Ent disorders

Describe nursing assessment of the ear, sinuses ,nose, throat.
Identify nursing responsibilities for patient undergo diagnostic test or procedure for ear, sinuses, nose, throat.
Describe the common therapeutic measures for ear, sinuses ,nose, throat.
Explain the pathophysiology, etiology, clinical manifestation and treatment for ENT disorders.
Assist in developing nursing care plans for patient with ENT disorders.

1. ENT Disorders Prepared by: Jamilah Saad Alqahtani Nurse Lecturer, MSN, TOT, OR Nurse Specialist, RGN, BSN,     10/26/2018 1 ENT Disorders

2. Learning Objectives Describe nursing assessment of the ear, sinuses ,nose, throat. Identify nursing responsibilities for patient undergo diagnostic test or procedure for ear, sinuses, nose, throat. Describe the common therapeutic measures for ear, sinuses ,nose, throat. Explain the pathophysiology, etiology, clinical manifestation and treatment for ENT disorders. Assist in developing nursing care plans for patient with ENT disorders. 10/26/2018 2 ENT Disorders

3. Content Common condition of ear otitis media, mastoiditis Common condition of nose rhinitis, epistaxis, nasal obstruction and adenoidectomy. Common condition of throat- acute pharyngitis, acute follicular tonsillitis, peritonsillar abscess and laryngitis. Management of patient with laryngectomy and tracheostomy. 10/26/2018 3 ENT Disorders

4. Anatomy and physiology. Anatomy and physiology of the ear, sinuses ,nose, throat. 10/26/2018 4 ENT Disorders

5. 10/26/2018 5 ENT Disorders

6. Diagnostic Tests And Procedures for ENT

7. Diagnostic tests and procedures for throat Using a scope to get a closer look at throat. Or Removing a tissue sample for testing.   By procedures called endoscopy or laryngoscopy (biopsy) or fine-needle aspiration. Imaging tests.  including X-ray, computerized tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET), 10/26/2018 7 ENT Disorders

8. Therapeutic Measures Nose drops Nasal/throat irrigation Humidification Suctioning Tracheostomy Nasal surgery 10/26/2018 8 ENT Disorders

9. Common ENT presentations Ear problems ■ Impacted wax ■ Foreign body ■ Otitis externa ■ Otitis media ■ Mastoiditis ■ Furunculosis ■ Perforated tympanic membrane ■ Trauma Nose problems ■ Epistaxis ■ Foreign body ■ Trauma Throat problems ■ Viral tonsillitis ■ Acute bacterial tonsillitis ■ Peritonsillar abscess ■ Foreign body ■ Airway obstruction 10/26/2018 9 ENT Disorders

10. Prevention a list of ways to prevent ear infections: Avoid exposure to cigarette smoke. Identify and treat allergies. Keep your child’s immunizations up to date. Do not remove earwax unless your physician tells you to. a list of ways to prevent Sinus infections: If you have a cold, use a saline nasal spray (available over the counter) to keep your nasal passages from becoming blocked. Do not fly if you have a cold. If you must fly, consider use of a decongestant and nasal spray 30 minutes before take-off. Identify and treat allergies; long-term sinusitis is usually caused by allergies, while acute sinusitis is usually caused by bacteria. Try using saline nasal spray daily for chronic sinusitis 10/26/2018 ENT Disorders 10

11. Prevention of ENT disorder a list of ways to prevent sore throat infections: Get plenty of rest and exercise to bolster your immune system. Avoid exposure to cigarette smoke. Do not spend long periods of time outside when the air quality in your area is poor. Treat esophageal reflux. Generally Not all ENT disorders can be prevented. Many depend on inherited traits; however, following these suggestions may serve to keep you healthier in the future. Hand washing remains at the forefront of disease prevention, along with other isolation practices, including coughing in to your sleeve and staying at home while you are sick. These guidelines can also help strengthen your immune system, decreasing the likelihood of catching an illness and limiting the amount of time you spend sick. 10/26/2018 ENT Disorders 11

12. 1- Ear

13. Anatomy and physiology of the ear 10/26/2018 13 ENT Disorders

14. 10/26/2018 14 ENT Disorders

15. Assessment of the ear History The following issues should be included: Classic symptoms of ear disease: deafness, tinnitus, discharge (otorrhea), pain (otalgia) and vertigo. Previous ear surgery, or head injury. Family history of deafness. Systemic disease ( eg , stroke, multiple sclerosis, cardiovascular disease). Ototoxic drugs (antibiotics ( eg , gentamicin), diuretics, cytotoxics ). Exposure to noise ( eg , pneumatic drill or shooting). History of atopy and allergy in children. 10/26/2018 15 ENT Disorders

16. Physical assessment of the ear Inspecting the external ear Inspect the external ear before examination with an otoscope/ auriscope . Swab any discharge and remove any wax. Look for obvious signs of abnormality. Size and shape of the pinna. Extra cartilage tags/pre-auricular sinuses or pits. Signs of trauma to the pinna. Suspicious skin lesions on the pinna, including neoplasia. Skin conditions of the pinna and external canal. Infection/inflammation of the external ear canal, with discharge. Signs/scars of previous surgery. 10/26/2018 16 ENT Disorders

17. Diagnostic tests and procedures for ear Pneumatic otoscope Tympanometry.  This test measures the movement of the eardrum. To provides an indirect measure of pressure within the middle ear. Acoustic reflectometry.  This test measures how much sound emitted from a device is reflected back from the eardrum — an indirect measure of fluids in the middle ear. Normally, the eardrum absorbs most of the sound. However, the more pressure there is from fluid in the middle ear, the more sound the eardrum will reflect. Tympanocentesis .  Rarely,— a procedure called tympanocentesis .. Other tests. a hearing specialist (audiologist), speech therapist or developmental therapist for tests of hearing, speech skills, language comprehension or developmental abilities. 10/26/2018 17 ENT Disorders

18. Ears disorders Otitis media/acute Otitis media/chronic mastoiditis Otosclerosis Meniere’s disease 10/26/2018 18 ENT Disorders

