Primary Care - Ear, Nose, and Throat Conditions PDF

NUR 7575 - Acute Ear, Nose, and Throat Conditions in Primary Care Ear Conditions Throat Conditions Nose Conditions 1 of 3 Ear Conditions Ear Pathophysiology Bones (ossicles): Malleus, incus, and stapes. Tympanic membrane TM: Appears as translucent off- white to gray color with th...

NUR 7575 - Acute Ear, Nose, and Throat Conditions in Primary Care Ear Conditions Throat Conditions Nose Conditions 1 of 3 Ear Conditions Ear Pathophysiology Bones (ossicles): Malleus, incus, and stapes. Tympanic membrane TM: Appears as translucent off- white to gray color with the cone of light intact. Pinna: Has a large amount of cartilage Tragus: Small cartilage flap of tissue that is on front of the ear. Cartilage: Found on the nose and ears. Does not regenerate. Refer injuries to plastic surgeon. Cerumen: Ear wax, color can range from yellow to dark brown Acute Otitis Externa Also known as Swimmer’s Ear Inflammation or infection of the external ear canal, the auricle, or both. Etiology Excessive moisture Bacterial: Pseudomonas (most common), Staphylococcus, Streptococcus Fungal: Aspergillus (most common), Candida albicans  Risk factors Prolonged exposure to water (swimming), hear aid use, ear bud use, absence of cerumen, diabetes, trauma to external canal OE Assessment Findings Pain with movement (traction of the pinna elicits pain is hallmark sign of OE) Edema and redness in external ear canal Discharge and/or flaky debris in ear canal Itching in external ear canal Normal tympanic membrane OE Treatment Pharmacologic Important to know which ear drops can and cannot be used when tympanic membrane is NOT intact Otic antibiotic with steroid combination effectively treats infection and decreases inflammation Hydrocortisone/neomycin/polymycin B (Cortisporin) Ciprofloxacin/dexamethasone (Ciprodex): product is sterile and may be used with ruptured TM Tobramycin/dexamethasone (TobraDex): may be used with ruptured TM Ofloxacin (Floxin): can be used in patients over 12 years with ruptured TM, over 6 months with intact TM Antifungals as needed Oral antibiotics reserved for severe cases May need to use ear wick if canal extremely edematous Click the play button below to view the video. YOUTUBE  Ear Wick Placement Job Aid - Final Ear Wick Placement Job Aid - Final Uploaded by NWP CME on 2017-01-06. VIEW ON YOUTUBE  OE Prevention Avoid prolonged exposure to warm, humid conditions (swimming, hot tubs, shower, bath) Dry ears after showering, profuse perspiration, and swimming Dry the ear with a hair dryer set on low heat. Position dryer 1 foot away and direct air for 1 minute Do not place objects in the ear that may cause trauma to the external auditory canal trauma (cotton swabs, paper clips, toothpicks, pen caps)  OTC Swimmer’s Ear drops (isopropyl alcohol ear drying drops), home mixture of vinegar, rubbing alcohol, water) Treat eczema before it affects the external auditory canal Otitis Media Acute Otitis Media (AOM) Otitis Media with Effusion (OME) Middle ear inflammation that causes bulging or full tympanic Fluid accumulation in the middle membrane (TM) associated with ear without evidence of infection. middle ear effusion. Ear infection. Etiology: viruses/bacteria, Strep Etiology: After AOM infection pneumoniae most common, H. resolves but fluid remains, influenzae, rhinovirus, influenza, eustachian tube dysfunction, can RSV  turn into infection if fluid sits in middle ear Assessment: Assessment: Rapid onset of ear pain Feeling of fullness in ear Fever Diminished hearing Distorted TM landmarks, displaced light reflex, Dull TM decreased TM mobility Decreased mobility of TM, Cloudy, dull, opaque, or retracted erythematous TM Visible air bubbles Moderate to severe bulging TM Acute Otitis Media Otitis Media with Effusion Otitis Media Treatment Otitis Media with Acute Otitis Media (AOM) Effusion (OME) Amoxicillin is 1st treatment for any age group. Oral decongestants 2nd line: oral Augmentin, Cefdinir are effective Steroid nasal spray against beta lactamase-producing strains of bacteria. Long-acting oral antihistamine Azithromycin 1st line for patients allergic (Type 1) to penicillin. Treat pain with oral analgesic (acetaminophen or ibuprofen). Treat eustachian tube dysfunction (becomes swollen due to inflammation and cannot drain) with NSAID Patients with AOM and TM tubes: antibiotic otic drops (Ciprodex otic, Floxin otic) Ear Tubes Discuss tympanostomy tubes with parents when child experiences 3 episodes of AOM in 6- month period or 4 episodes in 12-month period or persistent OME with hearing loss. Perforated TM Makes middle ear vulnerable to infections L treat with otic antibiotic drops, keep ear dry (avoid