SUMMARY OF EAR, NOSE AND THROAT DISORDERS INCLUDING DEFINITION, CAUSES, CLINICAL FEATURES, COMPLICATIONS, MANAGEMENT AND NURSING CARE

Ear, nose, and throat (ENT) disorders are common conditions that affect essential sensory and respiratory functions. Ear disorders like otitis media, otitis externa, hearing loss, and Meniere’s disease present with pain, discharge, tinnitus, or vertigo. Nose disorders such as allergic rhinitis, sinusitis, epistaxis, and nasal polyps cause congestion, facial pain, sneezing, or bleeding. Throat disorders including tonsillitis, pharyngitis, laryngitis, and throat cancer manifest with sore throat, hoarseness, dysphagia, or fever. Complications include hearing impairment, airway obstruction, chronic infection, and systemic spread. Management involves appropriate drugs (antibiotics, antihistamines, analgesics), surgery (tonsillectomy, polypectomy), lifestyle modification, and nursing care focusing on comfort, prevention, and patient education.

1. EYE, EAR, NOSE AND THROAT (EENT)

2. UNIT NAME: ENT AND OPHTHALMIC NURSING   Purpose of the Course The purpose of this course is to provide the learner with knowledge, skills and attitudes in management of ophthalmological and ENT conditions Expected Learning Outcomes At the end of the course, the learner should be able to: Review the anatomy and physiology of the eye, ear, nose and throat. Describe the principles of ophthalmology and conduct an ophthalmologic assessment Manage common disorders of the eye using the nursing process. Provide health education to individuals and communities for prevention of eye disorders Explain principles of ENT nursing and their application Conduct ENT assessment Manage clients with ENT conditions

3. Anatomy Review of Ear External Ear Auricle or Pinna Helix and antihelix External auditory meatus Tragus Lobule Concha Auditory canal Leads from outer ear to middle ear---ending at tympanic membrane 2.5 cm long in adults, much shorter and more direct in infants and children Outer 2/3 is cartilaginous, inner 1/3 is bony Eustachian tube connects middle ear to nasopharynx—opens briefly to allow pressure equalization in middle ear---so TM can vibrate freely In infants' tube is wider, shorter, more horizontal Contains glands that produce cerumen Various degrees of hair

4. Assessment, anatomy review and disorders of the ears

5. The Middle Ear review cont … This is a small sinus located within the temporal bone, it is air filled and is bordered by the tympanic membrane and the oval window. Functions of the Middle Ear To transmit sound vibrations across the TM via the ossicles to the oval window of the inner ear. To help protect the auditory apparatus from intense vibrations. To help prevent rupture of the TM by helping to equalize the pressure on both sides of the TM (ET) Auditory Ossicles----vibrate to transmit sound Malleus (Hammer) Incus (Anvil) Stapes (Stirrup) May become ossified due to ageing process---leads to decreased hearing acuity

6. Inner Ear Inner ear structures Vestibule Semicircular canals Cochlea Inner ear functions Cochlea transmits sound to eighth CN (organ of hearing) Semicircular canals are involved in vestibular function---equilibrium and balance Sound is also transmitted by bone directly to the inner ear

7. CONT’ Eighth cranial nerve a. The cochlear branch of the nerve transmits neuro-impulses from the cochlea to the brain, where they are interpreted as sound. b. The vestibular branch maintains balance and equilibrium

8. Assessment of the Ear Ears: Includes inspection, palpation, hearing tests and the use of an otoscope 1. Subjective data : Difficulty hearing, earaches, drainage from the ears, dizziness, ringing in the ears, exposure to environmental noise, use of a hearing aid, medications being taken, history of ear problems or infections 2 . Objective data a. Inspect and palpate the external ear, noting size, shape, symmetry, skin color, and the presence of pain.

9. CONT’ Inspect the external auditory meatus for size, swelling, redness, discharge, and foreign bodies; some cerumen (earwax) may be present. 3. Auditory assessment a. Sound is transmitted by air conduction and bone conduction. b. Air conduction takes 2 or 3 times longer than bone conduction. c. Hearing loss is categorized as conductive, sensorineural, or mixed conductive and sensorineural

10. CONT’ d. Conductive hearing loss is caused by any physical obstruction to the transmission of sound waves. e. Sensorineural hearing loss is caused by a defect in the cochlea, eighth cranial nerve, or the brain itself. f. A mixed hearing loss is a combination of conductive and sensorineural hearing loss; it results from problems in both the inner ear and the outer ear or middle ear

11. Voice (Whisper) test a. Used to determine whether hearing loss has occurred b. One ear is tested at a time (the ear not being tested is occluded by the client). c. The nurse stands 1 to 2 feet (30 to 60 centimeters) from the client, covers his or her mouth so that the client cannot read the lips, exhales fully, and softly whispers 2-syllable words in the direction of the unoccluded ear; the client points a finger up during the test when the nurse’s voice is heard (a ticking watch may also be used to test hearing acuity) Failure to hear the sounds could indicate possible fluid collection and/or consolidation, requiring further assessment

12. WATCH TEST a. A ticking watch is used to test for high frequency sounds. b. The examiner holds a ticking watch about 5 inches (12.5 centimeters) from each ear and asks the client if the ticking is heard.

13. TUNING FORK TESTS a. Used to measure hearing on the basis of air conduction or bone conduction; includes the Weber and Rinne tests b. To activate the tuning fork, the nurse holds the base and lightly taps the tines against the other hand, setting the fork in vibration.

14. WEBER TEST Determines whether the client has a conductive or sensorineural hearing loss Stem of the vibrating tuning fork is placed in the midline of the client’s skull and the client is asked if the tone sounds the same in both ears or better in 1 ear The client hears the tone by bone conduction and the sound should be heard equally in both ears In conductive loss, the sound travels toward the impaired ear. In sensorineural loss, the sound travels toward the good ear

15. RINNE TEST Stem of the vibrating tuning fork is placed on the client’s mastoid process. When the client no longer hears the sound, the tuning fork is quickly inverted and placed near the ear canal; the client should still hear a sound. Normally the sound is heard twice as long by way of air conduction (AC) (near the ear canal) than by way of bone conduction (BC) (at the mastoid process); AC> BC. In sensorineural hearing loss, air conduction is heard longer than bone conduction, but it is not heard to be twice as long

16. CONT’ In conductive hearing loss, the bone conduction sound is longer than or equal to the air conduction sound

17. OTOSCOPIC EXAM Before performing an otoscopic exam and inserting the speculum, check the auditory canal for foreign bodies. Instruct the client not to move the head during the examination to avoid damage to the canal and tympanic membrane.

18. CONT’ The client’s head is tilted slightly away and the otoscope is held upside down as if it were a large pen; this permits the examiner’s hand to lay against the client’s head for support. In an adult, pull the pinna up and back to straighten the external canal. Visualize the external canal while slowly inserting the speculum. The normal external canal is pink and intact, without lesions and with varying amounts of cerumen and fine little hairs

19. CONT’ Assess the tympanic membrane for intactness; the normal tympanic membrane is intact, without perforations, and should be free from lesions. The tympanic membrane is transparent, opaque, pearly gray, and slightly concave. A fluid line or the presence of air bubbles is not normally visible. If the tympanic membrane is bulging or retracting, the edges of the light reflex will be fuzzy (diffuse) and may spread over the tympanic membrane.

