Aging Patients

Sinusitis: Special Considerations for Aging Patients

People older than 65 represent the fastest-growing segment of the population. More than 20 percent of U.S. residents will be 65 or older in 2030. Of all Americans 65 and older, 14.1 percent report that they suffer from chronic sinusitis; for those 75 years and older, the rate declines to 13.5 percent. The prevalence of this condition among the elderly ranks behind arthritis, hypertension, hearing impairments, heart disease, cataracts, and orthopedic impairments. However, more Americans report having sinusitis than diabetes.

• constant need to clear the throat
• a sense of nasal obstruction
• nasal crusting
• vague facial pressure
• decreased sense of smell and taste

For the most part, sinusitis symptoms, diagnosis, and treatment are the same for the elderly as other adult age groups. However, there are special considerations in older Americans:

Changing physiology: With aging, the physiology and function of the nose changes. The nose lengthens, and the nasal tip begins to droop due to weakening of the supporting cartilage. This in turn causes a restriction of nasal airflow, particularly at the nasal valve region (where the upper and lower lateral cartilages meet). Narrowing in this area results in the complaint of nasal obstruction, often referred to as geriatric rhinitis.

Patients with geriatric rhinitis typically complain of constant "sinus drainage," a chronic need to clear the throat or "hawk" mucus, and a sense of nasal obstruction, most often when they lie down. Other features include nasal crusting especially in the winter and in patients taking diuretics, vague facial pressure (attributed to "sinus trouble"), and a decreased sense of smell and taste.

However, it is a mistake to blame all upper respiratory problems on the aging process. Elderly patients with symptoms such as repeated sneezing, and watery eyes, nasal obstruction with clear profuse watery runny nose, and soft, pale turbinates (top-shaped bones in the nose) may have allergic rhinitis. Patients with this diagnosis will benefit from consultation with an otolaryngic allergist.

Patients with chronic sinusitis will have a long history of thick drainage that is often foul smelling and tasting and is associated with nasal obstruction, headaches, and facial pressure. These patients usually have pus drainage and nasal redness. In contrast, the geriatric rhinitis patient usually has a dry, irritated nose. The diagnosis of chronic sinusitis can be confirmed with a screening coronal CT of the sinuses.

Recent studies by otolaryngologist-head and neck surgeons have sought to better define the association between rhinitis and sinusitis. They have concluded that sinusitis is often preceded by rhinitis and rarely occurs without concurrent rhinitis. The symptoms, nasal obstruction/discharge and loss of smell occur in both disorders. Most importantly, computed tomography (CT scan) findings have established that the mucosal linings of the nose and sinuses are simultaneously involved in the common cold (previously, thought to affect only the nasal passages). Otolaryngologists, acknowledging the inter-relationship between the nasal and sinus passages, now refer to sinusitis as rhinosinusitis.

The fluids within these cavities are dynamic and are related to dynamic pathologic changes in the bone and soft tissues of the nasal cavity and paranasal sinuses. Symptoms associated with rhinosinusitis include nasal obstruction, nasal congestion, nasal discharge, nasal purulence, postnasal drip, facial pressure and pain, alteration in the sense of smell, cough, fever, halitosis, fatigue, dental pain, pharyngitis, otologic symptoms (e.g., ear fullness and clicking), and headache.

Osteoporosis: Osteoporosis is a significant health problem in the United States affecting approximately 24 million Americans, 15 to 20 million of whom are women over 45 years of age. Because of the concerns regarding prolonged estrogen use in postmenopausal women, a nasal calcitonin spray is often prescribed to prevent bone loss in perimenopausal women who cannot tolerate estrogen. The most common side effect reported with nasal calcitonin spray is a runny nose. Other symptoms that may occur include nasal crust, dryness, redness, irritation, sinusitis, nose bleeds, and headache. Sinusitis sufferers using a nasal calcitonin spray should advise their physicians.

Medications: Treatment for this age group needs to be more individualized to meet the patient's slower metabolism and the increasing potential for side effects. The majority (80 to 85 percent) of the nation's elderly have chronic diseases and take multiple drugs including over-the-counter medications, and risk drug interactions more often than other patients.

Surgery: Nasal and sinus surgery is occasionally advised for older patients. Patients with structural abnormalities, such as a deviated septum or nasal valve collapse causing severe nasal problems, should be referred to an otolaryngologist for evaluation and possible surgical management. Patients with documented chronic sinusitis unresponsive to medications also should be referred to an otolaryngologist.

Sources: Administration on Aging (AoA), U.S. Department of Health and Human Services; Geriatrics.

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© 2004 AAO-HNS/AAO-HNSF