Ear,Nose & Throat Journal

Changing demographic trends in our country will have a profound influence on the future practice of otolaryngology. As a result of declining birth rates and increasing lifespans, the geriatric population has already become the fastest-growing segment of our society, and it will continue to be so for decades to come. A larger percentage of patients treated by otolaryngologists will be in the over-65 age group. It will become important to confront not only the medical treatment of this segment of the population, but also the socioeconomic effects of these demographic changes. Familiarity with the terminology, concepts, and statistics of demography is key to understanding the influence that the aging of the population will have on the practice of otolaryngology.

Clinical ethics is an intrinsic aspect of medical practice. Concerns for ethical conduct arise in the management of medical benefits, patient preferences, quality of life, and the relationship between patient care and its attendant familial, social, economic, and legal circumstances.

Ethical concerns in surgical practice are central to the essence of the Hippocratic doctrine, “First do no harm.” In caring for our patients, particularly in light of the modern practice of medicine, we often use the risk-benefit calculus. The range of ethical concerns for the otolaryngologist who deals with the elderly and infirm covers many diverse situations. Superimposed over this spectrum is the idea of patient autonomy, which is considered to be a cardinal issue in any ethical discussion. Furthermore, increasing medical care costs have created a debate regarding the rationing of healthcare. Ethicists continue the discussion as to whether age should be a decisive factor in the rationing of this care.

Definitions of “heroic” and “extraordinary” assume greater significance, and controversies of language become pivotal when the comprehension and cognitive orientation of the patient are compromised by disease and senescence.

Patients older than 65 years who develop acoustic neuromas have the same signs and symptoms as younger patients. Age limits beyond which surgery for acoustic neuroma is currently not recommended are unreasonable. Untreated vertigo in older patients frequently results in falls that can cause fracture of the femur and significant morbidity and mortality. Surgical removal of acoustic neuromas in patients older than 65 produces results that are as good as those seen in younger patients. The patient's general medical condition, life expectancy, and factors other than chronological age should be considered when surgery is being contemplated. Acoustic neuroma surgery for the older patient can provide gratifying results and should not be withheld strictly on the basis of age.

There are several safe and effective surgical options for the treatment of vertigo associated with Ménière's disease in the elderly patient. The choice of procedure depends on the patient's hearing status and overall health. Since 1987, combined retrolabyrinthine-retrosigmoid posterior fossa vestibular neurectomy was performed on 29 older patients who were in good physiologic health and whose hearing was better than 80 dB pure-tone average and 20% speech discrimination. Patients whose hearing is worse are offered transmastoid labyrinthectomy or transmeatal cochleovestibular neurectomy, barring contraindications. When extensive surgery is medically contraindicated and hearing is not a significant concern, cochleosacculotomy is preferred; this procedure has been performed with minimal morbidity on patients as old as 85. Finally, over the past several years, patients have been treated with transtympanic placement of gentamicin. Early results with this office-based local procedure demonstrate a high cure rate, but also a high incidence of sensorineural hearing loss.