12 Sinonasal Disease in the Elderly

David R. Edelstein

Introduction

As the population in the United States ages, the number of patients with nasal and sinus disease and complaints will multiply. Between 2000 and 2030, the percentage of people over the age of 65 will increase from 12.4% of the population to 19.6%.¹ This is a dramatic increase in the elderly, and physicians need to begin to think of this group differently, since it has its own unique problems and challenges. This increase will continue during our lifetimes given that the 65 to 85 age group is projected to increase by 135% between 2000 and 2050.² In 1960, only 9% of the U.S. population was over the age of 65, whereas today 13% is.³ Otolaryngologists will be treating many of the elderly based on the high prevalence of rhinitis, hay fever, asthma, chronic sinusitis, and hearing loss in this age group.

Many physicians have a difficult time thinking about aging of the nose and sinuses. We have been trained to appreciate the growth of the midface in the fetus and the development of the nose and dentition in childhood and adolescence. There has been little formal education, however, on the senescence of the midface, the skin of the nose, and the internal structures. Most of the literature on sinonasal disease was based on adults between the ages of 25 and 45, with little attention given to the aging of these structures over the age of 65.⁴ Some of the problems, about which the elderly complain, are normal changes to the nose and respiratory tract. The fact that some of the nasal symptoms do not represent disease needs to be explained to the elderly patient, whose symptoms need to be treated depending on the level of patient anxiety and the severity of the problem. Many elderly patients are concerned that their symptoms, such as excessive rhinorrhea, represent the signs of worse problems and are happy to hear that their issues are a variation of normal and consequently require no therapy. Other patients need medications or sprays, but the side effects of the treatments need to be carefully reviewed so that new issues and complications do not arise. The nose and sinuses are often taken for granted until they become dysfunctional, but they present a coordinated respiratory and neurological organ that is affected by old age, other diseases of aging, and medications commonly taken by the elderly. The great advantage of electronic medical records is the ability to check that medications given for symptomatic relief do not interact with other essential drugs given to the elderly patient, such as cardiac medication and blood thinners. When there are interactions or questions, the elderly need to understand the treatment choices, and their primary care doctors should be involved in the decision-making process.

Our biases regarding treating the elderly also extend to our surgical decision trees. As the average life span extends from 85 to 90, the 20 to 25 years over the age of 65 will present many opportunities to examine the nose and sinuses and to consider surgical options. If a quarter of the population will soon be over the age of 60, how can we ignore the surgical issues that may affect this group? The methodology for surgical treatment needs to be modified from that of the average adult and expanded to include the special preoperative and postoperative problems facing the elderly surgical patient. For example, preoperative medications need to be reviewed to avoid day of surgery diabetic crises or hypertensive episodes. Likewise, avoidance of complications needs to be included in the surgical planning and the postoperative care. How often we see patients postoperatively may vary based on their frailty, family support, and ability to treat their nose and use postop medications.

How we treat the elderly and their aging noses and sinuses will determine how well they live given that chronic sinusitis is one of the critical negative factors affecting quality of life.⁴ The care of the geriatric nose and sinuses is enhanced if the patient, the family, and the physician understand the differences between the normal and abnormal nose and sinuses. The goal of treatment is to help patients to understand their problems, recognize their options for therapy if they exist, appreciate any issues associated with the care options based on their age or infirmity, and make intelligent medical and surgical decisions. This chapter is about these challenges.

The nose is an essential organ of respiration during our entire lives. At birth, we are obligate nasal breathers and will die of asphyxiation if we have bilateral choanal atresia and blockage at birth. The nose is very dynamic and needs to function from the moment of birth, when it is suctioned of meconium, and will be exposed to many noxious stimuli before death. It is a vehicle through which over 12,000 L of air pass per day.5 Its purpose is not only to pass air, but also to warm, humidify, and clean the particles and bacteria in the air before it reaches the lungs. It serves to provide resistance or a type of positive end-expiratory pressure to keep the lungs expanded. It also provides a mechanism for olfaction. The sinuses lighten the face and hold the teeth, essential for proper nutrition. The midface serves as a buffer to protect the central nervous system and eyes from trauma.

