Rhinitis in the elderly

Long-Term Outcomes of Septoplasty With or Without Turbinoplasty: A Systematic Review

BACKGROUND

Septoplasty is used to correct nasal obstruction from nasal septum deviation. However, the long-term efficacy of septoplasty is unclear, and no literature reviews have examined long-term outcomes of septoplasty with or without turbinate modification. This systematic review aimed to evaluate the long-term efficacy of septoplasty with or without turbinate modification in improving nasal obstruction.

DATA SOURCES

PubMed, EMBASE, Cochrane CENTRAL.

METHODS

A systematic review of the literature was conducted using the aforementioned databases. Studies reporting outcomes 12+ months after functional septoplasty with or without turbinate surgery for nasal obstruction were included. Septorhinoplasties, concurrent sinus surgery, pediatric studies, and studies where septoplasty was performed for indications other than nasal obstruction were excluded.

RESULTS

After screening, 35 studies with 4,432 patients were included. Mean weighted post-operative follow-up time was 29.1 months (range 12-120 months). All studies reported significant improvement in subjective and objective outcomes at long-term follow-up compared to baseline. When comparing short-term (<12 months) to long-term (≥12 months) outcomes, four studies noticed that subjective outcomes worsened slightly over time, but no study found a significant change in objective outcomes over time. In addition, 23 studies reported patient satisfaction and/or improvement rates, with 75.4% (2,348/3,113) of patients expressing satisfaction/improvement at an average of 27.0 months after surgery.

CONCLUSIONS

Overall, septoplasty with or without turbinate modification shows significant improvement in obstructive symptoms at long-term follow-up per both objective and subjective measures. Whether outcomes may worsen slightly over time remains indeterminate based on mixed results in the literature.

LEVEL OF EVIDENCE

N/A Laryngoscope, 134:2525-2537, 2024.

The Objective Assessment of dry Nose

Background

Dry nose (DN) is a common symptom in both patients with rhinitis and healthy individuals; however, it is often overlooked.

Objective

This study aimed to investigate the characteristics of and propose objective diagnostic criteria for DN.

Methods

This study was conducted from December, 2018 to October, 2021. Patients with complaints of a dry nasal cavity and normal controls were recruited consecutively from the allergy-rhinology outpatient clinic of Beijing TongRen Hospital. Questionnaires were completed by each participant during recruitment to record demographic data. DN test strips were used to evaluate the severity of DN. The length of the strip was recorded at 30 s, 1 min, 2 min, 3 min, 4 min, and 5 min, respectively. Nasal secretions were collected on sponges and allergic status was assessed based on serum sage levels.

Results

Twenty (13 men and 7 women) patients with DN and 100 (47 men and 53 women) controls were recruited for the study. The participants’ ages ranged from 23 to 73 years (mean  =  47.7 years). Nine of the 20 DN patients were diagnosed with vasomotor rhinitis. The weight of the sponges of DN patients was significantly lower than that of controls. At the last time point (5 min), the strips in the control group were significantly longer than those in the DN group. The reference range of 30 s, 1 min, 2 min, 3 min, 4 min, and 5 min of controls was 3.0 mm, 6.0 mm, 10.9 mm, 13.2 mm, 16.8 mm, and 17.0 mm, respectively.

Conclusions

Our study indicated that the strip length less than 17.0 mm at 5 min is a valuable reference for the diagnostic of DN in Beijing.

[Symptoms, causes, and treatment options of geriatric nose]

With increasing age, structures of the internal and external nose change. Many elderly patients complain about rhinitis with nasal obstruction, endonasal crusting, epistaxis, intermittent rhinorrhea, and olfactory disorders. These symptoms are mainly caused by atrophy of the mucosa and the olfactory epithelium, but may also be an expression of drug side effects. Additionally, there are changes in the shape of the nose (continuous growth, altered elasticity of supporting structures) and in the dermis, which may develop tumors due to its sun-exposed position. These multiple internal and external changes of the nose can be summarized by the collective term "aging nose," whose treatment options are complex. These range from conservative (nasal care, medication changes, hemostatic measures) to surgical lines of therapy (septorhinoplasty, tumor excision, vascular ligation) and will require further scientific study in the future.

Mometasone furoate is not superior to saline for chronic rhinitis in the elderly

Introduction

Prevalence of diseases associated with ageing is rising; among these are the rhinologic problems. Chronic rhinitis appears as one of the most common worrisome nasal disorders in this age group. At the same time, the allergic form diminishes because of the immunosenescence.