20. CONT’ The otoscope is never introduced blindly into the external canal because of the risk of perforating the tympanic membrane.

21. DIAGNOSTIC TESTS FOR THE EAR Tomography 1. Description a. Tomography may be performed with or without contrast medium. b. Tomography assesses the mastoid, middle ear, and inner ear structures and is especially helpful in the diagnosis of acoustic tumors. c. Multiple radiographs of the head are obtained

22. CONT Interventions a. All jewelry is removed. b. Lead eye shields are used to cover the cornea to diminish the radiation dose to the eyes. c. The client must remain still in a supine position. d. No follow-up care is required. e. If contrast is to be used, assess for allergies or previous response to contrast.

23. AUDIOMETRY 1. Description Audiometry measures hearing acuity. Audiometry uses 2 types, pure tone audiometry speech audiometry. Pure tone audiometry is used to identify problems with hearing, speech, music, and other sounds in the environment. In speech audiometry, the client’s ability to hear spoken words is measured

24. CONT’ After testing, audiographic patterns are depicted on a graph to determine the type and level of the hearing loss. Interventions Inform the client regarding the procedure. Instruct the client to identify the sounds as they are heard

25. DISORDERS OF THE EAR Risk Factors for Ear Disorders Aging process Infection Medications Ototoxicity Trauma Tumors

26. CONDUCTIVE HEARING LOSS Description a. Occurs when sound waves are blocked to the inner ear fibers because of external or middle ear disorders b. Disorders often can be corrected with no damage to hearing or minimal permanent hearing loss.

27. CONT Causes Anti-inflammatory process or obstruction of the external or middle ear Tumors Otosclerosis A buildup of scar tissue on the ossicles from previous middle ear surgery

28. Conductive hearing loss Sensorineural hearing loss Mixed conductive sensorineural hearing loss tm ossicles pinna cochlea External ear Middle Inner ear Eight cranial nerve

29. SENSORINEURAL HEARING LOSS Description A pathological process of the inner ear or of the sensory fibers that lead to the cerebral cortex Sensorineural hearing loss is often permanent, and measures must be taken to reduce further damage.

30. CAUSES Damage to the inner ear structures Damage to the eighth cranial nerve or the brain itself Prolonged exposure to loud noise Medications Trauma

31. CONT’ Inherited disorders Metabolic and circulatory disorders Infections Surgery Meniere’s syndrome Diabetes mellitus Myxedema

32. MIXED HEARING LOSS Also known as conductive-sensorineural hearing loss The client has both sensorineural and conductive hearing loss Central hearing loss : Involves the inability to interpret sound, including speech, due to a problem in the brain

33. SIGNS OF HEARING LOSS Frequently asking others to repeat statements Straining to hear Turning the head or leaning forward to favor 1 ear Shouting in conversation Ringing in the ears

34. CONT’ Failing to respond when not looking in the direction of the sound Answering questions incorrectly Raising the volume of the television or radio Avoiding large groups Better understanding of speech when in small groups Withdrawing from social interactions

35. FACILITATING COMMUNICATION Using written words if the client is able to see, read, and write Providing plenty of light in the room Getting the attention of the client before beginning to speak Facing the client when speaking Talking in a room without distracting noises Moving close to the client and speaking slowly and clearly Keeping hands and other objects away from the mouth when talking to the client

36. CONT Talking in normal volume and at a lower pitch because shouting is not helpful and higher frequencies are less easily heard Rephrasing sentences and repeating information Validating with the client the understanding of statements made by asking the client to repeat what was said Reading lips.

37. CONT’ Encouraging the client to wear glasses when talking to someone to improve vision for lip reading Using sign language, which combines speech with hand movements that signify letters, words, or phrases Using telephone amplifiers Using flashing lights that are activated by ringing of the telephone or doorbell Using specially trained dogs to help the client be aware of sound and alert the client to potential danger

38. COCHLEAR IMPLANTATION Cochlear implants are used for sensorineural hearing loss. A small computer converts sound waves into electrical impulses. Electrodes are placed by the internal ear with a computer device attached to the external ear. Electronic impulses directly stimulate nerve fibers.

39. Hearing aids Used for the client with conductive hearing loss Have limited value for the client with sensorineural hearing loss, because they make sounds only louder, not clearer A difficulty that exists in the use of hearing aids is the amplification of background noise and voices

40. Assessing for hearing loss Speech deterioration: The person who slurs words or drops word endings, or produces flat-sounding speech, may not be hearing correctly. The ears guide the voice, both in loudness and in pronunciation Fatigue: If a person tires easily when listening to conversation or to a speech, fatigue may be the result of straining to hear False pride: often pretends to be hearing when he or she actually is not.

41. Indifference: depressed and disinterested in life Social withdrawal: withdraw from situations Insecurity:Lack of self-confidence and fear of mistakes Suspiciousness Indecision and procrastination Loneliness and unhappiness Tendency to dominate the conversation

42. Client Education Regarding a Hearing Aid Begin using the hearing aid slowly to adjust to the device Adjust the volume to the minimal hearing level to prevent feedback squealing Concentrate on the sounds that are to be heard and to filter out background noise Clean the ear mold and cannula per manufacturer’s instructions Keep the hearing aid dry

43. Client Education cont.. Turn the hearing aid off before removing from the ear to prevent squealing feedback; remove the battery when not in use Keep extra batteries on hand Keep the hearing aid in a safe place Prevent hairsprays, oils, or other hair and face products from coming into contact with the receiver of the hearing aid Instruct the client to keep the hearing aid in the proper environmental climate as recommended by the manufacturer in order to prolong the life of the device

44. Presbycusis Description A sensorineural hearing loss associated with aging The decreased ability to hear high-pitched tones that naturally begins in midlife as a result of irreversible inner ear changes Presbycusis leads to degeneration or atrophy of the ganglion cells in the cochlea and a loss of elasticity of the basilar membranes. Presbycusis leads to compromise of the vascular supply to the inner ear, with changes in several areas of the ear structure

45. Assessment Hearing loss is gradual and bilateral Client states that he or she has no problem with hearing but cannot understand what the words are Client thinks that the speaker is mumbling

46. Instruct the client that cotton-tipped applicators should not be inserted into the ear canal because their use can lead to trauma to the canal and puncture the tympanic membrane

47. Overview of topics Review of Ear structures Treatment Approach and Pharmacotherapy for: Otitis Media: Acute Otitis Media ( AOM ) Otitis Media with Effusion ( OME ) Otitis Externa ( OE )

48. Review of Ear Structures

49. External Ear: Pinna and Auditory Canal lead to the Eardrum. Site of Otitis Externa (OE). Middle ear: Between the Eardrum and the Oval window (where footplate of stapes connects to Cochlea/Semicircular Canals). Contains ossicles : malleus, incus, stapes. Also connects to the nasopharynx via the Eustacian tube. Site for Otitis Media - Acute Otitis Media (AOM) and Otitis Media with Effusion (OME) . Inner ear: Semicircular canals are responsible for balance, and cochlea is responsible for transmitting sound to the auditory nerve. Review of Ear Structures

50. Otitis Media (AOM, OME) and Otitis Externa (OE) Identification, diagnosis, and management of these conditions is essential to prevent the following: Permanent hearing loss Chronic or recurrent ear infections Mastoiditis Meningitis Speech or language delay

51. Types of Otitis: Arcangelo p. 218, table 18.1

52. Acute otitis media (AOM) AOM is an Acute infection of middle ear with pus buildup. After an upper respiratory infection (often viral), the inflammed mucus membranes swell and close the eustachian tube, preventing fluid drainage from the middle ear. Infection develops in the trapped fluid, usually caused by: Streptococcus pneumoniae (38% of infections), Haemophilus influenzae (27%), or Moraxella catarrhalis (10%). Less common are infections caused by group A Streptococcus (3%) and Staphylococcus aureus (2%).

