Otolaryngology in the Elderly 16

Susan D. Emmett | Meena Seshamani

Key Points
The population is aging as people are living longer.
The geriatric population comprises a significant proportion of otolaryngologic practice.
Presentation of diseases in older adults may be different than in the younger population, and the
spectrum of disease may be different.
Diagnosis, prognosis, and goals of therapy need to be discussed with patients and their families.

Sensory disorders that affect hearing, speech, taste, smell, and balance are common and may
significantly affect the quality of life of the geriatric patient.
Awareness of how otolaryngologic processes affect the geriatric population will allow for better
satisfaction for patients, their families, and the otolaryngologists involved in caring for this population.

T he social and economic significance of the so-called graying
of America has received a great deal of attention. In 2003,
there were 36 million older adults living in the United States,
which represents 12% of the population. By 2030, this number
is projected to double to 72 million, which will represent 20%
of the population by that time.1 Disability and disease are more
prevalent in older populations, and nearly half of lifetime-
per-capita health expenditures occur after the age of 64.2 The
expected growth of the geriatric population therefore portends
a significant impact on societys social, economic, medical, and
ethical needs and obligations.
Together, geriatricians and other specialists in geriatric med-
icine and surgery are developing a system of care that keeps
older adults healthier, more functional, and more independent
at older ages than was previously possible. Otolaryngologists
play a role as communication specialists and are a key resource
for helping older adults avoid isolation. The American Society
of Geriatric Otolaryngology was formed in 2007 to help the
specialty present a unified position in treating geriatric patients
with otolaryngologic conditions.
THE AGING EAR
The normal process of aging affects all parts of the ear, but the
greatest clinical impact is on cochlear and vestibular function.
Age-related hearing loss, or presbycusis, is the most common
type of auditory dysfunction and is thought to be due to a series
of insults over time that include age-related degeneration,
noise exposure, and diseases of the ear. Presbycusis is greatly
affected by genetic background, diet, and systemic disease. Ves-
tibular symptoms are present in more than half of older adults.
Because balance depends on input from the ears, eyes, and
peripheral sensory systems, all of which degenerate over time,
impaired function in any of these systems contributes to ves-
tibular complaints.
EXTERNAL EAR
The pinna is commonly involved in actinic disorders, especially
basal and squamous cell carcinoma, which makes sun protection
and frequent inspection essential. The external auditory canal
suffers a decrease in cerumen production because of degenera-
tion of cerumen glands and a reduction in the total number
of glands. This may lead to a drier cerumen that is less protective
of the underlying skin and may result in a higher incidence of
impaction and infection. Ceruminosis can be exacerbated by an
increase in hair at the external auditory meatus. The skin also
undergoes atrophy, which results in itching, fragility, and subse-
quent self-induced lacerations. The use of topical emollients has
been recommended for difficult cases.
PRESBYCUSIS
Hearing loss is highly prevalent in older adults and has been
associated with multiple adverse outcomes that include cogni-
tive decline,3-5 incident dementia,6 driving impairment,7 and
difficulty walking.8 Based on data from the National Health and
Nutritional Examination Survey (NHANES), 26.7 million U.S.
adults aged 50 years and older have clinically significant hearing
loss, defined by World Health Organization criteria as a speech-
frequency pure tone average (0.5, 1, 2 and 4 kHz) of greater
than 25 dB of hearing loss in both ears.9,10 Hearing-loss preva-
lence doubles in each decade of life from the second to seventh
decade and is present in nearly two thirds of U.S. adults 70 years
and older.11,12 Presbycusis may have a devastating effect on older
individuals by reducing their ability to communicate, thereby
jeopardizing autonomy and limiting opportunities to be active
members of society. This decrease in social engagement can
have profound consequences, and loneliness is a known deter-
minant of morbidity and mortality in the elderly.13
Gacek and Schuknecht14 initially defined four histopatho-
logic types of presbycusis. Subsequently, two more categories
were added: mixed and indeterminate. The indeterminate
category alone may account for 25% of cases.15 Recent studies
indicate that a mixture of pathologic changes may be present
most of the time.16
Sensory Presbycusis
The audiometric findings in this type of presbycusis include an
abrupt, steep, and high-frequency sensorineural hearing loss

231

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232 PART II | GENERAL OTOLARYNGOLOGY
with slow, symmetric bilateral progression, usually beginning
during middle age. Pathologic lesions are limited to the first
few millimeters of the basal turn of the cochlea. A flattening
and atrophy of the organ of Corti is due to the loss of hair cells
and supporting cells. An accumulation of lipofuscin, the aging
pigment, is also evident.
Neural Presbycusis
Audiometric findings include gradual hearing loss with a mod-
erate slope toward the high frequencies; however, the decrease
in speech discrimination is disproportionately severe. This dif-
ficulty with speech discrimination makes hearing loss refractory
to amplification in many cases. Atrophy of the spiral ganglion
and nerves of the osseous spiral lamina occur mainly in the
basal turn of the cochlea. The organ of Corti is largely intact,
as opposed to what is found in sensory presbycusis.
Strial Presbycusis (Metabolic Presbycusis)
The hearing loss associated with strial presbycusis is flat
sensory loss beginning during the third through sixth decades
and progressing slowly. Speech discrimination is generally
good, and no recruitment is present. This condition is often
familial, and patients do well with amplification. The charac-
teristic pathologic findings are that atrophy of the stria vascu-
laris is either patchy in the basal and apical turns or diffuse.
The organ of Corti and spiral ganglion cells are usually
unaffected.
