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13 The Dry Nose
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Fig. 13.1 Dry nose in a patient with Wegener’s disease
physiologically plausible, it has never been
conrmed as the sole cause. The mechanical and
functional integrity of the mucous membrane is
considered a major natural defence mechanism
against infection. Depending on the degree to
which it dries out, mucociliary transport and even
the epithelial barrier may be impaired.
Epidemiological data on the prevalence of dry
nose are not available. However, in particular,
when questioned, many people confess to be sufferers and admit to the use of numerous therapeutic measures, mostly ointments and sprays or
nasal douches.
In old age, anatomical changes and involution
atrophy of the mucosa result in an increase in
such complaints as impairment of nasal breathing
and dry nose, and the following phenomena may
occur:
• Hanging nasal tip and shortening of the colu-
mella [6].
• Reduced mucociliary clearance [7–10].
• Reduction in the number of goblet cells and
elastic bres in the nasal mucosa [11].
• Reduced sensitivity of the nasal mucosa [12].
• Enlargement of the nasal cavity resulting from
involution atrophy of the nasal mucosa [13, 14].
• Decrease in the body’s water content [15].
Altered airow due to changes in geometry
leads to changes in the conditioning situation [14,
147
16], with the result that in over 60-year-olds, the
air-conditioning capacity becomes impaired:
both intranasal air temperature and humidity
decrease [17].
A familial, i.e. genetic, impairment of nasal
air-conditioning has been reported by
Sahin- Yilmaz et al. [18], who investigated 47
pairs of twins [11].
13.2.1 Clinical Entities
In common with the symptom itself, a number of
individual diseases associated with the symptoms
dry nose and crusting are not only unclearly
dened but also overlap. In the literature, the following descriptions are to be found:
• Rhinitis sicca anterior (Fig.13.2).
• Primary rhinitis atrophicans/primary atrophic
rhinitis (= PAR) – rhinitis atrophicans with
foetor (ozaena) (Fig.13.3).
• Secondary rhinitis atrophicans/secondary or
diffuse atrophic rhinitis (= SAR).
13.2.1.1 Rhinitis Sicca Anterior
The term rhinitis sicca anterior denes a chronic
inammation in the region of the anterior part of
the nose usually affecting the anterior and caudal septum and/or the corresponding lateral
nasal vestibule. Due to irritation (mechanical,
nger picking; toxic; persistent secretion; respiration; (air)ow characteristics; dry, hot and
dusty environment), drying, supercial erosion
and/or ulceration with (thin) crust formation
occur.
Patients experience a sensation of dryness,
itching and increased crust formation. The crusts
are thin and dry and do not extend into the posterior part of the nasal cavity, as is the case with
atrophic rhinitis. Usually, there is no foetid
smell—only an occasional patient experiences
mild foetor caused by bacterial colonisation of
the small crusts. Manipulations may give rise to a
vicious circle of increased crusting and persistent
complaints. In the individual case, continued irritation and manipulation may result in perforation
of the nasal septum.
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Fig. 13.2 Rhinitis sicca anterior with dry skin in the
nasal vestibule and thin yellowish crusts
Fig. 13.3 Dry nose with persistent excessive crusting in
a female patient with primary atrophic rhinitis
Treatment consists of the application of a protective lm to the skin of the nasal vestibule, to
allow the chronic inammation disrupting its
integrity to self-heal while avoiding mechanical
irritation (Fig.13.1). This is usually achieved by
the application of ointments. Nasal sprays containing dexpanthenol have also been used with
success [19].
13.2.1.2 Primary Atrophic Rhinitis
(PAR)
Primary atrophic rhinitis is a gradually progressive chronic degenerative condition of the nasal
mucosa of unknown aetiology. Progressive atrophy of all the constituents of the mucosa (epithe-
R. K. Weber et al.
lium, glands and vessels together with osteoclasis)
mainly affects the turbinates. The respiratory epithelium undergoes stepwise metaplastic changes.