19. Otitis Media 10/26/2018 ENT Disorders 19

20. Otitis Media Defined by presence of fluid in the middle ear accompanied by signs and symptoms of the illness. Peak incidence occurs in the first 3 yrs of life. The disease is less common in the school aged child,adolescent and adult. types of Otitis Media are two acute and chronic 10/26/2018 20 ENT Disorders

21. Acute Otitis Media Acute otitis media is an acute infection of the middle ear, usually lasting less than 6 weeks. The primary cause is the entrance of pathogenic bacteria into the normally sterile middle ear when there is Eustachian tube dysfunction due to obstruction caused by upper respiratory infections, inflammation of the surrounding structures (sinusitis) or allergic reactions( allergenic rhinitis ) . Causative organisms are streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis. Models of entry of the bacteria are the eustachian tube from contaminated secretions in the nasopharynx, and the middle ear from a tympanic membrane perforation. The disorder is the most common in children. 10/26/2018 21 ENT Disorders

22. Clinical Manifestations Symptoms vary with the severity of the infection and may be either mild and transient or severe; usually unilateral in adults. Pain in and about the ear (otalgia) may be intense and relieved only after spontaneous perforation of the eardrum or after spontaneous perforation of the eardrum or after myringotomy. Fever, drainage from the ear Tympanic membrane is erythematous and often bulging or perforated Conductive hearing loss due to exudate in the middle ear Even if the condition becomes subacute (3weeks to 3months) with purulent discharge, permanent hearing loss is rare. 10/26/2018 22 ENT Disorders

23. Complications Perforation of tympanic membrane may persist and develop into chronic otitis media Secondary complications involve the mastoid (mastoiditis ) meningitis, or brain abscess (rare) 10/26/2018 23 ENT Disorders

24. Management With early and appropriate broad-spectrum antibiotic therapy, otitis media may clear with no serious sequelae. If drainage occurs an antibiotic preparation may be prescribed Patient must take antibiotic as prescribed and must complete all the prescribed medication. Outcome depends on efficiency of antibiotic therapy, virulence of bacteria and physical status of patient. 10/26/2018 24 ENT Disorders

25. Myringotomy (tympanotomy) If mild cases of otitis media are treated effectively, a myringotomy may not be necessary. If it is an incision is made into the tympanic membrane to relieve pressure and to drain serous or purulent fluid from the middle ear. This painless procedure usually take less than 15 minutes. If episodes of acute otitis media recur and there is no contraindication, a ventilating pressure-equalizing tube may be inserted. 10/26/2018 25 ENT Disorders

26. Chronic Otitis media Chronic otitis media results from repeated episode of acute otitis media, causing irreversible tissue pathology and persistent perforation of the eardrum. Chronic infections of the middle ear cause damage to the tympanic membrane can destroy the ossicles and can involve the mastoid. 10/26/2018 26 ENT Disorders

27. Clinical Manifestations Symptoms may be minimal with varying degrees of hearing loss and a persistent or intermitted foul-smelling otorrhea (discharge) Pain may be present if acute mastoiditis occurs when mastoiditis is present, postauricular area is tender; erythema and edema may be present. Chloasmata (sac fluid with degenerated skin and sebaceous material) may be present as white mass behind the tympanic membrane visible through an otoscope. If untreated, the cholesteatoma continues to grow and destroys structures of the temporal bone, possibly causing damage to the facial nerve and horizontal canal and destruction of other surround structures. Auditory tests often show a conductive or mixed hearing loss. 10/26/2018 27 ENT Disorders

28. Medical Management Careful suctioning and cleansing of the ear are done under microscopic guidance. Antibiotic drops are instilled or antibiotic powder is applied to treat purulent discharge. Tympanoplasty procedures (myringoplasty and more extensive types) may be performed to prevent recurrent infection, reestablish middle ear function, close the perforation and improve hearing. Mastoidectomy may be done to remove cholesteatoma. Ossiculoplasty may be done to reconstruct the middle ear bones to restore hearing. 10/26/2018 28 ENT Disorders

29. Mastoiditis 10/26/2018 ENT Disorders 29

30. Mastoiditis Mastoiditis is an inflammation of the mastoid resulting from an infection of the middle ear (otitis media ). Since the discovery of antibiotics, acute mastoiditis has been rare. Chronic mastoiditis can lead the formation of cholesteatoma (ingrowth of the skin of the external layer of the eardrum into middle ear) if mastoiditis. 10/26/2018 30 ENT Disorders

31. Mastoiditis Causes mastoiditis most often develops as a result of a middle ear infection. Bacteria from the middle ear can travel into the air cells of the mastoid bone. Less commonly, a growing collection of skin cells called a cholesteatoma, may block drainage of the ear, leading to mastoiditis. 10/26/2018 31 ENT Disorders

32. Clinical Manifestation Pain and tenderness behind the ear (postauricular) Discharge from middle ear (otorrhea) Mastoid area that become erythematous and edematous Otoscopic evaluation of tympanic membrane reveals chelesteatoma . 10/26/2018 32 ENT Disorders

33. Mastoiditis Complications Mastoiditis complications may include: Facial paralysis Nausea, vomiting, vertigo (labyrinthitis) Hearing loss Brain abscess or meningitis Vision changes or headaches (blood clots in the brain)  10/26/2018 33 ENT Disorders

34. Mastoiditis Diagnosis Any earache with fever or posterior ear tenderness, redness or swelling should be evaluated by a doctor. The doctor will first look for infection inside the ear with otoscope. Mastoiditis is uncommon without a coinciding ear infection. A sample of the infected ear fluid should be collected for culture. If complicated, severe or chronic mastoiditis is suspected pt will be referred for a CT scan to image the mastoid area. If a pocket of fluid or pus is found anywhere (in the ear, neck, mastoid, spine) it will need to be drained and then cultured so antibiotics can be tailored to the bug found. 10/26/2018 34 ENT Disorders

35. Medical Management General symptoms are usually successful treated with antibiotics Occasionally myringotomy is required 10/26/2018 35 ENT Disorders

36. Surgical Management If recurrent or persistent tenderness, fever, headache and discharge from the ear are evident, mastoidectomy may be necessary to remove the cholesteatoma and gain access to diseased structures. 10/26/2018 36 ENT Disorders