Inner Ear Conductive Presbycusis
Both inner ear conductive presbycusis and atrophy of the spiral
ligament cause bilateral symmetric sensorineural hearing loss
with an upward slope toward the high frequency and preserved
speech discrimination. No anatomic correlates with conductive
sensorineural hearing loss are known, but it is hypothesized
that the functional loss is due to stiffness of the basilar mem-
brane, which correlates with its anatomic shape. The histo-
pathologic pattern of atrophy of the spiral ligament includes
different degrees of pathologic changes that are progressive
through the patients life; it is most noticeable in the apical turn
and least apparent in the basal turn. Cystic degeneration may
cause detachment of the organ of Corti from the lateral
cochlear wall, thereby resulting in hearing loss.
PROPOSED ETIOLOGIES
Presbycusis is a multifactorial condition that represents the
lifetime accumulation of both intrinsic and extrinsic insults on
the inner ear, including the inner and outer hair cells, stria
vascularis, and afferent spiral ganglion neurons.15,17,18
RISK FACTORS
Recent epidemiologic studies on age-related hearing loss have
suggested four primary categories of risk factors for presbycusis:
cochlear aging, noise exposure, genetic predisposition, and
health comorbidities.19 The mechanistic pathways for these risk
factors tend to be overlapping, but specific changes are also
relevant to each category.
Increasing Age
Increasing age has shown a strong, consistent association with
risk of hearing loss across multiple studies.11,20-22 Increased
mutations and deletions in mitochondrial DNA are thought to
be a contributing factor in this association. Temporal bone
studies have observed higher frequency of common aging dele-
tions within the cochlea in subjects with age-related hearing loss
compared with normal hearing controls.23 Markaryan and col-
leagues24 found a significant difference in the level of common
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aging deletions in mitochondrial DNA in the cochlea based on
severity of hearing loss.
Noise
Noise exposure is a well-established cause of hearing loss and
is considered a risk factor for presbycusis. Recent studies have
shown substantial overlap in the pathways involved in noise-
induced cochlear damage and the cumulative effects of aging.
Reactive oxygen species are believed to play a major role in
cochlear aging, and they are also generated in excess response
to noise exposure.19 Whereas the direct correlation between
noise-induced inner ear damage and the frequency, intensity,
and duration of noise exposure has been well established, some
argue that noise exposure causes hearing loss at any age and is
not true presbycusis. Indeed, recent studies on the interaction
of noise-induced hearing loss and age-related hearing loss are
contradictory and variable, likely secondary to the underlying
influence of other intrinsic and environmental variables on
both mechanisms.25-28 More research is needed to determine
the differential effects of noise exposure on the elderly.
Genetic Predisposition
Male sex and race have both been associated with hearing loss in
multiple studies.11,29 When evaluating the relationship between
hearing loss and race, blacks consistently demonstrate 60% to
70% lower odds of hearing loss compared with whites.11,29-31 One
hypothesis for this association is that the higher melanin pro-
duction that results in darker skin color also indicates higher
levels of melanin produced by strial melanocytes within the
cochlea, and this intracochlear melanin protects the stria vascu-
laris by acting as a free-radical scavenger.32,33
Aside from the genetic contributions of sex and race, pres-
bycusis has been found to cluster strongly in families. Approxi-
mately half of the variability in presbycusis may be attributed
to genes.34,35 The effect of genes is more pronounced for the
strial atrophy pattern of hearing loss (flat audiogram) than the
sensory phenotype (high-frequency loss).36 Interestingly, many
of the candidate genes associated with hearing loss are also
associated with oxidative stress and atherosclerosis.19 Proposed
genes in recent studies include those that code for glutathione
peroxidase and superoxide dismutase, two antioxidant enzymes
active in the cochlea.37,38 Endothelin 1, a potent vasoactive
peptide involved in the development of atherosclerosis, can
also produce long-term constriction of the spiral modiolar
artery, leading to ischemia in the inner ear.39 An association
between a single-nucleotide polymorphism within the END1
gene and hearing loss has been observed in middle-aged and
elderly Japanese.40
Health Comorbidities
Other factors associated with age-related hearing loss include
smoking and circulatory disorders such as hypertension, car-
diovascular and cerebrovascular disease, and diabetes.29,31,36,41-44
In the Framingham cohort, coronary artery disease, stroke,
intermittent claudication, and hypertension were all linked to
hearing loss.36 Many of the gene candidates associated with
hearing loss are also associated with atherosclerosis. Overall the
data on cardiovascular disease and hearing loss are inconclu-
sive, however, and more work is needed to further characterize
the relationship between hearing loss and atherosclerosis.29,45
Hearing loss correlates with smoking and diabetes. In a
population of over 3700 adults aged 48 to 92 years, Cruick-
shanks and colleagues41 found that smokers were 1.69 times
more likely to have hearing loss than nonsmokers. A dose-
dependent effect of smoking on high-frequency hearing loss
was also noted in a recent multicenter study.46 An interaction
between noise exposure and smoking was also apparent in the
NHANES cohort: heavy smokers who reported firearm use

demonstrated a significantly greater hearing loss than non-
smokers with similar noise exposure.47 Diabetes has also been
associated with hearing loss in multiple studies and may involve
physiologic mechanisms similar to those of cardiovascular
disease and smoking.43,48,49
Despite the complexity of factors that contribute to age-related
hearing loss, substantial overlap exists in the mechanistic path-
ways involved. Furthermore, regardless of the etiology or mecha-
nistic pathway involved, presbycusis tends to produce the same
functional outcomenamely, a disproportionate effect on
speech understanding and perception in noise.50 Thus elderly
who suffer from age-related hearing loss tend to struggle with an
inability to understand words, which leads to complaints such as,
I can hear you, but I cant understand you, or Youre just
mumbling. As presbycusis worsens, the ability to extract
meaning from day-to-day conversations diminishes, such as
hearing Ill see you someday instead of Ill see you Sunday.19
HEARING LOSS AND DEMENTIA
Recent studies have observed an association between hearing
loss in older individuals and cognitive decline.3-5 Hearing loss
has been associated with increased risk for incident dementia
and incident cognitive impairment in two longitudinal obser-
vational cohorts.4,6 This relationship has substantial implica-
tions for the health and well-being of elderly patients with
presbycusis. More research is needed to determine whether
hearing rehabilitative interventions could affect this cognitive
decline.
