6/9/2015Prof. Sameer Bafaqeeh1 Geriatric Otolaryngology Prof.Sameer Bafaqeeh Otolaryngology...

04/18/2304/18/23 Prof. Sameer BafaqeehProf. Sameer Bafaqeeh 11

Geriatric OtolaryngologyGeriatric Otolaryngology

Prof.Sameer BafaqeehProf.Sameer Bafaqeeh

Otolaryngology DepartmentOtolaryngology Department

KSUKSU


IntroductionIntroduction

Multiple diseases coexist in patientsMultiple diseases coexist in patients Elderly suffer from a unique set of illnessesElderly suffer from a unique set of illnesses Unusual symptoms common without symptoms such as Unusual symptoms common without symptoms such as

pain and feverpain and fever Otolaryngologists play vital role in prevention of illnessOtolaryngologists play vital role in prevention of illness


Biology of AgingBiology of Aging

Wounds heal slowerWounds heal slower Retarded fibroplasiaRetarded fibroplasia Collagen decreases with ageCollagen decreases with age Elastic fibers decrease with ageElastic fibers decrease with age Functional capacity of cells are decreased Functional capacity of cells are decreased Decreased ability of older patients to remodel collagen Decreased ability of older patients to remodel collagen

laid downlaid down


Medical and Surgical treatment Medical and Surgical treatment in the elderlyin the elderly

Adverse side effects from medications commonAdverse side effects from medications common Sensitivity to drugs increases with ageSensitivity to drugs increases with age Renal clearance and hepatic metabolism both decrease Renal clearance and hepatic metabolism both decrease

with agewith age Evaluate drug - drug interactions before beginning new Evaluate drug - drug interactions before beginning new

treatmentstreatments Perform surgical procedures in the elderly with cautionPerform surgical procedures in the elderly with caution


Geriatric VoiceGeriatric Voice

10 to 15 percent of elderly have some 10 to 15 percent of elderly have some dysphoniadysphonia

Dysfunctions may be age related or Dysfunctions may be age related or related to disease processesrelated to disease processes

Characteristics of the aging voiceCharacteristics of the aging voice


Geriatric voice continuedGeriatric voice continued Laryngoscopy shows Laryngoscopy shows

discoloration, bowing, discoloration, bowing, atrophy and occasionally atrophy and occasionally edemaedema

Jitter (cycle to cycle Jitter (cycle to cycle frequency variation) frequency variation) increases with ageincreases with age

Increased fundamental Increased fundamental frequency in menfrequency in men

Decreased fundamental Decreased fundamental frequency in womenfrequency in women


Structural vocal fold changesStructural vocal fold changes

Decreased amounts of collagen fibersDecreased amounts of collagen fibers Vocal ligament fibrosisVocal ligament fibrosis Vocal fold atrophy with glottal gapVocal fold atrophy with glottal gap Laryngeal muscle atrophy with increased amounts of Laryngeal muscle atrophy with increased amounts of

connective tissue and fatty infiltrationconnective tissue and fatty infiltration Age related degenerative changesAge related degenerative changes Poor mucosal hygienePoor mucosal hygiene


Pathologies affecting the vocal Pathologies affecting the vocal foldsfolds

Essential tremor - can lead to ventricular dysphoniaEssential tremor - can lead to ventricular dysphonia Parkinson’s - low, breathy, monotonic voiceParkinson’s - low, breathy, monotonic voice Be aware of the benign and malignant lesions affecting Be aware of the benign and malignant lesions affecting

the vocal foldsthe vocal folds


Medical treatment of vocal fold Medical treatment of vocal fold disordersdisorders