submerging ear in water), nothing in ear, avoid pressure (blowing nose). S/S: pain that suddenly resolves, mucus, blood or puss on pillow, ear drainage. Causes: infection, acoustic trauma, objects, barotrauma, head trauma Pneumatic Otoscopy Otoscope with an insufflator to visualize TM and measure compliance Gold standard for diagnosis of middle ear effusion (TM does not move with gentle application of positive or negative pressure with insufflator. Type A- Normal curve, normal pressure in middle ear with normal movement of TM Type B- Flat curve, can present with effusion, perforated TM, patent ear tubes, cerumen impaction Type C- Retracted curve, significant negative pressure in middle ear. May suggest resolving AOM or eustachian tube dysfunction Mastoiditis Infection of the mastoid bone Usually caused by middle ear infection that results in damage to mastoid bone and pus- filled cysts. Symptoms: redness, swelling, and tenderness around the bone. Fever and ear pain. Refer for CT scan, possible IV antibiotics, hospitalization  Hearing Assessment Click through the slides for information on 3 different types of hearing assessments.  Step 1 Whisper test Examiner stands at arm’s length behind the patient. The opposite ear is occluded by patient or examiner. The examiner exhales and whispers a combination of numbers and letters (3). If heard correctly-passes. If heard incorrectly repeat and if passes by correctly hearing 3 out of 6 of the number, letter combinations, then passes.  Step 2 Weber Test Performed by striking the tuning fork and placing it midline on the forehead and asking the patient if the tone is equal in both ears. Place tuning fork midline on the forehead. Normal finding: No lateralization. Abnormal finding: lateralization present=patient hears sound only in one ear indicating sensorineural (inner ear) hearing loss.  Step 3 Rinne Test Performed by striking the tuning fork and placing it midline on the forehead and asking the patient if the tone is equal in both ears. Place tuning fork midline on the forehead. Normal finding: No lateralization. Abnormal finding: lateralization present=patient hears sound only in one ear indicating sensorineural (inner ear) hearing loss. Complete 2 of 3 Throat Conditions Acute Pharyngitis Oral Pathophysiology Buccal mucosa: Mucosal lining inside the mouth, pink to dark pink and moist Soft palate: Refers to the area where uvula, tonsils, anterior of throat are located Hard palate: Roof of mouth Salivary glands: Parotic, submandibular, and sublingual. Can become infected or blocked. Tonsils: Also known as the palatine tonsils, made up of lymphoid tissue., butterfly shaped gland with small pore-like openings that can secrete exudate Normal adult has 32 teeth Streptococcal Pharyngitis Acute infection of the pharynx and/or tonsils caused by group A streptococcal bacteria (Streptococcus pyogenes). Centor criteria (clinical decision tool used to help diagnose strep): Tonsillar exudate, tender anterior cervical adenopathy, history of fever, absence of cough. Suspect viral etiology if cough and symptoms such as stuffy nose, rhinitis with clear mucus, and watery eyes (coryza). CENTOR CLINICAL PREDICTION RULE (CENTOR SCORING) Streptococcal Pharyngitis Assessment Common in children and adults around children Presents with abrupt onset of fever, sore throat, pain with swallowing, enlarged submandibular lymph nodes, anterior lymphadenopathy and tenderness, may be exudate (yellow, green) on tonsils. Examination: Pharynx dark pink to bright red Adults usually afebrile or with mild fever Tonsillar exudate Petechiae on the hard palate Anterior cervical lymph nodes mildly enlarged Rapid antigen testing (RADT) “rapid strep test” or throat culture Streptococcal Pharyngitis Treatment First line Oral Penicillin V 500 mg BID to TID x 10 days Alternative Amoxicillin 500 mg BID x 10 days Penicillin allergy Azithromycin (Zpak) x 5 days Throat pain and fever Ibuprofen or acetaminophen Throat pain Saltwater gargles, throat lozenges May return to work or school 24 hours after antibiotic initiated (considered not contagious) New toothbrush 24 hours after antibiotic initiated Strep Throat Complications Scarlet fever (Scarlatina):  Sandpaper-textured pink rash with sore throat and strawberry tongue (red, sore tongue). Rash starts on the head and neck and spreads to the trunk, then to the extremities. Next, the skin desquamates (peels off). Increased risk of rheumatic fever Acute rheumatic fever: Inflammatory reaction to strep infection that may affect the heart and the valves, joints, and the brain. Fever Painful and tender joints — most often in the knees, ankles, elbows and wrists Pain in one joint that migrates