The nose develops early in fetal development (between weeks 4 and 8) from the lateral nasal placodes. The simultaneous development of the facial bones and skull bring the nose into shape. Between weeks 11 and 12, the early ethmoidal infundibulum develops, and the lateral walls of the nose grow medially, giving room to the developing paranasal sinuses. By 15 to 16 weeks of fetal development, the three primordial turbinates will form. The nasal cartilages will eventually interlace, leading to the development of the nasal vestibule and valve. The lateral nasal wall is complete by 24 weeks. The rest of the midface follows in development, with significant interaction with the early upper alveolus and dental buds. Small changes in this early fetal development will not only change how the nose looks in childhood and adolescence, but also set the stage for the changes that occur in the geriatric nose and sinuses.

Growth is distinctive from development. Growth is what happens to the nose in childhood and adolescence. The basic structures are set, but the nose, midface, sinuses, and teeth develop up to adulthood at age 18. The nasal cartilages develop during childhood, and their appearance changes as the nasal bones grow and the dentition changes. The relationships of the nasal cartilages make up the nasal valve, which is the rate-limiting area for nasal breathing and airflow. As children grow, the cross-sectional area of the nose increases, and the size of the airway increases.^6,7 The nasal bones continue to develop until the face is mature and may accentuate any genetic predisposition to hump deformities or nasal drooping.

Nasal function is affected by the nasal structures and by aging. Many older facial plastic researchers have found that the nose lengthens with age and thus droops over the age of 65.^8,9 Some of these projects studied ethnic noses and others looked at cadaver dissections.¹⁰ The oral surgical literature includes significant studies showing how the alveolus thins and reduces its bony support of the midface during aging.^11–13 This midfacial loss of support could explain the drooping of the nose, because there is no change in the nasal cartilage with aging.¹⁴ “Normal Aging of the Nose in Adults” is a broad study that questioned the traditional teaching that the nose itself changes but found that there was a change in the facial and nasal cephalometrics with aging due more to changes in surrounding structures and less to nasal bony or cartilage weakness as traditionally thought.¹⁵ The changes of the midface and nose may also occur with the loss of tensile strength in aging skin, giving the appearance of significant nasal deformity with aging.¹⁶ The presumption that all elderly patients have newly drooping noses and thus need nasal reconstruction is probably false, and the nose needs to be looked at in the context of all of the surrounding facial and dental structures.

With aging, there are several changes to the skin, especially in the face and nose, because the face is the most exposed part of the body to sun and weather. Therefore, it tends to show more changes with age due to a variety of factors. The changes occur to the epidermis, the dermis, the skin appendages, and the subcutaneous tissue. The epidermis has a decrease in thickness and a reduction in melanocytes with age. This helps to thin the skin over the nose and highlights any trauma or imperfections of growth. It also shows the outlines of the nasal cartilages. The dermis has a reduction in fibroblasts, mast cells, and capillaries. This will reduce the strength of the skin over and around the nose. The reduction in the skin appendages such as the eccrine glands and hair follicles will further thin the nasal skin. The skin tension lines are enhanced with age, which may reduce the natural movements of the nose and affect the nasal valve.

Nasal Physiology in the Elderly

The normal nose serves many purposes, including respiration, nasal cleaning, sound resonance, airway resistance for the lower respiratory tract, and temperature regulation of inhaled air. Most of the studies on nasal physiology have been conducted either on children or on healthy young adults. For example, studies on airflow in the young adult demonstrate that the greatest flow is anterior to the inferior turbinate and along the middle meatus.17 The resistance in the nose is made up of the nasal valve area with the intersection of the nasal vestibule, upper lateral cartilage, and anterior head of the inferior turbinate. This ratio and configuration have to work for a lifetime. However, the changes in the skin of the nose and lip and the regression of the teeth and alveolus may change how air flows into the older nose. The alar dilator muscle may also be reduced with age or by trauma in adulthood. Passive valvular collapse due to maximal inspiration may change transmural pressure and be affected by neuromuscular disease or muscle weakness of aging just as it is affected by facial palsies in young adulthood.

