You are on page 1of 26

07-Nov-13

Geriatric Otolaryngology
Literature Reading
Yanuar Iman Santosa
DEPARTMENT OF OTORHINOLARYNGOLOGY - HEAD&NECK SURGERY
PADJADJARAN UNIVERSITY / HASAN SADIKIN GENERAL HOSPITAL
BANDUNG
2OO9

ORL-HNSs role within the field of geriatrics (1)


1. Early detection & treating head and neck cancer
2. Hearing conservation and treatment of hearing loss

3. Managing annoying symptoms


(nasal congestion, chronic sinusitis, tinnitus, and vertigo);
4. Treating upper respiratory infections
(acute sinusitis, otitis media, and pharyngitis);

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

07-Nov-13

ORL-HNSs role within the field of geriatrics (2)


5. Managing conditions that limit social activity
(hearing loss, dys-equilibrium, and voice changes);
6. Improving the quality of life
(facial plastic and reconstructive surgery);
7. Improved management of trauma, cessation of smoking and
alcohol consumption

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

Some people just cant quit.

07-Nov-13

Biology of Aging

Etiology of aging not fully


understood.

Normal age changes : graying and


loss of hair, skin sagging and
wrinkling, reduced stamina,
menopause, presbyopia, and loss
of short-term memory

Decrease immune system


(normal age-related ) infection
and cancer

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

Human cells replication and function has a limit


Immortal cells (e.g., by exposure to radiation, chemicals, or
viruses) not truly immortal normal cells
Differ from normal cells (chromosome number, or
morphology ) inoculated into experimental animals
produce tumors

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

07-Nov-13

Theory of aging
Somatic mutation theory accumulation of mutations
decreases function aging
Error theory random errors in replication of DNA
Program theory a purposeful sequence of events is
written into the genome growth, development, aging, and
death

Other factors : Hormonal, oxidative damage, diets, stress and


disease
Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

Mutation

07-Nov-13

Error

Epidemiology and Demography


US : 29 million people > 65 years (12% of the population)
By the year 2020 54 million (18%)
Ranks number of people older than 80 years :
1. China
2. US
People live longer accumulate chronic health problems
Elderly problems everyday tasks of life
Elderly use the health-care system and spent more money
Economists project increase during the next 30 years

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

07-Nov-13

12% of population older than 65 years

Use 33% of physician time


Use 25% of medication

40% of hospital admissions


Elderly population impact on society
Future healthcare needs : aging population
number of physicians and nurses needed
Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

07-Nov-13

Epidemiology of otolaryngologic
disorders among the elderly
Diagnosis

Surgery

Otitis media

Sinus and mastoid procedures

Dysequilibrium
ENT malignancy

Major head and neck procedures

Epistaxis

Miscellaneous ENT procedures

Nasal trauma and deformity

Rhinoplasty

Other ENT diagnoses

Other ENT surgical procedures

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

Hearing, Presbycusis, Hearing Aids,


and Assistive Devices
9.2 million people >65 years
Problem : understanding speech in normal
background noise
Failure frustration, discouragement,
passivity, social withdrawal, slowed mental
processes, and depression

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

07-Nov-13

Presbycusis

Presbycusis

Hearing-aid technology
Increasing number and the decreasing cost hearing devices improve
quality of life
Presbycusis is no longer considered a major factor that causes older
patients to withdraw from the world around them.

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

07-Nov-13

Tinnitus

Tinnitus

20% in people > 50 years


Severe plagues me all day along (4% in people >50
years)
Association : tinnitus - psychological diagnoses
Dobie et al. depression in 24 of 40 patients with severe
tinnitus
Preliminary results : nortriptyline, a tricyclic antidepressant
reduce severity of tinnitus in these patients
Medication, counseling, psychological support, and training
in various coping strategies
Tinnitus-masking devices provide relief in some patients

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

07-Nov-13

Dysequilibrium and Ataxia of the Elderly

Presbyastasis : dysequilibrium that results from aging


Degenerative changes : vacuolization of the sensory epithelium of the
semicircular canal ampullae plus fragmentation of the otoconia, along
with morphologic changes in the vestibular nerves, Scarpa ganglion, and
the cerebellum.
Affected persons : progressive decline in ability to perform eye-tracking
tests, unable to maintain normal posture

