Cummings Otolaryngology 6th Ed Summary

CHAPTER 16: Otolaryngology in the Elderly

THE AGING EAR THE AGING NOSE
The normal process of aging affects all parts of the ear, but the greatest clinical impact is on cochlear and  Nasal structure and physiology are affected directly OLFACTORY CHANGES
vestibular function. by the aging process and by a multitude of  Smell and taste typically peak in the third to fourth
presbycusis, is the most common type of auditory dysfunction and is thought to be due to a series of indirect factors commonly seen in older adults. decades of life and decline at older ages
insults over time that include age-related degeneration, noise exposure, and diseases of the ear.  A decrease in olfactory epithelium and a reciprocal
External Ear COMMON SYMPTOMS increase in respiratory epithelium occur with
 The pinna is commonly involved in actinic disorders, especially basal and squamous cell carcinoma - nasal drainage age, with increased degenerative changes and
 The external auditory canal suffers a decrease in cerumen production - postnasal drip loss of olfactory bulb fibers
 The skin also undergoes atrophy, which results in itching, fragility, and subsequent self-induced lacerations. - sneezing
Presbycusis RISK FACTORS: - coughing CHANGES IN NASAL APPEARANCE AND
Sensory Presbycusis  increasing age - olfactory loss INTRANASAL EXAMINATION
 abrupt, steep, and high-frequency sensorineural  Noise - gustatory rhinitis  increase in the nasolabial angle and a decrease in
hearing loss with slow, symmetric bilateral  Genetic Predisposition the height-to-length ratio of the nose
progression, usually beginning during middle o Male sex and race have both been associated Gustatory rhinitis, nasal discharge stimulated by  The decreased height-to-length ratio accentuates
age with hearing loss in multiple studies eating, similarly may be caused by overactivation of the drooping of the nose as it ages.
 lesions are limited to the first few millimeters of the o The effect of genes is more pronounced for the autonomic control of the mucoserous and  Weakening of the lower lateral cartilage and the
basal turn of the cochlea. the strial atrophy pattern of hearing loss Bowman glands initiated by the sight of food or the caudal septum, along with loss of elasticity in
 flattening and atrophy of the organ of Corti (flat audiogram) than the sensory act of eating the enveloping skin, contributes to the descent
phenotype (high-frequency loss) of the aged nose tip
Neural Presbycusis  Health Comorbidities
 gradual hearing loss with a moderate slope toward o Smoking Treatment
the high frequencies o Cardiovascular Diseases  Humidification is generally helpful, as is the prudent avoidance of medications that desiccate the nose and
 decrease in speech discrimination is aggravate mucosal atrophy.
o Diabetes Mellitus
disproportionately severe  Surgical reconstruction is aimed at reconstituting support for the upper lateral cartilage and elevating the
drooping nasal tip.
TREATMENT
Strial Presbycusis (Metabolic Presbycusis)  Amplification remains the mainstay of treatment for
 flat sensory loss beginning during the third through THE AGING VOICE AND UPPER AERODIGESTIVE TRACT
age-related hearing loss
sixth decades and progressing slowly  Aside from amplification, correction of health factors  The phonatory organ is composed of the resonator (larynx), the articulators (supraglottic structures), and the
that may impact age-related hearing loss—such compressors (lungs)
Inner Ear Conductive Presbycusis as smoking, hypertension, and cholesterol levels
 bilateral symmetric sensorineural hearing loss with  Age-related changes in any one or all of these structures can have a direct impact on voice quality and
 Cochlear implantation may play a role in treating general comfort level
an upward slope toward the high frequency and older adults with severe to profound
preserved speech discrimination sensorineural deafness Histologic Changes
 Laryngeal tissues change a good deal before alterations in the voice are detected
Presbystasis
 the dysequilibrium of aging, is a group of disorders that affect the mobility of a large number of older persons
 degeneration of the vestibular, proprioceptive, and visual senses

