infectious and life-threatening. Those who have received the routine polio vaccine series are protected. For young children, it’s important to check that everyone is up to date.

Here are five key takeaways from the experts at Mount Sinai.

Young children may be at risk.

Some families have not been able to stay up to date with the standard childhood immunizations due to the COVID-19 pandemic. This leaves many children at risk for vaccine-preventable diseases, such as polio. If your child is behind on vaccines for polio, varicella, and other conditions, schedule a doctor’s appointment soon. “It’s really important now that everybody check to make sure they are up to date with their vaccinations,” says Kristin Oliver, MD, MHS, a pediatrician and preventive medicine physician at the Mount Sinai Health System.

It’s important for parents to stay up to date on getting their children vaccinated. Health authorities recommend children get four doses of polio vaccine. They should get one dose at each of the following ages: 2 months old, 4 months old, 6 through 18 months old, and 4 through 6 years old. You can find out if you child has been vaccinated by checking with your doctor or checking the New York City Department of Health website.

Children who are in the middle of their vaccine series should complete the series as scheduled.

They do not need to receive earlier or additional doses. Children who have had one or two doses of polio vaccine in the past should get the remaining doses when they are due. It does not matter how long it has been since the earlier dose(s).

Most adults ages 18 and over living in the United States are presumed to be immune to poliovirus from previous routine childhood immunization.

Adults who know they have not been vaccinated for polio, should start the vaccination series as soon as possible.

Most people who get infected with poliovirus will not have any visible symptoms.

According to the Centers for Disease Control and Prevention, about one in four people will have flu-like symptoms that last from two to five days and then go away. A smaller number of people will develop more serious symptoms, such as meningitis, an infection of the brain or spinal cord. Paralysis occurs in about 1 out of 200 to 1 in 2,000 people, and can lead to permanent disability.

If you want to discuss your child’s vaccination status, schedule an appointment with your doctor through MyMountSinai, Find a Doctor, or by calling the office directly. For assistance finding a new physician call 1-800-MD-SINAI or search on our Find a Doctor platform.

More detailed information is available from the New York State Department of Health and the New York City Department of Health and Mental Hygiene.

Fine lines and wrinkles. Volume loss. Blotchiness and age spots. You can’t escape the signs of aging.

Many of us want to freshen up our appearance but simply are not ready for plastic surgery.

Cosmetic injectables—which include neurotoxins such as Botox and fillers such as Juvederm™ and Restylane—are a simple alternative that can enhance your appearance and give you a more youthful look in a single office visit.

Mingyang Gray, MD, MPH

“These procedures camouflage some of the natural signs of aging,” says Mingyang Gray, MD, MPH, a facial plastic and reconstructive surgeon at Mount Sinai. “They bring your inner joy and positivity to the outside, make you look younger, and increase self-confidence in the way you look.”

No matter how well we take care of our skin, wrinkles catch up with all of us at some point. Wrinkles are perpendicular to the muscles underneath the skin, explains Dr. Gray. Every time we smile or squint the facial muscles contract and the skin on top of them folds. As we age, the skin also loses elasticity and collagen, causing ridges to form. Over time, these lines become more prominent.

“Some of us are luckier than others in terms of how much elasticity and collagen our skin holds onto with age,” explains Dr. Gray, who is also an Assistant Professor of Facial Plastic and Reconstructive Surgery at the Icahn School of Medicine at Mount Sinai. “But at some point, gravity and Father Time both win out.”

Still there are ways to prevent, or at least delay, the start of wrinkles. The most important thing you can do is limit the amount of time you spend in the sun. Wear sunscreen with an SPF of 30 or higher, cover your face with a wide-brimmed hat, and seek out shade especially in the heat of the day. Exposure to cigarette smoke, even if it is secondhand, can also take a toll on the skin. Staying hydrated and eating a well-balanced diet helps your skin maintain its elasticity.

Neurotoxins

Neurotoxins (Botox™, Dysport™, and Xeomin™) are botulinum toxin injections, which are approved by the Food and Drug Administration (FDA) and are the most common cosmetic procedure in the United States. For more than three decades they have been used to reduce lines and smooth wrinkles on the face. They are often used to treat:

•  Forehead lines, such as vertical wrinkles or “11 lines,” which appear between the eyebrows after years of muscle movement.
• Creases around the corner of the eyes, often referred to as crow’s feet.
• Neck lines and bands.
• Wrinkles around the lips known as smile or frown lines.
•  Gummy smiles that show a large portion of the teeth and gums.
• Sad or worried appearances, often a result of the corners of the mouth turning downward.