Histologically, atrophy of the serous and mucous
glands, loss of the cilia and goblet cells, chronic
inltration of the lamina propria with granulations and scar formation are seen. Some publications also report diminished vascular density
together with peri- and endarteritis. The histological changes explain the disturbance to mucociliary transport. Thick secretion that is not
transported away promotes the formation of bacterially contaminated crusts that may then be a
source of recurrent bacterial Infection. If rhinitis
atrophicans is complicated by foetid crust formation, rhinitis atrophicans with foetor (stinking
nose, ozaena) results. Microbiological investigation usually detects Klebsiella ozaenae (100% of
the 45 patients of Moore and Kern [20]) but also
Staphylococcus aureus, Proteus mirabilis, E. coli
and other bacteria (Bordetella bronchiseptica and
Pasteurella multocida). Endoscopic examination
reveals a markedly large and wide nasal cavity
and visibly dry mucosa. The turbinates are clearly
diminished in size. With ozaena, yellowish-green
crusts are found on the mucosa. Apart from crusting, the patient usually also suffers from hypo- or
anosmia. Foetor may give rise to social
problems.
The cause of PAR is unknown, but both
genetic and infectious causes are under discussion. The condition is more commonly seen in
association with low socio-economic status, a
poor diet and iron deciency. A much less frequent use of antibiotics in countries with a higher
incidence of the condition may have a role to
play. The fact that women are more frequently
affected suggests a possible endocrinal factor.
Over the past years and decades the prevalence of
PAR has declined.
13.2.1.3 Secondary Atrophic Rhinitis
(SAR)
Secondary atrophic rhinitis develops in the soil of
an underlying disease or may result from previous therapeutic measures. Therefore, it is a collective term for several conditions with a different
aetiology but a similar clinical feature with the
subjective feeling of a dry nose, crusting, gege-
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benenfalls nasal obstruction, foul smelling and
epistaxis as outlined above. In contrast to PAR,
there is no osteoclastic activity, so the term diffuse atrophic rhinitis may be more suitable.
Pathogenetic factors leading to SAR are as
follows:
• Prior radical endonasal surgery. Persistent
chronic rhinosinusitis in addition may increase
the probability of the development of SAR
[21].
• Prior radiotherapy of the head and neck.
• Sjögren’s syndrome.
• Extremely rarely: prior trauma.
In the largest collection of cases to date 197
patients with sRA, the following causes were
identied [20]:
• Complete removal of the lower and middle
nasal turbinates (24%).
• Partial removal of the lower and/or middle
nasal turbinates (56%).
• Endonasal sinus surgery without turbinectomy (10%).
• Partial maxillectomy to remove a tumour
(6%).
• Nasal trauma requiring surgical reconstruction (1%).
• Granulomatous disease (1%).
pharynx at increased velocity [24]. According to
Houser, the pain too is a typical symptom caused
by the action of cold air on the mucosa covering
the sphenopalatine ganglion [25].
Resection of the lower and middle turbinates
reduces the effectiveness of the climatisation
function of the nose by 23% [26, 27]. The paradoxical impairment of nasal respiration is
explained by the unphysiological airow, the
reduced nasal airway resistance, the lack of areas
of functional mucosa together with the simultaneous enlargement of the nasal cavity, and the
curtailed contact between air and mucosa [24].
Enlargement of the nasal cross-section reduces
the airway resistance and thus the pressure gradient at the air/mucosa surface. In turn, this causes
malfunction of the nasopulmonary reexes,
which may lead to a worsening of pulmonary
function. In contrast, optimal nasal airway resistance is important for the dilatation of the peripheral bronchioles and for improved alveolar gas
exchange.
The risk to develop SAR after resection of the
turbinates depends on the extent of resection,
individual factors of the patient itself and other
external factors which are not clearly dened up
to now. Some authors did not nd any sign of
SAR after total resection of the inferior turbinates [28–31]; others report SAR in 2–22% [27,
32–36].
Empty nose syndrome (ENS) is dened as a
form of iatrogenic SAR, occurring after radical
endonasal surgery in particular resection of the
nasal turbinates (lower and/or middle), usually in
connection with an operation on the nasal sinuses
[22–24]. It is characterised by the symptoms
nasal and pharyngeal dryness, paradoxical
impairment of nasal respiration, dyspnoea and
hyposmia, in some cases associated with depression [25].
The disturbed sense of smell is the result of the
changed airow. The dryness of the pharyngeal
mucosae is due to the fact that, in contrast to the
normal situation, drier intranasal air (no moisture
since turbinate mucosa is lacking) results in disrupted airow in the region of the choanae and
also impinges on the posterior wall of the naso-
13.3 Diagnosis
Extensive history taking is always followed by
inspection of the outer and inner nose (Table13.2).
