Ear,Nose and throat Disorders...

Ear , Nose , and Throat disorder

Topics
 • Review of anatomy and physiology of the Ear Nose and Throat –
 • Nursing Assessment-History and physical assessment
 • Etiology, Path physiology, clinical manifestations, diagnosis, treatment
modalities and medical & surgical nursing management of Ear Nose and
Throat disorder:
 • External ear: deformities otalgia, foreign bodies, and tumors
 • Middle Ear- Impacted wax, Tympanic membrane perforation, otitis media ,
otoselerosis, mastoiditis, tumors
 • Inner ear-Meniere’s Disease, labyrinthitis, ototoxicity, tumors
2

 • Upper airway infections- Common cold, sinusitis, ethinitis, rhinitis,
pharyngitis, tonsilits and adenoiditis, peritonsilar abscess, laryngitis
 • Upper respiratory airway- epistaxis,
 • Nasal obstruction, laryngeal obstruction, cancer of the larynx
 • Cancer of the oral cavity
 • Speech defects and speech therapy
 • Deafness-
 • Prevention, control and rehabilitation
 • Hearing Aids, implanted hearing devices
 • Special therapies
 • Nursing procedures
 • Drugs used in treatment of disorders of Ear Nose and Throat Role of nurse
Communicating with hearing impaired and muteness.
3

Anatomic and Physiologic
Overview of Ear
The ears are a pair of complex sensory organs
located in the middle of both sides of the head
(that attaches to the temporal bone of cranium)
at approximately eye level.
4

Anatomic view of the ear
Lecture Note for Third Year Extension Nursing
Students, November 2003/2010. 6

Anatomy of the external ear
The external ear, housed in the temporal bone, includes
the auricle (i.e., pinna) and the external auditory
canal.
The external ear is separated from the middle ear by a
disklike structure called the tympanic membrane (i.e.,
eardrum).
Auricle- the auricle, attached to the side of the head by
skin, is composed mainly of cartilage, except for the fat
and subcutaneous tissue in the earlobe.
The function of auricle is to collects the sound waves
and directs vibrations into the external auditory canal.
7

External Auditory Canal
The external auditory canal is approximately 2.5 cm long.
The lateral third is an elastic cartilaginous and dense
fibrous framework to which thin skin is attached.
The medial two thirds is bone lined with thin skin that
contains hair, sebaceous glands, and ceruminous
glands, which secrete a brown, wax like substance called
cerumen (i.e., ear wax).
The external auditory canal ends at the tympanic
membrane.
The ear’s self-cleaning mechanism moves old skin cells
and cerumen to the outer part of the ear.
9

Anatomic view of the ear

Anatomy of the middle ear
 The middle ear, an air-filled cavity, includes the
tympanic membrane laterally and the otic capsule
medially.
 The middle ear is connected by the tube (1 mm wide and
35 mm long) to the nasopharynx and is continuous with
air-filled cells in the adjacent mastoid portion of the
temporal bone.
 Normally, the tube is closed, but it opens by action of the
tensor veli palatini muscle when performing yawning
or swallowing.
 The tube serves as a drainage channel for normal and
abnormal secretions of the middle ear and equalizes
pressure in the middle ear with that of the atmosphere.
11

Tympanic Membrane
The tympanic membrane (i.e., eardrum), about 1 cm in
diameter and very thin, is normally pearly gray and
translucent.
The tympanic membrane consists of three layers of tissue:
an outer layer, continuous with the skin of the ear canal;
a fibrous middle layer; and
an inner mucosal layer, continuous with the lining of the
middle ear cavity.
The tympanic membrane protects the middle ear and
conducts sound vibrations from the external canal to
the ossicles.
12

Ossicles
The middle ear contains the three smallest bones
(i.e., ossicles) of the body:
- malleus,
- incus, and
- stapes. It has vibratory, resonance
function and modify the external stimulus.
The ossicles, which are held in place by joints,
muscles, and ligaments, assist in the transmission
of sound.
13

Anatomy of the inner ear
The inner ear is housed deep within the temporal bone.
The organs for hearing (i.e., cochlea) and balance (i.e.,
semicircular canals), as well as cranial nerves VII (i.e.,
facial nerve) and VIII (i.e., vestibulocochlear nerve),
are all part of this complex anatomy.
The cochlea and semicircular canals are housed in the
bony labyrinth.
The bony labyrinth surrounds and protects the
membranous labyrinth, which is bathed in a fluid called
perilymph.
14

Membranous Labyrinth
The membranous labyrinth is composed of the
utricle, the saccule, the cochlear duct, the
semicircular canals, and the organ of Corti.
The membranous labyrinth contains a fluid called
endolymph.
The three semicircular canals—posterior, superior,
and lateral, which lie at 90-degree angles to one
another—contain sensory receptor organs, arranged
to detect rotational movement.
These receptor end organs are stimulated by changes
in the rate or direction of an individual’s movement.
16