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

Age , decline in sensory input, decreased integrating ability and


weakened muscular function balance problems
Prevention of falls, treatment, and rehabilitation strategies
Elderly prone to falling hip fractures and head injuries.
Keep their homes free of any objects cause to fall
Adequate lighting
Tai Chi exercises produce an improvement in balance in the elderly
Pharmacologic agents no benefit in improving vestibular function

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

10

07-Nov-13

Voice Disorders in the Elderly

Vocal quality
Known causes :
ossification of the laryngeal cartilages
limitation of arytenoid cartilage excursion
incomplete glottic closure
decreased number of collagen and elastin
fibers
atrophy of the laryngeal muscles
Edema of the vocal folds (smokers)

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

Olfaction and Gustation in the Elderly


Senses of smell and taste important
Morphologic changes :
loss of zonal distribution of receptor
olfactory neuroepithelium reduced replace by respiratory
epithelium.

Other factors :

Degenerative diseases
drugs
radiation therapy
viral infections
endocrine disorders
Neoplasms
trauma

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

11

07-Nov-13

Geriatric Sinusitis and Nasal Symptoms

Older patients > nasal drainage, postnasal drip, rhinitis, and olfactory
ability
Upper respiratory infections underdiagnosed inappropriately treated
These infections account for a large proportion of the use of the
healthcare system.
Predisposing factors :
previous nasal fractures
- allergic rhinitis
viral upper respiratory infection
- Dehydration
foreign bodies
- dental abscesses
nasal polyposis
- use of nasal sprays
Aspirin
- nasal intubation
immune system
Kern et al. apoptotic of olfactory sensory neurons hyposmia and
anosmia

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

Presbyphagia

Swallowing disorders and aspiration serious problems


12% of hospitalized patients swallowing disorders
50% of nursing homes elderly need assistance with feeding
Aspiration swallowing spillover into the tracheobronchial tree
cough, intermittent fever, tracheobronchitis, pneumonia, atelectasis, or
empyema.
Neurologic disorders :
Stroke
epilepsy
drugs
tumors
infection

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

12

07-Nov-13

Peripheral Nerves

Changes in peripheral nerves


dysphagia, aspiration, and vocal
quality
Changes :
tendency to lose myelinated
nerve fibers
pathologic changes in Schwann
cells
vascular changes

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

Geriatric Immunology
Age immune system
Lymphocytes effectivity because :
function of helper and cytotoxic T-cell
The general response to antigens and immunogens
The thymus gland involutes
Older T and B cells produce a weaker response
The quality of the overall response (less IgG and fewer
antibodies)

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

13

07-Nov-13

Benign and Nonsquamous Neoplasms


clinical behavior Aggressive
delays in seeking medical attention
nonsquamous tumors :
most common : involving the thyroid and salivary glands
Fibroosseous tumors and hemangiomas rare
Anaplastic or undifferentiated thyroid cancer >common in
patients older than 65 years
medullary carcinoma and thyroid lymphomas >often
Well-differentiated thyroid carcinoma much more
aggressive
recurrence rate for papillary carcinoma higher
Substernal goiter disease of the middle-aged and elderly.
Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

Salivary gland malignancies > frequent in patients > 50 yrs


High-grade mucoepidermoid carcinoma > common in the
elderly
low-grade mucoepidermoid cancer > frequentl in young
patients
Older age poor prognostic factor
Non-Hodgkin's lymphoma of the upper aerodigestive tract
disease of the middle-aged and elderly.

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

14

07-Nov-13

Special considerations :
Anxiety about medical costs,
Lack of knowledge or concern about symptoms,
Social isolation,
Lack of personal physician, and
Fatalistic attitudes about disease and treatment outcome.

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

Squamous Cell Carcinoma

+/- 70,000 new cases of head and neck cancer / year


average patient age being 59 years
80% squamous cell carcinomas
overall 5-year survival rate
67% (localized disease)
30% (regional metastasis)
theory of carcinogenesis :
genetic predisposition
Carcinogen
defective immune surveillance system
Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

15

07-Nov-13

Facial Plastic Surgery in the Elderly


older patients demand surgical procedures that enhance
their appearance
cosmetic surgical procedures doubled in the past decade
(>50)
Procedures :
Rhinoplasty nasal hump
Blepharoplasty tired appearance
Rhytidectomy face lift

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

Aging of the Skin

Causes genetic and environmental factors


Genetic regulation : number of skin-cell replications
With aging mitotic activity atrophy
Crosslinking of nuclear DNA strands genetic abnormalities induction
of malignancy
Free radicals enhance formation of epoxides(potent crosslinking
agents)
Ionizing radiation and solar ultraviolet radiation trigger free-radical
chain reactions
Patients of all ages should be urged to use sunscreens.

