1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 53 Nose...

1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Chapter 53

Nose Sinus, and Throat Disorders


Learning Objectives

• Describe the nursing assessment of the nose, sinuses,and throat.

• Identify nursing responsibilities for patients undergoingtests or procedures to diagnose disorders of the nose,sinuses, or throat.

• Describe the nurse’s role when the following commontherapeutic measures are instituted: administration oftopical medications, irrigations, humidification, suctioning,tracheostomy care, and surgery.

• Explain the pathophysiology, signs and symptoms, complications,and medical or surgical treatment of selecteddisorders of the nose, sinuses, and throat.

• Assist in developing nursing care plans for patients withdisorders of the nose, sinuses, or throat.


Anatomy and Physiology of the Nose, Sinuses, and Throat

• Nose• External nose• Internal nose

• Sinuses• Maxillary, frontal, ethmoid, and sphenoid

• Throat


Figure 53-1


Figure 53-2


Health History

• Chief complaint and history of present illness • Obtain detailed description of the patient’s

complaints

• Past medical history • Previous streptococcal infections; sinus infections;

surgery on the nose, sinuses, or throat; known allergies; and current and recent medications


Health History

• Review of systems • Presence of nasal discharge (amount, color),

obstruction, bleeding, sneezing, snoring, throat pain or soreness, hoarseness, aphonia (loss of voice), and earache

• An altered sense of smell or facial pain should be noted


Physical Examination

• External nose examined for size, shape, color, and lesions

• If drainage, note amount, color, and consistency

• Examiner listens for abnormal breath sounds and notes whether the patient is breathing through the nose or the mouth

• Patency of the nostrils determined by gently closing one naris at a time and instructing the patient to breathe through the other naris

• The sinuses are assessed indirectly


Physical Examination

• Examiner palpates over the frontal and maxillary sinuses for tenderness or pain

• Inspect throat at the back of the oral cavity• Mucous membranes and tonsils inspected for

redness, swelling, drainage, lesions • Inspection and palpation of the neck may

reveal enlarged lymph nodes


Age-Related Changes in the Nose, Sinuses, and Throat

• Nasal obstruction more common because of the softening of the cartilage of the external nose

• Mucous membrane thinner; produces less mucus • Epistaxis (nosebleed) more common in older people• Decline in the sense of smell as people age • Tissues of larynx are drier and less elastic in older

adult • Weakened esophageal sphincter allows gastric

contents to flow back into the throat when the patient lies down


Diagnostic Tests and Procedures

• Throat culture• Isolate and identify infective organisms

• Laryngoscopy • Inspection of the larynx to aid in diagnosis of

abnormalities or to remove foreign bodies


Figure 53-3


Therapeutic Measures

• Nose drops• Nasal and throat irrigations• Humidification• Suctioning• Tracheostomy care• Nasal surgery


Care of the Patient Having Nasal Surgery

• Assessment• Pain, pressure, anxiety, and dyspnea • Monitor vital signs to detect signs of excessive

blood loss • Number of dressings saturated and the frequency of

changes • Bleeding from the nasal cavity may flow into throat

and be swallowed although the dressing remains dry

• Check back of throat for bleeding; be alert for frequent swallowing

• Inspect vomitus and stool for blood (bright red or “coffee ground” emesis and red, maroon, or black stools)


Care of the Patient Having Nasal Surgery

• Interventions• Decreased Cardiac Output • Acute Pain • Impaired Gas Exchange • Disturbed Body Image


Disorders of the Nose, Sinuses, Throat, and Larynx


Sinusitis

• Inflammation of the sinuses, most often the maxillary and frontal sinuses

• Most common organisms are Staphylococcus pneumoniae, Haemophilus influenzae, Diplococcus, and Bacteroides

• Signs and symptoms • Pain or a feeling of heaviness over the affected area • Purulent drainage from the nose • When maxillary sinuses affected, pain may seem like a toothache • Headache is common, especially in the morning • Fever may be present; white blood cell count may be elevated


Sinusitis

• Complications • Chronic sinusitis, meningitis, brain abscess, osteomyelitis, and

orbital cellulitis

• Medical diagnosis and treatment • Diagnosis

• Sinus radiographs, CT; sinus aspiration or nasal endoscopy

• Treatment• Antibiotics, decongestants, nasal corticosteroids, analgesics, and

antipyretics• Twice-daily hot showers, increased fluid intake, humidifier • Functional endoscopic sinus surgery (FESS); Caldwell-Luc

procedure


Care of the Patient Having Sinus Surgery

• After FESS, able to return to work in 4-5 days • Saline nasal sprays ordered to prevent crusting

and promote healing • After the Caldwell-Luc procedure, the semi-

Fowler’s position is recommended to prevent swelling and promote drainage

• Apply cold compresses as ordered during the first 24 hours

• Provide gentle oral care to avoid injury to the incision


Care of the Patient Having Sinus Surgery

• Nasal packing is usually left in place until the first postoperative day

• Antral packing is left in place for 36 to 72 hours • Caution the patient to avoid blowing the nose

or straining, which could cause bleeding and tissue damage

• Three to 5 days after the Caldwell-Luc procedure, nasal saline sprays may be ordered to moisten the nasal mucosa