Organ of Corti
The organ of Corti is located in the cochlea, a snail-
shaped, bony tube about 3.5 cm long with two and
one-half spiral turns.
The organ of Corti, also called the end organ for
hearing, transforms mechanical energy into
neural activity and separates sounds into different
frequencies.
17

Function of the ears
Hearing:-
 Hearing is conducted over two pathways: air and
bone.
 Sounds transmitted by air conduction travel over the air-
filled external and middle ear through vibration of the
tympanic membrane and ossicles.
 Sounds transmitted by bone conduction travel directly
through bone to the inner ear, bypassing the tympanic
membrane and ossicles.
 Normally, air conduction is the more efficient
pathway. (AC>BC)
18

Cont…d
Sound conduction and transmission
Sound enters the ear through the external auditory canal
causes the tympanic membrane to vibrate.
These vibrations transmit sound through the action of the
ossicles to the oval window as mechanical energy.
This mechanical energy is then transmitted through the
inner ear fluids to the cochlea, stimulating the hair cells,
and is subsequently converted to electrical energy.
The electrical energy travels through the
vestibulocochlear nerve to the central nervous system,
where it is analyzed and interpreted in its final form as
sound.
19

Assessment
HEALTH HISTORY:- It includes all the components
that are applied in other body system.
 Date of History.
 Identification.
 Chief compliant.
 History of present illness.
 History of past illness.
 Current health status (Current medication, addictive
drugs and allergies).
 Family history.
 Psychosocial and personal history.
20

Physical Examination
The external ear is examined by;
 Inspection of external ear :- for the presence of scar,
lesion, symmetry, attachment, any abnormal
discharge, color e.t.c.
Tympanic membrane is inspected with an otoscope.
Inspection of the middle ear with middle ear
endoscopy.
Direct palpation:- for tenderness, presence of
malignancy, free movement, circulation, e.t.c.
21

Otoscopic examination
To examine the external auditory canal and tympanic membrane, the
otoscope should be held in the examiner’s right hand, in a pencil-
hold position, with the bottom of the scope pointing up.
Before inserting the otoscope it is important to straighten the external
auditory canal by manipulation;
 Grasp the auricle firmly but gently and pull it upward, backward,
and slightly away from the head in adult.
 Grasp the auricle firmly but gently and pull it down ward, backward,
and slightly away from the head in Children.
Proper otoscopic examination of the external auditory canal and
tympanic membrane requires that the canal be free of large amounts
of cerumen.
The healthy tympanic membrane is pearly gray and is positioned
obliquely at the base of the canal.
22

Cont…d
Steady the hand against the patient’s head to avoid
inserting the otoscope too far into the external canal.
23

Evaluation of gross auditory acuity
A general estimation of hearing can be made by
assessing the patient’s by;
whisper test.
Weber .
Rinne tests
24

Whisper Test
To exclude one ear from the testing, the examiner
covers the untested ear with the palm of the hand.
Then the examiner whispers softly from a distance of
1 or 2 feet from the unoccluded ear and out of the
patient’s sight.
The patient with normal acuity can correctly repeat
what was whispered.
25

Weber Test (Lateralization Test)
The Weber test uses bone conduction to test
lateralization of sound.
A tuning fork (ideally, 512 Hz), set in motion by grasping it
firmly by its stem and tapping it on the examiner’s knee or
hand, is placed on the patient’s head or forehead.
A person with normal hearing will hear the sound
equally in both ears or describe the sound as centered in
the middle of the head.
In cases of conductive hearing loss, such as from
otosclerosis or otitis media, the sound is heard better
in the affected ear.
26

Cont…d
In cases of sensorineural
hearing loss, resulting
from damage to the
cochlear or
vestibulocochlear nerve, the
sound lateralizes to the
better-hearing ear.
The Weber test is useful for
detecting unilateral
hearing loss.
27

Rinne Test
In the Rinne test (pronounced rin-ay), the examiner shifts the
stem of a vibrating tuning fork between two positions: 2 inches
from the opening of the ear canal (i.e., for air conduction)
and against the mastoid bone (i.e., for bone conduction).
Normally, sound heard by air conduction is audible longer than
sound heard by bone conduction.
The Rinne test is useful for distinguishing between conductive
and sensorineural hearing losses.
With a conductive hearing loss, bone-conducted sound is
heard as long as or longer than air-conducted sound,
whereas with a sensorineural hearing loss, air-conducted
sound is audible longer than bone conducted sound.
28

Cont…d
Comparison of Weber and Rinne Tests
30

Diagnostic Evaluation
1. Audiometry { test to check the ability of hear sounds,}
2. Tympanogram {tympanometery is an examination used to test the
condition of the middle ear and tympanic membrane}
3. Auditory brain stem response {ABR- is an extracted from
ongoing electrical activity in the brain and recorded via electrodes placed on the
scalp.}
4. Electronystagmography{ ENG- used to evaluate patients with
dizziness, vertigo, or balance dysfunction or to record involuntary movements
of the eyes caused by a condition known as nystagmus.}
5. Platform posturography{ TOB- TEST OF BLANCE}
6. Sinusoidal harmonic acceleration{ TO CHECK THE VESTBULAR
FUNCTION}
7. Middle ear endoscopy
31