Fillers

(Juvederm™, Restylane™, Radiesse™, and Sculptra Aesthetic™)

Decades of smiling and squinting can cause deep creases to appear on your face. As we get older, our skin also becomes thinner, loses fat, and begins to sag. When these ridges are deep or when volume is lost (which leads to loose or sagging skin) freezing the facial muscles may not be effective in creating significant improvement.

Injectable fillers, also approved by the FDA, are most often made of hyaluronic acid and can be used to improve the appearance of deep lines and hollowed features of the face. These substances attract and hold water to restore volume and balance to the face.

They can be used to:

•  Fill in deep creases, wrinkles, or scars including laugh lines.
•  Enhance areas of the face that lose volume with age, such as the cheeks and temples.
•  Improve the dark appearance of shadow lines and uneven pigmentation, especially around the eyes and cheeks.
•  Plump up the lips.
•  Improve the contour and shape of the nasal bridge and tip.
• Define the jawline and chin.

Cosmetic injectables are administered during in-office procedures that are relatively painless with adequate numbing medications. No downtime is needed afterwards, but you should avoid exercise for a few hours to be safe.

Five Things You Should Know About Injectables

1. Cosmetic injections are not permanent: Botox™ needs to be refreshed about every four months because the muscles come back to life. After about six months, the body begins to break down fillers. “I tell my patients it is like coloring your hair. You will have to get your roots touched up,” describes Dr. Gray.

2. Facial balance is essential: You may only be concerned about the 11 lines on your forehead, but it is important to keep the entire face in harmony when using fillers. “All the muscles of the face act in conjunction like a seesaw. You can’t hit one side of the seesaw without affecting the other. Even if you just have one area that is concerning to you, we may have to treat other areas of the face as well to keep everything in balance,” says Dr. Gray.

3. Side effects are rare but real: People who have thin skin or veins that are very close to the surface are more likely to bruise. If this happens, any discoloration will go away after just a few days. In very rare circumstances, one eyebrow may appear droopy. “This is why it is very important to see a board certified facial plastic surgeon or someone with similar advanced training who has a deep understanding of facial anatomy,” explains Dr. Gray.

4. Faces can be optimized according to the patient’s race and ethnicity: The golden ratio is a tool plastic surgeons use to determine what proportions are most pleasing to the eye. This varies across different backgrounds. “This geometry is not universally translatable,” she explains. “We have developed a better eye for optimizing our patient’s faces and balancing ratios to be more conscious of their ethnicity and race. For example, Asians and Blacks tend to have full lips while Caucasians have a slightly thinner upper lip.”

5. Pain is minimal and downtime is short. Injectables are procedures that can be done in the office on the same day as a consultation. Some patients are more sensitive to injectables and require either topical numbing medicine and/or pain medications after the procedure. Most people are able to go back to work with very little downtime.

Dr. Mingyang Gray is a Facial Plastic and Reconstructive Surgeon in the Department of Otolaryngology – Head and Neck Surgery, who treats patients at New York Eye and Ear Infirmary of Mount Sinai  and Mount Sinai Doctors East 85th Street. For more information, call (212-979-4200) or email NYEEentreps@mountsinai.org.

So you think you may be pregnant. Perhaps you have been preparing for this for a while. Or maybe it’s unexpected. In any case, you are likely to have a lot of questions.

Here are answers to some of the questions most frequently asked by those who are just embarking on this journey. The answers come from Jane Owen, DO, an obstetrician-gynecologist at The Mount Sinai Hospital and an Assistant Professor in the Raquel and Jaime Gilinski Department of Obstetrics, Gynecology and Reproductive Science at the Icahn School of Medicine at Mount Sinai.

Are there signs of pregnancy other than a missed period?

Early symptoms of pregnancy can vary from individual to individual. Fatigue, nausea, vomiting, sensitivity to distinctive odors, or breast sensitivity are some common symptoms that may occur.  If someone is trying to get pregnant, they’re usually really in tune with their body and may notice these early signs of pregnancy.  If someone’s on birth control who is not looking to get pregnant and becomes pregnant, they may notice fatigue or feeling out of sorts. Some people don’t have regular cycles, so a missed period may not be the first indication of pregnancy. Some people feel nauseous, some will vomit when they’re around food that has a distinctive smell. It varies from individual to individual.

Jane Owen, DO

When should I take a home pregnancy test?

You should take a home pregnancy test if you’re trying to get pregnant or think you’re pregnant. Normally you would take a test about 11 days after conception. So when does a conception occur? That’s based on your last menstrual period. Ovulation typically occurs at day 14 of your menstrual cycle. Day one is when you begin the cycle, which is the first day you have any bleeding, spotting, or pink-tinged discharge. A urine test can determine a pregnancy after 11 days.  A more sensitive hCG blood test can determine pregnancy earlier than that.