This should, for example, identify any anatomical deformations that might cause dry nose by
changing the ow of air through the nose. For the
purpose of detecting minor lesions in the nasal
vestibule in patients with rhinitis sicca anterior,
the use of a microscope may prove useful.
Endonasal inspection should look for septal deviation or perforation and note the size and shape
of the turbinates, the presence and nature of
crusts, the humidity of the mucosa, polyps or
tumours, postnasal secretion and the nasopharyngeal status.
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Table 13.2 Diagnostic workup of dry nose
Medical history
Inspection of the external and inner nose
Endoscopy of the nasal cavity and nasopharynx, where
indicated, also of (operated) paranasal sinuses
Where indicated, CT of the paranasal sinuses
Allergy testing
Microbiological swab
A CT of the nasal sinuses is indicated when
signs of chronic rhinosinusitis are found or to
obtain adjunctive evidence of PAR.Typical signs
of PAR in the CT include:
• Thickened mucosa in the paranasal sinuses.
• The osteomeatal complex can no longer be
dened due to the destruction of the normal
anatomy.
• Hypoplasia of the maxillary sinus.
• Enlargement of the nasal cavity with destruc-
tion of the lateral nasal wall.
• Bony destruction of the inferior and middle
turbinates.
Testing for allergy is important, for example,
in order to diagnose a house mite allergy, which
may be associated with the symptom dry nose.
When endoscopic examination reveals purulent
streaks or crusting, swabs should be taken for a
microbiological examination.
The diagnosis is based on the case history,
endoscopic ndings and, where necessary,
adjunctive diagnostic measures.
13.4 Treatment
Treatment of dry nose comprises:
• Elimination or amelioration of triggering or
promoting factors.
• Moisturisation (Table13.3).
• Sufcient daily drinking amount.
• Cleansing (when crusts are present) and care
of the mucosa.
• Treatment of obvious infections.
• Where applicable, the elimination of an over-
large endonasal air space.
The individual may have only limited control
over environmental factors. The importance of
Table 13.3 Substances for moistening the nose and
mucosal care
Nasal douches with saline solution
NaCl solution
Special saline solution
Isotonic–hypertonic, with and without buffering
(alkaline)
Nasal ointments
Dexpanthenol
Salt-containing nasal ointments
Diverse other formulations
Nasal oils
Sesame oil
Vitamin A oil
Salt water sprays
Hyaluronic acid nasal spray
Dexpanthenol nasal spray
the latter is obvious when dry nose is no longer
experienced during a holiday but reappears when
this is over.
By far the most common complaint is a subjective dry nose with no endoscopic ndings with
the possible exception of a somewhat dry mucosa
in the anterior nose. This is the case in almost all
those patients exposed to unfavourable climatic
or workplace conditions and also the large group
of patients with obstructive sleep apnoea syndrome undergoing CPAP treatment. Also affected
are patients operated on the nose, before the climatisation function has normalised.
Apart from the strict avoidance of local
manipulation, these patients require humidication and care of the dry areas. For this purpose,
the market offers a wide range of ointments, oils,
sprays and nasal irrigation (Table13.4).
The nose should be humidied, viscous mucus
ushed and liqueed; all inammation-inducing
and inammation-promoting substances should
be cleared out. A protective lm should be
applied to prevent drying. Transepithelial water
loss can be countered by the nasal application of
saline solutions or other substances [37].
13.4.1 Nasal Irrigation, Nasal Saline
Spray andInhalation
Nasal irrigations are recommended for a large
number of diseases of the nose and nasal sinuses
[38]. Precisely, how nasal irrigation works is not
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Table 13.4 Basic rules for the treatment of dry nose
Elimination of promoting factors
Environmental and workplace situation
Dietary, iron and vitamin deciency (?)
Moistening
Local (nasal irrigation, inhalation, nasal spray)
Environment (elevated air humidity)
Systemic: Sufcient liquid intake
Removal of crusts (nasal irrigation, instrumental
removal by ENT clinician)
Avoidance of injurious factors
Local (nose picking, cotton carrier, decongestant
nose drops, ointments containing potentially
injurious substances– Imidazoline derivates,
cortisone applied to the skin of the nasal vestibule,
…)
Systemic drugs (see Table13.1)
Care of the mucosa
Oils
Ointments
Occlusion
Treatment of infections
Allergic rhinitis
Ozaena
Chronic rhinosinusitis
Correction of an overlarge air space
Occlusion
Augmentation
clear. It is postulated that the improvement in
mucosal function is due to:
• Direct physical cleansing by ushing out thick
mucus, crust, debris, allergens, environmental
toxins, etc. [39, 40]
• Removal of inammation mediators.