The inside of the nose is covered in respiratory mucosa except at the anterior nasal valve, where there is junctional squamous mucosa. This mucosa responds to a variety of stimuli, including temperature, moisture, emotion, hormones, and medication. Similarly, the capacitance vessels in the nasal septum and the inferior turbinates are also variable. This capacitance change at the nasal valve is the basis for the application of the Poiseuille principle in the nose. This principle states that pressure drops in a fluid or air flowing through a cylindrical pipe, in this case the anterior nose. The change in pressure is inversely related to the radius of the space to the fourth power.¹⁸ Therefore, any small change in the nasal valve resulting from an increase or decrease in mucosal or erectile tissue, or any change in the muscular control of the alar, will change airflow to a significant degree. Thus small changes in mucosa from medication or muscular weakness due to neuromuscular disease or medication can affect airflow negatively. In normal geriatric adults, however, there is generally no change in the resistance of the nose and no significant change of airflow with old age.¹⁵ In addition, normal elderly patients do have the potential for an increase in nasal airflow to make up for lower respiratory tract disease.

Compared with the nose, the lower respiratory tract shows significant changes in the elderly. The forced vital capacity, forced end expiratory volume, functional residual capacity, arterial pO₂ and perfusion progressively worsen with aging. The flow volume loop produced in the pulmonary function tests changes with aging. The forced expiratory volume in 1 second (FEV₁) is the volume that has been exhaled at the end of the first second of forced expiration. The elderly, if they are weak or infirm, cannot build up enough pressure, and this will reduce the FEV₁. The net effect of aging is to increase the work necessary for breathing and to decrease lung compliance.¹⁹ The differences in aging in the lower respiratory tract can be judged by the changes in the effects of asthma in a younger versus older population. Madeo and colleagues have explained how asthma in the elderly leads to more hospitalization; is stimulated by more factors such as reflux, infection, and medication; usually needs continuous and not symptomatic therapy; and has a higher mortality than in younger adults. The authors contend that this may be made worse by a lower compliance with treatment protocols by the elderly patient with asthma.²⁰ It is unclear how the upper respiratory tract affects the lung capacity, but any limitation in the nose will be reflected in lower respiratory tract problems, and elderly patients with asthma complain bitterly if their nose is blocked.

The nose is also an important cleaning vehicle. The nose will pick up any bacteria and viruses or fungi in the air and pass them into the nasopharynx or stomach where they are broken down. The nose is a dirty environment, but the sinuses are sterile. There are many factors that help the nose remove particles from the airstream, including the particle size, airflow rate, air flow turbulence, the mucous lining of the nose, and mucociliary clearance of the nasal cilia. Many of the medications prescribed for elderly patients dry the nose and reduce the sol or gel layer of mucus. This may affect the movement of particles through the nose. Nevertheless, ciliary beat frequency, which is a prime mover for mucociliary flow, does not change with the normal aging of the nose.¹⁵ This highlights the dynamic nature of the nasal lining, even with aging.

As the normal physiology of the nose changes with aging, the nasal symptoms of the elderly will vary. Table 12.1 shows that the odds ratio of having the various symptoms changes for every decade from age 20 to 90. For example, as one ages, there is a 1.35% increase in postnasal drip for every decade. The other common symptoms that increase with age are nasal drainage, sneezing, cough, smell disorders, and gustatory rhinitis.¹⁵ Sneezing is the primitive defense mechanism relied on by the nose to clear noxious elements. One can think of it as the cough of the nose, and sneezes can achieve 65 mile per hour rates at their highest. Gustatory rhinitis is a type of vasomotor rhinitis, which increases with age, that manifests as a runny nose during eating. Generally this is an autonomic dysfunction in which the brain sees food and tries to turn on the saliva glands, but mistakenly turns on the Bowman glands and mucoserous glands of the nose instead.

