GERIATRIC

OTOLARYNGOLO
GY
DR SURYA PRAKASH D R
ASSOCIATE PROFESSOR OF ENT
RAMAIAH MEDICAL COLLEGE
OTOLOGICAL
PROBLEMS IN
THE ELDERLY
 Introduction
• Geriatric competence broadly includes knowledge
of aging as an integral biological, psychological, and
social process;
• the functional consequences of aging along with
diseases, conditions, and syndromes common to
later life;
• and the means to recognize and mitigate the risks
of adverse events in the care of older people
 FIT V/S FRAIL
Practically frailty is assessed by the scale which uses five
items:
• Unintentional weight loss
• Muscle weakness
• Exhaustion
• Low physical activity
• Slowed walking speed
Each item is assigned a score of 0 if absent, 1 if present.
Fit has score of 0, whereas a very frail person would have
the maximum score of 5.
 Why speciality?
• Changes of ageing lead to reduced function that
requires compensation to maintain normal
physiology. These changes and compensatory
responses become more pronounced with
increasing age.
• Similar change occurs in all organ systems as a
function of age, resulting in the eventual loss of
dynamic range and lack of compensatory response
giving rise to an increased vulnerability to
disease…..
 Specific to ENT
• Familiarity with the unique otolaryngological
pathology profiles of elderly patients is important in
providing optimal care.
• The clinical manifestations may vary from age to
age.
• There is a drastic shift in the presentation spectrum
of diseases between old(65 -84 years) and the
oldest(>85 years)
• Rather than asking what is the problem, better to
ask what do they expect out of the consultation.
The problems in the elderly with relation to ENT can be
covered under
• 1. Hearing problems and infections of ear
• 2. Balance problems
• 3. Sinonasal problems
• 4. Voice and swallowing related problems
The goals and expectations of older adults usually differ
from those of younger adults. These include
independence, mobility, ability to communicate with
family and friends, and avoidance of being alone.
 EAR PROBLEMS
The presentation could be of
anxiety, depression, or apparent cognitive decline.
This could be due to
• Hearing loss
• Tinnitus
• Vertiginous syndromes/vestibular disorders

Have a low threshold for suspecting hearing loss in any

elderly patient.
WAX
 Treatment
Wax Solvents 5 drops every two hours for 5 days.
(soliwax, waxrim, otorex).
Wax drops applied by the displacement method(instill
drops and give tragal pressure)
Analgesics
Warn the patient that the ear block will increase after
using ear drops.
Avoid using ear buds
Refer for removal suction v/s syringing.
 Age Related Hearing Loss
• Aka- Presbycusis
• Can start at any age.
• Presbycusis occurs in 50 percent of seniors between the ages of 75
and 84 and increases to 95 percent by age 94.
• More disabling and severe if other comorbidities exist- Hypertension,
DM, IHD, CKD, Noise exposure,polypharmacy
• Co existing Menieres disease poses a serious threat
4 types
• Sensory
• Neural
• Mechanical or cochlear conductive
• Strial Metabolic
Electron Microgram of Cochlea Cochlear Hair Cells
 PATHOLOGY
• REDUCTION IN THE NUMBER OF HAIR CELLS
• CHANGES IN THE STIFFNESS OF THE BASILAR
MEMBRANE
• CHANGES IN THE ELECTROLYTE CONCENTRATION
OF THE INNER EAR FLUIDS
• CHANGES IN THE NERVE FIBRES AND HIGHER
PROCESSING CENTRES (NEUROPATHIES AND
DEMENTIAS)
• Start with initially inability to differentiate consonants which
present as muffled hearing.
• This causes disturbance in understanding regular words and
there is a frequent request for repetition.
• Pure Tone Audiometry(PTA) might be normal at this stage.
• The progress of hearing loss may be around 6 dB per year
initially to around 20 dB per year later.
• Later progress to high frequency hearing loss.
• This is more dangerous as the high frequency warning sounds
are not heard posing hazard of Road traffic accidents.
• Hence regular PTA has to be done.
• As it progresses, will not be able to contribute in a group
talk and ends up in embarrassment.
• This leads to keeping away from socializing.
• Avoids walks… avoids discussions…
• As time progresses, they start getting adjusted to their new
life style…. the greatest danger which can happen to
anyone.
• Reduced physical activity leads to muscle wasting and
exacerbates vertigo.
• Lack of interaction leads to depression and other
psychological problems.
• Hence the need for restoring auditory function as
early as possible to the maximum extent.
• Can be done by different measures.
 Medical v/s Surgical
*Periodic ear wax cleaning
use of wax solvents and suctioning or syringing with
warm sterile normal saline.
* Antioxidants
supplementing with omega 3 fatty acids and acetyl
cysteine . Adequate medications for Menieres.
*Recommendation of hearing aids
to be done as soon as audiometric deterioration is noted
*Cochlear implant
suitable for severe to profound hearing loss which sets in
early
 Hearing Aids
Don’t purchase a hearing aid without a medical
exam.
Never purchase a hearing aid by mail-order.
Hearing aids need to be custom fitted.
Wax can build up in the ear canal, and hearing aids
need to cleaned and readjusted.
Different types of hearing aids are available.
Better to choose a digital hearing aid with at least 6
channels for better performance and long life.
 Completely-in-The-Ear or CIC
Style.

