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Wise et al.

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40 healthy subjects between the ages of 5 and 75 years, and found an age-related increase in atrophic epithelium and thickened basement membranes in patients over 40 years old.

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Nasal dryness in the elderly population may also be caused by a decrease in intranasal temperature and humidity. 200 Lindemann et al. 199 measured these values in 80 healthy patients and found them to be significantly lower in older patients (age 61 to 84 years) than in younger patients (age 20 to 40 years). The authors attributed the difference to an increase in intranasal volume (INV) from age-related atrophy of the nasal mucosa, with INV measured by minimal cross-sectional areas and volumes of each nasal cavity. An increase in INV with age has also been demonstrated by Loftus et al. 215 using 3D-volumetric analysis of computed tomography (CT) scans from subjects without sinonasal pathology. Mean INV was 15.73 mL in the 20 to 30 year age group (n = 22), 17.30 mL in the 40 to 50 year age group (n = 20), and 18.38 mL in the over 70 year age group (n = 20). Allergic rhinitis in the elderly.: Although there is overlap between age-related rhinitis and AR in the elderly in terms of symptoms and recommended treatment with INCS, 210,216 the underlying physiologic process of each is quite different. AR is a type I IgE-mediated hypersensitivity reaction, 217,218 whereas allergy and allergens do not play a role in the symptoms and physiologic changes of age-related rhinitis. However, it has been shown that aging does not reduce the prevalence of AR and that AR in the elderly is likely underdiagnosed, so AR should be considered when diagnosing new-onset nasal symptoms in the elderly population. 210 III.C.12. Empty nose syndrome and atrophic rhinitis— The descriptive term “empty nose syndrome” (ENS) was originally coined in 1994 by Kern and Stenkvist to describe empty space in the region of the inferior and middle turbinates on coronal CT images of patients who had partial or total inferior and middle turbinectomies. 219 Today, ENS is defined as an upper airway disorder characterized by impaired nasal airflow sensation and often involves tissue loss from nasal surgery. ENS is divided into at least 3 subtypes: ENS-inferior turbinate, ENS-middle turbinate, and ENS-both, which are classified based on the site of tissue loss. 219 ENS-inferior turbinate is the most common type. 220 A fourth subtype is ENS-type, wherein a patient has sufficient appearing turbinate tissue but suffers ENS symptoms after surgery affecting the mucosal surface of the turbinates. ENS typically occurs following surgery in the turbinates. Most turbinate surgery has successful outcomes, with ENS occurring after a very small percentage of sinonasal procedures. 221,222 ENS occurs most frequently after total turbinate excision, but also with lesser procedures such as submucosal cautery or resection, laser therapy, and cryosurgery. 223 Patients often complain of dryness and crusting, although the hallmark complaint of ENS patients is paradoxical nasal congestion that may be so severe that they feel as if they are suffocating. 223 Recent research has validated that the primary physiological mechanism that produces the sensation of ample nasal airflow is activation of trigeminal cool thermoreceptors, specifically TRPM8, by nasal mucosal cooling. 224-228 Beyond alterations in airflow and a reduction in surface area, aberrations in neurosensory systems likely play a major role in the abnormal sensations ENS patients experience. Not only does turbinate resection remove nasal mucosa and consequently airflow sensing thermoreceptors, such

Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.