Objective

This study aimed to evaluate the effect of a corticosteroid nasal spray (mometasone furoate) over nasal patency and the severity of rhinitis and its impacts on quality of life as compared with the saline nasal spray.

Methods

This open label-trial randomized subjects ≥60y with chronic rhinitis (allergic and nonallergic rhinitis) with mometasone spray 100mcg/d and isotonic saline nasal spray or saline alone for two weeks. The primary endpoint was the improvement in nasal patency evaluated by the peak nasal inspiratory flow (PNIF). Secondary outcomes included the severity of symptoms and the quality of life assessed by a visual analogic scale (VAS) and the sinonasal outcome test (SNOT-22), respectively.

Results

Forty patients underwent randomization, in equal number in each group of treatment, either with allergic (AR) and nonallergic rhinitis (NAR). At week 2, the mean PNIF score was 79.5 in the corticosteroid (CE) plus saline group and 82.0 in the saline group (p = 0.37). Also, SNOT-22 and VAS were not improved with the addition of mometasone furoate.

Conclusions

Treatment with mometasone furoate nasal spray plus isotonic saline is not superior to saline alone in elderly patients with rhinitis in respect of improving nasal patency, quality of life, and reducing the intensity of symptoms.

Trial registration

The trial is registered at the Brazilian Clinical Trials Registry (ReBEC) #RBR-498bnq. Registered 05 July 2017.

[Schirmer test for determining the moisture status of the nasal mucosa]

BACKGROUND

There is no established method to objectively measure the moisture status of nasal mucosa. In a pilot study it was shown that a nasal Schirmer test is a possible method. The aim of the current study was to check whether the nasal Schirmer test is suitable to define moisture status in cases with an expected pathological secretion.

MATERIALS AND METHODS

Initially, 154 subjects participated, of whom n = 112 were included (healthy n = 65, deviated septum n = 47, ♂ 60, ♀ 52, median age 33 years). After evaluation of various test strips, the most suitable one was placed on both sides of the mucosa of the anterior septum. Secretion running distance (SRD) was measured in mm after 10 min. In addition, rhinomanometry (AAR) and acoustic rhinometry (AR) were performed. Healthy volunteers and subjects with septum deviation were compared, and subjects were also compared in terms of smoking behavior and age (<60 and ≥60 years).

RESULTS

The total median SRD was 12 mm. SRDs between 9 and 14 mm were considered physiological. In non-smokers, SRD was significantly higher in all groups compared to smokers (p > 0.05). Nasal side, age, and deviated septum had no significant influence on SRD (p < 0.05). There were no correlations between SRD and AAR or AR.

CONCLUSION

Our results confirm that a statement about moisture of the nasal mucosa is possible based on a nasal Schirmer test. Standard values of SRD are relevantly influenced by the respective test strip. Smoking is associated with a drier mucosa. Further investigations on the nasal Schirmer test in patients with expected atrophy of the nose, e. g., Sjogren's or empty nose syndrome, should be performed.

Prolonged effect of allergen sublingual immunotherapy to grass pollen

Background: The prolonged effect of allergen immunotherapy is unknown, especially in older patients. Objective: The three-year effect of sublingual allergen-specific immunotherapy (AIT) to grass pollen on elderly patients with allergic rhinitis was analyzed. Methods: Thirty-eight elderly patients (63.18 ± 3.12 yrs.) underwent AIT to grass pollen, were monitored for three years and were compared to a placebo group. AIT was performed with the use of an oral Staloral 300 SR grass extract (Stallergens Greer, London, UK) or a placebo. Symptoms and medication scores, represented by the average adjusted symptom score (AAdSS), the serum level of IgG4 to Phl p5 and the quality of life were assessed immediately after AIT and three years later. Results: After AIT, the AAdSS was significantly decreased and remained lower than in the placebo group during the three years after AIT. Serum-specific IgG4 against Phl p5 increased during the AIT trial in the study group. For the three years of observation after AIT, there were no significant changes in specific IgG4 levels against the analyzed allergens in comparison to the results immediately after AIT. The quality of life, based on the Rhinoconjunctivitis Quality of Life Questionnaire, was significantly decreased in patients who received AIT, from 1.83 (95%CI: 1.45-1.96) to 0.74 (95%CI: 0.39-1.92) (p < 0.05) to 0.82 (95%CI: 0.45- 1.04) three years after AIT. Conclusion: A prolonged positive effect after AIT to grass pollen was observed in elderly patients with allergic rhinitis. Further trials are needed to confirm this effect.

