Leaderboard Ad

To Operate or Not To Operate? That is the Question

Choosing between surgery and other management for older patients is a choice head and neck surgeons will face more often.

Most older people have at least one chronic condition and many have multiple comorbidities, including arthritis, heart disease, cancer, diabetes, and hypertension.

“Managing older patients is more complicated than younger patients,” said Ozlem T. Tulunay-Ugur, MD, University of Arkansas for Medical Sciences. “We undertreat them, especially in head and neck surgery.”

Frailty is the overarching concern in treating older adults.

“Frailty matters,” said David E. Eibling, MD, University of Pittsburgh. “Older people have reduced functional reserves and increased risk of system failure. A very small amount of stress can cross over from healthy elderly to ill elderly. We see this all the time in hip fractures and pneumonia.”

Because frailty is associated with poorer outcomes in head and neck surgery, surgeons have a responsibility to assess frailty before treatment, Dr. Eibling said. Few patients cannot be treated because of frailty, and exercise plus improved nutrition can improve physiologic status.

Voice loss is a tremendous blow, said Robert T. Sataloff, MD, DMA, Drexel University College of Medicine, Philadelphia.

“As they lose their voices, their friends are going deaf,” he said. “They become isolated. We can do something about that and we should do it much more aggressively than we usually do.”

He advised a team approach. The laryngologist works with speech-language pathologists, singing and acting voice specialists and the patient using strategic vocal exercises, aerobic reconditioning, voice therapy, and adjunctive psychological, pulmonary, and other intervention as needed.

“The results are extraordinary,” he said, “and it can usually be done without surgery.”

Zenker’s diverticulum is a specific geriatric problem.

“The prevalence of Zenker’s is highest in the sixth through ninth decades,” said Karen Kost, MD, McGill University, Montreal. “You almost never see it younger than 40.”

External surgery is effective, Dr. Kost said, but endoscopic management can be even more effective. Endoscopic treatment is faster, cheaper, has higher success rates, and fewer complications. Patients can be drinking within hours.

But surgeons must always be prepared to convert to open surgery or abort. Pathology specimens are small and dental injury is common.

“I won’t do an endoscopic procedure without a custom tooth guard,” she said.

Nasal and sinus surgery in older patients is similar to procedures in younger patients, said David R. Edelstein, MD, Weill Cornel Medical College, NY. He avoids epinephrine, dilutes vasoconstricting agents, limits cocaine use, uses softer fiber optic scopes, favors pediatric-sized instruments, and uses ointment on the septum.

“The nose is hugely dynamic,” he said. “The data, and experience, show that you can do surgery effectively with older patients.”

Head and neck cancer in older adults is different. A quarter of all head and neck cancer is found in patients older than 70, said Greg K. Hartig, MD, University of Wisconsin School of Medicine and Public Health, Madison, WI. At the same time, there is increased oral cavity cancer in older patients, less tobacco and alcohol use, more female patients, and less nodal disease compared to other age groups.

Treatment of head and neck cancer may be different in older patients, too. Older patients tend to do less well on chemotherapy, but standard therapy can often be adapted or modified for older patients.

“We can design therapy that is ontologically sound, but may be less invasive,” Dr. Hartig. “It is less a question of chronologic age than of physiologic condition.”

Older patients are the fastest growing population for otologic surgery. More older adults are living longer with greater expectations for health and hearing, but the otologic literature in this group is limited.

“Age is not a contraindication to ear surgery,” said Brian J. McKinnon, MD, MBA, University of Tennessee Health Science Center, Memphis. “Physiologic status is paramount, not chronologic age.”

Surgical outcomes and complications are similar in older and younger adults, he said, but older patients typically enter surgery with more advanced hearing loss.