This document outlines a presentation by Dr. Edoardo Cervoni, an ENT specialist, addressing various ENT conditions and the aging population's impact on referrals and treatments. It highlights the changes in ENT referral patterns, the effects of aging on sensory functions, and various conditions such as dysphagia, balance disorders, and hearing issues, along with their management strategies. It emphasizes the importance of holistic care for the elderly, given their unique health challenges within the field of otolaryngology.

1. Edoardo Cervoni, M.D.
Ear Nose Throat Specialist
6th March 2013 GP Trainees - Education Centre, RPH

2. Discolosures
 Grant/Research Support: no disclosure
 Consultant: no disclosure
 Major Shareholder: Locumdoctor4u Ltd. (Locum and
Concierge Medical Services)
 I will not be discussing “off-label” uses of medications
or investigations
6th March 2013 GP Trainees - Education Centre, RPH

3. ENT Referrals
i. Most ENT referrals are linked to Audiological and Otological problems.
ii. Out of 271 consecutive referrals to the RHP ENT Department triaged
in 2011, 58% could be potentially managed in Primary Care.
CLPCT NHS Survey 2011 – E Cervoni
6th March 2013 GP Trainees - Education Centre, RPH

4. ENT Referrals
i. Snoring and sleep apnoea were relatively common reasons of referrals.
ii. In a rather significant proportion of cases, relevant information, with specific
reference to the physical examination, were missing.
iii. Among the referrals redirected to the GPwSI in ENT, deafness with wax,
epistaxis and blocked nose were the most common complaints.
6thCLPCT NHS Survey 2011 – E Cervoni
March 2013 GP Trainees - Education Centre, RPH

5. Conditions referred
Cervoni E - 2011
6th March 2013 GP Trainees - Education Centre, RPH

6. ENT Referral Pattern is changing
WHY?
Ageing – Sanitation -
Vaccinations
6th March 2013 GP Trainees - Education Centre, RPH

7. Demographics
 Lancashire residents grew during the decade to
2011 by 3%. There was a 5% fall in the number of 0
to 19 year olds, which was greater than the regional
decrease.
 There was a 12% growth in people 65+ years, which
was also above the regional average.
 The growth rate of the 65+ year olds was positive in
all districts except Blackpool and the greatest in
Chorley and West Lancashire.
6th March 2013 GP Trainees - Education Centre, RPH

8.  Sensory Presbycusis Metabolic Presbycusis
 High frequency down- Slowly progressive
sloping SNHL Flat audiogram
 Speech discrimination Good speech discrimination
remains good Atropy of stria vascularis
 Degeneration a basal
potion of Organ of Corti Conductive Presbycusis
(predominately outer Thickening of basilar membrane
hair cells) Gradual down-sloping high
 Neural presbycusis frequency hearing loss
 Flat audiogram
 Rapid hearing loss Progressive
 Poor speech Speech discrimination for similar
discrimination pure tone hearing is worse in older
 Loss of spiral ganglion
cells patients than younger patients
6th March 2013 GP Trainees - Education Centre, RPH

9. Treatments
 Repeat testing
 Assistive devices
 Vibrating alarm clocks
 Flashing telephone and door signalers
 Television listening systems
 Personal amplifiers
 Hearing aids
In U.S.A. an estimated 4.5 million hearing aid users , but
only 10-20% who could use them do and 12% of people
who have them don’t wear them.
6th March 2013 GP Trainees - Education Centre, RPH

10. Types of hearing aid circuitry
 Analog
 Digitally controlled analog
 Digital sound processing
 Body Aids
 Behind-the-ear (BTE)
 In-the-ear(ITE)
 In-the-canal(ITC)
 Completely-in-canal(CIC)
6th March 2013 GP Trainees - Education Centre, RPH

11. Dysphagia
 Phases of swallowing
 Oral (reduced facial muscle strength, decreased
masticatory strength, reduced tongue control,
missing dentition)
 Pharyngeal (delayed in elderly subjects,
decreased pharyngolaryngeal sensory
discrimination, abnormal UES function,
increased penetration and silent aspiration)
 Oesophageal ( decreased or absent secondary
peristalsis)
6th March 2013 GP Trainees - Education Centre, RPH