Rhinitis and Sinusitis in the Geriatric Population

Rhinitis and sinusitis are common medical conditions that affect the geriatric population and have a significant impact on their quality of life. Because few studies examine differences in the clinical management between the geriatric and general adult population, therapies should be based on current guidelines. Special considerations should be made when treating these patients in regards to multiple comorbidities and the potential for drug interactions from polypharmacy. Further research on the pathogenesis of sinusitis in the geriatric population may provide specific differences in the clinical management in this population.

Rhinosinusitis and Allergies in Elderly Patients

The sinonasal tract plays important roles in respiration, olfaction, and defense against external pathogens. Like many organ systems, the nose and sinuses undergo several changes with advancing age that can play a role in the development of disease. This article discusses the physiology of the aging sinonasal tract and reviews the common diseases affecting older patients, such as rhinitis and rhinosinusitis.

Evidence of the efficacy and safety of house dust mite subcutaneous immunotherapy in elderly allergic rhinitis patients: a randomized, double-blind placebo-controlled trial

Background

Allergen specific immunotherapy (AIT) in elderly patients is controversial, and there is still little evidence supporting the safety and efficacy of this treatment in this population. The study objective was to evaluate the safety and efficacy of AIT for house dust mite allergens in patients over 65 years of age with allergic rhinitis (AR) and a documented allergy to house dust mites. The primary endpoint was the change from baseline in the mean average adjusted symptom score (AAdSS) and the total combined rhinitis score (TCRS) difference in the least square means for the label compared to placebo.

Methods

Fifty-eight AR elderly patients who were monosensitized to house dust mites were individually randomized in comparable numbers to one of two parallel groups with the following interventions: 2 years of perennial AIT using PURETHAL Mites or placebo. The symptoms and medication scores were presented as the AAdSS and TCRS. Quality of life, based on the rhinoconjunctivitis quality of life questionnaire (RQLQ), nasal allergen provocation responsiveness, serum allergen-specific IgG4 to D. pteronyssinus and D. farinae and Der p1 and Der p2 were monitored. The intent-to-treat population was analysed.

Results

After 24 months of AIT, AAdSS significantly decreased from 4.27 ± 1.58 to 1.82 ± 0.71 (p < 0.05). The TCRS was significantly decreased after 2 years of AIT. Serum-specific IgG4 against D. pteronyssinus, D. farinae, Der p1, and Der p2 increased during the AIT trial in the study group. The RQLQ score was significantly improved in patients who received AIT, from 1.86 (95% CI 1.51–1.78) to 1.26 (95% CI 1.09–1.55). Two mild systemic anaphylactic reactions (degree I) were reported after injections in the active group during the AIT therapy.

Conclusion

The DBPC trial showed AIT for house dust mite allergens was effective and safe in elderly patients with allergic rhinitis.

Trial registration

This randomized, double-blinded placebo-controlled (DBPC) trial was conducted at one centre (ClinicalTrials.gov no. NCT03209245)

Pharmacological Management of Allergic Rhinitis in the Elderly

Recent studies suggest that allergic rhinitis is highly prevalent in the elderly population, but is underdiagnosed and undertreated. This review article briefly introduces allergic rhinitis in the elderly (epidemiology and pathophysiology) and identifies the main goals of treatment in these patients with respect to age-related physiological factors, comorbid conditions and polypharmacy. The primary focus of the article is a narrative review of the literature concerning the different types of treatment options in elderly patients aged 60+ years (pharmacological therapy and allergen-specific immunotherapy). The main management trend for allergic rhinitis in elderly patients is the same as the trend in young patients. Second-generation antihistamines and nasal glucocorticosteroids are also the first-line therapies in seniors. In a few trials, allergen-specific immunotherapy for grass pollen or house dust mites has been shown to be effective and safe in patients aged 60 years or older with allergic rhinitis. In conclusion, undertreatment of allergic rhinitis in the elderly is a reality. Pharmacological treatment is quite similar in both older and younger patients with allergic rhinitis.

Prolonged effect of allergen sublingual immunotherapy for house dust mites in elderly patients

BACKGROUND

The prolonged effect of allergen immunotherapy is unknown, especially in older patients.

OBJECTIVE

To analyze the 3-year effect of sublingual allergen-specific immunotherapy (SLIT) to house dust mites in elderly patients with allergic rhinitis.

METHODS

Forty-seven elderly patients (65.78 ± 4.89 years old) underwent SLIT to house dust mites and were monitored for 3 years and compared with a placebo group. SLIT was performed with the use of oral Staloral 300 SR Der p and Der f 50/50% extract (Stallergens Greer, London, United Kingdom) or placebo. Symptoms and medication score, represented by the average adjusted symptom score (AAdSS), serum level of immunoglobulin (Ig) G4 to Dermatophagoides pteronyssinus, Dermatophagoides farinae, Der p 1, and Der p 2, and quality of life, were assessed immediately after SLIT and 3 years later.