• Improvement of mucociliary clearance by
improving the ciliary beat frequency [41, 42].
In a recent review article published in 2009
[43], nasal irrigation is recommended:
• As adjunctive treatment for chronic rhinosinusitis (Grade A evidence: consistent study
results of good quality).
• As adjunctive treatment for allergic rhinitis
and viral ARS and follow-up treatment after
nasal sinus surgery (Grade B evidence: inconsistent results or limited quality).
• For rhinitis of pregnancy, acute bacterial RS,
also sarcoidosis or Wegener’s disease (Grade C
evidence: consensus recommendations, usual
practice, expert opinion, results of case series).
The above shows that on the one hand, nasal
irrigation is a common recommendation, while
on the other hand, the indication dry nose is not
explicitly included in the recommendation,
since informative studies that can be integrated
into the evidence-based recommendations are
very rare.
Nevertheless, nasal irrigations are an impor-
tant therapeutic option in patients with dry nose.
In the case of recurrent crust formation, it is virtually indispensable as an adjunctive aid to
instrumental clearing by the ENT physician.
The most commonly employed nasal sprays
are salt solutions. In addition to household salt—
iodised or non-iodised—pharmaceutical grade
salts as well as special nasal spray salts and brines
are used [39, 40]. These solutions may be isotonic, hypotonic, hypertonic, unbuffered or buffered. Mildly hypertonic saline solutions (up to
approximately 3%), with or without buffering,
are all suitable for nasal irrigation. However, it is
currently not clear which saline solution is best
for what indication.
For isotonic saline solutions (isotonic unbuf-
fered, buffered Emser saline solution), numerous
investigations have shown that daily application
over the long-term produces positive results (prevention and treatment of upper airway infection/
rhinosinusitis, aftercare following surgery on
nasal sinuses) with no relevant side effects.
In principle, saline sprays serve the same pur-
pose as nasal irrigation. Although no systematic
comparison has been reported, the remark by
Schmidt that diffuse moistening of the nasal
mucosa can be achieved only with irrigation
since the spray is merely a punctiform application, is accurate and the potential therapeutic
effect must therefore be considered smaller. For
the present, the extent to which the admixture of
other substances results in a real benet in the
treatment of dry nose remains uncertain.
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Inhalation with saline solutions with the aim
of moistening the mucosa is also recommended
and applied. In view of the resulting diffuse
moistening of the mucosa, this can be considered
positive in the case of a dry nose. Unfortunately,
no meaningful studies are available.
13.4.2 Nasal Ointments
Despite the fact that many patients often use
nasal ointments, no meaningful studies on their
use in dry nose are available.
A moistening effect is achieved with intranasal use: the application of a nasal ointment
reduces nasal water loss—as also does the application of glycerol 10% [37].
Elberg reported on the effect of Emser salt
applied in the form of Nisita® Nasal Ointment in
1500 cases including pre- and post-operative
applications in patients undergoing operations on
the nose and nasal sinuses [44]. Neither pain nor
infections were observed with regular application, despite the fact that no antibiotic was given.
Follow-up care was reportedly considerably
facilitated and abbreviated.
The quality level must, however, as in
company- sponsored application studies—which
are not considered here—be Grade V evidence.
In comparison with dexpanthenol nasal ointment, dexpanthenol nasal spray proved just as
effective, or even tendentially superior, in terms
of its effect on mucociliary transport (saccharine
test) reported by Verse etal. in a prospective, randomised, open, crossover study [45]. Its advantage vis-à-vis the ointment is presumably the fact
that it reaches the upper parts of the nasal cavity.
Topical dexpanthenol is said to reduce transepidermal water loss, to activate in vivo and
invitro broblast proliferation and to accelerate
the re-epithelialisation process [46].
13.4.3 Nasal Oils
Oils in a not-too-high concentration bring about
an improvement in the nasal ciliary beat frequency (CBF). In contrast to Miglyol 840 and
thyme oil, sesame oil, soy oil, peanut oil, laven-
der oil, eucalyptus oil and menthol increased the
CBF, the effect being higher at a concentration of
the oils of 0.2% than at 2% [47]. According to
Riechelmann etal. a mixture of menthol, eucalyptus oil and pine needle oil in concentrations up
to 5% had no major negative effect on CBF but
did at concentrations of between 7.5 and 10g/m3
[48]. With conventional inhalation, concentrations of max. 1% are to be expected.