to another joint Red, hot or swollen joints Small, painless bumps (nodules) beneath the skin Chest pain, fatigue Flat or slightly raised, painless rash with a ragged edge Jerky, uncontrollable body movements Peritonsillar abscess: Displaced uvula, red bulging mass on one side of anterior pharyngeal space, dysphagia, fever. Increased saliva, drooling, muffled “hot potato” voice Refer to Emergency Department due to risk of airway closing Poststreptococcal glomerulonephritis: Abrupt onset of proteinuria, hematuria, dark-colored urine, and RBC casts (urine) accompanied by hypertension and edema. Strep Throat Complications Scarlet fever (Scarlatina): Sandpaper-textured pink rash with sore throat and strawberry tongue (red, sore tongue). Rash starts on the head and neck and spreads to the trunk, then to the extremities. Next, the skin desquamates (peels off). Increased risk of rheumatic fever Acute rheumatic fever: Inflammatory reaction to strep infection that may affect the heart and the valves, joints, and the brain. Fever Painful and tender joints — most often in the knees, ankles, elbows and wrists Pain in one joint that migrates to another joint Red, hot or swollen joints Small, painless bumps (nodules) beneath the skin Chest pain, fatigue Flat or slightly raised, painless rash with a ragged edge Jerky, uncontrollable body movements Peritonsillar abscess: Displaced uvula, red bulging mass on one side of anterior pharyngeal space, dysphagia, fever.  Increased saliva, drooling, muffled “hot potato” voice Refer to Emergency Department due to risk of airway closing Poststreptococcal glomerulonephritis: Abrupt onset of proteinuria, hematuria, dark- colored urine, and RBC casts (urine) accompanied by hypertension and edema. Mononucleosis Infection by the Epstein-Barr Virus (EBV) Presents similarly to viral and strep pharyngitis (acute symptoms, not prolonged) More common in 15 to 24 years. Mainly shed through saliva. “kissing disease” Classic triad of fever, pharyngitis, and lymphadenopathy (50%) prolonged fatigue (several weeks and may last months) enlarged cervical lymph nodes (may be tender) enlarged tonsils with white exudate After acute infection, EBV lies latent in the oropharyngeal tissue and can be reactivated and cause symptoms. Monospot (heterophile antibody) test Hepatomegaly (20%) and splenomegaly (50%) of patients. Avoid vigorous palpation of the abdomen. Ruptured spleen is a catastrophic event. Acute stages limit physical activity, no contact sports or weightlifting for 4 weeks due to risk of splenic rupture. Order abdominal ultrasound if splenomegaly/hepatomegaly is present. Repeat abdominal US in 4- 6 weeks if abnormal to document resolution. Treat symptoms (may use oral steroids for tonsillar edema, lidocaine gargle, analgesics). If concern of airway obstruction refer to emergency department for high-dose steroids. Up to 90% of people with mono who take amoxicillin will break out with a “nonallergic” generalized maculopapular rash. Avoid using amoxicillin for patients with mono and strep because it causes a generalized rash not related to allergy. (may use Penicillin VK (if not allergic) or macrolide antibiotic). 3 of 3 Nose Conditions Acute Bacterial Rhinosinusitis Maxillary and frontal sinuses are most commonly affected after history of viral URI “common cold” or allergic rhinitis flare. Fluid is trapped inside the sinuses, causing secondary bacterial infection (S. pneumoniae, H. influenzae). Symptoms of unilateral facial pain or upper molar pain (maxillary sinus) or frontal sinus pain with nasal congestion for 10 days or longer with purulent (dark yellow-to-green) nasal and/or postnasal drip. Hyposmia (reduced ability to smell) Postnasal drip cough worsens when supine and may interfere with sleep Self-treatment with OTC cold and sinus remedies provides no relief of symptoms Examination Posterior pharynx purulent postnasal drip Sinuses tender to palpation on front cheek (maxillary) and/or frontal sinus area above the inner canthus of the eye Fever Transillumination of frontal and maxillary sinus ”positive” if glow of light on infected sinus is duller than on normal sinus Transillumination of Sinuses Darken room Maxillary: place a bright light source directly on the surface of the cheek (maxillary sinus) Frontal: place light under the supraorbital ridge in the medial aspect Instruct patient to open mouth Look at roof of mouth (hard palate) for a round glow of light Compare both sides. The affected sinus has no glow or duller glow compared to the normal sinus Acute Bacterial Rhinosinusitis Treatment Treat with antibiotics if symptoms present for longer than 10 days or have worsened, severe symptoms (toxic, high fever, pain, purulent nasal discharge 2-3 days or longer), patient is immunocompromised. 