53. Symptoms: Otalgia , ear pulling, URI, fever, vertigo, otorrhea , decreased hearing. Exam findings: Erythema and Bulging of tympanic membrane Decreased movement of tympanic membrane Blisters on tympanic membrane. Acute otitis media (AOM)

54. Diagnostic Criteria for AOM

55. Goals of Drug Therapy for Otitis Symptomatic pain relief: Acetaminophen, nonsteroidal anti-inflammatory drugs (AOM) Otic analgesic drops (OE) Appropriate and judicious use of antibiotics: Critical to prevent complications such as mastoiditis and hearing impairment (all otitis types). Prevention of future antimicrobial resistance. The increasing rates of antimicrobial resistance are a major cause of treatment failure of AOM and OE.

56. AOM vs Otitis Media with Effusion (OME) The PRESENCE of ALL THREE of these characteristics from the previous table usually identifies that otitis media is an acute infection (AOM) instead of a chronic effusion (OME): Sudden, abrupt onset of symptoms Presence of Middle Ear Effusion AOM Signs or Symptoms of Middle Ear Inflammation OME is NOT a bacterial infection so is NOT treated with antibiotics!

57. Otitis Media with Effusion (OME) Chronic Buildup of sterile fluid in middle ear due to prolonged eustachian tube blockage. Does not necessitate presence of acute infection. Can appear after appropriately treating AOM, or develop into AOM if bacteria gain access to middle ear. Symptoms: Hearing loss, fullness, “popping” with swallow or nose blowing. Exam findings: clear, yellow, or bluish fluid behind tympanic membrane TM may be retracted. Usually no erythema; not always bulging.

58. Antibiotic Therapy for AOM The current treatment process for AOM allows for juducious use of antibiotics by evaluating patient’s condition depending upon age and disease severity to determine whether antibiotics should be started immediately or whether an “Observation Period” of 48-72 hours should be used. AOM does not always require antibiotics.

59. CERTAIN diagnosis of AOM contains all three elements: Sudden, abrupt onset of symptoms, Middle Ear Effusion (bulging TM, fluid behind TM), AND Middle Ear Inflammation (erythema of TM or otalgia) Severe illness is defined as severe otalgia PLUS fever >102.2F Mild illness is certain AOM without severe otalgia /fever>102.2F Antibiotic Therapy for AOM: Definitions

60. With a CERTAIN diagnosis of AOM: Younger than age 6 months AND 6 months-2 years require antibiotic therapy. Over 2 years up to adults, if disease is severe then antibiotics required . If mild symptoms, may observe for spontaneous improvement without antibiotics over 48-72 hours. With an UNCERTAIN diagnosis of AOM: Younger than age 6 months still require antibiotics. 6 months-2 years, if disease is severe then antibiotics required . If mild illness, may observe for spontaneous improvement without antibiotics over 48-72 hours. Over 2 years up to adults: Recommend observe for improvement without antibiotics over 48-72 hours. Antibiotic Therapy for AOM

61. First-line therapy for mild illness: amoxicillin (80mg/kg/day in 2 divided doses) First-line therapy for severe illness: amoxicillin- clavulanate (90 mg/kg per day of amoxicillin, 6.4 mg/kg per day of clavulanate ; in 2 divided doses) Dosing is based on Amoxicillin component. Antibiotic Therapy for AOM: Penicillins

62. Patients who have a Non-type 1 Hypersensitivity = Rash only when given Penicillin in the past. May give cephalosporins : Cefdinir , Ceftriaxone, Cefpodoxime , cefuroxime. Patients who have Type 1 hypersensitivity = Anaphylaxis or hives when given Penicillin in the past. Avoid penicillins and their derivatives, including cephalosporins . Give Macrolides or Clindamycin ( lincosamide ) instead. Antibiotic Therapy for AOM: Penicillin Allergic

63. Antibiotic Therapy for AOM: Cephalosporins Mild AOM: cefdinir , cefpodoxime , or cefuroxime (all PO) Severe AOM: ceftriaxone (IM only) These 4 cephalosporins are structurally the least related to penicillins of all the cephalosporins , so are least likely to cause cross-sensitivity allergic reactions.

64. Azithromycin, Clarithromycin, Erythromycin Macrolides are not first-line therapy due to the increased risk of treatment failure; they are reserved for patients with a contraindication (type 1 hypersensitivity) to amoxicillin. The AAP recommends the use of: Azithromycin for a 5-day course (standard duration) Clarithromycin for a 10-day course Antibiotic Therapy for AOM: Macrolides

65. Patients with Severe AOM who have a type I reaction to penicillin or its derivatives may also/alternately receive clindamycin, a lincosamide antibiotic. The limitation of clindamycin is that it lacks activity against common pathogens such as H. influenzae or M. catarrhalis . Antibiotic Therapy for AOM: Clindamycin

66. AOM: Time Frame for Response to Drug Therapy Standard duration of Antibiotic Therapy: 10 days for patients younger than age 6 OR for severe AOM 5 to 7 days for patients age 6 and older OR for mild AOM *Exception: Azithromycin’s duration is only 5 days! AOM should improve within 2 to 3 days The patient should achieve complete resolution of symptoms after 7 days.

67. AOM: Reasons for Treatment Failure The presence of a resistant organism to initial therapy A viral infection that is unresponsive to antibiotic therapy Inadequate concentration of antibiotic in the middle ear Dose based on weight calculated too low, or overweight adult patient needing more than standard adult dose. Noncompliance with the prescribed regimen Also, always a possibility.

68. Recurrent AOM Recurrence: more than three episodes within 6 months or four episodes within 12 months. This is most commonly due to relapse (infection with the same organism) or reinfection (infection with a different organism). Recurrent AOM can be managed either by the placement of tympanostomy tubes or antibiotic prophylaxis . REFER to ENT specialist ( otorhinolaryngologist ) for tympanostomy

69. Prevention : Vaccinate . H. Influenza type B (HIB ), Pneumococcal, AND yearly Influenza. Prevent URIs with good nutrition, rest, hygiene. Surgical management of Chronic OM Myringoplasty can reconstruct the tympanic membrane and ossicles and improve conductive hearing loss. Mastoidectomy may be performed if the infection has spread to involve the mastoid bone. Patient Education - AOM

70. Otitis Externa (OE) Inflammation with or without infection of the outer ear canal. Common term “ Swimmer’s Ear ” is due to this often occuring in moist ear canals. 90% of cases are bacterial : Bacteria in OE differ from those found in otitis media because the flora of the external auditory canal is more similar to that of the skin: Staphylococcus epidermidis , S. aureus , Corynebacteria , and Propionibacterium acnes . 10% may be caused by fungus . Malignant OE is an invasive, serious infection caused by the gram-negative bacilli Pseudomonas aeruginosa .

