Sinonasal Disease in the Elderly

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Sinonasal Disease in the Elderly

Geriatrics
Author Credentials 

Aaron Pearlman, MD 
Associate Professor
Department of Otolaryngology- Head & Neck Surgery
Weill Cornell Medical College
New York, NY 10065
anp2022@med.cornell.edu

Qasim Husain, MD
Resident
Department of Otolaryngology- Head & Neck Surgery
Weill Cornell Medical College
New York, NY 10065
qah9001@nyp.org

Module Summary

The US population is becoming increasingly older. While the pathogenesis of sinus disease does not significantly change, there are subtle anatomic and physiologic changes. Elderly patients have unique considerations due to medical co-morbidities as well as side effect of medications. There are changes in nasal mucosa that can make secretions thicker, as well as more susceptible to bleeding due to dryness. In addition, the bony anatomy can be more fragile which can lead to an increase unintended complications. A good understanding of pharmacology and drug interactions is important when medically mananging this patient population. Alterations in technique and the use of office techniques may also have a larger role in this population to reduce the need for general anesthesia.

Module Learning Objectives 
  1. Describe the physiologic and anatomic changes that occur in the elderly.
  2. Recognize the uniqe considerations that aging has on sinonasal disease and its management
  3. Review medications used to treat sinonasal disease and their side effects with elderly

Anatomy

Learning Objectives 
  1. Be able to describe the changes to structural nasal anatomy with age.
  2. Understand the impact of aging on nasal airflow.
References 
  1. Yilmaz AA, Corey JP. Rhinitis in the elderly. Current allergy and asthma reports. 2006 Mar 1;6(2):125-31.
  2. Patterson C. The aging nose: Characterisics and correction. Otolaryngol Clin North Am. 1980;13(2):275-88.

Pathogenesis

Learning Objectives 
  1. Understand why do elderly suffer from increased nasal dryness.
  2. Explain the changes with respect to mucociliary clearance in the elderly?
  3. Define the relationship between increasing age and olfaction.
  4. Differentiate between allergic, vasomotor, atrophic, and medication induced rhinitis.
References 
  1. Ho JC, Chan KN, Hu WH, Lam WK, Zheng L, Tipoe GL, Sun J, Leung R, Tsang KW. The effect of aging on nasal mucociliary clearance, beat frequency, and ultrastructure of respiratory cilia. American journal of respiratory and critical care medicine. 2001 Mar 15;163(4):983-8.
  2. Pinto JM, Jeswani S. Rhinitis in the geriatric population. Allergy, Asthma & Clinical Immunology. 2010 May 13;6(1):10.
  3. Murphy C, Schubert CR, Cruickshanks KJ, Klein BE, Klein R, Nondahl DM. Prevalence of olfactory impairment in older adults. JAMA. 2002 Nov 13;288(18):2307-12.

Basic Science

Learning Objectives 

Establish how the immune system changes with aging and their affects on nasal physiology.

References 
  1. Bellanti JA, Azem M, MacDowell-Carneiro AL, Tutuncuoglu SO, Wallerstedt DB. Possible mechanisms of late-life-onset allergic diseases and asthma in the senior citizen. Allergy Asthma Proc. 2000 Sep-Oct;21(5):267-70.

Incidence

Learning Objectives 

By 2030 it is expected that 70 million or 20% of the United States population will be older than 65. It is the 6th most common condition of those aged 65 and older.

  • Understand the increase in the geriatric population and importance of understandin the role of aging in sinonasla pathologic conditions.
References 
  1. Catalano PJ, Setliff RC, Catalano LA. Minimally invasive sinus surgery in the geriatric patient. Oper Tech Otolayngol Head Neck Surg. 2001 Jun 1;12(2):85-90.
  2. Murphy C, Schubert CR, Cruickshanks KJ, Klein BE, Klein R, Nondahl DM. Prevalence of olfactory impairment in older adults. JAMA. 2002 Nov 13;288(18):2307-12.
  3. Colclasure JC, Gross CW, Kountakis SE. Endoscopic sinus surgery in patients older than sixty. Otolaryngology—Head and Neck Surgery. 2004 Dec;131(6):946-9.
  4. Ongoing Federal Data Recources Relevant to the Study of the Aging. Federal Date Resources. Accessed on May 8, 2018. 

Patient Evaluation

Learning Objectives 
  1. Evaluation always begins with a complete history : length of symptoms, exacerbating factors, response to medications; hx of trauma; environmental exposure.
  2. Differentiate between physical exam findings consistent with chronic rhinitis compared to chronic sinusitis.
  3. Nasal endoscopy.
  4. CT sinus.
  5. Allergy testing atopy determined when total serum IgE >100 U/mL.
References 
  1. Reh DD, Mace J, Robinson JL, Smith TL. Impact of age on presentation of chronic rhinosinusitis and outcomes of endoscopic sinus surgery. Am J Rhinol. 2007 Mar 1;21(2):207-13.
  2. Pinto JM, Jeswani S. Rhinitis in the geriatric population. Allergy, Asthma Clin Immunol. 2010 May 13;6(1):10.

