Prevalence and Impact of Balance Disorders in the Elderly

Impaired balance and dizziness, among the most common chronic problems elderly people report to their physicians, can result from abnormalities in various organ systems, including the central and peripheral nervous vestibular, cardiovascular and cerebrovascular. Lin and Bhattacharyya from Harvard Medical School, Massachusetts, investigated balance disorder prevalence among the elderly population and its impact on activities of daily living (ADL). From the 2008 sample of the National Health Interview Survey, which is conducted annually by the US Census Bureau, data were extracted for 37.3 million people aged >= 65 years. The mean age of this population was 74.4 years; 56.9% were women. Of the total sample, 19.6% reported a problem with dizziness or balance in the preceding 12 months.

The problems included:

  • unsteadiness
  • difficulty walking on uneven surfaces
  • difficulty walking up stairs
  • difficulty walking in the dark
  • vertigo
  • lightheadedness

More than 18% reported that prescription medications triggered their balance problem, and about 2% cited over-the-counter medications as triggers.

When the survey population was asked about the impact of their problems on quality of life and ADL, 27.4% reported being prevented from participating in such activities as exercise, social events, driving, and work or school; 25.7% reported effects on ADL (bathing, dressing, eating and toilet). Overall, women were more likely to experience balance problems than were men (21.0% vs. 17.7%), but rates of negative impacts from balance problems were similar for both sexes.

Half the patients with balance problems sought care, primarily from a general practitioner. About 30% visited an internist/cardiologist and about 17% visited an otolaryngologist; also seen were neurologists, ophthalmologists and chiropractors.

Conclusions and Clinical Implications

That 7 million elderly people are affected by dizziness and balance problems emphasizes the great scope of this problem. With about half the sample reporting that the problems impair their lifestyles and >25%, saying the problems interfere with daily life activities, balance disorders merit special attention in the face of an aging population. Because one of the many causes may be vestibular disease, referral to an otolaryngologist is needed for accurate diagnosis and care, which could, in some instances, ameliorate the dysfunction.


Screening for Bleeding Disorders in Children with Recurrent Nosebleeds

Most cases of pediatric epistaxis are mild and respond to basic medical therapy, but a subset of patients who continue to have nosebleeds despite appropriate therapy may be at increased risk of having a bleeding disorder. The prevalence of undiagnosed bleeding disorders in children with epistaxis and the value of preoperative blood screening were investigated by Elden et al from the Children’s Hospital of Philadelphia and the University of Pennsylvania.

Of 248 patients evaluated for recurrent epistaxis at the Children’s Hospital of Philadelphia over a 4-year period, 191 were successfully treated with topical emollient therapy, 8 had a known preexisting bleeding disorder and 2 had a structural abnormality requiring repair. The remaining 47 (19%) met the study inclusion criteria and underwent electrocautery of the septal vessels. The mean age of these patients (29 boys, 18 girls) was 9.2 ± 0.5 years; 36 (76.6%) reported >25 episodes of epistaxis a year; 20 (43%) had bleeding of 25 minutes and 30 (63.8%) had bleeding from both nostrils.

Nine patients had visited an emergency room for epistaxis, 3 had required emergent nasal packing and 8 had prior nasal cautery. Only 1 patient had an additional history of bleeding, and although no patient reported a family history of a specific bleeding disorder, 10 reported a nonspecific family history of excessive bleeding.

Prior to undergoing cauterization, all 47 patients underwent a screening by complete blood count, prothrombin time (PT) and activated partial thromboplastin time (aPTT). Four patients (8.5%) were found to have anemia, with hemoglobin ranging from 8.1 to 11.1 g/dL, and 15 (31.9%) had either an abnormal PT, aPTT or both. Of these 15, 5 (33%) were subsequently diagnosed with a coagulopathy: 3 had type 1 von Willebrand’s disease; 1 had platelet aggregation disorder; and 1 had factor Vll deficiency.

Conclusions and Clinical Implications

In this study at a single institution, > 10% (5 of 47) of pediatric patients who experienced recurrent epistaxis despite medical therapy were diagnosed with an underlying bleeding diathesis, most commonly type 1 von Willebrand’s disease. The authors believed this was probably an underestimate, since fewer than one-third of the patients underwent a complete hemostatic evaluation. Unlike adults, children with bleeding disorders are less likely to exhibit other bleeding symptoms because they have not experienced such hemostatic challenges as surgery, dental procedures or onset of menses. The small number of patients in this study prevented identification of risk factors, but it appeared that children who had a history of emergency room visits for epistaxis and those at younger age when diagnosed were more likely to have a bleeding diathesis.

Elden L, Reinders M, Witmer C. Predictors of bleeding disorders in children with epistaxis: value of preoperative tests and clinical screening. Int J Pediatr Otorhinolaryngol 2012;76:767-771.