Avoidance of compensatory maneuversAvoidance of compensatory maneuvers Women strain to increase vocal pitch which can Women strain to increase vocal pitch which can

result in hyperadduction of the false vocal foldsresult in hyperadduction of the false vocal folds Men may attempt to lower pitch resulting in a Men may attempt to lower pitch resulting in a

gravelly, breathy voice that is easily fatiguedgravelly, breathy voice that is easily fatigued Thus prevention of compensatory functional Thus prevention of compensatory functional

misuse is importantmisuse is important Speech therapy - men may gradually adjust their Speech therapy - men may gradually adjust their

vocal pitch upwards, women attempt to relax vocal pitch upwards, women attempt to relax their laryngeal musclestheir laryngeal muscles


Surgical treatment of vocal fold Surgical treatment of vocal fold disordersdisorders

Isshiki type 4 thyroplastyIsshiki type 4 thyroplastyGelfoam or lipoinjectionGelfoam or lipoinjectionAnterior commissure laryngoplastyAnterior commissure laryngoplastySurgery remains a last resort if all other Surgery remains a last resort if all other

options have been exhaustedoptions have been exhausted


Effects of aging on swallowingEffects of aging on swallowing

Age related changes noted in the oral, pharyngeal and Age related changes noted in the oral, pharyngeal and esophageal phases of swallowingesophageal phases of swallowing

Increased fatty and connective tissue in the tongueIncreased fatty and connective tissue in the tongue Atrophy of the alveolar bone and reduced chewing Atrophy of the alveolar bone and reduced chewing

capabilitiescapabilities Transit times increased through pharynx and esophagusTransit times increased through pharynx and esophagus Most of these changes are academic because these Most of these changes are academic because these

changes do not generally increase the incidence of changes do not generally increase the incidence of dysphagia, laryngeal penetration or aspirationdysphagia, laryngeal penetration or aspiration


Age related disease processes Age related disease processes affecting swallowingaffecting swallowing

Left sided cva’s lead to difficulties during the oral phase of Left sided cva’s lead to difficulties during the oral phase of swallowingswallowing

Right sided cva’s lead to difficulties with the pharyngeal phase of Right sided cva’s lead to difficulties with the pharyngeal phase of swallowingswallowing

Motor neuron diseaseMotor neuron disease Parkinson’s has a typical pattern of repetitive tongue movements, Parkinson’s has a typical pattern of repetitive tongue movements,

delayed pharyngeal swallow and pharyngeal residuedelayed pharyngeal swallow and pharyngeal residue General medical conditions include rheumatoid arthritis, diabetes, General medical conditions include rheumatoid arthritis, diabetes,

and polymyositisand polymyositis Modified barium swallow crucial in providing informationModified barium swallow crucial in providing information Dysphagia may be related to cricopharyngeal achalasia- an Dysphagia may be related to cricopharyngeal achalasia- an

unexplained failure of the ues to relax in a coordinated mannerunexplained failure of the ues to relax in a coordinated manner


Treatment of swallowing Treatment of swallowing disordersdisorders

Treatment is multidisciplinaryTreatment is multidisciplinary Often rehabilitation is all that is needed to improve Often rehabilitation is all that is needed to improve

swallowingswallowing Voluntary maneuvers include the supraglottic swallow or Voluntary maneuvers include the supraglottic swallow or

mendelsohn maneuvermendelsohn maneuver In those patients who are unable to comply with In those patients who are unable to comply with

voluntary instructions, postural techniques, volume voluntary instructions, postural techniques, volume changes or changes in food or diet consistency is all that changes or changes in food or diet consistency is all that is needed to improve swallowingis needed to improve swallowing

CPM may be used in those patients with isolated CPM may be used in those patients with isolated cricopharyngeal achalasiacricopharyngeal achalasia


External and middle ear External and middle ear changeschanges

Actinic problems commonActinic problems common Decreased cerumen Decreased cerumen

productionproduction Longer tragi hairs Longer tragi hairs

contribute to decreased contribute to decreased cerumen migrationcerumen migration

Middle ear histologic Middle ear histologic changes noted but no changes noted but no hearing loss usually hearing loss usually results from these results from these changeschanges


