Nurs 422 Ent Disorders PDF

NURS 422 ENT DISORDERS Dr D.K. Sani Department of Nursing Science, Ahmadu Bello University, Zaria. DISORDERS OF THE EAR Structure of the Ear  Ear Infection Otitis externa, Otitis media Mastoiditis  Otitis externa Inflammation or infection of the ext...

NURS 422 ENT DISORDERS Dr D.K. Sani Department of Nursing Science, Ahmadu Bello University, Zaria. DISORDERS OF THE EAR Structure of the Ear  Ear Infection Otitis externa, Otitis media Mastoiditis  Otitis externa Inflammation or infection of the external auditory canal, the auricle, or both. Similar to other infection of skin and soft tissue. This could be: 1. Acute localised 2. Acute diffuse 3.Chronic 4.Malignant  Causes S. aureus Corynebacteria Streptococcus pneumoniae Haemophilus influenza Moraxella catarrhalis Pseudomonas aeruginosa Varicella-zoster virus Fungi -trachomatis, mycoplasma  Clinical Manifestations Acute localised otitis externa - pustule or furuncle with hair follicles - Haemorrhagic bullae on the canal and tympanic membrane. - Adenopathy in the lymphatic drainage  Clinical Manifestations Acute diffuse otitis externa - Itchy and painful. - Red and oedematous canal Chronic otitis externa Due to irritation of drainage from the middle. - Severe Itching  Malignant otitis externa: Infection that extends into the deeper tissues occurs primarily in immunocompromised adults (eg, diabetics, HIV/AIDS)  Treatment Depends on presentation; - Topical - Systemic antibiotics - Incision and drainage.  Otitis Media Infection or inflammation and presence of fluid in the middle ear. It could be: - Acute otitis media, or - Otitis media with effusion.  Associated factors Associated with; - Immunosuppression - Poor breastfeeding - Anatomical changes- cleft palate, cleft uvula, submucous cleft  Clinical manifestations Specific eg ear pains, ear discharge, hearing loss Non specific eg fever, irritability, tinnitus, lethargy.  Treatment Systemic antibiotics - Amoxicillin clavulanate, cefuroxime, cefixime, erythromycin. Oral and nasal decongestants given alone or in combination with antihistamine-may relieve obstruction of the eustachian tube.  Chronic otitis media Recurrent episodes of acute infection and prolonged duration of middle ear effusions. This can be managed surgically by Myringotomy- incision of the tympanic membrane, adenoidectomy, and insertion of tympanostomy tubes  Mastoiditis The proximity of the mastoid to the middle ear cleft suggests that most cases suppurative otitis media are associated with inflammation of the mastoid air cells. Hyperaemia, oedema, serous then purulent exudate collects in the cells Bone necrosis due to pressure of the exudate.  Clinical manifestations Acute mastoiditis is usually accompanied by acute infection in the middle ear. Specific features of mastoiditis include swelling, redness and tenderness over the mastoid bone, pinna is displaced outward and downward, and a purulent discharge may be seen after perforation of the tympanum.  Clinical manifestations Chronic otitis media with mastoiditis can erode through the roof of the antrum causing temporal lobe abscess or extend posteriorly causing septic thrombosis of the lateral sinus.  diagnosis Specimen- pus discharge from ear, freshly from the tympanic membrane If the tympanic membrane is not perforated,tympanocentesis should be performed to obtain specimen from middle ear. Cultures for bacteria  Treatment Antibiotics are similar as those used in otitis media Mastoidectomy- when mastoid abscess forms and sepsis has been controlled by antibiotics.  Hearing Loss More than 30 million people are exposed to noise levels that produce hearing loss on a daily basis. Occupations such as carpentry, plumbing, and coal mining have the highest risk of noise-induced hearing loss  Types of hearing Loss Conductive hearing loss - results from an impacted cerumen, otitis media or otosclerosis. There is an interruption of efficient sound transmission by air to the inner ear.  A sensorineural loss - involves damage to the cochlea or vestibulocochlear nerve. Mixed hearing loss - conductive loss and sensorineural loss, resulting from dysfunction of air and bone conduction.  Functional (psychogenic) hearing loss is nonorganic and unrelated to detectable structural changes in the hearing mechanisms. It is usually a manifestation of an emotional disturbance.  