TREATMENT
Amplification remains the mainstay of treatment for age-related
hearing loss; however, the current use of hearing aids in the
United States remains low. Only 3.8 million people, or 14.2%
of individuals over age 50 in the NHANES cohort, wear hearing
aids.9 Whereas the prevalence of hearing aid use increases with
every decade of life (Fig. 16-1), an estimated 22.9 million older
Americans with hearing loss still are not using amplification.9
A new debate is arising as to whether data from the nongeriatric
literature in support of binaural amplification should be
applied to elderly populations. Recent studies have demon-
strated that geriatric patients tend to perform better in noise
with a single hearing aid than with binaural amplification.51,52
Aside from amplification, correction of health factors that may
impact age-related hearing losssuch as smoking, hyperten-
sion, and cholesterol levelsshould also be considered.53
80
70
60
Prevalence (%)
50
40
30
20
10
0 dysfunction based on modified Romberg testing.60 The odds of
50-59 60-69 70-79
Age (years)
FIGURE 16-1. Prevalence of hearing loss (orange bars) and hearing aid use
(red bars) in adults aged 50 years and older in the United States. (Data from
Chien W, FR: Prevalence of hearing aid use among older adults in the United
States. Arch Int Med 2012;172:292-293.)
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16 | OTOLARYNGOLOGY IN THE ELDERLY 233
Cochlear implantation may play a role in treating older
adults with severe to profound sensorineural deafness. Such
a degree of hearing loss is most often due to an underlying
pathologic process such as Meniere disease or otosclerosis in
combination with presbycusis; the latter does not produce this
degree of hearing impairment on its own. A recent study of 749
adolescent and adult cochlear implant recipients found that
age was a clinically insignificant predictor of audiologic outcome
from cochlear implantation, compared with duration of pro-
found deafness and residual speech recognition.54 Multiple
studies have also found improvements in quality-of-life scores
in elderly cochlear implant recipients.55,56 As discussed previ-
ously, comorbid chronic health conditions seen more com-
monly in older populations will play a role in surgical planning
and perioperative management.
Overall, the goal of treatment for presbycusis is to enable effec-
tive communication in all settings. Although addressing periph-
eral functioning deficits through hearing aids and cochlear
implants is essential, the growing body of evidence suggesting a
link between hearing loss and cognitive decline suggests that a
more comprehensive management strategy is necessary. Expan-
sion of diagnostic testing to include speech in noise and cogni-
tive evaluation (or appropriate referrals for such evaluation), as
well as incorporation of rehabilitation and counseling, will con-
tribute to the this more comprehensive approach.57
PRESBYSTASIS
Presbystasis, the dysequilibrium of aging, is a group of disorders
that affect the mobility of a large number of older persons.
Because of the degeneration of the vestibular, proprioceptive,
and visual senses, the ability to walk and drive can be reduced
to the point of incapacitation; lessening spatial-orientation
abilities contribute to this as well. Falls are one of the most
common concerns relating to imbalance in older adults, and
falls often lead to functional decline, anxiety, depression, social
withdrawal, and increased medical costs.
Input from the vestibular, visual, proprioceptive, and other
systems can be thought of as providing input into a common
central processor that in turn controls posture and eye move-
ment. Disorders of these sensory organ systems have tradi
tionally been treated by otolaryngologists, neurologists, and
ophthalmologists, depending on the organ system causing the
most obvious dysfunction. However, development of the unify-
ing discipline of neurotology has led to an integrated approach
to, evaluation of, and care for older adults who experience dys-
equilibrium. Otolaryngologists must be aware of other causes of
dysequilibrium or dizziness, because a variety of organ systems
may contribute to these difficulties. For example, side effects
of psychotropic medications, abnormalities in blood pressure,
leg muscle weakness, neuromotor disorders such as Parkinson
disease, and generalized loss of coordination can contribute to
feelings of dysequilibrium and dizziness.58 The failure of one
organ system can be overcome with compensation, but with
multisystem failure, increasingly severe deficits occur.59
VESTIBULAR PATHOLOGY
Vestibular dysfunction is highly prevalent in older adults.
Based on the NHANES survey from 2001 to 2004, 69 million
Americans35.4% of adults aged 40 and olderhad vestibular
80+ vestibular dysfunction increase significantly with age regardless
of sex or race.60,61
A large number of vestibular disorders are seen in older
patients and include vascular disease, Meniere disease, benign
paroxysmal positional vertigo, and adaptation deficits. Age-
related degeneration has been noted in hair cells, neurons, and
234 PART II | GENERAL OTOLARYNGOLOGY
supporting structures of the peripheral vestibular system as well
as more centrally in the vestibular nuclei and cerebellum. Hair
cell loss has been found in the semicircular canals, the utricle,
and the saccule. This degeneration is most noted in the central
area of the cristae, whereas degeneration in the macula is more
diffuse. In a recent cross-sectional study of 50 adults aged 70
and older, increasing age was associated primarily with declines
in semicircular canal function in each plane. Saccular dysfunc-
tion was the next most common observation, followed by utric-
ular dysfunction.62
Recent studies have also observed a strong association
between hearing loss and incident falls.63,64 The pathways that
could explain this relationship have yet to be elucidated, but
some possibilities include concomitant cochlear and vestibular
dysfunction, decreased awareness of the spatial environment
with decreased auditory cues, and mediation between hearing
loss and cognitive load.63 Vestibular dysfunction, which is par-
ticularly prevalent in individuals with diabetes mellitus and may
represent a newly recognized complication of the disease, was
recently observed to act as a mediator of the effect of diabetes
on fall risk.65
DIAGNOSTIC METHODS
The use of objective tests to identify the etiologic basis of pres-
bystasis is essential. Vestibular function studies described else-
where are applicable in older adults as well. Avoidance of a
trash basket diagnosis of presbystasis and continuing clinical
research into etiologic diagnosis are essential. In particular,
studies of electronystagmography, platform posturography, and
sinusoidal harmonic acceleration in older adults are ongoing.