Steroid Injection for Vocal Fold Disorders

Benign vocal fold lesions such as nodules or polyps usually result from chronic voice overuse or abuse; initial treatment is generally voice therapy and education. Intralesional vocal fold steroid injection (VFSI) is an alternative approach. Wang et al from National Taiwan University conducted a systematic review and meta-analysis of this treatment.

A PubMED search identified 78 English-language articles of which 4 met the inclusion criteria: studies of benign vocal fold lesions treated in-office by VFSI under endoscopic guidance. Two other articles were identified through a hand search. The 6 articles included in the meta-analysis covered 321 patients treated for vocal nodules, polyp I cyst, granuloma, Reinke’s edema and vocal scar. The 3 earliest studies used the transoral approach under fiberscopic guidance; more recent studies used percutaneous injection through the thyroid or cricothyroid membrane or thyroid cartilage.

In all studies, the outcome measurements at 3 weeks to 1 month after VFSI showed subjective improvement; 3 studies using the voice handicap index reported a significant decrease (27.61 points [95% confidence interval (CI), 16.49-38.73 points]; p < .001). Four of the 5 studies measuring aerodynamic outcome found significant improvement in maximal phonation time (1.82 seconds [95%, CI, 0.29-3.35 seconds]; p < .001). Three studies that conducted complete acoustic analysis reported significant improvements in jitter and/or shimmer, and 2 studies demonstrated improved noise to harmonic ratio; 3 studies showed significant improvements in perceptual ratings of voice quality.

Posttreatment endoscopic evaluation found that in 89% to 100% of the patients, primary lesions had disappeared or improved; however, recurrence was common, with lesions appearing again from 4 weeks to 9 months after VFSI. The overall rate of recurrence ranged from 4% to 31%. The main reason for recurrence was persistent vocal abuse; it was recommended that patients who experience recurrence be managed with repeated steroid injections and continued voice therapy.

The primary adverse effect of VFSI, reported in 2 studies, was a whitish deposit after injection of triamcinolone, but this had no effect on vocal fold vibration and usually cleared up after 1 to 2 months. Four patients showed signs of mild vocal fold atrophy with breathy voice 1 month after VPST, and stroboscopy demonstrated decreased amplitude of the mucosal wave. All these patients had improved at the 2-month follow-up examination.

Conclusions and Clinical Implications

Steroid injection into the vocal fold resulted in significant subjective and objective improvement for patients with a variety of benign vocal fold disorders. VFSI was well tolerated under local anesthesia. Side effects were few and self-limiting. The authors urged further controlled studies with longer follow-up to more reliably evaluate this treatment.

Wang C-T, Liao L-J, Cheng P-W, et al. Intralesional steroid injection for benign vocal fold disorders: a systematic review and meta-analysis. Laryngoscope 2013;123:197-203.


Improved Breathing After Rhinoplasty

Functional rhinoplasty frequently includes septoplasty and turbinate reduction, often using cartilage grafts to decrease nasal obstruction, and so can result in less nasal congestion as well as improved esthetic appearance of the nose. Zoumalan from Cedars-Sinai Medical Center, California, and Constantinides from New York University School of Medicine analyzed the effects of septorhinoplasty on nasal patency judged both subjectively and objectively.

The study included 31 patients (22 women; age range, 18-57 years) who had requested septorhinoplasty for cosmetic and functional reasons. All patients underwent acoustic rhinometry before and after decongesting during the week prior to surgery and then during a follow-up visit 6 to 9 months later. Subjective evaluation was performed at the pre- and postoperative visits for 23 patients using modified Cottle maneuvers, a classic method to analyze the internal and external nasal valves, with each side and each lateral cartilage evaluated separately. For each maneuver, patients reported a score on a scale of 1 (totally obstructed) to 10 (excellent, unobstructed breathing).

Postoperatively, the mean overall volume of the nasal cavity measured by acoustic rhinometry increased bilaterally but reached significance only on the right side, which showed a 43% increase. Resistance decreased bilaterally but, again, the decrease was significant only on the right side (19%). The minimal cross-sectional area (MCA) did not change, but there were statistically significant anterior shifts in the distance of the MCA from the nasal sill.

Conclusions and Clinical Implications

This analysis provided objective and subjective evidence that septorhinoplasty can improve breathing. Acoustic rhinometry showed increased nasal volume and decreased nasal resistance postoperatively, changes that went along with subjective improvement in nasal patency. Patients who had severe obstruction preoperatively showed the best overall improvement.

Zoumalan RA, Constantinides M. Subjective and objective improvement in breathing after rhinoplasty. Arch Facial Plast Surg 2012;14:423-428.