Geriatric Otolaryngology
Mahesh H. Bhaya
Frank E. Lucente
The increase in the number of people older than 65 years represents a marked change in demographic patterns in the United States. This growth, which is a global phenomenon, is expected to have profound socioeconomic, medical, and personal consequences. It is estimated that by the year 2010, persons older than 65 years will represent 14% of the population; this estimate increases to 22% by the year 2030. Older persons use medical and surgical services at a greater rate than younger persons, and the cost of their care is much higher.
Cognition (learning, thinking, and remembering), mobility, and sensing (hearing, sensing, smelling, tasting, and feeling) are three important aspects of normal functioning for the geriatric age group. A disability in any one of these systems reduces one’s capacity to function independently and thus has a serious effect on quality of life. Although visual and hearing impairments are among the ten leading chronic diseases among the population older than 65 years, these conditions often are overlooked in terms of the role they play in the functional ability of older adults. Clinically significant hearing loss affects 50% of persons who reach the age of 75 years. Very often older persons deny the existence of problems or attribute them to the process of aging. Sometimes these problems are neglected for reasons associated with the stigma of aging. Early recognition and management of these disabilities prevents or delays entry into long-term facilities and lowers the psychological burden on these patients. Comprehensive geriatric assessment comprises, in addition to the history and physical examination, evaluation of functional and mental status, social and economic factors, and the values of patient and family.
PHYSIOLOGY AND GENERAL DISORDERS OF AGING
Reduction in physiologic processes in the human body occurs in a linear, steady manner beginning in the third decade until 80 or 90 years of age. These age-related changes vary from person to person and from one organ system to another. Knowing the role of immunity and connective tissue repair is important in understanding basic aspects of the aging process and facilitates the best care of this group of patients.
Fluid and Electrolyte Imbalances
Glomerular filtration rate declines in a linear manner from the third or fourth decade of life. This decrease is not accompanied by a simultaneous decrease in serum creatinine level, so estimation of serum creatinine level may not accurately indicate renal function among the elderly. A decrease of almost 50% in glomerular filtration rate causes severe impairment in the response to acute changes in fluid and electrolyte intake. The response to hyponatremia is delayed, and disorientation and confusion exhibited by a patient may lead the physician to withhold sodium-containing
fluids for fear of precipitating congestive heart failure. This leads to further extracellular fluid volume depletion and deterioration in cardiac, renal, and mental function.
fluids for fear of precipitating congestive heart failure. This leads to further extracellular fluid volume depletion and deterioration in cardiac, renal, and mental function.
Aged kidneys fail to handle acute salt and volume loads, and this condition can precipitate pulmonary edema. Aged kidneys concentrate urine at 70% of normal level. In cases of high ambient temperatures and poor fluid intake, volume depletion with consequent sodium intoxication may occur.
Pulmonary Dysfunction
Pulmonary dysfunction is common among the geriatric age group. Patients have a decrease in vital capacity, maximal breathing capacity, thoracic compliance, total lung volume, and muscle strength and an increase in pulmonary and residual volumes. This coupled with an increased pressure gradient between the alveoli and the blood leads to marked reduction in pulmonary function.
Endocrine Dysfunction
Endocrine dysfunction is common among the elderly. A decrease in thyroxine levels is caused by a reduction in peripheral function. This may occur as hypothyroidism and cause nasal congestion, hoarseness, snoring, hypersomnolence, vertigo, macroglossia, increased cerumen accumulation, and cold intolerance. An increase in catabolic steroid levels among the elderly may cause tissue wasting. Syndromes of hyperkalemia and hyponatremia usually have iatrogenic causes (thiazide or chlorpropamide therapy).
Impairment of Immunity
The immune system becomes less efficient with advancing age. Susceptibility to various diseases, such as infections, autoimmune disease, and cancer, increases. This is attributed to a progressive decrease in the number of circulating lymphocytes in the blood during and after middle age. A reduction in the absolute number of circulating T cells is probably accompanied by an increase in suppressor cells.
Levels of immunoglobulin A (IgA) and IgG probably increase with age. Antibodies against normal structures are called autoantibodies, and numbers of these antibodies increase with age, as do numbers of antigen-antibody complexes (immune complexes). Increased levels of autoantibodies and immune complexes are caused by faulty regulation of the humoral immune system and are involved in the development of various diseases. Autoimmune disease is a result of damage to one or more organs caused by excessive amounts of autoantibodies.