Risk Factors for Hearing Loss Family history of sensorineural impairment Congenital malformations of the cranial structure Use of ototoxic medications (eg, gentamicin, loop diuretics) Recurrent ear infections Bacterial meningitis Chronic exposure to loud noises Perforation of the tympanic membrane  Clinical Manifestations Increasing inability to hear in groups Need to turn up the volume of the television or radio. Hearing impairment can also trigger changes in attitude, the ability to communicate, the awareness of surroundings, and even the ability to protect oneself, affecting the person’s quality of life.  Symptoms of Hearing Loss Speech deterioration Indifference Social withdrawal Insecurity Indecision Suspiciousness False pride Loneliness and unhappiness:. Tendency to dominate the conversation  Investigations Tuning fork testing Audiometry Tympanogram  Management If a hearing loss is permanent or untreatable with medical or surgical intervention or if the patient elects not to have surgery, aural rehabilitation may be beneficial.  Meniere’s Disease Abnormal fluid balance in the inner ear caused by malabsorption in the endolymphatic sac. A blockage in the endolymphatic duct causing a dilation in the endolymphatic space. Increased pressure in the system or rupture of the inner ear membranes occurs.  The exact cause of is unknown. Defective absorption by endolymphatic sac Allergies Sodium and water retention Hypothyroidism Autoimmune  Clinical Manifestations Progressive sensorineural hearing loss Tinnitus Feeling of pressure or fullness in the ear Nausea and vomiting. Dizziness Vertigo Pain Vision problem Extreme fatigue  Assessment History is taken to determine the frequency, duration, severity, and character of the vertigo attacks. Vertigo lasts minutes to hours accompanied by nausea or vomiting. Complain of diaphoresis and a persistent feeling of imbalance or disequilibrium lasting for days.  An audiogram typically reveals a sensorineural hearing loss in the affected ear. The electronystagmogram may be normal or may show reduced vestibular response.  Management Low-sodium diet. Sodium and fluid retention disrupts the delicate balance between endolymph and perilymph in the inner ear. Pharmacologic therapy – - Antihistamines - Tranquilizers - Antiemetics - Diuretics  Surgical Management Endolymphatic sac decompression, or shunting, equalizes the pressure in the endolymphatic space. A shunt or drain is inserted in the endolymphatic sac through a postauricular incision.  Foreign body in the ear Condition where something is present in the ear that is not normally there. Common in children but can be found in adults.  Clinical manifestation Pain Discharge Loss of hearing in the ear Reduced hearing Fretfulness of child Child scratching at the ear  Type of foreign body Organic - (living): Nuts, beans, insect. worm Organic - (non-living): Sponge, wood, eraser, cotton buds Inorganic: Metal, beads, button, stone  Investigation Otoscopy  Management Equipment - Otoscope with removable lens - Microscopic otoscope - Headlamp - Crocodile forceps - Syringe - Gauze - Emesis basin - suction equipment and tubbing - Magnet for metallic foreign bodies - Ear speculum - Galipot - Olive oil  Ear Syringing Ideal for most foreign bodies excepts if vegetable material and organic type. Irrigation must be avoided with vegetable material and organic type INSECTS - Olive oil is used to drown lives insect in the external auditory. - Crocodile forceps are then used to remove the insect  Complication Abrasions, bleeding, infection. Perforation of the tympanic membrane. Otitis externa / otitis media Tetanus may occur from sharp infected foreign bodies.  Disorders of the nose Sinusitis Allergic rhinitis Epistaxis  Acute sinusitis Prolonged mucosal oedema, from sinus obstruction and retention of secretions, may lead to acute bacterial rhinosinusitis. Infection often develops after something blocks the openings to the sinus from a viral infection of the upper airways. Oedematous mucous membranes of the nasal cavity tend to block the openings of the sinuses. Major symptoms: Facial pressure/pain Facial congestion/fullness Purulent nasal discharge Nasal obstruction Other minor symptoms are: - Headache, fever, fatigue, cough, toothache, halitosis, and ear fullness  Symptoms lasting beyond 7–10 days, or worsening after 5 days, suggest bacterial infection. Organisms responsible include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.  Chronic Sinusitis Ongoing for more than 90 days. Involves factors that cause chronic inflammation. Factors include chronic allergies, nasal polyps, and exposure to environmental irritants. Family history, and a genetic predisposition. Bacterial or fungal infection, in which case the inflammation is much worse.  