In a randomised crossover study involving 79
patients with dry nasal mucosa, [49] showed that
in comparison with a sodium chloride solution,
treatment with sesame oil resulted in a superior
moistening effect [49]. Dryness and subjectively
impaired nasal respiration were improved signicantly better by sesame oil in comparison with
saline irrigation. Björk-Eriksson et al. also
reported a signicant effect of sesame oil (3×3
puffs of 25 μl spray daily for 30 days) on the
symptoms impaired nasal respiration, dryness
(burning sensation, itching, irritation) and crust
formation in 20 patients with dry nose and 15
patients post-radiation treatment [50]. A total of
ve patients reported side effects (one each with
unpleasant odour, itching and disturbed nasal respiration and runny nose in two).
13.4.4 Others
Home remedies and self-treatments recommended on the Internet are mostly concerned
with achieving moisturising, the application of
oils and the prevention of drying, but the efcacy
of the respective measures remains unclear.
Homoeopathy always recommends an individual
constitutional approach to treatment.
In the elderly patient with a dry nose, Slavin
recommends moistening the nasal mucosa and
looking out for medicament side effects (in particular avoidance of rst-generation antihistaminics and decongestive nose drops) [15].
A rough topographical endoscopically orientated classication may be useful for the differential treatment of the dry nose symptom:
• In the case of problems localised in the ante-
rior nose (rhinitis sicca anterior in the widest
sense) with a visible lesion and possibly crust-
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ing, the rst indication is the local application
of ointment. Relevant comparative studies are
not available. Potentially injurious substances
(decongestant medications, cortisone, allergising substances) should be avoided.
• Vague complaints of dry nose in the absence
of visible changes to the nasal mucosa would
appear the most likely indication for moisturising measures (nasal irrigation, inhalation,
moisturising sprays). The question as to
whether admixed medicaments can diminish
the water loss on expiration needs further
investigation.
• Dry nose with visible intranasal crust formation is the domain of nasal irrigation, which is
better able to remove crusts than inhalation or
sprays.
13.4.5 Treatment ofAtrophic Rhinitis
Basic treatment consists of the above outlined
measures for dry nose. In the case of atrophic rhinitis moistening measures must be accompanied
by removal of any crusts and scabs. For this purpose, not only the commonly employed instrumental removal by the ENT specialist but also
nasal irrigation is used. As suitable solutions, the
literature mentions not only the classical irrigation solutions (buffered and unbuffered solutions
of common salt or special salts) but also solutions
of 25% glucose in glycerine and antibiotics [51].
Tap water and other hypotonic solutions are to be
rejected.
Bacterial superinfections are treated with spe-
cic antibiotics. For ozaena, antibiotic treatment
is reported to achieve long-lasting results, e.g.
rifampicin 600mg daily for 12weeks [51] and
ciprooxacin 2×500–750mg for 8weeks [52].
Operative measures aim to reduce the size of,
or temporarily occlude, the nasal cavity. Although
occlusion can resolve the problem of crusting and
the considerable social stigma of foetor, it also
impairs nasal breathing and the sense of smell.
For the diminishment of nasal cavity size using
submucosal implantation of tissue, foreign material should not be used despite that some authors
describe promising result [53, 54]. [53] implanted
Plastipore, a high-density polyethylene sponge
with micropores, and reported excellent results in
six patients and good results with only minor
crusting in two patients and one extrusion after
18 months [53]. Rice used hydroxyapatite for
augmentation in one case and reported good
results [54]. According to Houser, more suitable
materials are the patient’s own cartilage (e.g. rib
cartilage) or acellular dermis (AlloDerm®) [25].
He treated eight patients with the implantation of
AlloDerm®, which resulted in a signicant
improvement in symptom scores (SNOT 20)
after at least 3months. For treatment planning,
the cotton test is suggested: moistened cotton is
applied to the area to be augmented for 20–30min.
If the test is positive, the patient can be offered
the augmentation. Friedman etal. [55] and Moore
and Kern [20] reported some success with acellular dermis, too, in 5 of 10 and 7 of patients,
respectively.