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

16

07-Nov-13

The aging skin

Important age-related skin changes :


Decreased moisture content
Effacement of the rete ridges of the epidermis
Heterogeneity of keratinocyte nuclei
Decreased population of melanocytes and Langerhans cells
(important part of the local immune system)
Thinning of the dermis
Decreased elastic tissue
Loss of oxytalan fibers (causes skin laxity)
Haphazard collagen deposition
Fewer small vessels, fibroblasts, macrophages, mast cells,
Pacini corpuscles, Meissner corpuscles, and sweat glands
Smaller sebaceous glands

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

17

07-Nov-13

These changes
slow wound healing and reduce inflammatory response
Common benign skin lesions :
seborrheic keratosis
skin tags
cherry hemangioma
chondrodermatitis nodularis chronica helices
angular cheilitis
Xanthelasma
Keratoacanthoma
Wrinkles

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

Airway Management

complicated by associated disease, pulmonary pathology, or medications

A major issue :
the need for prolonged intubation (longer than 2 weeks)

Injury caused by :
material biotoxicity
cuff pressure
tube wall pressure.

Complications :
tracheal stenosis : 5% to 10% after 10 days of intubation

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

18

07-Nov-13

Laryngotracheal pathology :
diffuse edema
mucosal erosion over the arytenoid vocal process
granulation tissue
vocal cord paralysis
Nasal ulceration or sinusitis may result from prolonged
intubation

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

Facial Fractures
Bone healing capacity
Due to :
endocrinopathy
disturbed calcium metabolism
suboptimal nutritional status
and a reduced blood supply
blood supply depends on vessels in the subperiosteal
minimum periosteal elevation during management
age, bone resorption loss > 50% mandibular height.

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

19

07-Nov-13

Osteoporosis

Facial bone
ADULT

ELDERLY

20

07-Nov-13

Resorption weakens the mandible fracture (< force )


problem reduced contact area
management :
minimally invasive techniques
less dissection
less hardware to the wound
Healing : 50% longer than young adults
Nutritional management critical in older patients.

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

Highlights
Aging is the sum of many phenomena: disease, environmental
insult, injuries, nutrition, and genetic programming.
The etiology is not fully understood.
Theories of aging : limited cell replications, somatic mutation
theory, the error theory, and the program theory.
Ataxia of the elderly (presbyastasis) damaging falls
significant morbidity, mortality, and high health-care costs.

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

21

07-Nov-13

Swallowing disorders and aspiration (presbyphagia) serious


problems may cause cough, fever, pneumonia, atelectasis,
empyema, or death.
The immune system becomes less effective
Malignant neoplasms more-aggressive clinical behavior
Delays in seeking medical attention

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

Facial plastic surgery (blepharoplasty and rhytidectomy)


more popular during the past decade
Management of the geriatric airway complicated by
associated disease, specific pulmonary pathology, or
medications
Prolonged intubation (>than 2 weeks) major issue in
managing respiratory problems in the elderly

Bailey, Byron J., Head & Neck Surgery - Otolaryngology, 4th Edition, Lippincott Williams & Wilkins, 2006, Ch 17. Geriatric Otolaryngology

22

07-Nov-13

THANK YOU
Thank you

Antioxidant

23

07-Nov-13

Spasmodic Disphonia
Botox treatment

LSVT VOICE THERAPY RESULTS

24

07-Nov-13

Cilia dysfunction

25

07-Nov-13

Types of Presbiacusis

Geriatric medicine : a branch of medicine that concerns itself with


the aging process; the prevention, diagnosis, and treatment of
health care problems in the aged
The aged or elderly population : persons aged 65 years or older
Practice of Geriatrics 3rd edition. Duthie & Katz . W B Saunders. 1998

26