External Ear disorder
1. CERUMEN IMPACTION
Cerumen normally accumulates in the external canal
in various amounts and colors.
 Although wax does not usually need to be removed,
impaction occasionally occurs, causing otalgia, a
sensation of fullness or pain in the ear, with or
without a hearing loss.
Accumulation of cerumen is especially significant in
the geriatric population as a cause of hearing
deficit.
32

Accumulated cerumen (earwax) may become
impacted due to use of cotton swabs to clean ears and
may be a problem for some people.
Cerumen becomes drier in elderly people, making
impaction more likely.

Management
o Cerumen can be removed by
o Irrigation: (Unless the patient has a perforated
eardrum or an inflamed external ear (i.e., otitis
externa), particularly if it is not tightly packed in
the external auditory canal).
o Suction: Using any softening solution two or three
times a day for several days is generally sufficient.
Instilling a few drops of warmed glycerin, mineral
oil, or half strength hydrogen peroxide into the ear
canal for 30 minutes can soften cerumen before its
removal.
36

Cont…d
o Instrumentation. If the cerumen cannot be dislodge
by these methods, instruments, such as a cerumen
curette, aural suction, and a binocular microscope for
magnification, can be used. Direct visual, mechanical
removal can be performed on a cooperative patient by a
trained health care provider.)
o To prevent injury, the lowest effective pressure
should be used.
o Ceruminolytic agents, such as peroxide in glyceryl
(Debrox), are available; however, these compounds
may cause an allergic dermatitis reaction.
37

Foreign bodies
Some objects are inserted intentionally into the ear by
adults who may have been trying to clean the external
canal or relieve itching or by children who introduce the
objects.
 Other objects, such as insects, peas, beans, pebbles
(Sand/stone), toys, and beads/droplet, may enter or be
introduced into the ear canal. In either case, the effects
may range from no symptoms to profound pain and
decreased hearing.
C/M –No symptoms,
- Swelling,
- Profound pain,
- Decreased hearing,
38

Cont..d
Management
The three standard methods for removing
foreign bodies are the same as those for
removing cerumen:
 Irrigation: Foreign vegetable bodies and insects
tend to swell; thus, irrigation is contraindicated.,
 Suction, and
 Instrumentation.
Usually, an insect can be dislodged by instilling
mineral oil, which will kill the insect and
allow it to be removed.
In difficult cases, the foreign body may have to
be extracted in the operating room with the
patient under general anesthesia.
39

External otitis (otitis externa)
 It is an inflammation of the external auditory canal.
 usually caused by acute infection.
Causes
 Water in the ear canal (i.e., swimmer’s ear).
 Trauma to the skin of the ear canal.
 Systemic conditions (such as vitamin deficiency (Vit.A) and
endocrine disorders).
 Bacterial infections (most common are Staphylococcus aureus and
Pseudomonas species).
 Fungal infection (most common is Aspergillus).
 Dermatosis (such as psoriasis, eczema, or seborrheic dermatitis).
 Allergic reactions to hair spray, hair dye, and permanent wave
lotions can cause dermatitis, which clears when the offending agent is
removed.
40

Cont…d
Clinical Manifestations
 Pain,
 Discharge (yellow or green and foul smelling),
 Aural tenderness (usually not present
 in middle ear infections),
 Fever,
 Cellulitis,
 Lymphadenopathy,
 Pruritus,
 hearing loss,
 Feeling of fullness,
 Erythematous and edematous (otoscopic examination),
 In fungal infections, the hair like black spores may even be
visible.
43

Cont…d
Medical Management
The principles of therapy are aimed at;
relieving the discomfort,
reducing the swelling of the ear canal, and
eradicating the infection.
Patients may require analgesics for the first 48 to 92
hours.
Antibiotic ear drops
Antifungal- clotrimazole ear drop 1% 2-3 times/d at
least for 14 days.
Avoid swimming & do not allow water to enter the ear.
44

Cont…d
Nursing Management
Nurses need to teach patients;
 not to clean the external auditory canal with cotton-tipped
applicators,
 to avoid swimming, and
 not to allow water to enter the ear when shampooing or
showering.
 A cotton ball can be covered in a water-insoluble gel such as
petroleum jelly and placed in the ear as a barrier to water
contamination.
 Infection can be prevented by using antiseptic otic
preparations after swimming (eg, Swim Ear, Ear Dry).
45

Middle Ear disoder
1. Tympanic membrane perforation
Causes
 Infection.
 Trauma (skull fracture, explosive injury, or a severe
blow to the ear).
 Foreign objects (eg, cotton-tipped applicators,
match pins, keys) that have been pushed too far into
the external auditory canal.
46