37. Otosclerosis 10/26/2018 ENT Disorders 37

38. Otosclerosis Involves the stapes and is thought to result from the formation of new abnormal spongy bone especially around the oval window with resulting fixation of the stapes. The efficient transmission of sound is prevented because the stapes cannot vibrate and carry the sound as conducted from malleus and incus to the inner ear. Otosclerosisis more common in women and frequently hereditary and pregnancy may worsen it. 10/26/2018 ENT Disorders 38

39. Otosclerosis Clinical Manifestations One or both ears conductive or hearing loss Tinnitus Otoscopic reveals normal tympanic membrane Rinne test bone conduction is better than air conduction Audiogram confirms conductive hearing loss or mix loss especially low frequencies. 10/26/2018 ENT Disorders 39

40. Otosclerosis Medical Management Sodium fluoride can mature the abnormal spongy bone growth and prevent the breakdown of the bone tissue. Amplification with a hearing aid may help. 10/26/2018 ENT Disorders 40

41. Surgical Management Of Otosclerosis Stapedectomy or Stapedotomy 10/26/2018 ENT Disorders 41 Stapedectomy Stapedotomy

42. Meniere’s disease

43. 10/26/2018 ENT Disorders 43

44. Meniere’s disease Meniere’s disease is a disorder that affects the inner ear. The inner ear is responsible for hearing and balance. The condition causes vertigo, the sensation of spinning. It also leads to hearing problems and a ringing sound in the ear. Meniere’s disease usually affects only one ear. The National Institute on Deafness and Other Communication Disorders (NIDCD) estimates that 615,000 people in the United States have Meniere’s disease. Around 45,500 people are diagnosed each year. It’s most likely to occur in people in their 40s and 50s. 10/26/2018 ENT Disorders 44

45. Meniere’s disease causes The cause of Meniere’s disease isn’t known, but scientists believe it’s caused by changes in the fluid in tubes of the inner ear. Other suggested causes include autoimmune disease, allergies, and genetics. 10/26/2018 ENT Disorders 45

46. 10/26/2018 ENT Disorders 46

47. Meniere’s Disease Symptoms Meniere’s disease symptoms tend to come on as “episodes” or “attacks.” These symptoms include: vertigo, with attacks lasting anywhere from a few minutes to 24 hours loss of hearing in the affected ear tinnitus, or the sensation of ringing, in the affected ear aural fullness, or the feeling that the ear is full or plugged loss of balance headaches nausea, vomiting, and sweating caused by severe vertigo Someone with Meniere’s disease will experience at least two to three of the following symptoms at one time: vertigo hearing loss tinnitus aural fullness 10/26/2018 ENT Disorders 47

48. Meniere’s Disease Diagnostic Tests   A hearing test, or audiometry , is used to determine if you’re experiencing hearing loss. In this test, pt ’ll put on headphones and hear noises of a variety of pitches and volumes and Auditory brainstem response (ABR) test  checks the function of the hearing nerves and the hearing center in the brain. Balance tests are performed to test the function of inner ear.. The balance test most commonly used to test for Meniere’s disease is  electronystagmography (ENG) is done to measure the electrical activity in the inner ear. . Other tests like,  head MRI or a cranial CT scan to assess possible problems with brain. 10/26/2018 ENT Disorders 48

49. Meniere’s disease treatment Medications include antiemetic, or anti-nausea medication. a diuretic to help reduce the amount of fluid in your body. Your doctor can also inject medication into your inner ear by way of your middle ear to help reduce vertigo symptoms Physical therapy Vestibular rehabilitation exercises can improve symptoms of vertigo. These exercises help to train the brain to account for the difference in balance between of two ears. A physical therapist can teach pt these exercises. Surgery Most people don’t require surgery, but it’s an option for those who have severe attacks and haven’t had success with other treatments. An endolymphatic sac procedure is done to help decrease the production of fluid and promote fluid drainage in the inner ear. 10/26/2018 ENT Disorders 49

50. 2- Nose

51. Anatomy And Physiology Of The Nose 10/26/2018 51 ENT Disorders

52. 10/26/2018 52 ENT Disorders

53. Assessment/Examination of the nose Full nose examinations assess the function, airway resistance and occasionally sense of smell. It includes looking into the mouth and pharynx. Common symptoms of nasal disease include: Airway obstruction. Rhinorrhea (runny nose). Sneezing. Loss of smell (anosmia). Facial pain caused by sinusitis. Snoring (associated with nasal obstruction). 10/26/2018 53 ENT Disorders

54. Assessment of the nose/ History The following issues should be covered: Allergies/atopic disease. Smoking. Pets at home. Occupation. History of previous surgery. Previous trauma. General medical history. Seasonal or daily variation in symptoms. Inspection of the nose 10/26/2018 54 ENT Disorders

55. Examination of the Nose Inspection of the nose First look at the external nose. Ask the patient to remove any glasses. Look at the nose from the front and side for any signs of the following: Size and shape. Obvious bend or deformity: a deviated nose is often best looked at from above. Swelling. Scars or abnormal creases. Redness (evidence of skin disease). Discharge or crusting. Offensive smell. 10/26/2018 55 ENT Disorders

56. Common Condition Of Nose Rhinitis Epistaxis Nasal obstruction 10/26/2018 ENT Disorders 56

57. Rhinitis

58. RHINITIS Defined as inflammation of the nasal mucosa characterized by two or more of the following symptoms: nasal congestion anterior/posterior rhinorrhea sneezing itchy nose 10/26/2018 58 ENT Disorders

59. 10/26/2018 59 ENT Disorders

60. ALLERGIC RHINITIS occurs when these nasal symptoms are the result of IgE -mediated inflammation following exposure to an allergen Prevalence 400 million suffers worldwide > 20% of population in UK All ages are affected, peaks in teens Boys more affected than girls but equalizes after puberty Most will be managed at Primary Health Care level 30% of patients with AR have asthma The majority of patients with asthma have AR AR is a major risk factor for poor asthma control All patients with AR should be assessed for asthma 10/26/2018 60 ENT Disorders Immunoglobulin E ( IgE ) are antibodies produced by the immune system.