1st line Adults: Amoxicillin-clavulanate (Augmentin) BID x 7 days (educate regarding GI side effects) Children: Amoxicillin 90mg/kg/day Penicillin allergy: Levofloxacin (tendon rupture) or doxycycline (discolor tooth enamel, not pregnant), cefdinir (Omnicef), cefuroxime (Ceftin) Pain or fever Ibuprofen or acetaminophen  Drainage Oral decongestants such as pseudoephedrine (Sudafed) or pseudoephedrine combined with guaifenesin (Mucinex D) Topical decongestant Afrin-limit use to 3 days maximum to avoid rebound congestion Saline nasal spray (Ocean Spray) Steroid nasal spray (Flonase ) Mucolytic (guaifenesin) and increased fluids to thin mucus Cough Dextromethorphan (Robitussin) Benzonatate (Tessalon Perles): do not crush or chew. Toxic for children < 10 years. Swallow pills with water. Acute Bacterial Rhinosinusitis Complications Preorbital or orbital cellulitis (more common in children): Swelling and redness at periorbital area, double-vision or impaired vision, and fever. May have abnormal EOM or altered LOC or mental status changes. Concern of abscess formation Refer to ED for hospitalization..  Meningitis: Acute onset of high fever, stiff neck, severe headache, photophobia, toxic. Positive Brudzinski’s (passively flex/bend the patient’s neck toward the chest, positive if patient reflexively flexes the hips and knee to relieve pressure and pain) or Kernig’s sign (flex hips one at a time, attempt to straighten leg while keeping hip flexed at 90 degrees, positive if resistance due to painful hamstring due to inflammation of lumbar nerve roots) and/or back pain. Refer to ED. Cavernous sinus thrombosis: Acute headache, abnormal neurologic exam, confusion, fever. Life-threatening emergency with high mortality. Refer to ED. Allergic Rhinitis Inflammatory changes of the nasal mucosa due to allergy Presentation: Chronic or seasonal nasal congestion with clear mucus rhinorrhea or postnasal drip Cough due to postnasal drip worse when supine Nasal, throat, eye itching, watery eyes, sneezing Nasal, throat, eye itching, watery eyes, sneezing Examination Pale, boggy turbinates Rhinorrhea clear, PND clear to yellow and thick (if green r/o sinusitis) Undereye dark circles “racoon eyes”  Children may have transverse nasal crease from frequent rubbing “allergic salute” Posterior pharynx may show cobblestoning Allergic Rhinitis Treatment First line Nasal steroid sprays daily OTC fluticasone (Flonase), triamcinolone (Nasacort) If only partial relief, topical antihistamine nasal spray azelastine (Astelin) If no relief, combination product azelastine and fluticasone (Dymista) Decongestants PRN (pseudoephedrine, Sudafed)  Oral antihistamine PRN. Second generation less sedating: cetirizine (Zyrtec), loratadine (Claritin) Eliminate environmental allergens Complications Acute sinusitis Acute otitis media Rhinitis medicamentosa: Prolonged use of nasal decongestants (>3days) causes rebound effects that result in severe and chronic nasal congestion (Afrin). Epistaxis Anterior nasal bleeds are more common than posterior (more serious and can lead to severe hemorrhage). Risks: Aspirin use, NSAIDS, cocaine abuse, severe hypertension, and anticoagulant use. Most episodes are self-limiting. Presentation: acute onset of nasal bleeding, bright-red blood may drip externally through the nasal passages and/or the posterior pharynx. Profuse bleeding can lead to vomiting blood. Treatment  Apply direct pressure on the front of the nose for several minutes. Use of nasal decongestant to shrink tissue helps stop bleeding. Apply triple antibiotic ointment or petroleum jelly in front of nose using cotton swab for a few days (if trauma i.e.. Nose picking). Cauterization via chemical silver nitrate or electrical device applied to nasal mucosa. Can be done in office with local anesthetic. References Ball, J., Dains, J., Flynn, J.A., Solomon, B.S., Stewart, R.W. (2023). Seidel’s physical examination handbook: An interprofessional approach (10th ed.). St. Louis, MO: Mosby Bunik, M., Hay, W., Levin, M. & Azbug, M. (2023). Current Diagnosis and Treatment Pediatrics (26th ed.). McGraw Hill. Hollier, A. (2021). Clinical guidelines in primary care (4th edition). Advanced Practice Education Associates. Dunphy, L.M., Winland-Brown, J.E., Porter, B.O., & Thomas, D.J. (2021). Primary Care: Art and science of advanced practice nursing (6th edition). Philadelphia, PA: F.A. Davis. Leik, M. (2021). Family nurse practitioner certification intensive review (4th ed.). New York: Springer Publishing. Papadakis, M., Rabow, M., McQuaid, K., Gandhi, M. (2024). Current Diagnosis and Treatment 2025 (64th ed.). McGraw Hill.