Smallest

Microphone is shielded from wind noise

In-The-Canal or ITC Style
 In-The-Ear or ITE Style

Most popular

Fills the bowl of the ear

Ease of handling and greater volume potential make this style a great choice
 Behind-The-Ear or BTE Style

Rests behind the ear

Small clear tube connects to an earmold in the bowl of the outer ear

Greater volume potential than any other style

Greater durability than any other style

 Infections
• Perichondritis
severe hyperaemia and edema over the pinna
with tenderness.
Managed with iv antibiotics and splintage if required.
• Malignant otitis externa
severe ear pain in a elderly diabetic .
Managed with IV antibiotics and surgery.
In the above conditions, better to refer.
 MALIGNANT OTITIS
PERICHONDRITIS EXTERNA
 Tinnitus
• Usual presentation is of anxiety and insomnia
• Associated with hearing loss.
• Clear distinction has to be made if it is objective or
subjective.
Management
• Tinnitus retraining therapy
• Cognitive behavioural therapy
• Hearing aids v/s tinnitus maskers
 Vertigo
The feeling of no balance and fear of falls
 PATHOLOGY
• CHANGES IN THE CUPULA AND MACULA
• CHANGES IN THE PROPRIOCEPTION
• CHANGES IN THE CENTRAL VESTIBULAR
CONNECTIONS
• SACCADIC DYSFUNCTION
• DEMENTIA
 Vicious cycle in Vertigo
Fear of a drop attack
Affects mental well-being
Reduction of physical activities
Affect bone and muscle strength
Slip into depression
Start of other lifestyle diseases-obesity, lowered
immunity, heart diseases etc.
 EVALUATION
DISTINCTION HAS TO BE MADE BETWEEN DISEQUILIBRIUM
OF AGING AND VERTIGO.
SIMPLE NEUROLOGICAL EXAMINATION
ROMBERGS, PROPRIOCEPTION, NYSTAGMUS
DIX HALLPIKE TEST FOR BPPV
AUDIOMETRY
CALORIC TEST
BEST TEST
FALL RISK ASSESSMENT
Many a times simple Epleys maneuvre is all that is needed.
 CAUSES OF DIZZINESS
• Peripheral vestibular disease (20–50 %) Benign paroxysmal
positional vertigo (BPPV), labyrinthitis, vestibular neuritis
• Cardiovascular disease (10–30 %) Arrhythmia, congestive heart
failure, vasovagal conditions (e.g., carotid sinus hypersensitivity)
• Systemic infection (10–20%) Systemic viral and bacterial
infection
• Psychiatric conditions (5–15%) Depression, anxiety,
hyperventilation
• Metabolic disturbances (5–10 %) Hypoglycemia, hyperglycemia,
electrolyte disturbances, thyrotoxicosis, anemia
• Medications (5–10 %) Antihypertensives, psychotropic
medications
EPLEYS MANEUVRE
 Holistic physical therapy
address the various needs of body’s imbalance
 Exploit neural plasticity
and Retrain the brain

• To Reduce Anxiety
• To adapt to the disturbed signals from the
malfunctioning vestibular system of the inner ear
• To create a new wide platform of body’s centre of
gravity
 MANAGEMENT
• Nonvestibular causes of presbyastasis such as postural hypotension
need to be identified and treated specifically
• Vestibular habituation involves repeated elicitation of minor degrees of
vertigo
• Other maneuvers involve visual tracking with the head held stationary
and also gaze stability with head movement
• Vestibular suppressants should be avoided
Vestibular Rehabilitation
Therapy
Physical exercises and coordinated movements
• Benefit the people suffering from balance
disorders.
• Help reconfigure the brain to find alternative ways
to receive the sensory information and initiate
required motor functions
• Strengthen the lower body (trunk) and its sensory
system to balance the body during turning, walking,
or bending
• Link for Vestibular rehabilitation therapy exercises

http://vertigoexercise.com/tearoff/exercise

Click on the link or copy and paste in browser.

Follow the instructions as prompted.
Walking path rehabilitation
TAI-CHI
 Tai Chi
• combine focus, breathing, and body movements to
relax the mind and body
• significantly reinforce coordination of vestibular,
visual and motor functions improving balance and
gait.
• increase whole body dynamic postural control and
contributes to functional improvement
• targets all the physical components needed to stay
upright—leg strength, flexibility, range of motion,
and reflexes—all of which tend to decline with age.
• largest muscle groups are put to work- the gluteus
and quadriceps are put to work which tend to
atrophy with age.
Chi loosely means“energy,”
Tai Chi postures and movements help concentrate
the energy below the belly button- hence create a
new centre of gravity.
Tai Chi class looks like a slow motion movement.
 Tai Chi improves balance in several
ways

Promotes a greater awareness of body and movement

Strengthens and improves ankle flexibility, creating a more

stable stance.

Distributes movement more evenly among the ankle, knee, and

hip joints, enabling faster and smoother walking.

It helps reduce postural sway by optimizing the use of

proprioception and sensory input received by the brain from
touch sensors in the muscles and joints in the balancing process.
• This exercise program is far more dynamic than it
looks
• Interestingly, one of Tai Chi's biggest benefits to
stability isn't physical—but emotional.
 Tai Chi for Balance
• eight-form style
• focus on “weight-bearing and non-weight-bearing
stances, posturally correct body alignment, and
multiple, coordinated movements executed in a
continuous, circular, and flowing manner.”
• borrow their names and movements from the
natural world as well as activities historically
common to Chinese life.
 When to refer to a specialist
• Serious vertigo that is disabling
• Ataxia out of proportion to vertigo
• Vertigo longer than 4 weeks
• Changes in hearing
• Vertical nystagmus
• Focal neurological signs
• Systemic disease or psychological origin
THANK
YOU