Measurement of Functional Status

Learning Objectives 
  1. Become familiar with the various quality of life measures including the Sino-Nasal Outcome Test- 20 (SNOT 20), Rhinosinusitis Disability Index (RSDI), Chronic Sinusitis Survey.
  2. Understand the quality of life changes with regards to cognitive function and chronic sinusitis.
References 
  1. Colclasure JC, Gross CW, Kountakis SE. Endoscopic sinus surgery in patients older than sixty. Otolaryngol Head Neck Surg. 2004 Dec;131(6):946-9.
  2. Pinto JM, Jeswani S. Rhinitis in the geriatric population. Allergy, Asthma Clin Immunol. 2010 May 13;6(1):10.
  3. Reh DD, Mace J, Robinson JL, Smith TL. Impact of age on presentation of chronic rhinosinusitis and outcomes of endoscopic sinus surgery. Am J. Rhinol. 2007 Mar 1;21(2):207-13.
  4. Matsui T, Arai H, Nakajo M. Role of chronic sinusitis in cognitive functioning in elderly. J Am Geriatr Soc. 2003 Dec;51(12):1818-9.

Imaging

Learning Objectives 

Describe Lund- Mackay Scores, what evidence suggests that it correlates with surgical outcomes.

References 
  1. Smith TL, Mendolia‐Loffredo S, Loehrl TA, Sparapani R, Laud PW, Nattinger AB. Predictive factors and outcomes in endoscopic sinus surgery for chronic rhinosinusitis. Laryngoscope. 2005 Dec 1;115(12):2199-205.

Pathology

Learning Objectives 

Describe if there are any differences between nasal endoscopy and imaging findings that separate the elderly from younger adults.

References 
  1. Lee JY, Lee SW. Influence of age on the surgical outcome after endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis. Laryngoscope. 2007 Jun 1;117(6):1084-9.
  2. Reh DD, Mace J, Robinson JL, Smith TL. Impact of age on presentation of chronic rhinosinusitis and outcomes of endoscopic sinus surgery. Am J Rhinol. 2007 Mar 1;21(2):207-13.
  3. Colclasure JC, Gross CW, Kountakis SE. Endoscopic sinus surgery in patients older than sixty. Otolaryngol Head Neck Surg. 2004 Dec;131(6):946-9.

Treatment

Learning Objectives 

List general treatment measures in elderly patients with rhinosinusitis:

  1. Saline irrigations, humidifications, avoidance, mucolytic agents
  2. Antimirobial therapy
References 
  1. Snow V, Mottur-Pilson C, Hickner JM. Principles of appropriate antibiotic use for acute sinusitis in adults. Ann Intern Med. 2001 Mar 20;134(6):495-7.
  2. Subramanian HN, Schechtman KB, Hamilos DL. A retrospective analysis of treatment outcomes and time to relapse after intensive medical treatment for chronic sinusitis. American journal of rhinology. 2002 Nov 1;16(6):303-12.

Medical Therapies

Learning Objectives 

Geriatric patients can have extensive medical histories that increase their surgical and anesthetic risks therefore there is a trend to manage these patients medically.

  • Undertand the different pathways to treatment: inflammatory vs. allergic
References 
  1. Nyenhuis SM, Mathur SK. Rhinitis in older adults. Curr Allergy Asthma Rep. 2013 Apr 1;13(2):171-7.
  2. Pinto JM, Jeswani S. Rhinitis in the geriatric population. Allergy Asthma Clin Immunol. 2010 May 13;6(1):10.

Pharmacology

Learning Objectives 
  1. Familiarize yourself with the most common medications used in the treatment of chronic rhinosinusitis.
  2. Recognize which medications to avoid in elderly patients.
References 
  1. Nyenhuis SM, Mathur SK. Rhinitis in older adults. Curr Allergy Asthma Rep. 2013 Apr 1;13(2):171-7.

Surgical Therapies

Learning Objectives 
  1. Be familiar with the reasons why geriatric patients may have better healing and reduced mucosal edema and recurrence.
  2. Decreased muscosal regeneration, decreased cellular proliferative ability, reduced outdoor activity and exposure.
References 
  1. Catalano PJ, Setliff RC, Catalano LA. Minimally invasive sinus surgery in the geriatric patient. Oper Tech Otolaryngol Head Neck Surg. 2001 Jun 1;12(2):85-90.
  2. Ramadan HH, VanMetre R. Endoscopic sinus surgery in geriatric population. Am J Rhinol. 2004 Mar 1;18(2):125-7.
  3. Busaba NY, Hossain M. Clinical outcomes of septoplasty and inferior turbinate reduction in the geriatric veterans' population. Am J Rhinol. 2004 Dec 1;18(6):343-7
  4. Lee JY, Lee SW. Influence of age on the surgical outcome after endoscopic sinus surgery for chronic rhinosinusitis with nasal polyposis. Laryngoscope. 2007 Jun 1;117(6):1084-9.