Symptoms Acute and chronic sinusitis cause similar symptoms Yellow or green pus discharged from the nose Pressure and pain in the face Congestion and blockage in the nose Tenderness and swelling over the affected sinus Reduced ability to smell (hyposmia) Bad breath (halitosis) A productive cough  Sinus manifestations Maxillary sinusitis causes pain over the cheeks just below the eyes, toothache, and headache. Frontal sinusitis causes headache over the forehead. Ethmoid sinusitis causes pain behind and between the eyes, tearing, and headache (often described as splitting) over the forehead. Sphenoid sinusitis causes pain that does not occur in well-defined areas and may be felt in the front or back of the head.  Management Antibiotics  Allergic rhinitis Characterised by nasal congestion, clear rhinorrhoea, itchy watery eyes, and sometimes ear or palatal itching, post- nasal drip, and throat irritation. Fatigue due to sleep disturbance from nasal obstruction, perhaps with other immune contributors.  May occur only in certain seasons or locations. If one parent has inhalant allergies, a child has about a 30% chance of developing allergies. If both parents have allergies, this increases to about 60%.  Management Pharmacotherapy Avoidance of the provoking allergen Immunotherapy  Pharmacotherapy: - Antihistamines (oral or nasal topical) - Nasal steroid sprays - Decongestants -Topical nasal cromolyn - Oral antileukotrienes  Allergen avoidance requires determining what allergens are specific triggers for an individual, either by skin testing or in-vitro testing for elevated levels of IgE.  Epistaxis Epistaxis has been reported to occur in up to 60 percent of the general population The condition has a bimodal distribution, with incidence peaks at ages younger than 10 years and older than 50 years Certain high-risk groups, such as the elderly, require rapid intervention to stem bleeding and prevent further complications  Most cases of epistaxis occur in the anterior part of the nose, with the bleeding usually arising from the rich arterial anastomoses of the nasal septum (Kiesselbach’s plexus). In most cases, anterior bleeding is clinically obvious.  Posterior epistaxis generally arises from the posterior nasal cavity via branches of the sphenopalatine arteries. Posterior bleeding may be asymptomatic or may present insidiously as nausea, haematemesis, anaemia, haemoptysis, or melena.  Causes Local - Chronic sinusitis - Epistaxis digitorum (nose picking) - Foreign bodies - Intranasal neoplasm or polyps - Irritants (e.g., cigarette smoke) - Medications (e.g topical corticosteroids) - Rhinitis - Septal deviation or perforation - Trauma  Systemic - Haemophilia - Hypertension - Leukaemia - Liver disease (e.g., cirrhosis) - Medications (e.g., aspirin, anticoagulants, nonsteroidal anti-inflammatory drugs) - Platelet dysfunction - Thrombocytopenia  Management Compression of the nostrils (application of direct pressure to the septal area) and plugging of the affected nostril with gauze or cotton that has been soaked in a topical decongestant. Direct pressure should be applied continuously for at least five minutes, and for up to 20 minutes.  Tilting the head forward prevents blood from pooling in the posterior pharynx, thereby avoiding nausea and airway obstruction. Haemodynamic stability and airway patency should be confirmed. Fluid resuscitation should be initiated if volume depletion is suspected.  management Every attempt should be made to locate the source of bleeding that does not respond to simple compression and nasal plugging Diffuse oozing, multiple bleeding sites, or recurrent bleeding may indicate a systemic process such as hypertension, anticoagulation, or coagulopathy. In such cases, a haematologic evaluation should be performed  Admission and close observation should be considered for elderly patients and patients with posterior bleeding or coagulopathy. Also for patients with complicating comorbid conditions such as coronary artery disease, severe hypertension, or significant anaemia  Anterior bleeds Topical oxymetazoline (Afrin) spray alone often stops the heamorrhage. LET solution (lidocaine 4%, epinephrine 0.1%, and tetracaine 0.4%) applied to a cotton ball or gauze and allowed to remain in the nares for 10-15 minutes is very useful in providing vasoconstriction and analgesia.  