In cases of presbystasis that arise in the peripheral labyrinth,
generalized hypofunction is often found. Symmetric maximum
slow-phase velocity responses to warm and cool caloric stimula-
tion of less than 10C per second per irrigation can be empiri-
cally used to identify this condition. In cases of peripheral
hypofunction, the use of vestibular nerve suppressants may
be contraindicated. Such treatment further reduces the
already reduced vestibular input, thereby resulting in further
incapacitation.
TREATMENT
Nonvestibular causes of presbystasis need to be identified and
treated. Examples include postural hypotension associated with
antihypertensive medications, endocrine imbalances, malnutri-
tion, and cardiovascular insufficiency.
Because of the adaptive control feedback mechanism in the
complex vestibular system, treatment modalities have been
developed to allow for compensation. Vestibular habituation
training involves exercises based on feedback control initiated
by the habituation effect. Mechanisms of adaptation and
compensation are stimulated through repeated elicitation of
minor degrees of vertigo. 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. These exercises are
designed to incorporate visual and proprioceptive experiences
with vestibular cues in order to reestablish balance and reduce
symptoms of dizziness and disorientation. In many cases, con-
sultation and therapy with a physical or occupational therapist
trained in vestibular compensation exercises can be extremely
helpful.
Another important consideration that must be stressed to
the patient is the prevention of falls. Precautions include the
use of night lights, especially en route to the bathroom;
the removal of throw rugs; avoidance of stairs; and use of
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ambulatory assistance devices, such as walkers and canes, when
necessary.
THE AGING NOSE
Nasal structure and physiology are affected directly by the
aging process and by a multitude of indirect factors commonly
seen in older adults. For example, older adults are more likely
to suffer from falls, which can lead to head and face trauma
that can affect nasal function and the sense of smell. The
elderly are also more likely to suffer from olfactory dysfunction
following a viral upper respiratory tract infection.66 Some medi-
cations used commonly by older adults (e.g., lipid-lowering
drugs, antiinflammatory medications, and antihypertensives)
may desiccate the nose and alter smell and taste.67 Deconges-
tants and antihistamines make secretions thicker and worsen
postnasal drip, and blood thinners can precipitate epistaxis.
Age-related deficits in nasal function can adversely affect sleep,
eating, and breathing and can significantly alter a patients
quality of life.
COMMON SYMPTOMS
The most common nasal complaints in older adults are nasal
drainage, postnasal drip, sneezing, coughing, olfactory loss,
and gustatory rhinitis. Other symptomssuch as nasal obstruc-
tion, epistaxis, and sinus painhave not been shown to signifi-
cantly increase with age. It is thought that nasal discharge and
postnasal drip among older adults may be explained by the loss
of autonomic control. Gustatory rhinitis, nasal discharge stimu-
lated by eating, similarly may be caused by overactivation of the
autonomic control of the mucoserous and Bowman glands
initiated by the sight of food or the act of eating.68
A general increase in nasal resistance develops with age
despite the lack of subjective symptoms of nasal obstruction.
This may be explained by the fact that many older patients
believe that some nasal obstruction is normal and hence not
worth mentioning. However, older people often notice that
nasal airflow is subjectively less with exertion.68
OLFACTORY CHANGES
Smell and taste typically peak in the third to fourth decades of
life and decline at older ages.48 Many studies have shown that
olfactory thresholds for a wide range of odorants progressively
decrease with age.69-72 The process is probably due to a combi-
nation of a loss of receptors and neurons with alterations in
neurotransmitters and central pathways.73 A decrease in olfac-
tory epithelium and a reciprocal increase in respiratory epithe-
lium occur with age, with increased degenerative changes and
loss of olfactory bulb fibers.74-76 One mechanism for the change
in the number of olfactory receptor neurons is an increase in
apoptosis.75 Ossification of the cribriform plate foramina with
age also appears to contribute.77
A growing body of evidence links olfactory dysfunction in
older subjects to neurodegenerative disorders that include
Alzheimer disease and Parkinson disease.78-81 Across studies a
significant association between olfactory dysfunction and
nigrostriatal denervation has been observed. Importantly for
the otolaryngologist, olfactory deficits typically precede motor
signs of Parkinson disease by several years, which suggests that
some patients may come to medical attention with complaints
of anosmia before receiving a diagnosis of Parkinson disease.
Wilson and colleagues81 have also noted that underlying Lewy
body disease is associated with impaired olfaction even in oth-
erwise asymptomatic subjects. Given these findings, it is possi-
ble that olfactory dysfunction could be used as a screening tool
for neurodegenerative disorders in the future.