71. Symptoms: Otalgia (ear pain), Otorrhea (watery/thick discharge from ear canal), redness and swelling of outer ear. Muffled hearing due to pressure/fullness Exam findings: Pain with movement of tragus (“ Tragal pain”), erythematous/swollen ear canal that is moist with white/yellow discharge. Otitis Externa (OE)

72. Otitis Externa (OE): To rule out concurrent otitis media: Visualize tympanic membrane (TM), which should move normally during pneumatic otoscopy . It is possible to have AOM and OE concurrently.

73. Goals of Drug Therapy for OE Eradicating the causative organisms. Decreasing the accompanying pain. Re-establishing an acidic environment in the external auditory canal. Clearing any obstructing debris or excess cerumen from the ear canal. Checking the integrity of the tympanic membrane and if manifestations of the infection have spread beyond the ear canal.

74. Use of topical, otic drops: astringents , antiseptics , antibiotics , steroids , or combination treatments Mild, uncomplicated OE resulting from prolonged exposure to water or humidity is treated topically with an antiseptic such as acetic acid or boric acid applied to the external canal. Acute OE warrants the use of an antimicrobial ototopical agent (drops). Drug Therapy for OE

75. FIRST LINE for OE: ciprofloxacin and ofloxacin otic drops These cover pseudomonas well and ALSO are effective for fungal causes. Comparable in efficacy to neomycin/ polymyxin B. Side effects: pruritis , site reaction, dizziness, earache, vertigo, rash. Not recommended for perforated ear drum, however less ototoxic than Aminoglycosides, and could be used if TM ruptured. Contraindications : Age < 1yo Drug Therapy for OE: Fluoroquinolone otic solution

76. SECOND LINE for OE: neomycin sulfate/ polymyxin B/hydrocortisone acetate ( Cortisporin ), a combination product. Side effects: superinfection, dermatitis, ototoxicity with prolonged use. Contraindications : Perforated ear drum! * VERY OTOTOXIC. Fungal infection Drug Therapy for OE: Aminoglycoside otic solution

77. Drug Therapy for OE: Asttringent /antibacterial/antifungal combinations THIRD LINE for OE: Acetic acid/propylene glycol/ ciacetate /hydrocortisone ( Vosol ) Acetic acid in aluminum sulfate ( Domeboro otic ) Side effects: ear discomfort Stop use if excessive discomfort. Contraindications : Perforated ear drum!

78. Order of Treatment for OE

79. Monitoring Patient Response: OE A gallium scan may be performed to ensure reduction in the inflammatory process. This is done by ENT. Cleaning the local affected area is needed, but extensive debridement can be reserved until the initial antibiotic therapy is completed. Have the patient return in approx. 1 week for Ear Lavage. Prevention is the key and plays a significant role in reducing the overall burden of illness. See next slide.

80. Patient Education - OE Procedure for instilling ear drops Nutrition/lifestyle changes Vaccinate for Prevention : HIB, pneumococcal, influenza. Complementary and alternative medications Instillation of a few drops of a 1:1 solution of white vinegar and rubbing alcohol before and after contact with water is good prophylaxis.

81. Foreign Bodies Objects inserted intentionally into the ear by adults or children to clean the external canal or relieve itching like peas, beans, pebbles, toys, and beads Insects may also enter the ear canal effects may range from no symptoms to profound pain and decreased hearing

82. Management Irrigation, suction, and instrumentation Foreign vegetable bodies and insects tend to swell; thus, irrigation is contraindicated. An insect can be dislodged by instilling mineral oil, which will kill the insect and allow it to be removed

83. Tympanic membrane perforation Perforation of the tympanic membrane is usually caused by infection or trauma During infection, the tympanic membrane can rupture if the pressure in the middle ear exceeds the atmospheric pressure in the external auditory canal

84. Management Tympanic membrane perforations heal spontaneously within weeks after rupture, some may take several months to heal In the case of a head injury or temporal bone fracture, a patient is observed for evidence of cerebrospinal fluid otorrhea or rhinorrhea

85. Surgical management Tympanoplasty (surgical repair of the tympanic membrane) is usually based on the need to prevent potential infection from water entering the ear or the desire to improve the patient’s hearing Closes the perforation permanently and improves hearing

86. Otosclerosis 1. Description A genetic disorder of the labyrinthine capsule of the middle ear that results in a bony overgrowth of the tissue surrounding the ossicles Otosclerosis causes the development of irregular areas of new bone formation and causes the fixation of the bones. Stapes fixation leads to a conductive hearing loss. If the disease involves the inner ear, sensorineural hearing loss is present

87. Bilateral involvement is common, although hearing loss may be worse in 1 ear. Nonsurgical intervention promotes the improvement of hearing through amplification. Surgical intervention involves removal of the bony growth causing the hearing loss. A partial stapedectomy or complete stapedectomy with prosthesis (fenestration) may be performed surgically.

88. Assessment Slowly progressing conductive hearing loss Bilateral hearing loss A ringing or roaring type of constant tinnitus Loud sounds heard in the ear when chewing Pinkish discoloration ( Schwartze’s sign) of the tympanic membrane, which indicates vascular changes within the ear Negative Rinne test Weber’s test shows lateralization of sound to the ear with the greatest degree of conductive hearing loss.

89. Fenestration Description Removal of the stapes, with a small hole drilled in the footplate; a prosthesis is connected between the incus and footplate Sounds cause the prosthesis to vibrate in the same manner as the stapes. Complications include complete hearing loss, prolonged vertigo, infection, and facial nerve damage.

90. Preoperative interventions Instruct the client in measures to prevent middle ear or external ear infections. Instruct the client to avoid excessive nose blowing.

91. Postoperative interventions Inform the client that hearing is initially worse after the surgical procedure because of swelling, and that no noticeable improvement in hearing may occur for as long as 6 weeks. Inform the client that the Gelfoam ear packing (if used) interferes with hearing but is used to decrease bleeding. Assist with ambulating during the first 1 to 2 days after surgery. Administer antibiotic, antivertiginous , and pain medications as prescribed. Assess for facial nerve damage, weakness, changes in tactile sensation and taste sensation, vertigo, nausea, and vomiting.

92. Postoperative interventions cont.. Instruct the client to move the head slowly when changing positions to prevent vertigo. Instruct the client to avoid persons with upper respiratory infections. Instruct the client to avoid showering and getting the head and wound wet. Instruct the client to avoid rapid extreme changes in pressure caused by quick head movements, sneezing, nose blowing, straining, and changes in altitude. Instruct the client to avoid changes in middle ear pressure because they could dislodge the graft or prosthesis.