Nutritional deficiencies exert a marked effect on the immune system throughout life. Impaired immunity has been found among patients with deficiencies of iron, zinc, vitamins A and B12, pyridoxine, and folic acid, and with excess of essential fatty acids and vitamin E. The immune response of malnourished elderly patients is profoundly impaired. The elderly are particularly susceptible to malnutrition because of a number of factors, such as inadequate financial support, lack of motivation, and poorly fitting dentures.
Impairment in Connective Tissue Repair
Aging affects various aspects of connective tissue repair, including multiplication of fibroblasts, synthesis of collagen, the nature of the elastic tissue, the rate of growth of fibroblasts, and the amount of soluble versus insoluble collagen. Nutrition and metabolic factors play an important role in wound healing for the elderly. Vitamin A deficiency retards wound epithelialization and collagen synthesis. Vitamin C deficiency impairs collagen synthesis, resistance to infection, and capillary formation. Zinc and serum albumin are needed for biomembrane stabilization and formation of RNA and DNA polymerase and cellular proliferation. In zinc deficiency, there is a higher rate of tissue necrosis and a greater susceptibility to damage from noxious agents.
OTOLARYNGOLOGIC DISORDERS
Otolaryngologic disorders among the geriatric age group, although not different in presentation, do present a challenge in formulating a management strategy. The sequelae of otolaryngologic diseases are especially serious because they disrupt communication, an important human function. This is particularly important among older adults. Persons with communicative disabilities may withdraw from the environment and social situations.
Speech Alterations
Dysphonia and dysarthria are the common manifestations of speech disorders among the elderly. Dysphonia results from various physiologic changes such as atrophy of the vocal folds and laryngeal muscles, drying and metaplasia of the false vocal cords, and reduced mobility of the cricoarytenoid and cricothyroid joints. Dysphonia also occurs among patients with obesity and gastroesophageal reflux disease. Speech therapy may be useful for patients with dysphonia. The use of antacids and head elevation is recommended for patients with gastroesophageal reflux disease. Dysarthria is a common communication problem among patients with cerebrovascular accidents, supranuclear palsy, Parkinson’s disease, Huntington’s chorea, motor neuron disease, or trauma. Aphasia, which is usually caused by a focal lesion, can affect spoken and written language, auditory comprehension, and reading ability but by itself does not affect intellectual and cognitive ability. Voice and speech impairment may lead to self-imposed social isolation and depression.
Otologic Disorders
External Ear
A decrease in the number and function of the ceruminous and sebaceous glands causes atrophy and dryness of the epithelium and the formation of dry cerumen. This results in cerumen impaction, dryness, itching, and a high incidence of self-induced trauma. Avoidance of trauma and moisture and application of an emollient often ameliorate the symptoms.
Middle Ear
Arthritic changes of the middle ear joints have been described among the elderly but do not always cause conductive hearing
loss. Otosclerosis most commonly starts in early adult life but may not be recognized until secondary presbyacusis occurs. Surgical therapy, hearing amplification, or a combination of the two may be used to manage conductive hearing loss. Age is not necessarily a limitation to surgical treatment as long as the general condition of the patient is good.
loss. Otosclerosis most commonly starts in early adult life but may not be recognized until secondary presbyacusis occurs. Surgical therapy, hearing amplification, or a combination of the two may be used to manage conductive hearing loss. Age is not necessarily a limitation to surgical treatment as long as the general condition of the patient is good.
Inner Ear
Sensorineural hearing loss is frequent among the elderly. It may be associated with depression, cognitive decline, reduction in functional status, and emotional and social disabilities. Screening by physicians is important, because older adults tend to underestimate the degree of hearing impairment. Diet, metabolism, atherosclerosis, smoking, noise, genetic factors, and even stress have been described as contributing factors. Four categories of this disorder, called presbyacusis, have been described.
Sensory—Progressive, high frequency loss that occurs in middle age. Speech frequencies usually are spared. There is atrophy of the organ of Corti in the basal turn of the cochlea.
Metabolic—Progressive, flat loss beginning in middle age. Speech discrimination is good until late in the disease. There are defects in the chemical and physical processes involved in the production of energy in the inner ear.
Neural—Progressive, higher frequencies more commonly involved. Begins at any age, and loss of speech discrimination is disproportionate to the degree of hearing loss. May be caused by loss of neurons throughout the cochlea.
Mechanical—Straight-line descending curve, higher frequencies more commonly involved. Begins in middle age, and speech discrimination is related to the degree of pure-tone loss. Attributed to a disorder of the mechanics of the cochlear duct without concomitant changes in the cochlea or auditory nerve.
The most important predictor of candidacy for use of a hearing aid is not the severity of the hearing loss but the patient’s motivation and perception of the disabling effects of the hearing impairment. A complete discussion of hearing aids and devices is presented in Chapter 7.
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