 16 | OTOLARYNGOLOGY IN THE ELDERLY 235

TABLE 16-1. Common Factors with a Direct Effect

CHANGES IN NASAL APPEARANCE AND on Vocal Quality
INTRANASAL EXAMINATION Factors Effect on Vocal Quality
A significant increase in the nasolabial angle and a decrease in Laryngeal muscle atrophy/ Effect on glottic gap and
the height-to-length ratio of the nose occur with age. This may fibrosis vocal fold thickness results
be due to the lengthening of the upper lip, resorption of pre- in increased air loss and
maxillary fat, resorption of the malar and alveolar ridge, and abnormal acoustics
changes in dentition caused by the degenerative process of Cricoarytenoid joint changes
aging. The decreased height-to-length ratio accentuates the Mucosal atrophy Increased chance for injury,
drooping of the nose as it ages. Weakening of the lower lateral pain, and guarding, which
cartilage and the caudal septum, along with loss of elasticity affect articulation
Salivary gland atrophy Decreased lubrication, dry
in the enveloping skin, contributes to the descent of the aged
mouth, and secondary
nose tip. dental problems
On intranasal examination, nasal polyps are more common Alveolar bone resorption Increased chance for injury,
with advancing years.82 Abnormalities of the nasopharynx are pain, and guarding affect
not common in older subjects. articulation
Lower respiratory tract Decreased chest elasticity,
TREATMENT changes abdominal tone, and breath
support result in decreased
As is the case with younger age groups, medical or surgical vital capacity, vocal fatigue,
treatment of rhinologic problems in older adults requires an and decreased volume
accurate diagnosis to select appropriate treatment. Humidifica- Dental/gingival loss
tion is generally helpful, as is the prudent avoidance of medica-
Temporomandibular joint
tions that desiccate the nose and aggravate mucosal atrophy, disease
such as topical and systemic decongestants. Underlying osteo-
meatal blockage as a result of allergies or infection should be
addressed; this may involve treatment in a multidisciplinary
setting by the pulmonologist, allergist, otolaryngologist, and
other specialists. The treatment of associated medical condi-
tions may be helpful. In patients with vasomotor or gustatory
rhinitis, anticholinergics such as ipratropium bromide spray both sexes. Histologic examination suggests that the yellowish
may be effective. discoloration seen clinically represents fat degeneration or
Surgical reconstruction is aimed at reconstituting support keratosis of the mucous membrane. Vocal fold atrophy is
for the upper lateral cartilage and elevating the drooping nasal thought to represent the laryngeal manifestation of senescent
tip.83 The removal of turbinate mucosa should be avoided, changes in muscle and mucous membranes. Collagen fibers
especially when excessive dryness is already a factor. Vidian within the vocal fold become more disorganized, and the
neurectomy may be indicated in select cases. lamina propria thins with age, the latter of which especially
occurs in men.89,90 Both of these changes alter the vibratory
properties of the vocal fold. Muscle atrophy can also lead to
THE AGING VOICE AND UPPER vocal fold bowing and subsequent glottal insufficiency.91,92
Studies suggest these changes may be caused by changes in
AERODIGESTIVE TRACT neural input to the muscles.93 Decreased fiber density is also
The phonatory organ is composed of the resonator (larynx), seen in the laryngeal ligaments and the conus elasticus.
the articulators (supraglottic structures), and the compressors Progressive calcification of the laryngeal cartilages occurs
(lungs).84 Age-related changes in any one or all of these struc- with age.94 Calcification and ossification begins during the early
tures can have a direct impact on voice quality and general twenties and is essentially complete by the sixth decade. Small
comfort level (Table 16-1). Furthermore, older people are islands of cartilage remain in the central portion of the thyroid
often exposed to a wide array of environmental and medicinal cartilage of men, and preservation of cartilage is found in the
irritants that compound the problem, particularly in the case upper portion in women; the cricoid may be almost completely
of long-term tobacco smoking. Older patients may also suffer ossified, whereas the arytenoid undergoes ossification of the
from a host of medical conditions that can affect vocal quality, body and muscular process, and the apex remains cartilagi-
such as cancer, vocal fold paralysis, Parkinson disease, amyo- nous. There seems to be some controversy regarding whether
trophic lateral sclerosis, benign essential tremor, diabetes, and the vocalis process ossifies.95 This ossification represents the
other endocrine dysfunctions.85-88 The frequent occurrence of creation of a true haversian system with lamellae, osteocytes,
depression with sensorineural hearing loss can lead to a hyper- and fat marrow. In general, the onset of ossification is later and
functional voice and muscular tension dysphonia; therefore less extensive in women, and the entire process is quite variable
treatment of geriatric patients with vocal problems must be among individuals. Similar age-related changes may occur in
directed not only at maximizing the efficiency of the aging the cricoarytenoid joint as well.96 In combination with descent
phonatory organ through appropriate voice therapy or surgery of the larynx in the neck, which is known to occur with aging,
but also at treatment of the underlying medical, neurologic, or ossification of the laryngeal cartilages alters the resonance
psychiatric disorder. properties of the larynx.91,97

HISTOLOGIC CHANGES LARYNGOSCOPIC APPEARANCE

Laryngeal tissues change a good deal before alterations in the Laryngoscopic characteristics of the aging larynx include
voice are detected. Histologic changes seen within the aging edema, a yellowish or dark grayish discoloration of the vocal
larynx appear to occur with approximately equal frequency in fold, and vocal fold atrophy. This results in bowing of the vocal

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236 PART II | GENERAL OTOLARYNGOLOGY
fold edges, incomplete glottic closure, and visibility of the ven-
tricle. The prominence of the contour of the vocal process
leads to the typical arrowhead configuration of the glottis
seen so often in the senescent larynx.98,99
ACOUSTIC CHANGES
Dysphonia is present in at least 10% of older adults. Although
variable, the senescent voice is typically stereotyped as being
tremulous, weak, hoarse, and altered in pitch. Overall, jitter
(cycle-to-cycle frequency variation) continues to be significantly
greater in the aging population as compared with younger age
groups, particularly in men.100 Aging of the larynx is also associ-
ated with a slowing in the opening quotient of the vocal folds,
which further adversely affects vocal quality.101 The fundamen-
tal frequency of the speaking voice decreases with age in both
men and women.102 Vocal fold edema, which is seen in some
women, is thought to be due to general endocrine changes that
occur after menopause. The latter, along with the lowering of
laryngeal position that occurs in women over 60 years old,
results in marked lowering of the fundamental frequency and
roughness of the voice.103 The aging woman also tends to read
with larger intonation ranges and a greater number of inflec-
tions than a younger adult.104 The acoustic characteristics of
womens voices show a significant lowering of the frequency of
the first formant (f1) with advancing age, which suggests age-
related changes in the vocal tract and mentons or positions of
speech structures.