61. ALLERGIC RHINITIS AND OTHER COMORBIDITIES Up to 80% of patients with bilateral chronic sinusitis have AR Otitis media Conjunctivitis Lower respiratory tract infections Dental problems – malocclusion, discoloration Sleep disorders 10/26/2018 61 ENT Disorders

62. ALLERGIC RHINITIS (ARIA) Subdivided into intermittent (IAR) .v. persistent (PER) Severity classified as mild .v. moderate/severe Allergic Rhinitis and its Impact on Asthma (ARIA) 10/26/2018 62 ENT Disorders

63. ALLERGIC RHINITIS (ARIA) Symptoms 10/26/2018 63 ENT Disorders

64. DIAGNOSIS History and Examination Skin prick test Radio allegro absorbent tests (RAST)for specific IgE (Nasal allergen challenge) 10/26/2018 64 ENT Disorders

65. TREATMENT EDUCATION/ALLERGEN AVOIDANCE PHARMACOTHERAPY IMMUNOTHERAPY Others – Nasal douching SURGERY 10/26/2018 65 ENT Disorders

66. EDUCATION/ALLERGEN AVOIDANCE Explanation of disease, progress (typical progression of allergic),and it’s treatments Genetics Breastfeeding Parental smoking Allergen avoidance – primary/secondary 10/26/2018 66 ENT Disorders

67. PHARMACOTHERAPY Topical Nasal Treatments Corticosteroids Antihistamines Chromones Anticholinergics Decongestants Oral Treatments Antihistamines Corticosteroids Antileukotrienes Decongestants 10/26/2018 67 ENT Disorders

68. PHARMACOTHERAPY Itch/Sneezing Discharge Blockage Impaired Smell Sodium cromoglycate + + +/- - Oral Antihistamines +++ ++ +/- - Ipratropium bromide - +++ - - Topical Decongestants - - +++ - Topical Corticosteroids +++ +++ ++ + Oral Corticosteroids +++ +++ +++ ++ Antileukotrienes - ++ + +/- 10/26/2018 68 ENT Disorders

69. IMMUNOTHERAPY Involves repeated administration of an allergen extract to induce a state of immunological tolerance More effective in limited spectrum of allergies in particular seasonal pollen allergy Severe symptoms failing to respond to usual prognosis ( Px ) Subcutaneous injection/sublingual route Studies indicate that 3 years therapy necessary 10/26/2018 69 ENT Disorders

70. OTHER TREATMENTS Nasal douches - adjuvant to other treatments - studies indicate can be useful in children with seasonal rhinitis - pregnancy 10/26/2018 70 ENT Disorders

71. Allergic Rhinitis and its Impact on Asthma (ARIA) Recommendations Topical corticosteroids and oral antihistamines (non-sedating) form the mainstay of treatment The newer topical steroids e.g. Mometasone furoate and Fluticasone propionate were highest recommended Other drugs should only be considered as second-line treatment Immunotherapy in selected patients can be highly effective. 10/26/2018 71 ENT Disorders

72. Epistaxis

73. Epistaxis (NASAL BLEEDING) Epistaxis is agreek word meaning nose bleed. has been a part of the human experience from earliest times Hippocrates commented that holding pressure on the nose helped to abate bleeding. Kiesselbach and Little(1879) were the first to identify the nasal septum’s anterior plexus as a source of nasal bleeding. Pilz (1869) was the first to surgically treat epistaxis with arterial ligation 10/26/2018 73 ENT Disorders

74. Incidence Epistaxis, has been reported to occur in up to 60 percent of the general population. It has a bimodal distribution, with peaks at ages younger than 10 years and older than 50 years. Affected persons usually do not seek medical attention, particularly if the bleeding is minor or self-limited. In rare cases, however, massive nasal bleeding can lead to death. The incidence increases with advancing age, during the winter months, and is more common in males 10/26/2018 74 ENT Disorders

75. Common Nasal bleeding Sites 10/26/2018 75 ENT Disorders

76. Local causes Epistaxis digitorum (nose picking) &Trauma Foreign bodies Intranasal neoplasm or polyps Irritants (e.g., cigarette smoke) Medications (e.g., topical corticosteroids) Rhinitis, Sinusitis acute and chronic Septal deviation , Septal perforation Adenoids Vascular malformation or telangiectasia( spider veins) 10/26/2018 76 ENT Disorders

77. Systemic causes Hemophilia Hypertension Leukemia Liver disease (e.g., cirrhosis, Factor deficiency) Medications e.g., aspirin, anticoagulants, nonsteroidal anti-inflammatory drugs Platelet dysfunction & Thrombocytopenia Others Diffuse oozing, multiple bleeding sites, or recurrent bleeding may indicate a systemic process 10/26/2018 77 ENT Disorders

78. DO & DO NOT IN Epistaxis’s Nursing Interventions DO Put on protective gear, including gown, gloves, and goggles. Quickly assess the ABCs (airway, breathing, and circulation) and support them as indicated. Reassure the patient. * Ensure bedside suction is functioning properly. Provide an emesis basin and tissues. Tell her to spit blood into the basin if necessary. This helps prevent nausea and vomiting and lets you estimate the amount of bleeding. * Obtain vital signs and SpO2 level, and assess her breath sounds. Administer supplemental oxygen via facemask if needed. * Continue to monitor vital signs closely. * Assess for signs and symptoms of hemodynamic instability, including change in mental status, pallor, diaphoresis, hypotension, tachycardia, and tachypnea. 10/26/2018 78 ENT Disorders

79. DO & DO NOT IN Epistaxis’s Nursing Interventions If bleeding is significant, establish vascular access, place the patient on a cardiac monitor, and begin fluid resuscitation with a crystalloid solution, as ordered. Obtain specimens for blood work, including complete blood cell count and coagulation profile, as ordered. * Obtain a history about previous nosebleeds, other bleeding episodes, easy bruising, and medication use, especially use of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), antiplatelet agents, warfarin, and herbal products. * If bleeding persists, assist in preparing the epistaxis tray and a headlamp. Make sure lighting is adequate. Assist the healthcare provider as needed during the exam and treatment. Reassure the patient, monitor vital signs, and assess for hypoxia. 10/26/2018 ENT Disorders 79

