SCOTTSDALE, Ariz.—A growing elderly patient population is one of the biggest challenges otolaryngology, and most medical specialties, will face over the next several decades, and the cases presented by this population introduce special circumstances that can call for extra reflection and finesse, as a panel of experts illustrated in a discussion here on Jan. 25 at the Triological Society Combined Sections Meeting. Click here to listen to the complete session on geriatric care.
The aging of baby boomers will put a big strain on the otolaryngology community, said panel moderator David Eibling, MD, professor of otolaryngology at the University of Pittsburgh. “There is an insufficient number of providers specifically trained to handle geriatric issues and the older population,” he said. “Each of us will be facing these patients and their unique issues in the years to come.”
The panel delved into several cases that covered the difficult terrain otolaryngologists must sometimes navigate with this particular population.
Case 1: Worsening Hearing Loss
Marc Bennett, MD, assistant professor of otolaryngology at Vanderbilt University Medical Center in Nashville, presented the case of a 50-year-old woman with a 12-year history of hearing loss, which had gotten much worse over the previous two years. She also had “slightly bothersome” tinnitus in both ears. Her physical exam, neurologic exam and eardrums were all normal.
Robert Sataloff, MD, chair of otolaryngology-head and neck surgery at Drexel University College of Medicine in Philadelphia, said he orders an extensive, and “arguably excessive,” neurological workup on these patients. “Every once in a while, you find that asymmetry is due to something structural,” he said. “Not infrequently, you find something medical.”
He would also order an MRI, he said, though Steven Parnes, MD, chairman of otolaryngology at Albany Medical Center in New York, said he might have a different view. “We’re getting more sensitive to how many imaging studies we’re going to order,” he said. “I think it depends also on the
patient’s presentation. If tinnitus was so dominant unilaterally and [the patient] had some real balance issues, then it might suggest I get an MRI. But other than that, I probably wouldn’t.”
The panel also touched on how much the age of the patient should factor into decisions made by the physician. Dr. Sataloff said, “Until people get very, very old, I personally am uncomfortable withholding treatment that I would give to a 50-year-old from a 75-year-old who may turn out to be a 100-year-old.”
In Dr. Bennett’s specific case, the woman was given hearing aids, but over time her hearing worsened, with slight cognitive decline and discrimination scores in the mid-30s. Dr. Sataloff said he’d be looking for a cause like an autoimmune disorder. “A lot of people don’t look until it’s very late, but it’s there early,” he said.
The patient eventually had a cochlear implant workup and was implanted in the worse-performing ear. Dr. Bennett said this might have been a case of a feedback loop involving dementia and hearing loss, with hearing loss leading to social isolation, which led to dementia, more isolation and more hearing loss, and so on.
Case 2: Facial Paralysis
Dr. Parnes discussed a 78-year-old man with facial paralysis on the right side that had come about gradually over five months. An MRI two months earlier had reportedly shown nothing abnormal. The patient’s overall health seemed good: He was alert and oriented, with a normal gait, ear exam and neurological exam.
“In the world I live in, this is a parotid tumor until proven otherwise,” Dr. Eibling said. Dr. Parnes said an MRI was re-done and was negative. Gold weight placement was done to protect the movement of the right eye, he said. An MRI performed 11 months after the man first sought medical help showed an increased signal in the right mastoid air cells, but no sign of a tumor. The man declined intervention at that point, including facial re-animation.
“In every discussion I had with this gentleman, I said, ‘You know, I think you have a tumor and we’ve just been unable to find it,’” said Dr. Parnes.
Four months later, the man reported hearing loss on his right side. Dr. Sataloff said his first step would be a repeat MRI, because he would worry about that change. Dr. Parnes said that option was decided against, because the patient had already undergone three MRIs, with normal results. Facial re-animation was performed at that point and, aesthetically, the results were good. But the man’s overall health declined, with more hearing loss, rapid decline in mental status and weakness. Eventually, the patient was taken to the ER.
His worst suspicion was confirmed, Dr. Parnes said: “Despite the fact of having three normal MRIs prior to this, he had a massive tumor at the base of the skull…. It’s surprising to me that a tumor of this size could not have been seen on previous MRIs. But I think in retrospect, if we’d gotten an MRI when we started to get the unilateral hearing loss, we probably would have picked something up.” The family, with physician guidance, opted for palliative care rather than medical intervention, and the man died about six months later.
Dr. Eibling said he thinks training on how to handle situations like this will become more common. “This is going to become a greater part of what we all do with our trainees, is help them in rehearsing and practicing this kind of decision-making,” he said.
Case 3: Radiesse Injection
Dr. Sataloff discussed the case of a 52-year-old man with dysphonia whose symptoms made him “functionally elderly.” He had developed a weak voice 10 years prior to this, and a laryngoscopy had found bowing and glottic insufficiency. Three Radiesse injections into the vocal fold, given by another doctor, had brought “somewhat satisfactory” results. A fourth injection had made his symptoms worse, however. Video footage showed the left fold not pliable and moving as a block.
When Dr. Sataloff saw the man, he debulked the Radiesse, which is easier to do than with Teflon, because Radiesse resorbs over time. Most of the Radiesse can be removed, while the remnants will eventually disappear. The patient ended up with glottic insufficiency again, so Dr. Sataloff waited a year and then did a bilateral thyroplasty. The man now has better glottic closure and no longer has to exert himself so much to use his voice.
Dr. Sataloff said it’s a cautionary tale about Radiesse. “Overinjection is a real problem,” he said. “Although hydroxylapatite is much like bone and is supposed to be nonreactive and usually is fine, there are a small number of patients who develop histopathology and clinical pathology that is indistinguishable from a Teflon granuloma.”