MUCOSAL CHANGES
The aging process results in significant changes within the
mucosa of the oral cavity, salivary glands, teeth, mandible,
maxilla, temporomandibular joint (TMJ), and taste buds. In
combination or individually, oral dryness, soft tissue atrophy,
decreased mandibular excursion, and TMJ disease can signifi-
cantly affect the voice by altering its resonant characteristics.
The epithelium of the mouth becomes atrophic, especially
in the prickle cell layer. Parakeratosis and hyperkeratosis may
be present, particularly in areas of denture use. Histologically,
thinning of the tunica propria and blunting of the rete pegs
occurs along with decreases in capillaries, water content, hyal-
uronic acid, and collagen content and an increase in ground
substance. In combination with small-vessel disease (e.g., arte-
riosclerosis), these changes make oral tissues more prone to
injury, prolong wound healing, and contribute to the shiny,
smooth appearance of the senescent oral mucosa.105 Guarding
as a result of oral trauma may adversely affect the voice by
modifying the way a person articulates and projects speech
sounds.
GLANDULAR CHANGES
Normal physiologic changes that occur in the salivary glands of
older adults are the principal cause of dry mouth syndrome,
which is one of the most common complaints of this popula-
tion.106,107 Secretory rates diminish, and salivary viscosity
increases in these patients. Submandibular gland parenchymal
volume decreases as a result of a reduction in acinar tissue,
whereas ducts enlarge. Increase in focal chronic inflammatory
changes also occurs as a result of hyalinization of the acini and
an increase in salivary duct adhesions and obstructions. The
end result is a loss of one fourth of the active secretory paren-
chymal volume and its replacement by connective tissue and
fat.107 As a consequence, the flow rates from both submandibu-
lar and sublingual glands decrease significantly with age.108
Because adequate lubrication is essential for the production of
sound in the phonatory apparatus, the presence of dry mouth
should be recognized and treated.
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SENSE OF TASTE
Many older patients complain of a metallic or salty taste and
decreased levels of sensitivity to sweet, bitter, and sour foods.
Both a reduction in salivation and a reduction in the number
of taste buds can occur normally during the aging process.109
This loss of taste is multifactorial and is often exacerbated by
certain medical conditions and drug interactions.110 Alterations
in taste represent a risk factor for nutritional deficiencies. Some
studies recommend flavor-enhanced food for the elderly, par-
ticularly in a hospital setting.111-113
DENTAL/MANDIBULAR CHANGES
Resorption of mandibular and maxillary alveolar bone and a
diminution in regenerative capacity occurs with aging, which
leads to a loss in the vertical height of the face and a purse-
string appearance of the mouth. This problem is magnified in
edentulous patients, in whom up to 50% of mandibular height
may be lost. Histologically, the aging mandible often displays
signs of osteoporosis in the form of cortical thinning and loss
of coarse trabeculation patterns. Bone resorption and the
diminution of connective tissue around the nerves allow the
neurovascular surface to be more easily damaged. Common
complaints are paresthesia or pain because of irritation of the
mental nerve by ill-fitting dentures and a burning sensation of
the hard palate. As in other areas of the oral cavity, these con-
nective tissue changes contribute to a reduction in the repair
capacity after injury.
As far as teeth are concerned, a calcified secondary dentin
replaces most of the dental pulp. The cementum shows contin-
ued deposition and calcification throughout life. Apical migra-
tion of gingival tissue leads to a gradual exposure of the tooth
root. These processes make older individuals prone to periapi-
cal infection and periodontal disease.
Any changes in the bony architecture of the maxilla or
mandible may adversely affect the voice by affecting the reso-
nance characteristics of speech sounds. The absence of teeth,
the use of ill-fitting dentures, oral or dental pain, and paresthe-
sias may further affect certain speech sounds, particularly those
that involve tongue-to-lip, palate, or teeth apposition. The
ability to produce clear plosive (p, t, k, b, d, and g) and fricative
(s, z, f, v, sh, ph, and th) sounds may therefore be affected.
The TMJ may also be affected by the aging process. 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. Com-
plaints such as joint clicking, dislocation, subluxation, and frac-
ture of the articular head with subsequent decrease in mouth
opening may indirectly affect the voice, again by altering reso-
nance characteristics and the projection of speech sounds.
Speaking with a tight oral aperture narrows resonance of sound
within the oral cavity; it may further result in laryngeal eleva-
tion, which increases tension in the vocal tract.
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 to phonate. Over time, this can
fatigue the laryngeal apparatus and can result in secondary
muscular tension dysphonia.