13.5 Prophylaxis
Since the uncritical resection of the nasal turbinates represents a signicant and frequent factor
in the genesis of dry nose, secondary RA and
ENS, the following points must be strongly
emphasised:
• The main objective of nasal turbinate surgery
must be the preservation of functional mucosa
while creating an adequately large volume
capable of ensuring climatisation and the
cleansing of the respired air and also preserving physiological airway resistance [24].
• Without adequate justication the middle
turbinate should not be resected. Reduction
of the lower nasal turbinate should rst be
given careful consideration, simultaneous
removal of both the lower and middle turbinates should not be done for a non-tumorous
condition [56].
13.6 Conclusions
Despite that there is no clear denition of dry
nose, many patients complain of this symptom. A
carefully taken patient’s history and thorough
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rhinologic examination by an experienced and
vigilant clinician are the key elements to optimal
outcomes. The turbinates should be handled very
cautiously in sinonasal surgery.
Pearls
• There is no clear definition of what a dry
nose is.
• Symptoms range from the purely subjective
sensation of a rather dry nose to visible crusting of the (inner) nose (nasal mucosa).
• Relevant diseases are rhinitis sicca anterior,
primary and secondary rhinitis atrophicans,
rhinitis atrophicans with foetor (ozaena) and
empty nose syndrome.
• Drugs and environmental factors can induce a
dry nose.
• The diagnosis is based mainly on the patient’s
history, inspection of the nose and endoscopy
of the nasal cavity, sinuses and nasopharynx.
• Treatment consists in the elimination of predisposing factors, moistening, removal of
crusts, avoidance of injurious factors, care of
the mucosa, treatment of infections and, where
applicable, correction of an overlarge air
space.
• Normal turbinates should be preserved in
sinonasal surgery.
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Physiology oftheAging Nose
https://t.me/medicina_free
andGeriatric Rhinitis
YazanEliyan, VictoriaE.Varga-Huettner,
andJayantM.Pinto
14
Core Messages
• The world’s population is rapidly aging due to
increasing life expectancy.
• Physiological changes of the nose with age
include external structural changes, alterations of the thickness of the respiratory epithelium, decreased ciliary function, blunted
vascular responses, decreased intranasal
sensitivity and olfaction, reduced immune
defense, and decreased ability to humidify
the air.
• Such changes contribute to rhinitis in older
patients as well as a range of nasal diseases.
• Geriatric rhinitis is poorly understood from a
mechanistic standpoint but can be divided by
cause into allergic and nonallergic categories.
• Allergic causes can receive standard therapies
and symptoms tend to be milder in older
patients.
• Nonallergic causes are more difcult to treat
and require careful attention to the precise
Y. Eliyan
Pritzker School of Medicine, Chicago, IL, USA
e-mail: Yazan.Eliyan@uchospitals.edu
V. E. Varga-Huettner
Ellis Medical Group, Ear, Nose and Throat Care,
Schenectady, NY, USA
J. M. Pinto (*)
Section of Otolaryngology-Head and Neck Surgery,
Department of Surgery, The University of Chicago
Medicine and Biological Sciences, Chicago, IL, USA
e-mail: jpinto@surgery.bsd.uchicago.edu
triggers and symptoms; therapies are targeted
to the symptom.
• Nonspecic treatments such as humidication, mucolytics, and saline irrigations are
generally safe and effective.
• Surgical and medical treatments for geriatric
rhinitis are safe and effective, but special considerations of geriatric issues such as polypharmacy, alterations in hepatic and renal
function, and side effect proles must be
made.
14.1 Importance ofAging
inRhinology
The world is facing a massive demographic shift in
the next 30years. Both developed and developing
nations are experiencing growth in the oldest age
groups and declines in children. Indeed, the proportion of older persons was 8% in 1950, 10% in
2000, and is projected to reach 21% in 2050 (http://
www.un.org/esa/population/publications/worldageing19502050/). The global median age has
increased from 21.5years in 1970 to over 30years
in 2019. As people have fewer children and those
children are more likely to survive, and adults live
longer due to advances in hygiene and medicine,
the age structure continues to change toward
increased numbers and proportions of older adults.
For example, 8% are older than 65in 2019 (https://
ourworldindata.org/age- structure). These trends
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Ö. Ö. Celebi, T. M. Önerci (eds.), Nasal Physiology and Pathophysiology of Nasal Disorders,
https://doi.org/10.1007/978-3-031-12386-3_14
157
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