Cont…d
Medical Management
Most tympanic membrane perforations heal
spontaneously within weeks after rupture.
In the case of a head injury or temporal bone fracture,
a patient is observed for evidence of cerebrospinal
fluid leakage, otorrhea or rhinorrhea (a clear,
watery drainage from the ear or nose), respectively.
While healing, the ear must be protected from water.
48

Cont…d
Surgical management
Tympanoplasty (i.e., surgical repair of the
tympanic membrane).
Surgery is usually successful in closing the perforation
permanently and improving hearing.
49

2. Acute otitis media
It is an acute infection of the middle ear, usually lasting less
than 6 weeks.
Acute otitis media is an inflammation and infection of the
middle ear caused by the entrance of pathogenic organisms,
with rapid onset of signs and symptoms. It is a major problem
in children but may occur at any age.
Causes
Primarily Streptococcus pneumoniae, Haemophilus
influenzae, and Moraxella catarrhalis.
Inflammation of surrounding structures (eg, sinusitis, adenoid
hypertrophy).
Allergic reactions (eg, allergic rhinitis). It is usually present in
the middle ear, resulting in a conductive hearing loss.
50

Cont…d
Otalgia : ear pain (unilateral in adults) may
awaken patient at night. Pain relieved after tympanic
perforation.
drainage from the ear (purulent exudate).
Fever, headache
Hearing loss (conductive hearing loss).
The patient reports no pain with movement of the
auricle. The tympanic membrane is erythematous and
often bulging.
51

Pneumatic otoscopy shows a
tympanic membrane that is
full, bulging, and opaque
with impaired mobility (or
retracted with impaired
mobility).
Cultures of discharge
through ruptured tympanic
membrane may suggest
causative organism

Cont…d
Medical Management
Antibiotics:-
Co-trimoxazole, 4mg/kg trimethoprin 20mg/kg
sulphomethaxozole twice a day for 05 days.
Amoxicillin, 20-40mg/kg/day divided into 3 doses
po/for 5 days
Clean the external auditory canal
Cover with cotton
53

Cont…d
Surgical management
An incision in the tympanic membrane is known as myringotomy or
tympanotomy.
The incision heals within 24 to 72 hours.
Indication;
 For analysis of drainage (by culture and sensitivity testing).
 If pain persists.
If episodes of acute otitis media recur and there is no
contraindication, a ventilating, or pressure-equalizing tube may
be inserted.
The ventilating tube, which temporarily takes the place of the
eustachian tube in equalizing pressure, is retained for 6 to 18 months.
Ventilating tubes are more commonly used to treat recurrent episodes
of acute otitis media in children than in adults.
54

Cont…d
Complications
 Chronic OM
 Mastoiditis
 Meniningitis
 Brain abscess
55

Cont…d
Comparison between AOE and AOM
56

3. Serous otitis media
Serous otitis media (i.e., middle ear effusion) implies fluid,
without evidence of active infection, in the middle ear.
Causes
Children:- eustachian tube obstruction (negative pressure in
the middle ear)
Adults:- eustachian tube dysfunction (concurrent upper
respiratory infection or allergy)
-Radiation therapy.
-Barotrauma(results from sudden pressure changes in
the middle ear caused by changes in barometric pressure,
as in scuba diving or airplane descent.
- Carcinoma (eg, nasopharyngeal cancer).
57

Cont…d
Hearing loss (conductive hearing loss),
Fullness in ear,
Sensation of congestion,
Popping and crackling noises,
 Dull tympanic membrane
Diagnosis
• Otoscope-dull TM, and air bubble shown in the middle
ear.
• Audiogram- to exclude conductive hearing loss.
58

Cont…d
Management
Myringotomy.( To relieve pressure or or drain fluid
by incision)
Tube may be placed to keep the middle ear
ventilated.
Corticosteroids.
 Valsalva maneuver (do cautiously).
59

4. Chronic otitis media
Chronic otitis media is the result of repeated
episodes of acute otitis media causing irreversible
tissue pathology and persistent perforation of the
tympanic membrane.
Chronic infections of the middle ear damage the tympanic
membrane, destroy the ossicles, and involve the mastoid.
The most common organisms are group A beta-hemolytic
streptococci, S. pneumoniae, and H. influenzae.
Other organisms may be present, such as Pseudomonas,
Proteus, and Bacteroides species.
60

Cont…d
Presence of a persistent or intermittent, foul-smelling
otorrhea .
Pain is not usually experienced, except in cases of acute
mastoiditis.
Otoscopic exam;
 Perforated tympanic membrane.
 Cholesteatoma (an ingrowth of the skin of the external
layer of the eardrum into the middle ear).
Audiometric tests often show a conductive or mixed
hearing loss.
61

Air conductive hearing loss is present through
audiometric tests.
X-rays may show mastoid pathology, for example,
cholesteatoma or haziness of mastoid cells.
Culture of exudate from middle ear (through
ruptured tympanic membrane or at time of surgery).