93. INNER EAR DISORDERS

94. Introduction The term dizziness is used frequently by patients and health care providers to describe any altered sensation of orientation in space. Vertigo is defined as the misperception or illusion of motion of the person or the surroundings Most people with vertigo describe a spinning sensation

95. Mastoiditis Mastoiditis may be acute or chronic and results from untreated or inadequately treated chronic or acute otitis media The pain is not relieved by myringotomy Assessment Swelling behind the ear and pain with minimal movement of the head Cellulitis on the skin or external scalp over the mastoid process A reddened, dull, thick, immobile tympanic membrane, with or without perforation Tender and enlarged post-auricular lymph nodes Low-grade fever

96. Interventions Prepare the client for surgical removal of infected material Simple or modified radical mastoidectomy with tympanoplasty is the most common treatment Once infected tissue is removed, the tympanoplasty is performed to reconstruct the ossicles and tympanic membrane To restore normal hearing

97. Complications Damage to the abducens and facial cranial nerves; exhibited by an inability to look laterally (cranial nerve VI, abducens ) and A drooping of the mouth on the affected side (cranial nerve VII, facial) Meningitis Brain abscess Chronic purulent otitis media Wound infections Vertigo, if the infection spreads into the labyrinth

98. Postoperative interventions Monitor for dizziness. Monitor for signs of meningitis, as evidenced by a stiff neck and vomiting, and for other complications Prepare for a wound dressing change 24 hours postoperatively Monitor the surgical incision for edema, drainage, and redness Position the client flat with the operative side up as prescribed. Restrict the client to bed with bedside commode privileges for 24 hours as prescribed Assist the client with getting out of bed to prevent falling or injuries from dizziness With reconstruction of the ossicles via a graft, take precautions to prevent dislodging of the graft

99. MOTION SICKNESS Motion sickness is a disturbance of equilibrium caused by constant motion Clinical Manifestations sweating, pallor, nausea, and vomiting caused by vestibular overstimulation These manifestations may persist for several hours after the stimulation stops

100. Management Over-the-counter antihistamines used to treat vertigo, such as dimenhydrinate (Dramamine) or meclizine hydrochloride ( Bonine ), provide some relief Anticholinergic medications such as scopolamine patches : s/e dry mouth and drowsiness, avoid driving and operating heavy machinery

101. MÉNIÈRE’S DISEASE Ménière’s disease is an abnormal inner ear fluid balance caused by a malabsorption in the endolymphatic sac Can be due to blockage in the endolymphatic duct Endolymphatic hydrops , a dilation in the endolymphatic space, develops Either increased pressure in the system or rupture of the inner ear membranes occurs, producing symptoms of Ménière’s disease

102. Clinical Manifestations The syndrome is characterized by tinnitus, unilateral sensorineural hearing loss, and vertigo Symptoms occur in attacks and last for several days, and the client becomes totally incapacitated during the attacks. Initial hearing loss is reversible but as the frequency of attacks increases, hearing loss becomes permanent

103. Two subsets of the disease, known as atypical Ménière’s disease: cochlear and vestibular Cochlear Ménière’s disease is recognized as a fluctuating, progressive sensorineural hearing loss associated with tinnitus and aural pressure in the absence of vestibular symptoms or findings Vestibular Ménière’s disease is characterized as the occurrence of episodic vertigo associated with aural pressure but no cochlear symptoms

104. Causes Any factor that increases endolymphatic secretion in the labyrinth Viral and bacterial infections Allergic reactions Biochemical disturbances Vascular disturbance, producing changes in the microcirculation in the labyrinth Long-term stress may be a contributing factor

105. Assessment and Diagnostic Findings Feelings of fullness in the ear Tinnitus, as a continuous low-pitched roar or humming sound, that is present much of the time but worsens just before and during severe attacks Hearing loss that is worse during an attack Vertigo; that is, a sensation of whirling that might cause the client to fall to the ground Vertigo that is so intense that even while lying down, the client holds the bed or ground in an attempt to prevent the whirling Nausea and vomiting Nystagmus Severe headaches

106. Nonsurgical interventions Prevent injury during vertigo attacks Provide bed rest in a quiet environment Provide assistance with walking Instruct the client to move the head slowly to prevent worsening of the vertigo Initiate sodium and fluid restrictions as prescribed Instruct the client to stop smoking Instruct the client to avoid watching television because the flickering of lights may exacerbate symptoms Inform client about vestibular rehabilitation

107. Medical Management Adhering to a low-sodium (2,000 mg/day) diet Pharmacologic therapy Antihistamines such as meclizine ( Antivert ), which suppress the vestibular system Tranquilizers such as diazepam (Valium) may be used in acute instances to help control vertigo. Antiemetics such as promethazine (Phenergan) suppositories help control the nausea and vomiting and the vertigo because of their antihistamine effect Diuretic therapy ( eg , hydrochlorothiazide) sometimes relieves symptoms by lowering the pressure in the endolymphatic system Intake of foods containing potassium ( eg , bananas, tomatoes, oranges) is necessary if the patient takes a diuretic that causes potassium loss. Vasodilators, such as nicotinic acid, papaverine hydrochloride ( Pavabid ), and methantheline bromide ( Banthine ) have no scientific basis for alleviating the symptoms, but they are often used in conjunction with other therapies

108. Surgical interventions Surgery is performed when medical therapy is ineffective and the functional level of the client has decreased significantly Endolymphatic drainage and insertion of a shunt may be an option early in the course of the disease to assist with the drainage of excess fluids A resection of the vestibular nerve or total removal of the labyrinth (i.e., a labyrinthectomy ) may be performed.

109. Postoperative interventions Assess packing and dressing on the ear. Speak to the client on the side of the unaffected ear Perform neurological assessments. Maintain safety Assist with ambulating Encourage the client to use a bedside commode rather than ambulating to the bathroom. Administer antivertiginous and antiemetic medications as prescribed

110. DRUG OTOTOXICITY Many drugs can damage the inner ear. Some drugs differentially affect the cochlea, causing hearing loss and tinnitus, while others pick out the vestibular system, causing vertigo Aminoglycosides such as gentamicin are well known to be ototoxic, as are some diuretics such as furosemide, certain antimalarial drugs

111. Drug ototoxicity cont.. Many ear drops contain an aminoglycoside and are used regularly in treating ear infections There is a small risk of ototoxicity Short courses of such drops, are safe and effective Prolonged use of such drops in a perforated ear can cause permanent hearing loss and as such should be avoided

112. To prevent loss of hearing or balance, patients receiving potentially ototoxic medications should be: counseled about the side effects of these medications. Blood levels of the medications should be monitored patients receiving long-term intravenous antibiotics should be monitored with an audiogram twice each week during therapy

113. Vertigo Vertigo is an abnormal sensation of movement/spinning sensation Misperception or illusion of motion of the person or the surroundings When due to acute vestibular disease, this sensation is often rotary in nature Cardiac and neurological disorders may give symptoms that patients describe as ‘dizziness’ but are not actually vertiginous in nature

114. Vertigo cont.. Peripheral causes include the following: Labyrinthitis BPPV Ménière’s disease Endolymphatic hydrops from other causes Middle-ear diseases Post-ear surgery Post-trauma Vascular insufficiency Drugs Dead labyrinth from any cause

115. Vertigo cont.. Central causes include the following: Vestibular neuronitis Tumours , e.g. acoustic neuroma Multiple sclerosis Head injury Vascular occlusion Drug-induced

116. Vertigo cont.. Other causes of balance disturbance include the following: Cardiac insufficiency Cervical spine disease Neurological disorders Metabolic disorders, e.g. diabetes Anaemia Epilepsy Migraine.