Treatment
 Nonvestibular causes of presbystasis need to be identified and treated
 Vestibular habituation training involves exercises based on feedback control initiated by the habituation effect
 Other goals of vestibular exercise programs include the improvement of visual tracking when the head is
stationary, gaze stability during head movement, and visual-vestibular interactions during head movement
and maintenance of general balance
 Another important consideration that must be stressed to the patient is the prevention of falls
 Laryngoscopic Appearance PRESBYPHAGIA FACIAL TRAUMA
 Laryngoscopic characteristics of the aging larynx include edema, a yellowish or dark grayish discoloration of  Dysphagia is relatively common in older adults and  Wound healing is affected by aging, in that
the vocal fold, and vocal fold atrophy affects 15% of those in the community and angiogenesis, epithelialization, and remodeling
 This results in bowing of the vocal fold edges, incomplete glottic closure, and visibility of the ventricle approximately 40% of patients in are all delayed in older patients
institutionalized settings  a decrease in immunologic response can lead to
ACOUSTIC CHANGES  Primary effects of aging on swallowing include increased susceptibility to wound infection
 Dysphonia is present in at least 10% of older adults physiologic and structural changes in the oral  most prominent change is resorption of the alveolar
 Aging of the larynx is also associated with a slowing in the opening quotient of the vocal folds, which further cavity, pharyngeal, and laryngeal structures bone in the maxilla and mandible
adversely affects vocal quality  Secondary effects include a plethora of general
medical and neurologic conditions, such as head HEAD AND NECK ONCOLOGY
and neck cancers and their treatments, ETIOLOGY
MUCOSAL CHANGES neuromotor disorders that include stroke and  Environmental exposure to carcinogens, most
 The aging process results in significant changes within the mucosa of the oral cavity, salivary glands, teeth, cricopharyngeal spasm, or the general notably tobacco and alcohol, is an important
mandible, maxilla, temporomandibular joint (TMJ), and taste buds deconditioning associated with illness cause of these cancers
 Histologically, thinning of the tunica propria and blunting of the rete pegs occurs along with decreases in  Tertiary effects involve those changes that can  The occurrence of cancer in advanced age is
capillaries, water content, hyaluronic acid, and collagen content and an increase in ground substance result from social, environmental, and probably related to both the duration of
psychologic factors carcinogen exposure and immune senescence
GLANDULAR CHANGES  Autoimmune diseases are also more common with
 Normal physiologic changes that occur in the salivary glands of older adults are the principal cause of dry advancing age and may facilitate tumor
mouth syndrome DIAGNOSTIC TESTING progression
 Secretory rates diminish, and salivary viscosity increases in these patients  Modified Barium Swallow - a video fluoroscopic
 Submandibular gland parenchymal volume decreases as a result of a reduction in acinar tissue, whereas ducts swallowing study of the head and neck, provides TREATMENT
enlarge critical physiologic information (i.e., bolus transit  aging leads to multiorgan functional decline,
 Increase in focal chronic inflammatory changes also occurs as a result of hyalinization of the acini and an from the mouth to the cervical esophagus), reduced nutritional status, and psychosocial
increase in salivary duct adhesions and obstructions swallow transitions, and biomechanics of the factors that include depression and absence of
 flow rates from both submandibular and sublingual glands decrease significantly with age swallow that are necessary for treatment social support
 Flexible endoscopic evaluation – adjunctive  More intensive combination therapies must take into
SENSE OF TASTE assessment tool to the modified barium swallow. account the presence of comorbidities, age-
 Many older patients complain of a metallic or salty taste and decreased levels of sensitivity to sweet, bitter, Visualization of the pharyngeal-laryngeal related frailty, and underlying psychosocial
and sour foods mechanism provides symptomatic information problems
 Alterations in taste represent a risk factor for nutritional deficiencies about the swallow  Preoperative education is important for all patients
and their families, and selected patients may
DENTAL/MANDIBULAR CHANGES TREATMENT benefit from a 2-week course of nutritional and
 Resorption of mandibular and maxillary alveolar bone and a diminution in regenerative capacity occurs with  Treatment may be medical or surgical, but it is physical therapy aimed primarily at improving
aging, which leads to a loss in the vertical height of the face and a “purse-string” appearance of the mouth more often rehabilitative in nature cardiorespiratory function
 Bone resorption and the diminution of connective tissue around the nerves allow the neurovascular surface to  These include swallowing therapy strategies, such
be more easily damaged as the supraglottic swallow or Mendelsohn END
 As far as teeth are concerned, a calcified secondary dentin replaces most of the dental pulp maneuver, and other oropharyngeal exercises
 The cementum shows continued deposition and calcification throughout life
 The absence of teeth, the use of ill-fitting dentures, oral or dental pain, and paresthesias may further affect
certain speech sounds, particularly those that involve tongue-to-lip, palate, or teeth apposition
 A loss of elasticity and hardening of the articular disc and capsular ligament, thinning of the articular disc,
fibrosis of the articular space, and a flattening of the articular surfaces is evident

RESPIRATORY CHANGES
 Age causes changes in the musculature of the lower respiratory tract that affect the function of the chest wall,
abdomen, and diaphragm and can result in inadequate breath support and excessively harsh glottal
closure.

TREATMENT
 directed at controlling the underlying medical illness and maximizing the efficiency of the phonatory apparatus
 involves the expertise of a speech pathologist, otolaryngologist, pulmonologist, neurologist, psychiatrist, oral
surgeon, and a generalist
 Voice therapy is considered a first-line treatment and has been shown to improve subjective quality of life as
well as perceived voice
 injection augmentation has been shown to improve glottal competence in the setting of vocal fold atrophy
 laryngeal framework surgery, may be considered as a possible permanent solution in patients who have
already benefited from injection laryngoplasty