Cont…d
Medical Management
Suctioning of the ear.
Instillation of antibiotic drops or application of
antibiotic powder.
Systemic antibiotics are usually not prescribed
except in cases of acute infection.
Dry the ear by wicking.
63

Cont…d
Surgical management
Tympanoplasty (most common surgical procedure).
 There are five types of tympanoplasties.
 Type I (myringoplasty)-closing the perforated TM, and it is
the simplest.
 Types II through V-more extensive.
Ossiculoplasty (surgical reconstruction of the
middle ear bones-ossicles).
Mastoidectomy (The objectives of mastoid surgery
are to remove the cholesteatoma, gain access to
diseased structures, and create a dry and healthy ear).
64

Cont…d
Complications
 facial nerve palsy.
 Chronic mastoiditis.
 Meningitis.
 Brain abscess.
65

Inner Ear disorder
Common compliant that individual with IED are;
Dizziness (any altered sensation of orientation in space).
Vertigo (the misperception or illusion of motion of the
person or the surroundings). Most people with vertigo
describe a spinning sensation or say they feel as though
objects are moving around them.
 Ataxia (failure of muscular coordination due to vestibular
system).
Nystagmus (an involuntary rhythmic movement of the
eyes).
 can be horizontal, vertical, or rotary.
66

1. Motion sickness
Motion sickness is a disturbance of equilibrium caused
by constant motion (aboard a ship, while riding on a
merry-go-round or swing, or in the back seat of a car)
that over stimulate the vestibular system.
Sweating,
 Pallor,
 vertigo,
Nausea, and
Vomiting.
These manifestations may persist for several hours after the
stimulation stops.
67

Cont…d
Management
 Over-the-counter antihistamines.
 dimenhydrinate (Dramamine) or
 meclizine hydrochloride (Bonine),
Anticholinergic medications (scopolamine patch,
promethazine, e.t.c.).
Avoide potentially hazardous activities (operating
heavy machinery, driving a car).
68

2. Ménière’s disease
Ménière’s disease is an abnormal inner ear fluid
balance caused by a malabsorption in the endolymphatic
sac.
MÃ©niÃ¨re's disease (endolymphatic hydrops) is a
chronic disease that involves the inner ear and causes a
triad of symptomsâ€”vertigo, hearing loss, and tinnitus.
Ménière’s disease appears to be equally common in both
genders.
69

Sudden attacks occur, in which patient feels that the room
is spinning (vertigo); may last 10 minutes to several hours.
Dizziness, tinnitus, and reduced hearing occur on
involved side.
Headache, nausea, vomiting, and incoordination are
present.
Sudden motion of the head may precipitate vomiting.
Irritability; other personality changes.
After multiple attacks, tinnitus and impaired hearing may
be continuous

Cont…d
Assessment and Diagnostic Findings
Hx.
P/E.
Audiogram.
Electronystagmogram.
71

Cont…d
Pharmacologic therapy
Antihistamines (meclizine (Antivert)).
Tranquilizers (diazepam (Valium)).
 Antiemetics (promethazine (Phenergan))
suppositories.
Diuretic therapy (eg, hydrochlorothiazide).
 Vasodilators (nicotinic acid, papaverine hydrochloride
(Pavabid), and methantheline bromide (Banthine)).
72

Cont…d
Surgical management
Destructive surgery:
Labyrinthectomy :
recommended if the patient
experiences progressive hearing
loss and severe vertigo attacks
so normal tasks cannot be
performed; results in total
deafness of affected ear.
73

3. Labyrinthitis
Labyrinthitis is an inflammation of the inner ear vestibular
labyrinth system. It may be due to a viral or bacterial
infection.
Labyrinthitis, an inflammation of the inner ear.
Causes
Bacterial (complication of otitis media).
Viral in origin (mumps, rubella, rubeola, and influenza)
Viral illnesses of the upper respiratory tract.
Herpetiform disorders of the facial and acoustic nerves
(i.e., Ramsay Hunt syndrome).
74

Cont…d
sudden onset of incapacitating vertigo,
Nausea,
vomiting,
various degrees of hearing loss, and
 tinnitus.
75

Cont…d
Management
Intravenous antibiotic therapy,
Fluid replacement,
Vestibular suppressant (meclizine)
Antiemetic medications.
Symptomatic for the viral one.
76

Anatomic and Physiologic overview of Nose
Nose surface anatomy
77

Disorder of Nose
1. Epistaxis
 It is hemorrhage from the nose.
 It can be;
A. Anterior Bleed
 Kiesselbach’s plexus vessels.
Easy to locate and treatment.
B. Posterior Bleed
Larger vessels.
Severe bleeding.
Harder to locate and treatment.
80

Cont…d
Etiology
 Dry cracked mucosal membrane
 Trauma
Picking
Blunt contact
 Forceful nose blowing
sneezing
 HTN
 Chronic infection (AFI)
 Substance abuse
 Arteriosclerosis
 Liver disease
 Chronic bleeding disorder
Leukemia
Hemophilia
 Anticoagulant Rx
81