Case Studies

  1. An 83 year old man presents with the complaint of five years of persistent bilateral clear nasal drainage that occurs throughout the day.  He denies any facial pain or pressure, no smell complaint, and no nasal obstruction.  He reports that his rhinitis worsens during meals.  His primary care provider gave him fluticasone nasal spray that he used for about six weeks without improvement.  He has also received trials of oral and nasal anti histamines that were unhelpful.  On exam, he has a normal appearing nasal mucosa without any evidence of nasal polyposis or other chronic inflammatory disease.   ​What condition is the most likely explanation for this patient's symptoms?  What medical therapy could be given that might help with symptomatic improvement?  Is there a surgical option for this patient?
  2. A 65 year old woman with a history of high cholesterol and high blood pressure reports greater than three months of nasal congestion, obstruction and purulent mucus.  She notes bilateral malar pressure.  Initially she was treated with a five day course of azithromycin but her symptoms have persisted.  She has a remote history of rhinosinusitis.  On exam, she has purulent mucus draining from both middle meatus.  As her symptoms have been present for greater than 12 weeks, her otolaryngologist opts to treat her for chronic sinusitis with three weeks of antibiotics, nasal steroid spray daily, and saline rinsing.  Clarithromycin is chosen for both its antibacterial and anti inflammatory effects.  After five days of treatment, the patient begins complaining of diffuse muscle pain.   You recommend that she go to the emergency room and on EKG, she is found to have a prolonged QT interval.  What is the mostly likely cause of the patient's symptoms that required the emergency room visit?  What could the Otolaryngologist have asked prior to prescribing Clarithromycin?  Would it have been appropriate to stop any of the patient's daily medications to treat her current chronic rhinosinusitis?
References 
  1. Bernstein JA. Nonallergic rhinitis: therapeutic options. Curr Opin Allergy Clin Immunol. 2013 Aug;13(4):410-6.
  2. Halderman A, Sindwani R. Surgical management of vasomotor rhinitis: a systematic review. Am J Rhinol Allergy.2015 Mar-Apr;29(2):128-34.
  3. Salimi A, Eybagi S, Seydi E, Naserzadeh P, Kazerouni NP, Pourahmad J. Toxicity of macrolide antibiotics on isolated heart mitochondria: a justification for their cardiotoxic adverse effect. Xenobiotica. 2016;46(1):82-93.
  4. Patel AM, Shariff S, Bailey DG, Juurlink DN, Gandhi S, Mamdani M, Gomes T, Fleet J, Hwang YJ, Garg AX. Statin toxicity from macrolide antibiotic coprescription: a population-based cohort study. Ann Intern Med. 2013 Jun 18;158(12):869-76.

Complications

Learning Objectives 
  1. Describe the differences in complications between the adult and elderly population.
  2. List types of complications that increase in the elderly compared to adult population.
References 
  1. Ramadan HH, VanMetre R. Endoscopic sinus surgery in geriatric population. Am J Rhinol. 2004 Mar 1;18(2):125-7.
  2. Jiang RS, Chen-Yi H. Endoscopic sinus surgery for the treatment of chronic sinusitis in geriatric patients. Ear Nose Throat J. 2001 Apr 1;80(4):230.

Review

Review Questions 
  1. What is the most common manifestation of geriatric sinus disease?
  2. How does nasal anatomy change structurally with age? How do these changes affect nasal airflow?
  3. What happens to mucociliary clearance with age?
  4. Why do geriatric patients have high complication rates in endoscopic sinus surgery?
  5. What is the prevalence of olfactory impairment in older adults?
  6. Which two classes of medications should be avoided in treating sinonasal disease in the elderly?
References 
  1. Ramadan HH, VanMetre R. Endoscopic sinus surgery in geriatric population. Am J Rhinol. 2004 Mar 1;18(2):125-7.
  2. Pinto JM, Jeswani S. Rhinitis in the geriatric population. Allergy Asthma Clin Immunol. 2010 May 13;6(1):10.
  3. Murphy C, Schubert CR, Cruickshanks KJ, Klein BE, Klein R, Nondahl DM. Prevalence of olfactory impairment in older adults. JAMA. 2002 Nov 13;288(18):2307-12.
  4. Nyenhuis SM, Mathur SK. Rhinitis in older adults. Curr Allergy Asthma Rep. 2013 Apr 1;13(2):171-7.