80. DO & DO NOT IN Epistaxis’s Nursing Interventions * After bleeding is controlled, reassess the patient and provide oral care. * If packing is used, especially posterior packing, monitor for respiratory compromise. Tell the patient to report signs and symptoms of infection and teach her about any prescribed antibiotics. If she has posterior packing, she'll be admitted to the hospital. A patient with anterior packing will follow up with an ear, nose, and throat specialist as an outpatient. * Instruct the patient to avoid exerting herself, forcefully blowing her nose, or bending over during the first 24 hours. She should also avoid NSAIDs, alcoholic beverages, and smoking for 5 days. Tell her to apply water-soluble ointment to her lips and nostrils while packing is in place and to use a cool-mist room humidifier. Advise her to take steps to prevent constipation and straining, which increases the risk of more bleeding. 10/26/2018 80 ENT Disorders

81. DO & DO NOT IN Epistaxis DON'T  * Don't leave the patient unattended during epistaxis.  * Don't underestimate the amount of blood that can be lost from epistaxis 10/26/2018 81 ENT Disorders

82. Patient teaching for Epistaxis Firmly pinch the entire soft part of the nose just above the nostrils. Sit and lean forward (this will ensure that blood and other secretions do not go down your throat). Breathe through your mouth. Hold this position for 5 minutes. If bleeding continues, hold the position for an additional 10 minutes. If bleeding does not stop, go to the emergency department. 10/26/2018 82 ENT Disorders

83. Anterior nasal packing 10/26/2018 83 ENT Disorders A patient with anterior packing will follow up with an ear, nose, and throat specialist as an outpatient.

84. Post nasal packing 10/26/2018 84 ENT Disorders If packing is used, especially posterior packing, monitor for respiratory compromise. Tell the patient to report signs and symptoms of infection and teach her about any prescribed antibiotics. If she has posterior packing, she'll be admitted to the hospital.

85. How to avoid Epistaxis Avoid damaging the nose and excessive nose-picking. Seek medical treatment for any disease causing the nosebleeds. Get a humidifier if you live in a dry climate or at high altitude. 10/26/2018 85 ENT Disorders

86. Nursing care plan for Epistaxis Nursing diagnosis Risk for Bleeding Goal: minimize bleeding Expected Outcomes: No bleeding, vital signs within normal limits, no anemia. Interventions: Monitor the patient's general condition Monitor vital signs Monitor the amount of bleeding patients Monitor the event of anemia Collaboration with the doctor about the problems that occur with bleeding: transfusion, medication. 10/26/2018 86 ENT Disorders

87. Nursing care plan for Epistaxis Nursing diagnosis Ineffective airway clearance Goal : to be effective airway clearance Expected Outcomes : Frequency of normal breathing, no additional breath sounds, do not use additional respiratory muscles, dyspnea and cyanosis does not occur. Independent Assess the sound or the depth of breathing and chest movement. Rational: Decreased breath sounds may lead to atelectasis, Ronchi, and wheezing showed accumulation of secretions. Note the ability to remove mucous / coughing effectively Rational: bright lumpy or bloody sputum may result from damage to lungs or bronchial injury. Give Fowler's or semi-Fowler position. Rational: Positioning helps maximize lung expansion and reduce respiratory effort. Clean secretions from the mouth and trachea Rational: To prevent obstruction / aspiration. Maintain a fluid inclusion at least as much as 250 ml / day unless contraindicated. Rational: Helping dilution of secretions. Collaboration Give medication in accordance with the indications mucolytic, expectorant, bronchodilator. Rational: Mucolytic to reduce cough, expectorant to help mobilize secretions, bronchodilators reduce bronchial spasms and analgesics are given to reduce discomfort. 10/26/2018 87 ENT Disorders

88. Nursing care plan for Epistaxis Nursing diagnosis Acute pain Goa l: pain diminished or disappeared Expected Outcomes: Clients express the pain diminished or disappeared Clients do not grimace in pain Interventions: Assess client's level of pain Rational: Knowing the client's level of pain in determining further action. Explain the causes and consequences of pain to the client and his family. Rational: The causes and consequences of pain the client is expected to participate in treatment to reduce pain. Teach relaxation and distraction techniques. Rational: The client knows the distraction, and relaxation techniques can be practiced so as if in pain. Observation of vital signs and client complaints. Rational: Knowing the prevailing circumstances and conditions of client development. 10/26/2018 88 ENT Disorders

89. Nasal Polyps

90. Nasal Polyps Non – cancerous growth (benign) Develop on the lining of the passages at sinuses Growth : -small growth(may cause no problem) -big growth(cause many complications) -Come in many sizes and shapes. (1998-2010 Mayo Foundation for Medical Education and Research (MFMER), 20th February,2009) 10/26/2018 90 ENT Disorders

91. Incidence of Nasal Polyps Common in adult. Rare in children. 4 times are common in men than women. 1 and 20 out of every 1000 people will develop Nasal Polyp. 10/26/2018 91 ENT Disorders

92. Pathophysiology ENT Disorders 10/26/2018 92 Triggering Factors of Nasal Polyps

93. Symptoms of Nasal Polyps If pt have any symptoms, they may include: Stuffy or blocked nose Sneezing Postnasal drip Runny nose Facial pain Trouble with sense of smell Loss of taste Itching around the eyes Infections 10/26/2018 93 ENT Disorders

94. Treatment of Nasal Polyps Confirmation of nasal polyps by a nasal endoscope, may take a small sample (a biopsy) of the polyp. pt’ll probably start with a nasal corticosteroid spray to shrink or even get rid of nasal polyps In some cases Oral corticosteroids such as prednisone for a week. In general, medications such as antihistamines and decongestants aren’t great at managing nasal polyps. But pt may need antihistamines to control allergies or antibiotics if pt have an infection before pt start on steroids. If nasal sprays don’t work. In such cases, surgery may be an option where nasal telescope is used to removes nasal polyps. Surgery helps in most cases. It may be less effective if pt have nasal polyps, asthma, and aspirin sensitivity. If that’s medication may be more helpful. 10/26/2018 94 ENT Disorders