Cont…d
Management
Anterior
Simple first aid
Apply pressure for 5-10 minutes.
Apply ice packs to nose & forehead.
Sitting position leaning forward.
Discourage swallowing blood.
Medications
Topical vasoconstrictors
Cocaine
Neo-Synephrine
Adrenaline
Nasal spray or on cotton swab held against bleeding site
82

Cont…d
Sitting position leaning forward.
83

Cont…d
Chemical cauterization
 Silver nitrate
 Gelfoam
Topical anesthetic (pre-packing)
 Tetracaine
 Lidocaine
 Cocaine
Nasal Packing -Anterior
Petroleum gauze.
24-72 hours commonly.
84

Cont…d
Nasal Packing -Posterior
Pack both anterior & posterior for 2-5 days.
Monitor for hypoxemia.
Administer oxygen as ordered.
Frequent oral hygiene.
Administer narcotic analgesics as ordered.
Monitor for complications.
 Toxic shock syndrome
 Otitis media
 Sinusitis
85

Cont…d
Endoscopic Surgery
Cauterizing bleeding vessel.
Ligation of internal maxillary artery.
86

2. Nasal Polyps
It is a benign grapelike growth of mucous membrane.
Form in areas of dependent mucous membrane.
Usually bilateral.
Stem-like base makes them moveable.
It may enlarge and cause nasal obstruction.
87

Cont…d
Management
Medication;
 Topical corticosteroid nasal spray.
 Low-dose oral corticosteroids.
Surgery;
 Polypectomy under local anesthesia.
 Nasal packing to control bleeding
 Avoid blowing nose 24-48 hours post removal of packing.
 Avoid straining at stool, vigorous coughing, strenuous exercise.
 Monitor for bleeding
 Frequent swallowing
 Visible blood at back of throat
 Laser surgery to remove polyps.
 May require multiple surgeries as polyps tend to recur.
88

3. Deviated Septum
May result from trauma
May be present from birth
Causes nasal obstruction
Management
Relief of airway obstruction.
Repair visible deformity.
Reshaping of nose by manipulation of septal cartilage
by;
Moving
Rearranging
Augmenting
89

Cont…d
Surgery;
Septoplasty or submucous resection.
Rhinoplasty or surgical reconstruction of the nose.
Post operatively;
 Bilateral Nasal packing for 72 hours.
 Temporary plastic splint for 3-5 days.
 Swelling subsides within 10-14 days.
 Normal sensation returns within several months.
90

4. Rhinitis
It is an inflammation of the mucous membranes of
the nose.
It has different classification;
 Based on duration,
a) Acute
b) Chronic
 Based on cause,
a) Allergic rhinitis /hay fever /:due to allergy.
b) Non-allergic rhinitis: following URTI (Bacteria and
Viral).
91

4.1. Acute Rhinitis (Coryza)or
common cold
 Affects almost every one at some time and most often in the
winter, with additional high incidence in early fall and spring.
Cause
Common etiology is virus.
 Rhinovirus
 Corona virus
 Adenovirus
 Influenza virus
 Parainfluenza virus
 Echovirus
 Coxsakiervirus
 Respiratory syncytial virus (RSV),
Each virus may have multiple strains. For example, there are over 100
strains of rhinovirus, which accounts for 50% of all colds.
92

Cont…d
It is highly contagious because virus is shed for about
2 days before the symptoms appear and after 3 days of
the symptom.
Common cold spread by;
 Droplet nuclei from sneezing.
 Contaminated hand or fomites.
Secondary invasion by bacteria may cause;
Pneumonia
Acute bronchitis
Sinusitis
Otitis media
93

Cont…d
Clinical manifestation
 Sneezing
 Nasal discharge (runny nose)
 Nasal obstruction
 Head ache
 Nasal congestion
 Chilliness
 Nasal itchiness
 Fever
 Shyness/nervousness
 Sore throat
 Malaise
94

Cont…d
Medical management
Usually self –limiting and lasts for about 1 week.
Goal of management;
1. To relieve symptoms
2. Inhibit spread of the infection
3. Reduce risk of bacterial complication
95

Cont…d
 Adequate fluid intake.
 Encouraging rest.
 Preventing chilling.
 Increasing intake of vitamin C.
 Using expectorants as needed.
 Warm salt-water gargles soothe the sore throat.
 Nonsteroidal anti-inflammatory agents (NSAIDs) such as aspirin or ibuprofen.
 Antihistamines (chlorpheniramine maleate , diphenhydramine (Benadryl)
 Topical (nasal) decongestant ( e.g. oxymetazoline maleate (Afrin),
phenylephrine (Neo-synephrine), pseudoephedrine (Sudafed) orally.
 Zinc lozenges may reduce the duration of cold symptoms if taken within the
first 24 hours of onset.
 Amantadine (Symmetrel) or rimantadine (Flumadine) may be prescribed
prophylactically.
 Antimicrobial agents (antibiotics) should not be used because they do not
affect the virus or reduce the incidence of bacterial complications.
96

