Thinking outside the (voice) box: considering respiratory function in presbyphonia

PURPOSE OF REVIEW: Presbyphonia has long been framed as a laryngeal disorder driven by presbylaryngis, yet emerging evidence suggests that age-related respiratory decline plays a central but under-recognized role in symptomatic vocal aging. This review synthesizes work on respiratory aging, speech-breathing patterns, and respiratory muscle performance in older adults with presbyphonia, and evaluates early attempts to target these systems in rehabilitation. RECENT FINDINGS: Laryngeal atrophy and glottic insufficiency are common in aging but do not reliably predict presbyphonia. Age-related reductions in lung elasticity, chest wall compliance, respiratory muscle strength, and respiratory interoception alter speech breathing and may compound glottic inefficiency. Recent studies indicate that "exuberant" voice therapies targeting maximal vocal function outperform gentler, skill-based approaches. Preliminary trials combining these therapies with respiratory muscle strength training, particularly inspiratory training, suggest added benefits for vocal effort, fatigue, and connected speech, though underlying mechanisms remain unclear. SUMMARY: Respiratory aging appears to meaningfully influence symptom severity in presbyphonia yet remains poorly characterized in the condition. Incorporating respiratory assessment, kinematic measures of speech breathing, and targeted respiratory training may enhance diagnostic precision and optimize therapy outcomes. Future work should clarify how respiratory mechanics and sensory monitoring interact with laryngeal deficits and identify which older adults benefit most from respiration-focused rehabilitation.