RESULTS

The AAdSS was significantly decreased after SLIT, and the level remained low during the 3 years after SLIT compared with placebo. Serum-specific IgG4 against D pteronyssinus, D farinae, Der p 1, and Der p 2 increased during the SLIT trial in the study group. For the 3 years of observation after SLIT, there were no significant changes of specific IgG4 levels against the analyzed allergens compared with results just after SLIT. Quality of life based on the Rhinoconjunctivitis Quality of Life Questionnaire score was significantly decreased in patients who received SLIT, from 1.48 (95% confidence interval 1.33-1.79) to 0.98 (95% confidence interval 0.67-1.07; P < .05) compared with 0.94 (95% confidence interval 0.55-1.04) 3 years after SLIT.

CONCLUSION

The prolonged positive effect after SLIT to house dust mites was observed in elderly patients with allergic rhinitis. Further trials are needed to confirm this effect.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01605760.

Allergy and Aging: An Old/New Emerging Health Issue

Allergy reactions are the most common immunological diseases and represent one of the most widespread and fast growing chronic human health problems among people over 15 years of age in developed countries. As populations get older worldwide, allergy manifestations in aged persons will occur more often in the future. To date, there has been much more studies on allergies in children than in adults. As the population ages, clinicians must be prepared to meet all the elderly's health care needs, including these new and emerging health issue. Allergic diseases represent an old/new emerging health issue. Because many common illnesses masquerade as atopic disease, the differential diagnosis of suspected allergic diseases becomes more expanded in an aging population. Research in the field needs to focus on both human and animal model systems to investigate the impact of the aging process on the immunologic pathways underpinning allergy and its different facets.

Radiofrequency turbinoplasty for nonallergic rhinitis in geriatric patients

BACKGROUND AND OBJECTIVE

Radiofrequency (RF) turbinoplasty may be effective in treating nonallergic rhinitis in elderly patients. The present study evaluated the efficacy of nasal turbinate surgery with RF for the treatment of nonallergic rhinitis in elderly patients refractory to medical therapy.

METHODS

A total of 35 consecutive patients older than 65 years of age (mean subject age, 75.5 ± 9.6 [standard deviation] years) with nonallergic rhinitis refractory to medical therapy who underwent RF turbinate surgery were enrolled in this study. The efficacy of RF turbinoplasty in treating nonallergic rhinitis in elderly patients was evaluated by using rhinoscopy and a visual analog scale score of nasal symptoms.

RESULTS

The response rate of primary RF turbinate surgery for nonallergic rhinitis refractory to medical therapy was 68.6%. Postoperative symptom scores for rhinorrhea and nasal obstruction were significantly improved. Persistent crust formation developed in seven patients (20.0%). No patient experienced major complications (e.g., septal hematoma, abscess, septal perforation), but partial bone necrosis was observed in one patient.

CONCLUSION

RF turbinoplasty appeared to be effective for treating some nonallergic rhinitis symptoms in elderly patients, including rhinorrhea and nasal obstruction. These preliminary results are encouraging and warrant further investigation.

The intranasal Schirmer test: a preliminary study to quantify nasal secretion

Adequate secretion of the nasal mucosa is essential for normal nasal physiology. A "dry" nose is a frequent complaint of ENT patients. Measurement of secretion is currently impossible because of the absence of a recognized test. The aim of the present study was to investigate the feasibility of an intranasal Schirmer test in a large number of patients and to define standard values for nasal secretion. The test population comprised 159 healthy, non-smoking volunteers and 30 healthy smoking volunteers. All subjects were examined by nasal endoscopy for anatomic or mucosal disease. A Schirmer test strip was placed on both sides of the mucosa of the anterior nasal septum by anterior rhinoscopy. After 10 min in standardized conditions, the strip was removed and the wetted distance was measured. Active anterior rhinomanometry (ARR) and acoustic rhinometry (AR) were later performed. In the non-smoking group (n = 159), the median wetting distance of the test strip was 10.3 mm (range 3.6-35.0 mm). Age, gender, nasal geometry, and flow (according to ARR and AR) had no significant influence on nasal secretion. The test for normal distribution was negative. In the smoking group (n = 30), the median wetting distance was 8.4 mm (range 2.5-28.0 mm), significantly shorter than the wetting distance in the non-smoking group (p < 0.05). The Schirmer test offers a practical method to quantify mucosal humidification. The test is inexpensive and well tolerated by patients. In healthy people, wetting distances from 6 to 18 mm are considered normal.

