Presbylarynx Revisited: A Multidimensional Approach to Laryngeal Aging and Clinical Decision-Making

Background: Presbylarynx describes the structural phenotype of an aging larynx, whereas presbyphonia refers to its clinically relevant perceptual and functional expression. Although vocal fold atrophy, bowing, and glottic insufficiency are common in older adults, their presence and severity do not consistently correspond to patient-reported voice impairments. Therefore, presbylaryngeal morphology should be interpreted within the broader context of compensatory capacity, physiological reserve, systemic health, and individual communication demands. Objective: This narrative review aims to provide a clinically oriented and multidimensional synthesis of presbylarynx, encompassing its terminology, morphological and functional characteristics, relationship with systemic aging, differential diagnosis, clinical assessment, management strategies, and emerging diagnostic and therapeutic approaches. Methods: A targeted literature search of PubMed/MEDLINE, Scopus, and Web of Science was conducted in August 2026, with additional targeted searches and citation checking during revision. Relevant systematic and narrative reviews, clinical practice guidelines, consensus statements, prospective and retrospective clinical studies, translational investigations, and landmark publications addressing the presbylarynx, presbyphonia, vocal fold atrophy, laryngeal aging, assessment, and treatment were reviewed and synthesized narratively. No formal systematic review protocol, duplicate screening, standardized data extraction, or risk-of-bias assessment was performed. Results: Presbylarynx encompasses age-related alterations in the vocal fold epithelium, lamina propria, intrinsic laryngeal musculature, and neuromuscular control, which may produce vocal fold atrophy, bowing, glottic insufficiency, and reduced vibratory efficiency. However, structural findings alone neither establish the cause of dysphonia nor determine the need for treatment. Clinical expression is modified by respiratory function, frailty, comorbidities, cognition, hearing status, compensatory behavior, and communication requirements. Assessment should integrate laryngeal morphology with patient-reported, auditory-perceptual, acoustic, aerodynamic, respiratory, and systemic findings, while excluding alternative and coexisting causes of dysphonia. Management should target meaningful functional impairment and may include observation, behavioral voice therapy, injection augmentation, durable medialization, or combined approaches within a flexible, nonlinear, and patient-centered pathway. Artificial intelligence, digital voice biomarkers, regenerative interventions, advanced biomaterials, and neuromuscular stimulation represent emerging opportunities; however, their clinical application remains limited by insufficient validation and predominantly preliminary or preclinical evidence. Conclusions: The presbylarynx is not inherently pathological or an indication for treatment. Its clinical significance emerges when age-related laryngeal changes contribute to meaningful limitations in voice function, communication, or quality of life. A multidimensional, system-aware, and function-driven approach is essential for accurate interpretation and individualized management. Future research should prioritize standardized definitions, reproducible phenotyping, comparable outcome measures, prospective comparative studies, and careful validation of new technologies.