Christopher de Souza: DORL, MS, DNB, FACS, FRCS (England), FRCS (Ireland), FRCP (Edinburgh), Fellow of the American Neurotology Society, D. Lit (MUHS) Honoris Causa.

Key words

Chronic Rhinosinusitis in the elderly – Endoscopic Sinus Surgery in advanced age population – immunosenescence ( immunoaging ) inflammaging– Endoscopic sinus surgery outcomes in the elderly.

Article

The medical management of rhinosinusitis is a well-established treatment modality. It is effective and safe. However, chronic rhinosinusitis (CRS) at times proves refractory to medical management and requires surgical intervention. Endoscopic sinus surgery (ESS) has been proven to be effective in the treatment of chronic rhinosinusitis (CRS).

There are now several reports outlining differences in outcomes in ESS when performed in older patients as compared to a younger set of patients. Reports state that older / advanced patients do not experience very pronounced improvements in outcomes when compared to that in the younger age group. Improvements do manifest themselves but are far less dramatic and are much more subdued.

These muted outcomes have been attributed to several factors. Namely (1) atrophy of the nasal mucosa, (2) diminished nasal mucociliary clearance, (3) a change in the character of the nasal microbiome, (4) Reduced / alterations in the quality of nasal mucus and (5) Comorbidities. These factors are considered to be age related. They are factors that influence the course of CRS in the elderly as well as influence outcome of ESS when performed in this population. In addition, patients of advanced age have in all probability gone through several ESS procedures previously. This can likely result in distorted anatomy, synechiae and other conditions that could contribute to the persistence of CRS and modify outcomes.

The other factor thought to be part of the underlying pathology that causes CRS to persist and dampen the trajectory of outcomes is the concept of “ immunosenescence (immunoaging) and inflammaging” or in other words ‘ burnt out” disease . This concept describes the immune response shifting from type 2 (Th2 eosinophilic ) inflammation towards non type 2 (neutrophilic of Th1/ Th17) profiles. This results in a low grade inflammatory state that will favour good ( although less dramatic) outcomes when ESS is performed. The principles of ESS are (1) to provide an adequate nasal passage to allow for comfortable breathing , (2) Ventilation and drainage of the paranasal sinuses, (3) Preservation of nasal and sinus mucosa. These were also applied to ESS in advanced age patients as well. The difference found between advanced (older) age patients versus that of the younger age group was that older patients were found to be far more compliant with postoperative procedural requirements that were necessary to ensure optimization of results/ outcomes. This compliance played a significant role in improving results.

Conclusion

Endoscopic sinus surgery can and should be performed in the elderly when indicated. However, outcomes are modest. Expectations of both surgeon and patient should be adjusted accordingly when considering ESS for the treatment of CRS.

References

(1) Mirza AA, Hernaiz- Leonardo JC, Marglani O A, Lee JM, Sedaghat AR, Javer AR : Advanced age in sinus surgery: Diminished symptom gains but enhanced surgical durability in chronic rhinosinusitis. Otolaryngol – Head and Neck Surg Vol 173(6) 1348- 1358 DOI; 10.1002.ohn.70043.

(2) Ban JH, Kwon HJ, Lee K C : Outcomes of endoscopic sinus surgery in an elderly population; comparison with those in an adult population. Clin Otolaryngol.2010; 35 (4):300-306 DOI: 10.1111/j.1749 – 4486.2010.02155x