12. Evaluation
 History: Feeding problem vs. swallowing disorder
 Liquids vs. solids
 Globus, halitosis, wet vocal quality, reflux,
odynophagia, recurrent pneumonia, hoarseness,
dysarthria
 Physical Exam
 Oral cavity and upper aerodigestive tract, saliva
quality/dentition/dentures
 Neurological evaluation including arousal,
orientation, cognition, cranial nerves
6th March 2013 GP Trainees - Education Centre, RPH

13. Investigations
 Barium swallow (anatomic lesions)
 Modified barium swallow (dinamic view) of
swallowing from oral cavity to lower
esophageal sphincter)
 FEES – Functional endoscopic evaluation of
swallowing
 Videofluoroscopic swallowing study, or
VFSS test
6th March 2013 GP Trainees - Education Centre, RPH

14. Causes of dysphagia
 Stroke
 Neuromuscular disease - Parkinson’s disease (pill-
rolling tremor, bradykinesia, cog-wheeling
rigidity), Amyotrophic lateral sclerosis
 Medications (xerostomia, mental status change,
dyskinesia, GERD, esophagitis)
 Cricopharyngeus dysfunction (functional,
structural, “bar” on barium swallow)
 Zenker’s diverticulum (regurgitation)
 Neoplasms
6th March 2013 GP Trainees - Education Centre, RPH

15. Treatments
 Swallowing therapy
 Dietary modifications
 Rationalization of medications
 PEG
 Cricopharyngeal myotomy, Botox injection of
cricopharyngeal bar
 Surgical repair of Zenker’s (open vs. endoscopic)
6th March 2013 GP Trainees - Education Centre, RPH

16. Balance Disorders
 Difficulties with sensory function, central nervous
system integration, neuromuscular and skeletal
function
 30-50% persons 65 and older fall in a given year
 50% per year fall age 80 or older
 1% of falls suffer hip fractures, 5% some type of
fracture
 Roughly half of hip fractures are estimated to
never recover normal function again
6th March 2013 GP Trainees - Education Centre, RPH

17. Vestibular changes with age
 Termed presbystasis
 Loss of hair cells primarily in the ampulla
 Total number of vestibular nerve axons is 37% than
younger patients
 Loss of neurons in vestibular nuclei of 3% per decade
age 40-90
 Reduction in gain of VOR, smooth pursuit, increase in
saccade latencies
Postural stability: Sensory (visual, hearing, vestibular,
proprioceptive)/Musculoskeletal/Cognitive/Integrative
function
6th March 2013 GP Trainees - Education Centre, RPH

18. Other factors in balance disorders
 Cerebellar degeneration, Parkinson’s disease,
Huntington’s disease, vitamin B12 deficiency,
dementia, diabetic neuropathy, brain and spinal cord
tumors, postural hypotension, cerebrovascular disease,
atherosclerosis, musculoskeletal disease, metabolic
disorders, cardiovascular disorders, medications,
visual impairment
6th March 2013 GP Trainees - Education Centre, RPH

19.  History
 Dizziness, dysequilibrium, vertigo
 Onset, duration, frequency, severity, provocation,
associated symptoms, falls
 Medications, medical conditions
 Physical exam
 Examine sensory functions, posture, gait,
neurological function
 Adjunctive testing
 Audiogram, electronystagmography, MRI,
posturography
6th March 2013 GP Trainees - Education Centre, RPH

20. Treatments
6th March 2013 GP Trainees - Education Centre, RPH

21. Objective -Pulsatile tinnitus
 Arteriovenous  Cardiac murmurs
malformations  Pregnancy
 Vascular tumors  Anemia
 Venous hum  Thyrotoxicosis
 Atherosclerosis  Paget’s disease
 Ectopic carotid artery  Benign intracranial
 Persistent stapedial hypertension
artery
 Dehiscent jugular bulb
Idiopathic stapedial muscle spasm
 Vascular loops Palatal myoclonus
Patulous eustachian tube
6th March 2013 GP Trainees - Education Centre, RPH

22. Subjective tinnitus
 Presbycusis
 Noise exposure
 Meniere’s disease
 Otosclerosis
 Head trauma
 Acoustic neuroma
 Drugs
 Middle ear effusion
 TMJ problems
 Depression
 Hyperlipidemia
 Meningitis
 Syphilis
6th March 2013 GP Trainees - Education Centre, RPH