117. BENIGN PAROXYSMAL POSITIONAL VERTIGO Brief period of incapacitating vertigo that occurs when the position of the patient’s head is changed with respect to gravity, typically by placing the head back with the affected ear turned down The onset is sudden and followed by a predisposition for positional vertigo, usually for hours to weeks but occasionally for months or years

118. BPPV cont … Caused by the disruption of debris within the semicircular canal This debris is formed from small crystals of calcium carbonate from the inner ear structure, the utricle. This is frequently stimulated by head trauma, infection In severe cases, vertigo may easily be induced by any head movement. The vertigo is usually accompanied by nausea and vomiting

119. Management of BPPV Bed rest is recommended for patients with acute symptoms. Canalith repositioning procedures (CRP) may be used to provide resolution of vertigo The Epley procedure is a repositioning technique that is safe, inexpensive, and easy to perform for these patients Meclizine for 1 to 2 weeks then reassesment after severe positional vertigo patients may be premedicated with prochloperazine (Compazine) 1 hour before performing the CRP

120. The Dix- Hallpike test is used to assess for BPPV When the Dix- Hallpike test results are positive on the right side, a left-sided CRP is used Vestibular rehabilitation

121. The Nose and Sinuses The nose warms and humidifies the air that we breathe. The sinuses are out- pouchings of the nose. Therefore, diseases that affect one often have secondary effects on the other. Most of the sinuses drain into the middle meatus. The eustachian tubes open into the postnasal space When these are affected by disease, a middle-ear effusion may occur and the patient will usually notice a deterioration in hearing

122. Anatomy review cont.. Internal nose Septum Choanae Turbinates -much surface area—helps to humidify and filter and warm the air Cribriform plates Kiesselbach plexus ( site of many nosebleeds) Adenoids (part of lymphoid immune system)

123. Anatomy review :Nose Structure External nose Bone and cartilage Nares Sinuses Maxillary Frontal Ethmoid Sphenoid

124. Rhinitis Rhinitis is a group of disorders characterized by inflammation and irritation of the mucous membranes of the nose It may be classified as nonallergic or allergic

125. Pathophysiology Nonallergic rhinitis may be caused by a variety of factors, environmental factors such as changes in temperature or humidity, odors, or foods; infection; age; systemic disease; drugs (cocaine) or prescribed medications; or the presence of a foreign body

126. Drug-induced rhinitis is associated with use of antihypertensive agents and oral contraceptives and chronic use of nasal decongestants

127. Clinical Manifestations rhinorrhea (excessive nasal drainage, runny nose) nasal congestion nasal discharge (purulent with bacterial rhinitis) nasal itchiness sneezing. Headache may occur, particularly if sinusitis is also present

128. Medical management Management of rhinitis depends on the cause History and physical examination Viral rhinitis : medications are given to relieve the symptoms In allergic rhinitis, tests may be performed to identify possible allergens Depending on the severity of the allergy, desensitizing immunizations and corticosteroids may be required Bacterial infection, an antimicrobial agent will be used

129. PHARMACOLOGIC THERAPY Medication therapy for allergic and nonallergic rhinitis focuses on symptom relief Antihistamines are administered for sneezing, itching, and rhinorrhea Oral decongestant agents are used for nasal obstruction Intranasal corticosteroids may be used for severe congestion ophthalmic agents are used to relieve irritation, itching, and redness of the eyes

130. Nursing Management Allergic rhinitis: avoid or reduce exposure to allergens and irritants, such as dusts, molds, animals, fumes, odors, powders, sprays, and tobacco smoke Saline nasal or aerosol sprays may be helpful in soothing mucous membranes, softening crusted secretions, and removing irritants

131. Nursing management To achieve maximal relief, the patient is instructed to blow the nose before applying any medication into the nasal cavity. In the case of infectious rhinitis, the nurse reviews with the patient hand hygiene technique as a measure to prevent transmission of organisms The nurse reviews the value of receiving a vaccination for high risk patients

132. The septum Septal deviation This may result from trauma, either during descent down the birth canal or from direct nasal trauma in later life Deviation of the septum, either at its caudal end ( columellar dislocation) or further back in the nasal cavity, can lead to symptomatic nasal obstruction

133. Septal surgery To correct deflection of the septum either by removing the deviated cartilage/bone (sub-mucous resection; SMR) or By mobilizing and repositioning the deviated cartilaginous septum ( septoplasty )

134. CASE STUDY DISCUSSION Tom is 3 years old and for the past week has had a runny nose, but only from the left side. Over the past couple of days, his mother has complained that he ‘smells awful’ and the discharge from the nose is now a little blood-stained. 1 What is the diagnosis? 2 How and when should he be treated?

135. Answers TO THE CASE STUDY 1 Tom has all the features of a foreign body in his nose. 2 The object must be removed, under general anaesthesia if necessary. There is a theoretical risk of inhalation of the object into the lower respiratory tract; therefore, the object should be removed as soon as this can be arranged

136. NASAL POLYPOSIS A nasal polyp is simply a descriptive term for a pedunculated swelling arising in the nose or paranasal sinuses Polyps may develop in both benign and malignant conditions An ulcerated or bleeding nasal polyp must be biopsied

137. Features of nasal polyposis Nasal obstruction Anosmia Anterior rhinorrhoea the diagnosis is usually easy to make on examination of the nose Simple polyps are usually seen bilaterally and tend to occupy the middle meatus because they arise within the ethmoid sinuses, which drain into this region of the nose. They are grey/white and often appear slightly translucent They are soft and mobile on gentle probing middle or inferior turbinates

138. Treatment Medical treatments antihistamines and nasal decongestants (used sparingly) Steroids In severe cases, a ‘medical polypectomy ’ Once polyps have been controlled, either by medical or surgical means, maintenance therapy with long-term inhaled steroids is recommended

139. Surgical treatments The surgical treatment for nasal polyps may consist of simple intranasal polypectomy ; in severe/ recurrent cases, it may be necessary to open the ethmoid sinuses to allow complete removal of the polyps This also has the effect of allowing the nasal steroids to enter this area easily after surgery. Such an ethmoidectomy may be performed through the nose or via an external approach.

140. EPISTAXIS causes of epistaxis are nose-picking and idiopathic causes Local causes include: idiopathic causes; trauma; infection; tumours . Systemic causes include: hypertension; use of anticoagulant drugs coagulopathy hereditary haemorrhagic telangiectasia (HHT

141. Due to its rich blood supply and propensity for digital trauma, the anterior septum is the most frequent site of bleeding

142. HOW TO STOP A NOSEBLEED (EPISTAXIS) Provoking factors From the history, consider, and where possible correct, the following provoking factors: Trauma Hypertension Non-steroidal anti-inflammatory drugs (NSAIDs) and anticoagulants Upper respiratory tract infections Clotting disorder.

143. CONT’ First aid Lean forward Pinch the fleshy part of the nose (not the bridge) for 10 min Avoid swallowing the blood Apply an icepack on the nasal bridge

144. Resuscitation Resuscitate as follows in cases of severe epistaxis: Assess blood loss. Assess pulse. Assess blood pressure. Gain intravenous access. Set up an intravenous infusion if the blood loss is great or if there is cardiovascular compromise. Take a full blood count. Assess coagulation. Group and save.