Table 12.1 Symptoms by age: statistical significance and odds ratios

Smell Disorders

All of our senses are reduced with aging, but none seems to cause as much anxiety as the loss of the sense of smell and taste. It has been estimated that we lose 1% of the sense of smell for every year we age over the age of 60.21 This means that if the average life expectancy is 85, most elderly will have lost at least 25% of their sense of smell by the last year of life. The National Interview survey found that 40% of all the patients with a reduced sense of smell are over the age of 65.²² Murphy et al have found that 62.5% of the elderly over the age of 80 had some smell impairment as defined by clinical olfactory testing.²³

There are a variety of reasons for the reduced sense of smell in the elderly.²⁴ First, olfactory receptors may be reduced as a result of both aging and all of the infections and trauma that the upper nose may experience by late adulthood. Second, the olfactory bulb is an extension of the brain and thus may experience similar problems found in other parts of the brain due to demyelination during aging or the effects of Alzheimer disease or dementia. Third, many of the diseases affecting the elderly can also affect the sense of smell, including diabetes, hypothyroidism, liver disease, and renal failure. Fourth, medications and smoking have a profound effect on the nature of respiratory epithelium and neuroepithelium. Fifth, nutritional problems and malnutrition in the elderly can affect their sense of smell. Indeed, the rate of malnutrition in the elderly may be underestimated, partially because we often neglect to think of the risks of malabsorption of nutrients associated with inflammatory bowel disease, the use of proton pump inhibitors, and gastritis. Malnutrition may be greater in the elderly who are homebound or who have trouble taking care of themselves and can be present even among residents of nursing homes and rehabilitation centers, as evident in the reduction in weight and strength found in the elderly (Table 12.2).²⁵

Olfactory neurons reproduce on a cycle of 1 to 2 months. This degeneration may be increased in the face of other neurological diseases such as Alzheimer and Parkinson disease. In some older patients, significant olfactory disturbances may be the earliest sign of intracranial and neurological deficits.²⁶ Neural changes occur in the anterior olfactory cortex and hippocampus in normal elderly patients.²⁷ Magnetic resonance studies of the elderly also show brain volume loss related to olfactory loss.²⁸ Serby has identified olfactory testing as a possible method to determine whether relatives of patients with Alzheimer disease are affected by the disease.²⁹

The workup of olfactory disturbances in the elderly is not difficult for the average otolaryngologist. A detailed history is essential and should include a careful description of patients’ sense of smell, starting with their everyday smells and working to a discussion of more complex smells. A simple question is whether they can taste and smell their coffee in the morning or the peel of an orange. Smells that are derived from or produce oils can be more stimulating to the olfactory epithelium. Coffee, garlic, ginger, orange, lemon, lime, and grapefruit are a few things common in the home and kitchen that will produce a longer-lasting sense of smell. An inability to smell these items is a significant sign of possible olfactory problems. For patients with a fluctuating sense of smell, the details of when and how they smell may help to determine the source and significance of the problem. This includes a fluctuation during seasons, which may be due to dry heat hurting the olfactory epithelium or due to inflammation from seasonal allergies. A good history will also include prior toxin exposure, smoking, trauma, nasal/sinus surgery, and occupation.

An examination of the nose and sinuses is important to the olfactory disturbance exam. This includes looking at the airflow patterns adjacent to the inferior and middle meatus because smell is directly related to airflow in the nose. The status of the osteomeatal complex will also give some idea if infection or irritation is the source of the smell disturbance. The presence of polyps could mean that there may be an excess of inflammatory cells, fungus, bacteria, or mucus, which can affect the roof of the nose. The examination of the nasopharynx may also give some insight by revealing infection, sphenoid drainage, or excessive esophageal reflux, which can dry the nose and cause hyposmia. Computed tomographic scanning can be used prudently if there is a suspicion of chronic infection and a possible failure of appropriate medications. The use of magnetic resonance imaging should be limited and coordinated with the internist or neurologist if a workup of Alzheimer disease or other central neurological disorders seems indicated. The likelihood of finding an olfactory tumor is extremely small.

Table 12.2 Causes of olfactory disturbances in the elderly patient

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