PresbycusisPresbycusis

Age related decline in auditory functionAge related decline in auditory function Noise induced hearing loss is complementaryNoise induced hearing loss is complementary Outer and inner hair cells lost from the basal Outer and inner hair cells lost from the basal

turn of the cochleaturn of the cochlea Speech discrimination is affected commonlySpeech discrimination is affected commonly Older patients required an increased interaural Older patients required an increased interaural

time delay to discern high frequency soundstime delay to discern high frequency sounds This affects their ability to understand speech in This affects their ability to understand speech in

social settingssocial settings


Sensory PresbycusisSensory Presbycusis

Bilateral abruptly sloping high frequency sensorineural Bilateral abruptly sloping high frequency sensorineural hearing losshearing loss

Speech discrimination goodSpeech discrimination good Degeneration noted near the basal portion of the organ Degeneration noted near the basal portion of the organ

of cortiof corti


Neural PresbycusisNeural Presbycusis

Rapid hearing lossRapid hearing loss Difficulties with speech discriminationDifficulties with speech discrimination Pure tone reveals a moderate to a flat tone lossPure tone reveals a moderate to a flat tone loss Loss of spiral ganglion cellsLoss of spiral ganglion cells


Metabolic PresbycusisMetabolic Presbycusis

Slowly progressive sensorineural hearing lossSlowly progressive sensorineural hearing loss Flat loss with good discriminationFlat loss with good discrimination Atrophy of the stria vascularis may be notedAtrophy of the stria vascularis may be noted


Cochlear or conductive Cochlear or conductive presbycusispresbycusis

Thickened basilar membraneThickened basilar membrane No hair cell lossNo hair cell loss Good speech discrimination with gradual sloping high Good speech discrimination with gradual sloping high

tone losstone loss


PresbyastasisPresbyastasis

Dysequilibrium of agingDysequilibrium of aging Diagnosis of exclusionDiagnosis of exclusion Sense of imbalance commonSense of imbalance common Risk of falling significantRisk of falling significant Increased body sway commonIncreased body sway common Reduced hair cells in the crista and maculaReduced hair cells in the crista and macula Generalized peripheral hypofunction of the labyrinth Generalized peripheral hypofunction of the labyrinth

common which can lead to imbalancecommon which can lead to imbalance


Treatment of presbyastasisTreatment of presbyastasis Balance disorders involve the vestibular, proprioceptive, visual and Balance disorders involve the vestibular, proprioceptive, visual and

central nervous systemcentral nervous system Deficits can be partially compensated by the other systemsDeficits can be partially compensated by the other systems Nonvestibular causes of presbyastasis such as postural Nonvestibular causes of presbyastasis such as postural

hypotension need to be identified and treated specificallyhypotension need to be identified and treated specifically Vestibular habituation involves repeated elicitation of minor degrees Vestibular habituation involves repeated elicitation of minor degrees

of vertigoof vertigo Other maneuvers involve visual tracking withOther maneuvers involve visual tracking with the head held the head held

stationary and also gaze stability with head movementstationary and also gaze stability with head movement Vestibular suppressants should be avoidedVestibular suppressants should be avoided


Aging FaceAging Face

Atrophy of the subcutaneous fatAtrophy of the subcutaneous fat Slow degeneration of the skin’s elastic and collagen Slow degeneration of the skin’s elastic and collagen

networknetwork Gradual resorption of the facial skeletonGradual resorption of the facial skeleton Descent of brows and glabellar tissues below the bony Descent of brows and glabellar tissues below the bony

supraorbital rimssupraorbital rims Correction involves standard or endoscopic browlifts and Correction involves standard or endoscopic browlifts and

midface procedures with implants or rhytidectomymidface procedures with implants or rhytidectomy


Aging NoseAging Nose

Tip ptosisTip ptosis Weakness of the tip support mechanismsWeakness of the tip support mechanisms Inferior and posterior repositioning of the nasal Inferior and posterior repositioning of the nasal

tiptip Techniques to correct this include a “nose lift”Techniques to correct this include a “nose lift” This may involve resection of the cephalic This may involve resection of the cephalic

border of the lower lateral crura and/or strut border of the lower lateral crura and/or strut placement between the medial crura which placement between the medial crura which allows the medial crura to be positioned more allows the medial crura to be positioned more anteriorlyanteriorly