145. Further management Use a thudicum speculum or auroscope to examine Little’s area (anterior part of the septum) This is most often the site of bleeding. If a bleeding point is seen, spray the nose with 5% cocaine, lidocaine or another topical local anaesthetic and attempt nasal cautery If the bleeding is severe and no bleeding point is seen, then the nose will need to be packed

146. How to cauterize the nose Apply one or two cotton wool balls or a dental roll soaked in 1 : 200 000 adrenaline or 5% cocaine solution to the area and apply pressure for at least 2 min Use silver nitrate cautery sticks, which should be applied for 1–2 s at a time. Start a few millimetres from the bleeding point and work in a circle to cauterize any feeder blood vessels before attempting to cauterize the main bleeding point. Most anterior nose bleeds can be cauterized successfully with skill and patience. reapply the adrenaline or cocaine as above in order to reduce the blood flow between attempts at cautery. If unsuccessful, reapply pressure to stem the flow and pack the nose.

147. How to pack the nose Nasal packs are usually left in place for 24–48 hours. The packs must be secured anteriorly to prevent them prolapsing backwards into the airway Nasal tampons/balloons Consist desiccated compressed sponge that expands dramatically when inflated with any water-based fluid Require lubrication before insertion using chlorhexidine and neomycin cream Effective haemostasis is usually achieved and no other equipment is required

148. CONT’ Nasal balloons are also easy to use They are inserted in the same fashion as nasal tampons and inflated within the nose, thus putting pressure on the bleeding point

149. HOW TO PACK THE NOSE Bismuth iodIne and paraffin paste It consists of a length of ribbon gauze impregnated with a mixture of antiseptics It is effective if inserted properly, but considerable skill is required to place correctly and it can cause marked trauma to the nasal lining A thudicum speculum is inserted and the gauze is placed in a layered fashion into the nasal cavity using Tilley’s dressing forceps. Topical anaesthetic and vasoconstrictive spray are essential.

150. CONT’ Posterior packing or Foley urinary catheter When used in combination with an anterior nasal pack, a Foley urinary catheter is effective for severe nosebleeds. The catheter is passed to the nasopharynx , inflated and then pulled anteriorly so that it lodges in the posterior choana . Its position is maintained by using a clamp at the nasal vestibule This must be cushioned to prevent pressure necrosis of the nasal inlet. An anterior pack is also required with this method. In all cases, pack the side that is actively bleeding first. If bleeding continues, pack the other side as well; this splints the septum and may achieve haemostasis .

151. CONT’ Severe epistaxis may require examination of the nose under anaesthesia , with diathermy, PNS packing or even ligation of the maxillary, anterior ethmoidal or external carotid arteries

152. Foreign Bodies In The Nose The following features may accompany a foreign body in the nose: Unilateral foul-smelling nasal discharge Unilateral nasal obstruction Unilateral vestibulitis Epistaxis.

153. Management Ask child to blow nose, if able. If the foreign body is soft or has a thin free edge, then it may be grasped and removed with crocodile or Tilley’s forceps If the foreign body is solid and round, then it is best removed using a Jobson Horne probe that has been bent slightly at the tip Pass the probe beyond the foreign body and draw slowly towards you An auroscope is often best for examining a child’s nose

154. ACUTE SINUSITIS Acute sinusitis is an infection of the paranasal sinuses It frequently develops as a result of an upper respiratory infection, such as an unresolved viral or bacterial infection, or an exacerbation of allergic rhinitis

155. PATHOPHYSIOLOGY Nasal congestion, caused by inflammation, edema, and transudation of fluid, leads to obstruction of the sinus cavities This provides an excellent medium for bacterial growth. Bacterial organisms account for more than 60% of the cases of acute sinusitis, namely Streptococcus pneumoniae, Haemophilus influenzae , and Moraxella catarrhalis Dental infections also have been associated with acute sinusitis.

156. CLINICAL MANIFESTATIONS facial pain or pressure over the affected sinus area Nasal obstruction Fatigue Purulent nasal discharge Fever Headache Ear pain

157. CONT’ Fullness Dental pain Cough A decreased sense of smell Sore throat Eyelid edema or facial congestion or fullness

158. LARYNGITIS Laryngitis , an inflammation of the larynx, often occurs as a result of voice abuse or exposure to dust, chemicals, smoke, and other pollutants, or as part of an upper respiratory tract infection It also may be caused by isolated infection involving only the vocal cords

159. LARYNGITIS CONT.. The cause of infection is almost always a virus. Bacterial invasion may be secondary Associated with allergic rhinitis or pharyngitis onset may be associated with exposure to sudden temperature changes, dietary deficiencies, malnutrition, and an immunosuppressed state

160. CLINICAL MANIFESTATIONS Hoarseness or aphonia (complete loss of voice) Severe cough Chronic laryngitis is marked by persistent hoarseness Laryngitis may be a complication of upper respiratory infections

161. Medical Management Acute laryngitis includes: resting the voice avoiding smoking Resting inhaling cool steam or an aerosol If extensive or severe antibacterial therapy is instituted

162. CONT’ In chronic laryngitis, the treatment includes: Eliminating any primary respiratory tract infection Eliminating smoking Resting the voice Avoiding second-hand smoke Topical corticosteroids, such as beclomethasone dipropionate ( Vanceril inhalation, may also be used to reduce inflammmation

163. Nursing Management Rest the voice Maintain a well-humidified environment If Laryngeal secretions are present during acute episodes, expectorant agents are suggested, along with a daily fluid intake of 3 L to thin secretions

164. Epiglottitis Bacterial form of croup Inflammation of the epiglottis occurs, which may be caused by Haemophilus influenzae type b or Streptococcus pneumoniae; children immunized with H. influenzae type b ( Hib vaccine) are at less risk for epiglottitis Occurs most frequently in children 2 to 8 years old , but can occur from infancy to adulthood Onset is abrupt , and the condition occurs most often in winter Considered an emergency situation because it can progress rapidly to severe respiratory distress

165. Assessment High fever Sore, red, and inflamed throat (large, cherry red, edematous epiglottis) and pain on swallowing Absence of spontaneous cough Dysphonia (muffled voice), dysphagia, dyspnea, and drooling Agitation

166. Assessment Retractions as the child struggles to breathe Inspiratory stridor aggravated by the supine position Tachycardia Tachypnea progressing to more severe respiratory distress (hypoxia, hypercapnia , respiratory acidosis, decreased level of consciousness) Tripod positioning: While supporting the body with the hands, the child leans forward, thrusts the chin forward and opens the mouth in an attempt to widen the airway

167. Interventions Maintain a patent airway. Assess respiratory status and breath sounds, noting nasal flaring, the use of accessory muscles, retractions, and the presence of stridor Do not measure the temperature by the oral route. Monitor pulse oximetry Maintain NPO (nothing by mouth) status Do not leave the child unattended. Avoid placing the child in a supine position because this position would affect the respiratory status further

168. Interventions cont.. Do not restrain the child or take any other measure that may agitate the child Administer intravenous (IV) fluids as prescribed; insertion of an IV line may need to be delayed until an adequate airway is established because this procedure may agitate the child

169. Interventions cont.. Administer IV antibiotics as prescribed; these are usually followed by oral antibiotics Administer analgesics and antipyretics (acetaminophen or ibuprofen) to reduce fever and throat pain as prescribed Administer corticosteroids to decrease inflammation and reduce throat edema as prescribed

170. Interventions cont.. Nebulized epinephrine (racemic epinephrine) may be prescribed for severe cases (causes mucosal vasoconstriction and reduces edema); heliox (mixture of helium and oxygen) may also be prescribed to reduce mucosal edema. Provide cool mist oxygen therapy as prescribed; high humidification cools the airway and decreases swelling Have resuscitation equipment available, and prepare for endotracheal intubation or tracheotomy for severe respiratory distress

171. Caution If epiglottitis is suspected, no attempts should be made to visualize the posterior pharynx, obtain a throat culture, or take an oral temperature Otherwise, spasm of the epiglottis can occur, leading to complete airway occlusion

172. Foreign bodies in the throat A carefully taken history will often give the diagnosis. Features of oropharyngeal foreign bodies include: symptoms that usually come on straight away, not a few hours or days later; Bones, usually fish, chicken or lamb; Pricking sensation or pain on every swallow; dysphagia Drooling Stridor (rare) Point tenderness in the neck or pain on gently rocking the larynx from side to side.