TREATMENT
Treatment of presbyphonia is directed at controlling the under-
lying medical illness and maximizing the efficiency of the
phonatory apparatus. This typically involves a multidisciplinary

approach that involves the expertise of a speech pathologist,
otolaryngologist, pulmonologist, neurologist, psychiatrist, oral
surgeon, and a generalist. Treatment for gastric acid reflux and
attention to proper hydration and other general vocal hygiene
measures are important. Maximization of pulmonary efficiency
in patients with underlying pulmonary disease is a necessity,
and general conditioning may be quite helpful in motivated
patients. Symptomatic dryness can be addressed with the judi-
cious use of sialogogues, salivary substitutes, and expectorants.
Other specific medical illnesses discussed above must be
addressed when present.
Current therapeutic options for presbyphonia include voice
therapy, injection augmentation, and laryngeal framework
surgery. Voice therapy is considered a first-line treatment and has
been shown to improve subjective quality of life as well as per-
ceived voice.114,115 If voice therapy is unsuccessful, injection aug-
mentation has been shown to improve glottal competence in the
setting of vocal fold atrophy.116 Short-term injectable options
include hyaluronic acid gels (e.g., Hylaform, Restylane) and
collagen-based products (e.g., Cymetra), and calcium hydrox-
ylapatite (e.g., Radiesse) provides more long-term results.117
Although awake office-based injections are becoming more
prevalent, elderly patients are more likely to be taking antico-
agulation medications and therefore have a relative contrain-
dication to office-based procedures.92,118 The third therapeutic
option for presbyphonia, laryngeal framework surgery, may be
considered as a possible permanent solution in patients who
have already benefited from injection laryngoplasty. Proce-
dures have been devised in an attempt to adjust vocal pitch and
strengthen the voice of patients with flaccid or bowed vocal
folds.119 Bilateral medialization thyroplasty has been shown to
be effective for presbylaryngis.120,121 Others have advocated
advancement of the anterior commissure to adjust vocal cord
tension through an anterior commissure laryngoplasty.122 Short-
term success with these procedures has been achieved with
improvement in loudness and clarity and a decrease in breathi-
ness and air escape.
PRESBYPHAGIA
Dysphagia is relatively common in older adults and affects 15%
of those in the community and approximately 40% of patients
in institutionalized settings.123 This has contributed to the sup-
position that swallowing deficits may reflect normal age-related
changes. Granieri124 suggests that the effects of aging on swal-
lowing can be divided into primary, secondary, and tertiary
categories.
Primary effects of aging on swallowing include physiologic
and structural changes in the oral cavity, pharyngeal, and laryn-
geal structures. Older adults have a smaller cross-sectional area
of masticatory muscles, increased lingual atrophy and fatty infil-
tration, and diminished strength, mobility, and endurance of
these muscles. As a result, swallowing becomes slower with age;
the pharyngeal swallow response initiates later, and the swallow-
ing motor response is not as responsive to sensory stimuli.125-137
Secondary effects include a plethora of general medical and neu-
rologic conditions, such as head and neck cancers and their
treatments, neuromotor disorders that include stroke and cri-
copharyngeal spasm, or the general deconditioning associated
with illness. Side effects from the use of pharmacologic agents
are also more common in older adults. Tertiary effects involve
those changes that can result from social, environmental, and
psychologic factors.
DIAGNOSTIC TESTING
When swallowing disorders are suspected, a complete oropha-
ryngeal and esophageal swallowing evaluation is warranted
because of the increased incidence of concomitant problems
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16 | OTOLARYNGOLOGY IN THE ELDERLY 237
in both areas. A careful history and physical examination
should allow the clinician to distinguish between the two
major categories of swallowing impairment: difficulty initiat-
ing swallowing and obstruction.138 Because speech, voice, and
swallowing problems are often the first signs of degenerative
neurologic or neuromuscular disease, the physical examina-
tion should include both head and neck and neurologic
evaluations.
Radiographic assessment is considered the gold standard
for dysphagia assessment. The modified barium swallow
(MBS), which is a videofluoroscopic swallowing study of the
head and neck, provides critical physiologic information
(i.e., bolus transit from the mouth to the cervical esophagus),
swallow transitions, and biomechanics of the swallow that
are necessary for treatment. The procedure also provides valu-
able information about the timing and etiology of aspiration
and the effectiveness of rehabilitative strategies. If the study
reveals structural or motility disorders of the esophagus, endos-
copy and manometric examination are the next diagnostic
steps.
Flexible endoscopic evaluation of swallowing is an adjunctive
assessment tool to the modified barium swallow. Visualization
of the pharyngeal-laryngeal mechanism provides symptomatic
information about the swallow (i.e., aspiration and pharyngeal
residue). This type of endoscopic evaluation is also a valuable
biofeedback tool for airway closure maneuvers.
TREATMENT
Proper treatment of swallowing disorders in older adults
requires management by the multidisciplinary team and is
contingent on correct diagnosis that considers primary, sec-
ondary, and tertiary effects. Treatment may be medical or sur-
gical, but it is more often rehabilitative in nature. Rehabilitative
treatment strategies that will improve the safety and efficiency
of the swallow are identified during the radiographic proce-
dure and are based on the nature of the patients disorder.
Many swallowing rehabilitation techniques require the applica-
tion of voluntary control to disordered aspects of swallow phys-
iology. These include swallowing therapy strategies, such as the
supraglottic swallow or Mendelsohn maneuver, and other oro-
pharyngeal exercises. However, a number of treatment strate-
gies require little patient cognition or cooperation by the older
individual, such as postural techniques or changes in diet
or food consistency. Recent randomized trials indicate that
more research is needed to assess the efficacy of combining
these modalities.139,140 Moreover, few studies have looked into
sensory-based swallowing therapies, such as delivering a sour
or cold bolus, given that intraoral stimulation does affect swal-
lowing biomechanics.141-143 If nonoral feeding is required,
reevaluation at regular intervals should be conducted to deter-
mine progress in recovery and the optimal time to reinitiate
oral intake.