95. Prevention of Nasal Polyps Nurse need to educate the patient the following : Not everyone will be able to prevent nasal polyps. However, there are a few ways you may be able to help yourself. The strategies include the following: Follow your doctor’s instructions on taking your allergy and asthma medications. Avoid breathing airborne allergens or irritants that lead to inflammation of your nose and sinus cavities. Practice good hygiene. Use a humidifier in your home to help moisten your breathing passages. Use a saline nasal rinse or spray to remove allergens or other irritants that may cause nasal polyps. 10/26/2018 95 ENT Disorders

96. Care Of The Patient Undergo Nasal Surgery Assessment Pain, pressure, anxiety and dyspnea. Monitor vital signs to detect signs of excessive blood loss Number of dressings saturated and frequency of change. Bleeding from the nasal cavity may flow into throat and be swallowed although the dressing remains dry. Check back of throat for bleeding; be alert for frequent swallowing. Inspect vomitus and stool for blood (bright red or ‘’coffee ground ‘’ emesis and red, maroon or black stool). 10/26/2018 96 ENT Disorders

97. Care Of The Patient Undergo Nasal Surgery Nursing diagnosis : Decrease cardiac output Acute pain Impaired gas exchange Disturbed body image 10/26/2018 97 ENT Disorders

98. sinuses 10/26/2018 ENT Disorders 98

99. Anatomy and physiology of the sinuses. Sinuses Maxillary, frontal, ethmoid, and sphenoid The sinuses are spaces in the bones of the skull; they are lined with mucous membrane and filled with air. Maxillary, Frontal, Ethmoidal, sphenoidal 10/26/2018 99 ENT Disorders

100. Functions of Sinuses Speech Lighten the skull Drain tears from the eyes (nasolacrimal ducts) 10/26/2018 ENT Disorders 100

101. Sinusitis Sinusitis  is an inflammation, or swelling, of the tissue lining the  sinuses . Normally,  sinuses  are filled with air, but when sinuses become blocked and filled with fluid. Just a Cold … at First Sinusitis usually starts with inflammation triggered by a cold, allergy attack, or irritant. But it may not end there. Colds, allergies, and irritants make sinus tissues swell. 101

102. Sinusitis Etiology/pathophysiology of Sinusitis : 32 million people suffer from at least one episode of sinusitis each year. Most often the maxillary and frontal s inuses. Acute maxillary sinusitis may follow viral respiratory infection Most common organisms are: Staphylococcus pneumoniae . Haemophilus influenzae . Diplococcusand bacteroides

103. Sinusitis Predispose factors :   Common cold .  Allergic rhinitis   (swelling of the lining of the nose).   Nasal polyps   (small growths in the lining of the nose).   Deviated septum   (a shift in the nasal cavity).

104. Types of Sinusitis Here are different types of  sinusitis , including: Acute sinusitis : A sudden onset of cold-like symptoms such as runny, stuffy nose and facial pain that does not go away after 10 to 14 days. Acute sinusitis typically lasts 4 weeks or less. Subacute sinusitis:  An inflammation lasting 4 to 8 weeks. Chronic sinusitis : A condition characterized by sinus inflammation symptoms lasting 8 weeks or longer. Recurrent sinusitis :  Several attacks within a year . 104

105. Sinusitis Clinical manifestations/assessment Most people have a stuffy nose and pain or pressure in several locations around the face or teeth. (heaviness over the affected area) When maxillary sinuses affected, pain may seem like a toothache . There's usually a nasal discharge that may be yellow , green, or clear.

106. Sinusitis Clinical manifestations/assessment (continued) Fatigue Decreased sense of smell and/or taste, sore throat, bad breath, Purulent drainage from the nose. Headache is common, especially in the morning . Fever may be present; white blood cell count may be elevated. Cough in the chronic sinusitis 106

107. Sinusitis Complications : Meningitis, brain abscess Osteomyelitis Orbital cellulitis 107

108. Assessment and Diagnostic Findings: A careful history and physical examination are performed. There may be tenderness to palpation over the infected sinus area . The sinuses are percussed using the index finger, tapping lightly to determine if the patient experiences pain .

109. Assessment and Diagnostic Findings: Diagnostic tests Biopsy & Culture Sinus x-rays. Computed tomography scanning MRI Transillumination of the sinus: Otoscope with transillumination attachment Completely darken the room Decreased light transmission suggests  Sinusitis

110. Management of sinusitis Goals of Sinusitis Treatment Alleviate sinusitis symptoms. Keep the nasal passages draining. Reduce sinus inflammation. Eliminate the underlying cause of sinusitis. Reduce the frequency of sinusitis.

111. Management of sinusitis A ntibiotics N asal Decongestants A nti-histamines N asal steroid sprays  A nalgesics, and antipyretics T wice-daily hot showers I ncreased fluid intake H umidifier F unctional e ndoscopic s inus s urgery ( FESS ) for chronic sinusitis

112. 112

113. Management of sinusitis (duration) Clinical improvemement usually occurs within 48 to 72 hours of antimicrobial therapy. The antibiotic therapy should be continued for a minimum of 7 days after the symptoms' have disappeared The average duration of treatment should be 10 days and often 2 weeks.

114. Nursing Management Because the patient usually performs care measures for sinusitis at home, nursing management consists mainly of patient teaching. 114

115. Nursing diagnoses Infection Acute Pain related to Sinusitis Knowledge, deficient related to disease 115

116. Nursing Management The nurse instructs the patient and family members to: I ncreasing fluid intake A pplying local heat (hot wet packs). F ollowing the medication regimen. 116

117. Nursing Management (continued) The nurse teaches the patient how to promote sinus drainage by increasing the environmental humidity (steam bath, hot shower, and facial sauna), Instructions on the early signs of a sinus infection are provided and preventive measures. 117

118. Preventing Sinusitis 118

119. Preventing Sinusitis Keep sinuses moist -- use saline sprays, nasal lubricant sprays, or nasal irrigation often. Avoid very dry indoor environments. Avoid exposure to irritants , such as cigarette smoke or strong chemical odors.   119

120. 3. Throat

121. Anatomy and physiology of throat Throat includes esophagus, windpipe (trachea), voice box (larynx), tonsils and epiglottis.