173. CONT’ If the patient localizes it to above the thyroid cartilage, especially to one side, look carefully at the tongue base and tonsil. Perform lateral soft tissue X-rays of the neck (Figure 13.7) and look for foreign bodies at the common sites (tongue base and posterior pharyngeal wall). Soft-tissue swelling alone is suggestive. Air in the upper esophagus is suggestive of an esophageal foreign body Remember that small flecks of calcification around the thyroid and cricoid cartilages are quite common.

174. MANAGEMENT Use a good light source (torch or head-mirror). Use lidocaine spray to anaesthetize the throat. Use your finger to see if you can feel a foreign body, even if you cannot see one. Use Tilley’s forceps for foreign bodies in the mouth or tonsil. Use McGill intubating forceps for foreign bodies in the tongue base or pharynx. Lie the patient flat, extend the neck and use an intubating laryngoscope to lift the tongue forward.

175. COMPLICATIONS There is potential for inflammation/infection around an impacted foreign body, leading to abscess formation or perforation of the esophagus. Acute airway problem

176. Tonsillitis & Tonsillectomy

177. Describe the manifestations of tonsillitis Describe the medical management of a child with tonsillitis State the indications for tonsillectomy Describe the surgical management of a child with tonsillitis The nursing management pre and post operatively. OBJECTIVES

178. Masses of lymphoid tissue in the pharyngeal cavity. Provide protection for respiratory and alimentary tracts from pathogenic organisms. Have an antibody formation role Are larger in children than in adolescents and adults. TONSILS

179. Several pairs of tonsils surround the nasal and oral pharynx The palatine tonsils located on either side of the oropharynx . The pharyngeal tonsils, or adenoids , located above the palatine tonsils on the posterior wall of the nasopharynx. CONT

180. The main function of tonsils is to trap germs (bacteria and viruses) which we may breathe in. Proteins called antibodies produced by the immune cells in the tonsils help kill germs and help prevent throat and lung infections. Therefore, has role in our immune system. FUNCTIONS OF TONSILS

181. Anatomy of tonsils

182. Tonsils are the two lymph nodes located on each side of the back of our throat. They function as a defense mechanism. They help prevent our body from infection. When the tonsils become infected, the condition is called tonsillitis. CONT’

183. Often occurs with pharyngitis Is a common cause of morbidity in young children because of the frequency of URIs. Causative agent may be Viral or bacterial. TONSILLITIS

184. Dry, irritated mucous membranes of the oropharynx due to mouth breathing May develop offensive mouth odor, impaired senses of taste and smell. Persisted cough Blockage of eustachian tubes by swollen adenoids, interfering with normal drainage may lead to: Otitis media Difficulty in hearing. MANIFESTATIONS OF TONSILLITIS

185. Medical treatment In most cases, Viral Pharyngitis – symptomatic treatment. Early rapid tests for Throat swab (+ ve for Group A- β .Strep infection), antibiotics. THERAPEUTIC MANAGEMENT

186. Surgical treatment - Tonsillectomy Indicated: Documented cases of recurrent, frequent streptococcal infection, History of development of peritonsillar abscess. Several studies have shown that a tonsillectomy is an effective treatment for children with frequently recurring tonsillitis (chronic tonsillitis). Therapeutic management

187. Is the removal of the palatine tonsils where massive hypertrophy results in difficulty in breathing or eating. Tonsillectomy

188. Generally, the removal of tonsils should not occur until 3 or 4 years of age. Problem of excessive blood loss Possibility of regrowth. Absolute indications include: Malignacy Obstruction of the airway that can result in cor pulmonale. TONSILLECTOMY

189. Removal of the adenoids is recommended for children with hypertrophied adenoids that obstruct nasal breathing May be performed without tonsillectomy ADENOIDECTOMY

190. Follow-up after adenoidectomy should include: Assessment of hearing, smell and taste for expected improvement. ADENOIDECTOMY

191. Cleft palate – both tonsils can help minimize escape of air during speech. Acute infections at the time of surgery, risk of bleeding from inflamed tissues, Uncontrolled systemic diseases CONTRAINDICATIONS TO EITHER TONSILLECTOMY & ADENOIDECTOMY

192. Pre-operatively Complete history including any bleeding tendencies Baseline vital signs for post op monitoring and observation Bleeding and clotting time plus other lab work requests Note and report signs of URI General pre-op care for any other patient NURSING CARE

193. Post-op Child placed on abdomen or side to facilitate drainage, till fully awake to prevent aspiration Vital signs monitoring Suction machine and oxygen be nearby Careful suctioning, if need be, to avoid trauma to oropharynx When alert, may prefer sitting, but should remain in bed Provision of comfort NURSING CARE

194. Minimize activities that might precipitate bleeding. Discourage from coughing frequently, clearing the throat, blowing the nose, or doing anything that may aggravate the operative site. Inspect all secretions/vomitus for evidence of fresh bleeding. Analgesic for first 24 hours at regular intervals/ antipyretic drugs NURSING CARE

195. Soft to liquid diet started on first or second post-op day. Observe throat directly for evidence of bleeding. Observe child for signs of hemorrhage – pulse >120, pallor, frequent clearing the throat or continuous swallowing, vomiting bright red blood, low BP a late sign of shock Surgery may be required to ligate any bleeding vessels NURSING CARE

196. Observe for signs of respiratory distress, eg stridor, drooling, restlessness, agitation, tachypnoea and progressive cyanosis. Warm salt water gaggles may promote comfort. NURSING CARE

197. Educate parents on: avoidance of irritating foods, discouraging child from coughing, limiting child's activity, etc , as haemorrhage may occur up to 10 days post-op. If any sign, to urgently seek medical attention. They need not worry in case of some slight ear pain, low grade fever, and mouth odor that may occur. NURSING CARE

198. PERITONSILLAR ABSCESS (QUINSY) Peritonsillar abscess is the most common infective complication of tonsillitis The infection spreads to the tissues lateral to the tonsil, and an abscess develops. The features include the following: Due to the laterally based swelling, the tonsil is pushed medially There is characteristic displacement of the uvula from the midline and towards the unaffected side The patient is generally more unwell than with simple tonsillitis Drooling and fetor occur Trismus (pain on opening the mouth) is a prominent feature due to inflammation of the pterygoid muscles.