Allergic diseases in the elderly

Demographic distribution of the population is progressively changing with the proportion of elderly persons increasing in most societies. This entails that there is a need to evaluate the impact of common diseases, such as asthma and other allergic conditions, in this age segment. Frailty, comorbidities and polymedication are some of the factors that condition management in geriatric patients. The objective of this review is to highlight the characteristics of allergic diseases in older age groups, from the influence of immunosenescence, to particular clinical implications and management issues, such as drug interactions or age-related side effects.

Treating rhinitis in the older population: special considerations

Rhinitis in the elderly is a common but often neglected condition. Structural changes in the nose associated with aging, predisposes the elderly to rhinitis. There are a number of specific factors that affect medical treatment of the elderly including polypharmacy, cognitive dysfunction, changes in body composition, impairment of liver and renal function and the cost of medications in the face of limited resources. Rhinitis in the elderly can be placed in several categories and treatment should be appropriate for each condition. The most important aim is to moisten the nasal mucosa since the nose of the elderly is so dry. Great caution should be used in treatment with first generation antihistamines and decongestants. Medications generally well tolerated by the elderly are second generation antihistamines, intra-nasal anti-inflammatory agents, leukotriene modifiers and iprapropium nasal spray.

Clinical presentation and management of geriatric rhinitis

The population of Americans over 65 years of age is growing at an unprecedented rate. Rhinitis is a common and burdensome complaint in this group, and physicians should be aware of the diagnosis and management of the disease. Geriatric rhinitis is a nasal disorder of older persons that presents with a constellation of nasal symptoms. The etiologies of this condition include both inflammatory diseases and the effects of aging on physiology of the upper airway. Possible causes include allergic rhinitis, nonallergic rhinitis (vasomotor rhinitis and gustatory rhinitis), adverse effects of medications, hormonal changes, postnasal drip syndrome, chronic rhinosinusitis and atrophic rhinitis. Nasal symptoms in the older patient present a clinical challenge because of the physiologic effects of the aging nose, the unusual clinical presentation, the presence of multiple comorbidities and the problem of polypharmacy. A number of therapeutic options exist for this disorder, although definitive studies of effective regimens are needed.

Complexities of diagnosis and treatment of allergic respiratory disease in the elderly

Atopic diseases such as rhinitis and asthma are relatively common in children and young adults. However, many patients aged >65 years are also affected by these disorders. Indeed, the literature suggests that between 3-12% and 4-13% of individuals in this age range have allergic rhinitis and asthma, respectively. However, these numbers are most likely underestimates because atopic diseases are frequently not considered in older patients. The diagnosis of both allergic rhinitis and asthma in older patients is more difficult than in younger patients because of a wide differential diagnosis of other diseases that can produce similar symptoms and must be excluded. Furthermore, treatment of these disorders is complicated by the potential for drug interactions, concern about the adverse effects of medications, in particular corticosteroids, and the lack of drug trials specifically targeting treatment of older patients with allergic rhinitis and asthma.

Prick puncture skin tests and serum specific IgE as predictors of nasal challenge response to dermatophagoides pteronyssinus in older adults

BACKGROUND

The ability of prick puncture skin test (PPST) results and the presence of serum specific IgE (sIgE) to Dermatophagoides pteronyssinus to predict positive or negative nasal challenge (NC) results has not been determined in older adults.

OBJECTIVE

To determine if allergy skin test and/or serum sIgE is diagnostic of allergic rhinitis in older adults.

METHODS

Forty-eight adults (20 younger and 28 older) with rhinitis underwent NC to D. pteronyssinus 1 to 4 weeks after PPST and sIgE to D. pteronyssinus. Patients were not aware of their in vivo or in vitro results at the time of their NC.

RESULTS

Fourteen of 48 adults (10 younger and 4 older) were NC positive. The positive predictive values for older adults with positive NC results ranged from 28.57% to 42.86% for PPST and was 16.67% for sIgE. In contrast, positive predictive values in younger adults ranged from 76.92% to 100% for PPST and was 100% for sIgE. However, negative PPST results and sIgE had high predictive values for a negative NC result to D. pteronyssinus in older adults (90.48%-95.24% for PPST and 89.47% for sIgE).

CONCLUSIONS

Although PPST and sIgE negative results were good predictors of negative NC outcomes, neither positive PPST results nor serum sIgE to D. pteronyssinus predicted positive NC results in older adults. PPST and sIgE to D. pteronyssinus were excellent predictors of both positive and negative NC outcomes in younger adults.