122. Common condition of throat Acute pharyngitis Acute follicular tonsillitis Peritonsillar abscess Laryngitis Management of patient with : Laryngectomy Tracheostomy

123. Acute pharyngitis Acute pharyngitis is an inflammatory syndrome of the pharynx and/or tonsils caused by several different groups of microorganisms. Most common throat disorder Usually subsides in 3 to 10 days unless complications occur.

124. Etiology of Acute pharyngitis Viral or bacterial infection Beta-hemolytic streptococcus (15%to 20% of acute pharyngitis cases). Mononucleosis Streptococcus bacterial infections(in children) Candida  infection is common as a source of sore throat in immunocompromised individuals, including those undergoing chemotherapy or oropharyngeal irradiation for cancer.

125. Pathophysiology Acute pharyngitis results from infection and inflammation of the pharynx, the details of which are both pathogen- and host-specific. Most commonly the disease is localized to the pharynx alone, but rarely it may be part of a systemic infection (e.g., infectious mononucleosis, tularemia, or HIV).

126. Incidence of Acute pharyngitis Widespread among adults who: Live or work in dusty or dry environments. Uses their voice excessively Use tobacco or alcohol habitually Suffer from chronic sinusitis, persistent coughs, or allergies.

127. Clinical manifestations of Acute pharyngitis History Sore throat Slight difficulty swallowing Sensation of lump in the throat Content aggravating urge to swallow Headache Muscles and joint pain

128. Physical finding The following symptom complex carries a 40% to 60% positive predictive value for GAS pharyngitis.  Swollen, Pharyngeal exudates, flecked tonsils. Fever Lack of cough or rhinorrhea. Bacterial pharyngitis ( Acute inflamed throat with white patches and yellow follicles & strawberry red tongue, enlarged, tender cervical lymph nodes)

129. Test Results Lab (throat culture, rapid strep test & WBC) Imaging (CT allocate the abscess)

130. Risk Factors of Acute pharyngitis nasal colonization with group A Streptococcus (GAS) GAS-infected contact sexual activity or abuse ingestion of nondomestic meats immunocompromised host use of inhaled corticosteroids lack of immunization or vaccine failure chemotherapy or oropharyngeal irradiation for cancer

131. Complications Otitis media Sinusitis Mastoiditis Rheumatic fever Nephritis

132. Treatment of acute pharyngitis General (warm saline gargles, hospitalization for dehydration, elimination of the underlying cause & adequate humidification) Diet (adequate diet, avoidance of citrus juices, easy to swallow food) Activity (bed rest while febrile) Medications( anesthetic throat lozenges, analgesics as needed, antibiotics, antifungal agents, antipyretics and equine antitoxins) Surgical (abscess drainage)

133. Nursing consideration Nursing diagnosis (acute pain, fatigue, imbalance nutrition; less than body requirements, impaired oral mucous membrane or risk for deficient fluid volume) Outcomes (the pt will express feeling of increase comfort decreased pain, verbalizes importance of adequate daily calorie intake , maintain intact mucous membranes or maintain normal fluid volume ) Nursing interventions (administer medication as orders, throat culture as orders, instruct pt to use a warm saline gargles, encourage adequate oral fluid intake and perform meticulous moth care and maintain as restful environment

134. NURSING ALTER Examine the pt’s skin twice per day for rashes caused by drug sensitivity or could indicate a communicable disease)

135. Patient teaching Be sure to cover : Disorder, diagnostic test and treatment Importance of completing prescribed antibiotic therapy Adverse reactions to medications Avoidance of excessive exposure toair conditioning Smoking cessation Ways to minimize environmental sources of throat irritation Importance of throat cultures

136. Summary Hallmarked by acute onset of sore throat; the absence of cough, nasal congestion and discharge suggests a bacterial etiology. Rapid antigen detection tests allow immediate point-of-care assessment of group A  Streptococcus  (GAS) pharyngitis. The goal of treatment of GAS is to prevent acute rheumatic fever, reduce the severity and duration of symptoms, and prevent transmission. Acute pharyngitis is generally a self-limited condition with resolution within two weeks. Infected individuals are not, however, immune to reinfection with most etiologic pathogens. The only situation in which antibiotic prophylaxis to prevent GAS infections is recommended is for individuals with a history of rheumatic fever

137. Acute Follicular Tonsillitis

138. Acute Follicular Tonsillitis Inflammation of tonsils Common viral infection that’s mild and limited duration Common characteristics (sore throat, enlarge tonsils)

139. Etiology Acute Follicular Tonsillitis Acute tonsillitis Viral (50–80% of cases): adenovirus, EBV, CMV, HSV, rhinovirus, coronavirus, influenza, and parainfluenza virus , HIV Bacterial (15–30% of cases) Streptococcus pyogenes (most common) Rarely, Staphylococcus aureus, Streptococcus pneumoniae, Mycoplasma pneumoniae Recurrent tonsillitis and chronic tonsillitis: polymicrobial infections with aerobic bacteria (typically streptococci, staphylococci, Haemophilus influenzae) and anaerobic bacteria

140. Pathophysiology of Acute Follicular Tonsillitis The inflammation response to cell damage by viruses or bacteria results in hyperemia and fluid exudation. Incidence Commonly affects children between age 5 to 10 Tonsils tend to hypertrophy during childhood and atrophy after puberty.

141. Clinical Manifestations Sudden onset of symptoms Red and swollen pharynx, tonsillar exudates Fever, sore throat, dysphagia Painful, swollen cervical lymph nodes Foul breath If viral: headache, earache, nasal congestion, and cough Trismus and changes in voice quality indicate the formation of potentially life-threatening peritonsillar abscess Trismus : spasm of the jaw muscles, causing the mouth to remain tightly closed, typically as a symptom of tetanus.

