Too Many Birthdays
If we are fortunate enough, and are blessed with good sense, good medical care and good genes, we will grow old. Try as we may, we cannot stave off the deterioration of our bodies and mind forever. In my specialty (Otolaryngology-Head and Neck Surgery), there exist predictable age-related problems for which we usually can offer some support or treatment. When I tell a patient their medical issue is “age-related,” they often become discouraged immediately, sensing that the next statement I make will regard my inability to do much to help them. While there certainly are physical problems that worsen with age, there is always some degree of help we offer patients. I encourage patients to accept the inevitable decline, but to aggressively manage these matters if possible.
Listed below are some of the more common age-related ENT problems we see, and the treatments we have to deal with them.
The prefix “presby-“ is derived from the Greek meaning “old (man).” You will note that healthcare people will use this frequently, tacking on the appropriate suffix. In the case of hearing, old age hearing loss is “presby-cusis.” Presbycusis is age related deterioration of the inner ear cochlear “hair cells,” deterioration of the 8th cranial nerve that brings inner ear impulses to the brain, and lastly, some atrophy and deterioration of the auditory centers within the brain. This occurs at different rates, as some individuals show this loss in their 50’s, while others experience it in the 8th and 9th decades of life. There is no cure for this process, but its impact can be minimized by adherence to a healthy lifestyle throughout one’s life, including avoidance of inner ear toxic drugs and exposure to loud noise.
The gold standard treatment is hearing aid use, either ITE (in-the-ear), BTE (behind-the-ear) or implantable varieties. There is clear evidence that Alzheimer’s and dementia in general occur with much greater frequency in older adults who avoid or defer appropriate hearing aid use.
“Balance” is a complex function in general, calling upon vision, hearing, inner ear balance function, touch and proprioception (feeling one’s position on the ground= sensory input from extremities), strength, coordination and stamina. All of these capabilities deteriorate with aging. Dizziness and imbalance in the elderly can be a function of any combination of weaknesses in these categories noted above.
Just as the sensory hair cells in the hearing organ die and deteriorate with aging, so do the sensory cells of balance in the neighboring vestibular system. In addition, otoconia (crystals) that normally reside in the balance canals of the inner ear can become displaced. So-called “BPPV” (benign paroxysmal positional vertigo) is increasingly common with age, and can become disabling.
We evaluate older individuals with balance complaints with inner ear testing, including VNG (video-nystagmography) to determine the nature of the inner ear disorder and to define the proper therapy. BPPV can be easily treated with Epley maneuvers (done by my staff, or the patient at home) to move wayward crystals into a less offending position in the balance canals. Vestibular rehabilitation is a form of physical therapy that is very successful in helping senior citizens stay on their feet and function safely.
Nose and Sinuses
Nasal and sinus function are not exempt from the aging process. As we age, the cartilage structure of our noses weakens, and the structure of the nasal airway (“nasal valves”) collapses more easily during inspiration. In addition, the nasal mucosa (membrane) deteriorates as the mucous producing glands atrophy, causing abnormal secretion. The sense of smell depends on the olfactory nerves high in the nasal passage, and these deteriorate with aging as well.
The sum result of these losses cause increasing resistance to nasal airflow, dryness and vulnerability to infection. Often, older individuals also use medication to prevent stroke and heart attack (anticoagulants = blood thinners), which, in combination with the above, can nasal bleeding. This can be a simple nuisance, or become heavy and life-threatening.
From a therapeutic point of view, continuous use of nasal emollients and moisturizing sprays and rinses is recommended. Various steroid and non-steroidal sprays are useful in controlling symptoms of the aging nose. We also perform minimal nasal surgeries to open collapsed nasal valve areas for increased airflow. Use of zinc supplements may fend off aging of the olfactory system to some degree but there is no solid data to support this therapy.
Fortunately, the sinus cavities set off to the side of the nasal passage do not deteriorate themselves with aging per se. Recurrent sinus infections over a lifetime, however, can cause chronic sinus infection that worsens as the years pass.
“Presbylarnyx” is the official term for geriatric vocal issues, and there are many varied factors which contribute to the weakening of the voice. Loss of pulmonary function strength lessens the velocity and volume of expired air through the larynx and by itself can impair vocal quality and projection. If is common for those with COPD (asthma, bronchitis, emphysema) to experience breathy voice. The cartilaginous joints of the larynx move less briskly with age, and the intrinsic laryngeal musculature that form the bulk of the vocal cords atrophies and stiffens with age.
Other factors complicating vocal use include oral dryness, dental issues (loss of teeth, dental bridges or dentures) and some loss of tongue coordination.
The mainstay of therapy for dysphonia of aging is speech therapy which is often very helpful in maximizing voice by focusing on the basics: breathing, posture, articulation and control of the musculature of the larynx. ENT surgeons are able to help by injecting implant material (collagen, “Radiesse Voice”) into weak, flaccid and thin vocal cords versus surgically re-positioning the cords, thus rejuvenating their bulk and function.
Swallowing and Speech
Difficulty chewing and swallowing, as well as difficulty articulating words, is another result of “too many birthdays”. The membranes of the oral cavity become dry as the salivary glands produce less and less saliva. The muscles of the lips, tongue and upper throat (pharynx) gradually weaken and become less coordinated. Often dental issues (bridges, dentures, etc) interfere with chewing of food, and articulating words accurately.
The swallowing mechanism begins in the oral cavity and ends as food is propelled from the esophagus into the stomach. One hundred (fifty pairs) of muscles are involved in the entire swallowing process from lips to stomach. With age, the muscles weaken and deteriorate, and the nerves that activate the muscles can be effected by general aging, as well as distinct medical disorders such as Parkinson’s, Alzheimers, subtle or large strokes, dementias of all variety, ALS, multiple sclerosis, diabetes, just to name a few. A lifetime of poorly treated acid reflux can result in scarring and strictures of the esophagus, blocking the passage of food. Muscular incoordination of the lower throat and upper esophagus can cause a “blow-out” of the lining of the throat through weakened muscle layers called a “Zenker’s diverticulum,” which causes people to regurgitate food trapped in the Zenker’s pouch, and obstruction to swallowing solids. Zenker’s pouches are common in elderly individuals, but I have seen them develop in the mid-40’s as well.
I can often help patients with these problems with a variety of medical and surgical solutions. Medications and moisturizers can lubricate the dry oral cavities. There are medications used to control muscle spasm and acid reflux. We often employ the services of the speech and swallowing physical therapists to re-train people to enjoy better swallowing and oral function. Growths, scarring or “blow-outs” (Zenkers) can be corrected surgically.
We all aspire to age with grace and dignity, but the ravages of aging will always provide challenge after challenge to all of us. It is the responsibility of physicians, in my opinion, to realistically discuss the impact aging has on a given medical issue, but to use all of his/her resources and knowledge to help the patient cope with these inevitable conditions. To dismiss a patient problem without offering help as “a normal part of the aging process” is not responsible medicine.