Cont..d
Nursing Management;
Perform hand hygiene often.
Use disposable tissues.
Avoid crowds during the flu season.
Avoid individuals with colds or respiratory
infections.
Obtain influenza vaccination, if recommended
(especially if elderly or diagnosed with a chronic
illness)
97

4.2. Chronic rhinitis
A chronic inflammation of the nasal mucosal
membrane characterized by increased nasal mucus.
Cause
 Repeated acute infection or allergy.
 Vasomotor rhinitis (an instability of the autonomic
nervous system caused by stress, tension , or some
endocrine disorder).
 Chronic irritation by nasal drug
98

Cont…d
no acute symptom.
 nasal obstruction (stuffiness).
pressure in the nose.
Polyp formation .
Vertigo.
99

Cont…d
Management
 Nursing interventions
The pt with allergic rhinitis is instructed to avoid
allergens and irritants i.e. dusts, fumes, odor, powder
sprays.
Proper use and administration of medication.
Obtain additional rest.
Drink at least 2 to 32 times fluid daily.
Use nasal spray or nose drops.
100

5. Sinusitis
It is an inflammation of the mucous membranes in
the sinuses.
Sinusitis can be;
1. Acute bacterial.
2.Sub acute.
3.Chronic.
101

5.1. Acute Sinusitis
The most common types of acute sinusitis are;
 Allergic. Usually seasonal.
 Viral.
Acute bacterial (Streptococcus pneumonia,
haemophilus influenza, beta hemolytic
streptococcus, klebsiella pneumonia and
various anaerobic organisms).
102

Cont…d
Slowly developing pressure over the involved sinus
General malaise
fever
malaise
Systemic symptoms i.e., achiness
Stuffy nose
Persistent cough
Postnasal drip
Head ache
Redness and itching of the eye
Sign of tooth infection
103

Cont…d
In acute frontal and maxillary sinusitis, pain
usually does not appear until 1 to 2 hours after
awakening.
It increases for 3 to 4 hours and then becomes less
severe in the afternoon and evening usually this is
due to increased drainage as result of gravity from
standing during the day.
Bloody or blood –tinged discharge from the nose in
the first 24 to 48 hours.
The discharge rapidly becomes thick, green, and
copious, blocking the nose.
104

Cont…d
Diagnosis
Hx.
P/E;
 Tenderness in the involved sinus,
 Hyperemic and edematous nasal mucosa, and
 The turbinate's are enlarged.
X-ray examination
 Clouded sinus and fluid level is visible.
105

Cont…d
Managements
 Aim is to relief a pain and shrinkage of the nasal mucosa.
 Medication
 Analgesics i.e. . Ibuprofen.
 Oral decongestant pseudoephedrine.
 Antibiotics i.e., Amoxicillin for 10 days to 14 days .
Failure of the infection to respond to amoxicillin is an
indication for aspiration of the maxillary sinus to take
specimen for culture and sensitivity and to remove the
accumulated secretion.
Acute frontal sinusitis with pain, tenderness, and edema of the
frontal or sphenoid sinus require hospitalization b/c of risk of
intracranial complication or Osteomyelitis . High doses of
IV antibiotic nasal decongestant or by spray is needed.
106

5.2. Chronic Bacterial Sinusitis
Chronic bacterial sinusitis develops when irreversible
mucosa damage occurs.
Damage car result from recurrent attacks of acute
sinusitis or from suppurative sinusitis either being
untreated or inadequately treated during the
acute or sub acute phase.
Etiology
S.aureus
H. influenza
Anaerobes (Klebsiella)
107

Cont…d
Nasal congestion
Thick, green purulent discharge, present for at least 3
months
Fever
Facial pain
Light headness /does not have headache
Diagnosis
Culture and sensitivity
108

Cont…d
Management
Medication
Decongestant.
Antibiotic according to result of the culture.
Nasal saline irrigation and surgery are the major
treatments.
Pt. benefits from thing that increase the drainage.
Increasing the humidity (steam bath hot shower, facial
sauna).
Increasing fluid intake applying local heat (hot wet packs).
109

Anatomic and Physiologic
review of throat
110

1. Pharangitis
1.1. Acute pharyngitis
Acute pharangitis is a febrile inflammation of the
throat that is caused by 70% viral cause and 30%
bacteria i.e. hemolytic streptococci,
staphylococci.
It is the most common throat inflammation.
A severe form of acute pharangitis often is termed
“Step throat” because of the frequency of
streptococci as the causative organism.
111

Cont…d
Dryness of the throat
Fiery read throat and pharyngeal membrane and tonsils
Sever pain which lead to difficulty in swallowing
Enlarged and tender cervical lymph nodes
Fever
Malaise
Sore throat
Hoarseness
cough
Rhinitis
112