How accurate are home pregnancy tests?

Home pregnancy tests are about 90 percent accurate, which means it is possible to get a false positive, which can be upsetting. Some can have a positive test and then have a normal period. A lot of my patients will take a series of pregnancy tests. A positive pregnancy test is just the beginning, and then we need to conduct an exam to find out exactly what’s going on with that pregnancy.

When should I see my OBGYN if I think I am pregnant?

For a normal pregnancy with prenatal care, you should see your gynecologist at seven to eight weeks of pregnancy. Your initial evaluation will involve an ultrasound to evaluate for the presence of the gestational sac and fetal heart rate; to confirm the estimated due date; to scan for anatomic issues, such as any small pooling of blood, also known as hematomas; and to determine multiple gestation, meaning if it is twins. Some patients like to come earlier if they have any spotting or cramping, which can happen early in pregnancy.

What can I expect at my first doctor’s visit?

Your first visit is called your pregnancy confirmation visit. We start by taking a thorough history from you. We will ask about prior pregnancies, prior deliveries, medical problems, and surgical issues. Then you’ll be brought into the gynecology evaluation room. Usually I start off with a transvaginal ultrasound because that’s going to give me the most information about your pregnancy. The ultrasound will help us with dating, or determining how far along you are in the pregnancy. A lot of people are not sure, especially if you have an irregular cycle. If you need a Pap smear or a vaginal culture, we will also collect those samples at the initial visit. We will also perform an exam to check your anatomy. Then I walk patients through the schedule of visits. We usually see a patient about 13 times, maybe more depending on if the pregnancy is more complicated. Finally, we will do a series of blood tests, including genetic testing to check for the risk of some conditions such as sickle cell disease or cystic fibrosis. Your first doctor visit will be pretty long, especially here at Mount Sinai. We follow best practices, which means we’ve looked at all the requirements that you need for your prenatal care, and we’ve chosen what we consider to be the most important to get the most information. Not too much, not too little.

What happens next?

At 10 weeks we will perform a non-invasive prenatal screening, which is a blood test. This test allows us to assess the baby’s risk for a genetic disorder, such as  Trisomy 13 or Trisomy 21 (also known as Down syndrome). We also have the technology to tell, if a patient wants to know, the baby’s gender. We can do the ultrasounds right here in our office, and then the provider is able to discuss the results with patients right away. We do a nuchal translucency test at 12 weeks,  an ultrasound that checks the space behind the baby’s neck, which can inform about the risk for disorders such as Trisomy 21.  At 16 weeks we do an hour-long anatomy scan, mostly focusing on neural tube defects such as spinal bifida. At 24 weeks I like to go over the delivery plan with the patient and discuss postpartum expectations and plans, including breastfeeding. If desired, we provide breast pump prescriptions at this time, as most insurance plans will cover this service. At 28 weeks, we screen for gestational diabetes and offer the Tdap vaccine (Tetanus, Diphtheria, Pertussis). Starting at 35 weeks, we see pregnant patients every week up until delivery.

What are some of the best pregnancy apps?

There are many apps available. One of the apps that I recommend is BabyCenter, which gives patients good advice on what to expect during each stage of pregnancy and how the baby is growing and developing. Pregnancy is a time when you’re in training and preparing for delivering a healthy baby. A lot of my patients like exercise apps, and the Juna app is a good exercise app. The only problem with some of the apps is because they require your information for use, you’ll likely receive emails and advertisements from them.

How do I find the right doctor to deliver my baby?

The most important decision is probably choosing where to go for your prenatal care. You want a doctor who you can communicate with, who doesn’t intimidate you, who really listens to your needs, and who’s flexible, because things change with your prenatal care. You want to feel like you can talk to your OBGYN because it’s a long relationship. And you want to be in a place where you know you’ll have a safe delivery. Often my patients will check other options, and then we welcome them back if they want to come back. It takes a while for you to know exactly what you want with your prenatal care. You’ll know. Trust your gut. Just because someone recommends a prenatal care provider to you doesn’t mean that you’re going to click with that person. Everyone remembers their delivery story, and they remember their prenatal care. They remember everything. So you want to have a really good relationship with your OBGYN and the hospital. Each patient should feel special.

Any other tips?

There are many things you can do to optimize your pregnancy, to stay as healthy as possible. Make sure you’re eating a healthy diet, that you’re getting enough rest. I look at prenatal care as a way to help patients learn about themselves, such as their family history. For example, if we diagnose gestational diabetes—or diabetes that occurs during pregnancy—we may need to adjust your diet. It is important to be open to realizing more about your health. Many people don’t go to the doctor until they’re pregnant. And then they’re seeing us so frequently that we pick up a lot of issues that patients never were aware of.