23. Treatments
 Multiple treatments  Reassurance
 Avoidance of dietary  White noise from
stimulants: coffee, tea, radio or home
cola, etc. masking machine
 Smoking cessation
 Avoid medications
known to cause tinnitus
6th March 2013 GP Trainees - Education Centre, RPH

24. Nasal Complaints
 Nasal obstruction
 Rhinorrhea
 Epistaxis
 Olfactory dysfunction
6th March 2013 GP Trainees - Education Centre, RPH

25. Causes
 Inflammation: decrease immune function, mucociliary
dysfunction, allergy, dehydration with thickening of
secretions
 Dystrophic changes: both atrophy of nasal mucosa and
increase in vasomotor rhinitis are common
 Neoplasia: nasal obstruction, pain, epistaxis, rhinorrhea
 Trauma: old traumas, previous surgery
 Endocrine-metabolic disorders: hypothyroidism, decreased
vitamin A and zinc
 Pharmacologic effects: diuretics, tricyclic antidepressants,
antihistamines
6th March 2013 GP Trainees - Education Centre, RPH

26. Voice changes
 Estimated 12% of the elderly have vocal dysfunction
 Fundamental frequency of the male voice tends to
increase with age
 Fundamental frequency in females decreases with age
6th March 2013 GP Trainees - Education Centre, RPH

27. Voice changes
 Common vocal cord findings
 Atrophy
 Bowed cords
 Oedema
 Loss of collagen and elastic fibers, decrease in
density of fibroblasts, atrophy of submucous
glands, fibrosis, disorganization of collagen fibers
6th March 2013 GP Trainees - Education Centre, RPH

28. Neurological disorders with voice changes
 Essential tremor
 Parkinson’s disease: low volume, breathy, and
monotonic
 Stroke
 Myasthenia gravis
 Amyotrophic lateral sclerosis
6th March 2013 GP Trainees - Education Centre, RPH

29. Treatments
 Speech therapy
 Medialization thyroplasty
 Diagnosis and treatment of underlying disorder
6th March 2013 GP Trainees - Education Centre, RPH

30. Cancer
 Squamous cell cancers
 Thyroid malignancies
 Well differentiated have worse course
 Anaplastic or undifferentiated more common
 Salivary gland malignancies
 Lymphomas
6th March 2013 GP Trainees - Education Centre, RPH

31. Laryngeal Cancer – UK
6th March 2013 GP Trainees - Education Centre, RPH

32. Cosmetics
 Elderly are leading more active lives for much longer
than in the past
 With the explosive growth of cosmetic facial plastic
surgery paired with the explosive growth of the elderly
population there will be many more “elderly” cosmetic
patients
6th March 2013 GP Trainees - Education Centre, RPH

33.  Skin- loss of tone, dynamic and static wrinkling,
thinning, pigmentary changes, gravitational
descent of soft tissues
 Chemical peel, laser resurfacing
 Botox injection
 Rhytidectomy
 Upper third-ptosis of eyebrows and forehead
 Direct brow lift
 Pretrichial/coronal/endoscopic
6th March 2013 GP Trainees - Education Centre, RPH

34.  Periorbital Region - lower eyelid laxity, prolapsed lacrimal gland, ptosis
(usually dermatochalasis)
 Dacryoadenopexy
 Lower lid shortening
 Upper/lower blepharoplasty
 Nose – tip ptosis from loss of attachments between upper and lower lateral
cartilages, loss of connections between medial crura and septum,
ligamentous connections between domes of lower lateral cartilages and
anterior septal angle
 Rhinoplasty-shorten lateral crura, place septal strut
 Lower third – loss of premental fat pad “witches chin”, cheiloptosis,
platysmal bands
 Genioplasty
 Lip-lift
 Plication, imbrication, suture suspension, Z-plasty of platysma
6th March 2013 GP Trainees - Education Centre, RPH

35. Conclusions
 With the expected explosive growth of the elderly
population, this group will become a larger proportion
of patients
 The otolaryngologist must consider the patient’s
health and well being as a whole especially in this
group of patients who often have multiple problems
6th March 2013 GP Trainees - Education Centre, RPH

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6th March 2013 GP Trainees - Education Centre, RPH