FACIAL TRAUMA
Wound healing is affected by aging, in that angiogenesis,
epithelialization, and remodeling are all delayed in older
patients.144 Moreover, a decrease in immunologic response can
lead to increased susceptibility to wound infection.145 The facial
skeleton undergoes changes with aging; as mentioned above,
the most prominent change is resorption of the alveolar bone
in the maxilla and mandible. The bone of the facial skeleton
becomes brittle, and decreased metabolic activity in the bone
makes healing times prolonged. Resorption of bone and its
fragility can make placing fixation plates difficult. In particular,
the repair of fractures in an edentulous mandible presents a
particular challenge: an atrophic mandible makes iatrogenic
fractures during repair more likely, and the lack of teeth makes
238 PART II | GENERAL OTOLARYNGOLOGY
the determination of appropriate reduction and occlusion
more difficult.145 Planning for repair of facial fractures in older
adults must take these factors into account to ensure the best
possible outcome.
HEAD AND NECK ONCOLOGY
ETIOLOGY
Approximately one fourth of head and neck cancers occur in
patients older than 70 years.146 Environmental exposure to car-
cinogens, most notably tobacco and alcohol, is an important
cause of these cancers. The occurrence of cancer in advanced
age is probably related to both the duration of carcinogen
exposure and immune senescence. Immune dysfunction associ-
ated with aging is complex and involves several components of
the immune system. Gluckman and Wolfe suggest that the most
important deficit may occur in antigen-specific T-cell cytotoxic
function.71 Autoimmune diseases are also more common with
advancing age and may facilitate tumor progression.
TREATMENT
Interestingly, although many cancer patients are older than 65
years, they represent a minority of participants in clinical
trials.147 To encourage the inclusion of older adults in clinical
trials, President Clinton issued a directive in 2000 for Medicare
to reimburse the costs of routine patient care during clinical
trials.148 However, treatment paradigms are often applied from
studies that examine younger patients.
As discussed, aging leads to multiorgan functional decline,
reduced nutritional status, and psychosocial factors that
include depression and absence of social support. These factors
must be considered with any treatment protocol. In general,
older patients tolerate major head and neck cancer surgery
well. The data are mixed on whether elderly patients suffer
increased complications or adverse outcomes secondary to
their age. Morgan and colleagues149 reviewed 1773 patients
undergoing major head and neck operations under general
anesthesia. Of the 810 patients between the ages of 65 and
95 years, 3.5% died, and 32% suffered nonlethal complica-
tions. By contrast, only 8 of 863 patients between the ages of
35 and 65 years died (0.8%), and the complication rate was
21%. The differences in mortality and complication rates are
both significant, but a mortality rate of 3.5% in those older
than 65 years does not seem prohibitive. In a more recent
study, McGuirt and Davis150 found that patients who were older
than 80 years had a similar prognosis to that of patients between
65 and 80 years old, but complications were more common
with advancing age. A third study by Milet and colleagues151
found no significant difference in the complication rates from
head and neck surgery in patients younger than 70 versus
those 70 years and older. Several studies of reconstructive
surgery with free flaps suggest that the risk of postoperative
complications is related to the presence of comorbidities and
not age.152-155 Length of time under anesthesia also correlates
with complication rates.156
More intensive combination therapies must take into
account the presence of comorbidities, age-related frailty, and
underlying psychosocial problems. For example, toxic side
effects from chemotherapy are more common in older age
groups, and older patientsparticularly those with poor per-
formance statusmay demonstrate reduced compliance and
tolerance to radiation therapy.157
Thyroid disease is common in the geriatric population, and
thyroid cancer behaves more aggressively in older patients.
Undifferentiated carcinoma is more common, and recurrence
and metastasis occur more frequently in the older adult, even
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with well-differentiated thyroid cancer. The mainstay of man-
agement for well-differentiated thyroid cancer is surgery, but
multimodality therapy that includes radioactive iodine is com-
monly advised in older patients, especially those who have fol-
licular cancer. Bliss and colleagues158 investigated thyroid
surgery in patients who were older than 50 years. They found
no difference in morbidity or mortality when comparing
patients 50 to 60 years old with patients 61 to 70 years old and
with patients who were older than 70.
Regardless of pathology, before advising a major surgical
procedure, careful consideration is given to the patients moti-
vation as evidenced by his or her current level of function. An
active 80-year-old patient with good muscle tone may be a better
surgical candidate than a sedentary 65-year-old patient with
poor functional residual capacity; therefore a comprehensive
preoperative evaluation must be completed in all surgical
candidates.159
Preoperative education is important for all patients and
their families, and selected patients may benefit from a
2-week course of nutritional and physical therapy aimed pri-
marily at improving cardiorespiratory function. Patients should
understand that they will need to participate in the recovery
process, which may last several months; a substantial portion of
this time will not be spent in an acute care setting. Patients
should understand that recovery may entail a period of reha-
bilitation at a rehabilitation facility or a subacute care facility;
placement in one of these facilities is not to be construed by
the patient or his or her family as an adverse event or failure
of treatment.
CONCLUSION
Otolaryngologists and all health care providers are faced with
an aging population. Although the spectrum of disease is likely
to remain constant for practitioners, the makeup of individual
practices may reflect this change in demographics. To prepare
for this change, we must continue to expand our knowledge
base of the disease processes that affect older adults and our
ability to treat this population. Future research will also need
to include this group.
For a complete list of references, see expertconsult.com.
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