Cont…d
Complication
Sinusitis
Otitis media
Peritonsilar abscess
Mastoiditis
Cervical adenitis
Rheumatic fever
Rheumatic nephritis
113

Cont…d
Diagnosis
Throat culture.
Nasal swabbing and blood culture may be done.
114

Cont…d
Medical management
Penicillin is a drug of choice.
Erythromycin for 10 day.
Liquid and soft diet.
lozenges – to relive local soreness .
Nursing intervention
Bed rest at febrile stage.
Proper tissue disposal.
115

cont…d
Asses as for possible skin rash b/c pharyngitis may
precede some other communicable disease.
Warm saline gargles or irrigations are used.
Analgesic medication.
Prophylactic antibiotic therapy for pharygitis in
patients with a history of rheumatic fever or infective
endocarditis to prevent re-infection.
116

1.2. Chronic pharyngitis
It is a persistent inflammation of the pharynx.
It is common in adults who work or live in dusty
surroundings, use their voice to excess, suffer from
chronic cough, an habitually use alcohol and tobacco.
Three types of chronic pharyngitis are recognized:
• Hypertrophic:-general thickening and congestion of the
pharyngeal mucous membrane
• Atrophic: probably a late stage of the first type (the
membrane is thin, whitish, glistening, and at times
wrinkled)
• Chronic granular (“clergyman’s sore throat”):
characterized by numerous swollen lymph follicles on
the pharyngeal wall.
117

Cont…d
Clinical Manifestations;
-a constant sense of irritation or fullness in the throat,
- mucus that collects in the throat and can be expelled by coughing, and
- difficulty swallowing.
Medical Management;
 is based on
-relieving symptoms,
- avoiding exposure to irritants, and
- correcting any upper respiratory, pulmonary, or cardiac condition
that might be responsible for a chronic cough.
 Nasal sprays or medications containing ephedrine sulfate (Kondon’s Nasal)
or phenylephrine hydrochloride (Neo-Synephrine).
 Antihistamine decongestant medications, such as Drixoral or Dimetapp, is
taken orally every 4 to 6 hours.
 Anti-inflammatory and analgesic agent like Aspirin or acetaminophen.
118

Cont…d
Nursing Management;
avoid contact with others until the fever subsides.
Alcohol, tobacco, second-hand smoke, and exposure
to cold are avoided.
The patient may minimize exposure to pollutants by
wearing a disposable facemask.
drink plenty of fluids.
Gargling with warm saline solutions
Lozenges will keep the throat moistened.
119

2. Tonsillitis and adenoiditis
Tonsillitis is inflammation and enlargement of the tonsil
tissue.
Tonsil tissue are situated on each side of the oropharynx
Cause
Group A streptococcus is the most common organism
associated with tonsillitis.
Adenoiditis is inflammation of the adenoid tissue
The adenoid consist of an abnormally large lymphoid
tissue mass near the center of the posterior wall of the
nasopharynx.
Infection of the adenoids frequently accompanies acute
tonsillitis.
120

Cont…d
Tonsillitis
Sore throat
Fever
chills
 general muscle ache
Snoring
Difficulty in swallowing
121

Cont…d
Adenoiditis
Mouth breathing
Earache
Draining ear
Yellowish exudates drain
122

Cont…d
Diagnosis
Hx.
P/E.
Culture of tonsil swab.
Audiometric examination (hearing loss).
123

Cont…d
Treatment
Benzantine penicillin
Tonsillectomy
Adenoidectomy
Indication
 Repeated bout of tonsillitis.
 Respiratory obstruction.
 Hypertrophy of the tonsils and adenoids.
 Recurrent otitis media.
 Peritonsilar abscess.
Mouth care may for comfort
124

Cont…d
Prophylaxis
Prophylactically pencillin may be given.
Educate on the continueuation of the therapy.
125

3. Laryngitis
It is inflammation of the larynx.
Predisposing factor /associated to;
Voice abuse.
Exposure to dust.
Chemicals.
Smoke and other pollutants.
126

Cont…d
Etiology
Almost alloys is a virus bacterial invasion may be
 Acute rhinitis or
 Naso pharyngitis.
The onset of infection may be associated with exposure
to sudden temperature change.
Diet as deficiencies
Lack of immunity
Laryngitis is common in the winter and is easily
transmitted.
127

Cont…d
Chronic laryngitis
Persistent hoarsoness.
Hoarseness or complete loss of voice (aphonia).
Severe may be a complication of chronic sinusitis
and chronic bronchitis.
128

Cont…d
Management
resting the voice,
Avoid smoking,
Resting in bed , and
inhaling cool steam or an aerosol
For chronic laryngitis
Resting the voice.
Eliminating any primary respiratory tract infection.
Restricting smoking.
129

Cont…d
Nursing interventions
The patient is instructed to rest the voice and to
maintain a well humidified environment.
High fluid intake.
130

“Teaching is an intimate
contact b/n a more mature
personality and less
mature one which is
designed to further the
education of the latter.”
(H.C.Morrison)
131

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