Other treatment options include haemostatic packing with absorbable gelatin foam (Gelfoam) or oxidized cellulose (Surgicel). Use of desmopressin spray may be considered in a patient with a known bleeding disorder. Larger vessels generally respond more readily to electrocautery.  Posterior bleeds Posterior bleeding is much less common than anterior bleeding and usually is treated by an otolaryngologist. The double-balloon device is passed into the affected nostril under topical anaesthesia until it reaches the nasopharynx. The posterior balloon then is inflated with 7 to 10 mL of saline, and the catheter is withdrawn carefully so that the balloon seats in the posterior nasal cavity to tamponade the bleeding source.  Next, the anterior balloon is inflated with roughly 15 to 30 mL of saline in the anterior nasal cavity to prevent retrograde travel of the posterior balloon and subsequent airway obstruction. If a specialized balloon device is not available, a Foley catheter with a 30-mL balloon may be used.  Nasal polyps Soft abnormal growths or tumour emanating from the sinuses cavities on the surface of the nasal mucosa. Develop on the surface of ethmoid sinuses, just in the roof of the nose and grow into the open areas. A polyp may develop singularly or in clusters, and when grown enough, they are visible in the nostrils.  Polyps can be very painful and may cause an obstruction and heaviness in the nose. Some people use their mouth to breath because the polyps have blocked their nasal passages. Mouth-breathing often causes sore throats. Therefore, a sore throat is also a symptom of nasal polyps  Most cases of polyp development are associated with certain health conditions that are virally or bacterially transmitted such as hayfever, asthma and sinus infection.  Symptoms Long-term nasal congestion Distorted sense of smell A runny nose Chronic sinus infections Headaches Snoring Visible Nasal Polyp  Treatment Avoid medication that contain aspirin Avoid over-the-counter nasal sprays. Treat allergens that cause nasal disorders Surgery - functional endoscopic sinus surgery (FESS), but there are chances of recurrence  Nasal obstruction Blockage within the nasal cavity, Manifested as a sensation of insufficient airflow through the nose. May be the cardinal presenting symptom of rhinitis, sinusitis, septal deviation, adenoid hypertrophy, and nasal trauma.  Risk factors History of atopy Recurrent sinusitis Nasal trauma Nasal surgery Having household pets Exposure to poor air quality Family history  Acute tonsillitis Mostly affects children in the age group of 5-15 years, may also affect adults Organisms: beta-heamolytic streptococci (most common), staphylococci, pneumococci, H. influenzae Symptoms: sore throat, difficulty in swallowing, fever, earache, constitutional symptoms  Types Acute catarrhal/superficial - tonsillitis is a part of generalized pharyngitis, mostly seen in viral infections. Acute follicular - infection spread into the crypts with purulent material, presenting at the opening of crypts as yellow spots Acute parenchymatous - tonsil is uniformly enlarged and congested Acute membranous - follows stage of acute follicular tonsillitis where exudates form membrane on the surface  Signs Halitosis Coated tongue Congestion of soft palate and uvula Jugulo-digastric nodes enlarged and tender Tonsils are congested and enlarged depending on type of acute tonsillitis  Treatment Bed rest Plenty of oral fluids Analgesics Antibiotics  Complications Chronic tonsillitis Peritonsillar abscess Parapharyngeal abscess Cervical abscess Acute otitis media Rheumatic fever  Chronic tonsillitis Causes: - Complication of acute tonsillitis - Sub clinical infection of tonsil - Chronic sinusitis or - Dental sepsis  Types of chronic tonsillitis Chronic follicular tonsillitis Chronic parenchymatous tonsillitis : - tonsils are very much enlarged uniformly and may interfere with speech, deglutition and respiration  Clinical features Recurrent attacks of sore throat Chronic irritation in throat with cough Halitosis Dysphagia Odynophagia Thick speech  Signs Tonsil may show varying degree of enlargement depending on the type Irwin-moore sign - pressure on the anterior pillar expresses frank pus or cheesy material Flushing of the anterior pillar compared to rest of the pharyngeal mucosa Enlargement of the jugulo-digastric node  Management Conservative management Tonsillectomy  Complications Peritonsillar abscess Parapharyngeal abscess Retro pharyngeal abscess Intra tonsillar abscess Tonsillar cyst