142. Complications Chronic upper airway obstruction Sleep disturbance, sleep apnea Cor pulmonale Failure to thrive Eating or swallowing disorders Speech abnormalities Febrile seizures Otitis media Cardiac valvular disease Peritonsillar abscesses Glomerulonephritis Bacterial endocarditis Cervical lymph node abscesses

143. Diagnostic test Adults: assessment based on  Centor score (< 2 points makes  GAS  unlikely); microbiologic testing is indicated in patients that score > 3 points Tonsillar exudates (1 point) Cervical  adenopathy  (1 point) Fever  (1 point) No  cough  (1 point) Microbiologic testing   Confirmatory tests : rapid antigen detection test and/or throat culture Rapid  GAS  antigen detection test Throat swab allows simple and quick detection of group A  streptococcal  infection (highly specific, sensitivity 70–90%)  A negative test should be backed up by throat culture in children and adolescents Throat  culture : to identify pathogen and determine  antibiotic  sensitivity  Blood tests Inflammatory markers  (↑  CRP , ↑  ESR ,  leukocytosis ) Potential elevation of the  antistreptolysin O  titer

144. Treatment General goal (symptom relief) Diet (adequate fluid intake) Activity (rest as needed) Medications (aspirin or acetaminophen, antibiotics) Surgery (possible tonsillectomy )

145. Nursing considerations Nursing diagnosis (acute pain, anxiety, impaired swallowing, ineffective breathing pattern, risk for aspiration or risk for deficient fluid volume) Outcomes : pt will (express feeling of increase comfort and decrease pain, verbalize a decrease in anxiety, swallow without pain or aspiration, maintain effective breathing pattern, show no signs of aspiration, demonstrate adequate fluid intake and balance intake and output.

146. Nursing considerations Nursing interventions Encourage oral fluids Provide humidification Encourage gargling

147. Peritonsillar abscess

148. Peritonsillar abscess is a bacterial infection that usually begins as a complication of untreated strep throat or tonsillitis. It generally involves a pus-filled pocket that forms near one of tonsils.  most common in children, adolescents, and young adults. Affects more male than female

149. Causes of a peritonsillar abscess usually occur as a complication of tonsillitis. If the infection breaks out of a tonsil and spreads to the surrounding area, an abscess can form. Peritonsillar abscesses are becoming less common due to the use of antibiotics in the treatment of strep throat and tonsillitis. Mononucleosis( commonly referred to as mono ) can also cause peritonsillar abscesses , as well as tooth and gum infections . In much rarer cases, it’s possible for peritonsillar abscesses to occur without an infection. This is generally due to inflammation of the Weber glands . ( These glands are under tongue and produce saliva ).

150. Laryngitis

151. Laryngitis Laryngitis occurs when voice box or vocal cords become inflamed from overuse, irritation, or infection. Laryngitis can be acute (short-term), lasting less than three weeks. Or it can be chronic (long-term), lasting more than three weeks. Many conditions can cause the inflammation that results in laryngitis.

152. Etiology Viral infections similar to those that cause a cold Vocal strain, caused by yelling or overusing your voice Bacterial infections, such as diphtheria, although this is rare, in large part due to increasing rates of vaccination

153. Diagnostic test Laryngoscopy.   Biopsy.  

154. Clinical manifestations of Laryngitis laryngitis signs and symptoms can include: Hoarseness Weak voice or voice loss Tickling sensation and rawness of your throat Sore throat Dry throat Dry cough

155. Risk factors for laryngitis Having a respiratory infection, such as a cold, bronchitis or sinusitis Exposure to irritating substances, such as cigarette smoke, excessive alcohol intake, stomach acid or workplace chemicals Overusing of voice, by speaking too much, speaking too loudly, shouting or singing

156. Treatment Acute laryngitis often gets better on its own within a week or so. Self-care measures also can help improve symptoms. Chronic laryngitis treatments are aimed at treating the underlying causes, such as heartburn, smoking or excessive use of alcohol. Medications used in some cases include:(Antibiotics. Corticosteroids).

157. Prevention To prevent dryness or irritation to vocal cords: Don't smoke, and avoid secondhand smoke.   Limit alcohol and caffeine.  These cause to lose total body water. Drink plenty of water.  Fluids help keep the mucus in the throat thin and easy to clear. Avoid eating spicy foods.  Spicy foods can cause stomach acid to move into the throat or esophagus, causing heartburn or gastroesophageal reflux disease (GERD). Include whole grains, fruits and vegetables in your diet.  These foods contain vitamins A, E and C, and help keep the mucous membranes that line the throat healthy. Avoid clearing throat.  This does more harm than good. Avoid upper respiratory infections.  Wash own hands often, and avoid contact with people who have upper respiratory infections such as colds.

158. Laryngectomy Laryngectomy is the removal of the larynx and separation of the airway from the mouth, nose and esophagus. In a total laryngectomy, the entire larynx is removed. In a partial laryngectomy, only a portion of the larynx is removed

159. Tracheostomy Management 10/26/2018 ENT Disorders 160

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161. References Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 10th edition Mosby items and derived items © 2011, 2006, 2003, 1999, 1995, 1991 by Mosby, Inc., an affiliate of Elsevier Inc. Adibelli ZH, Songu M, Adibelli H ; Paranasal sinus development in children: A magnetic resonance imaging analysis. Am J Rhinol Allergy. 2011 Jan-Feb;25(1):30-5. doi : 10.2500/ajra.2011.25.3552. Sinusitis ; NICE CKS, October 2013 Snell RS, Lemp MA; Clinical Anatomy of the Eye (2nd ed.), 1998, chapter 6. Blackwell Science Fokkens W, Lund V, Mullol J ; European position paper on rhinosinusitis and nasal polyps 2007. Rhinol Suppl. 2007;(20):1-136. Ah-See KW, Evans AS ; Sinusitis and its management. BMJ. 2007 Feb 17;334(7589):358-61. Fagnan LJ ; Acute Sinusitis: A Cost-Effective Approach to Diagnosis and Treatment, American Family Physician (online), 1998 Woodson GE; Ear, Nose and Throat Disorders in Primary Care, WB Saunders, 2001 Hall & Colman's Diseases of the Ear, Nose and Throat (15th ed.); Burton M, Leighton S, Robson A, Russell J. Churchill Livingstone, 2001 10/26/2018 162 ENT Disorders