Facial fractures and agingFacial fractures and aging

Resorption of mandibular and maxillary alveolar boneResorption of mandibular and maxillary alveolar bone Total mandibular height may be reduced up to 50% in Total mandibular height may be reduced up to 50% in

edentulous patientsedentulous patients Techniques used in repair are less invasive, require less Techniques used in repair are less invasive, require less

dissection and introduce less hardware into the wounddissection and introduce less hardware into the wound Healing is prolongedHealing is prolonged TMJ often affected in agingTMJ often affected in aging


Aging and pulmonary functionAging and pulmonary function

Decreased vital capacity, Decreased vital capacity, pulmonary compliance pulmonary compliance and elastic recoil notedand elastic recoil noted

Body weight increasesBody weight increases Phonation affected by this Phonation affected by this

decreased vital capacitydecreased vital capacity Decreased ability to Decreased ability to

maintain pitch, loudness maintain pitch, loudness and airflowand airflow


Aging and the paranasal Aging and the paranasal sinusessinuses

Nasal ciliary epithelium generally not altered by age or Nasal ciliary epithelium generally not altered by age or smokingsmoking

Effect of age on mucociliary transport is modestEffect of age on mucociliary transport is modest Loss of nasal structural support can increase nasal Loss of nasal structural support can increase nasal

obstructionobstruction Nasal complaints commonNasal complaints common Avoidance of decongestants, diuretics and Avoidance of decongestants, diuretics and

antihypertensives which may dessicate the noseantihypertensives which may dessicate the nose


OlfactionOlfaction Olfactory neuroepithelium Olfactory neuroepithelium

replaced by respiratory replaced by respiratory epithelium with ageepithelium with age

Degenerative diseases, Degenerative diseases, viral infections, endocrine viral infections, endocrine disorders and trauma disorders and trauma also play a role in also play a role in decreased olfactiondecreased olfaction

Basis for changes in age Basis for changes in age related olfaction still not related olfaction still not entirely clear and is entirely clear and is clouded by other factors clouded by other factors in these patientsin these patients


Head and Neck OncologyHead and Neck Oncology More than one half of all cancer patients are older than 65More than one half of all cancer patients are older than 65 Many elderly patients with proper preop counseling and preparation can Many elderly patients with proper preop counseling and preparation can

tolerate head and neck cancer surgery well - as few as two weeks of preop tolerate head and neck cancer surgery well - as few as two weeks of preop preparation may be all that is needed to get patients ready for surgerypreparation may be all that is needed to get patients ready for surgery

Speech and swallowing rehabilitation delayedSpeech and swallowing rehabilitation delayed Most common nonsquamous tumors are thyroid and parotid malignanciesMost common nonsquamous tumors are thyroid and parotid malignancies Anaplastic thyroid carcinoma is much more common in patients over 65Anaplastic thyroid carcinoma is much more common in patients over 65 Medullary and thyroid lymphomas are also commonly seenMedullary and thyroid lymphomas are also commonly seen Even well differentiated thyroid cancer behaves more aggressivelyEven well differentiated thyroid cancer behaves more aggressively Parotid neoplasms tend to be higher grade neoplasms especially Parotid neoplasms tend to be higher grade neoplasms especially

mucoepidermoid carcinomamucoepidermoid carcinoma

Tuesday, April 18, 2023Tuesday, April 18, 2023 Professor Sameer Ali BafaqeehProfessor Sameer Ali Bafaqeeh 4141

Tuesday, April 18, 2023Tuesday, April 18, 2023 Professor Sameer Ali BafaqeehProfessor Sameer Ali Bafaqeeh 4242

6/9/2015Prof. Sameer Bafaqeeh1 Geriatric Otolaryngology Prof.Sameer Bafaqeeh Otolaryngology...

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