Nasal Polyps

• Swollen masses of sinus or nasal mucosa and connective tissue that extend into the nasal passages

• Exact cause is unknown, but patients often have a history of allergic rhinitis or infections

• The size of the polyps may be reduced by removing allergens or treating the allergic response

• Corticosteroids inhaled nasally may be prescribed • Surgical removal under local anesthesia, however, is

often necessary • Nasal polyps tend to recur


Care of the Patient Having Nasal Polyp Surgery

• Often in an outpatient surgical facility, so patient teaching before discharge is especially important

• Advise patient not to take aspirin because it increases the risk of bleeding and because some patients are allergic to aspirin


Allergic Rhinitis

• “Hay fever”: acute (seasonal) or chronic (perennial) • Follows exposure to a substance (allergen) that causes

an allergic response • A reaction to the release of chemicals, including histamine,

that cause vasodilation and increased capillary permeability

• Fluid leaks from capillaries; causes swelling of nasal mucosa

• Occasionally these changes are triggered by overuse of decongestant nose drops or sprays

• Acute allergic rhinitis often from exposure to pollens • The chronic form is more likely due to allergens that

are continuously in the environment


Allergic Rhinitis

• Signs and symptoms

• Nasal obstruction; sneezing; clear nasal discharge; frontal headache; and itchy, watery eyes

• Nasal mucosa is often pale, but it can be red or bluish

• Medical diagnosis

• Made on the basis of a detailed history • With chronic symptoms, the patient may be

instructed to keep a diary describing all episodes

• This can help identify possible allergens


Allergic Rhinitis

• Medical treatment • Desensitizing injections may be advised to decrease

the patient’s reaction to the offending allergens • The drugs used to treat allergic rhinitis are primarily

antihistamines and decongestants

• Nursing care• Patients with allergic rhinitis are usually outpatients • The nurse who works in a clinic or physician’s office

may need to reinforce teaching about desensitization and drug therapy


Acute Viral Coryza

• The common cold• Can be caused by any of some 30 viruses • It is contagious and spread by droplet infection • Signs and symptoms

• Fever, fatigue, nasal discharge, and sore throat

• Complications• Otitis media, sinusitis, bronchitis, and pneumonia


Acute Viral Coryza

• Medical treatment • Antihistamines, decongestants, and antipyretics

• Prevention • Best accomplished by avoiding people with colds

• Nursing care• Primarily public education about prevention and

about drugs prescribed for treatment • Encourage patients to rest and to drink plenty of

fluids


Tumors

• Signs and symptoms • Nasal obstruction • Bloody discharge from one nasal passage • Lesions on the external nose typically begin as

small, painless ulcers that do not heal

• Medical diagnosis• Diagnosed by taking a biopsy of the tumor or

removing the entire tumor for examination


Tumors

• Medical treatment • Combination of surgery, radiation therapy, and chemotherapy • Surgical procedures may be extensive and disfiguring,

depending on the site and extent of the cancer • Reconstructive surgery or prostheses may be needed

• Nursing care• Patient may be especially anxious and fearful of disfigurement

or even death • Be supportive and encourage the patient to ask questions and

express concerns


Deviated Nasal Septum

• Nose divided into two passages by a cartilaginous wall called the septum

• In most adults, septum is slightly deviated, meaning it is off center

• Minor deviations cause no symptoms and require no treatment

• Major deviations, however, can obstruct the nasal passages and block sinus drainage

• Headaches, sinusitis, and epistaxis• Treatment: submucosal resection/nasal septoplasty


Epistaxis

• Nosebleed; from trauma, clotting disorders, dryness, inflammation, and hypertension

• First aid • The patient should sit down and lean forward • Direct pressure should be applied for 3 to 5 minutes

• Medical treatment • Nasal balloon catheter • Nasal packing • Complications

• Infection, blockage of the eustachian tube, and airway obstruction


Figure 16-7


Figure 53-5


Epistaxis

• Assessment • Inspect the nose and back of the throat for obvious

bleeding and observe for frequent swallowing • Level of consciousness and vital signs to detect

signs of hypovolemia• Document allergies and major illnesses

• Interventions

• Decreased Cardiac Output • Anxiety • Risk for Injury and Infection


Pharyngitis

• Inflammation of the mucous membranes of the throat or pharynx

• Usually is caused by a virus but sometimes by bacteria

• Also can follow exposure to irritating substances in the environment


Pharyngitis

• Signs and symptoms • Dryness, pain, dysphagia (difficulty swallowing), and

fever • The throat appears red, and the tonsils may be

enlarged• Compared with viral pharyngitis, bacterial

pharyngitis has abrupt onset; characterized by abnormal blood cell counts, fever greater than

101° F, and muscle and joint pain


Pharyngitis

• Complications • Acute glomerulonephritis and rheumatic fever

• Medical diagnosis • Throat culture and a complete blood count


Pharyngitis

• Medical treatment • Rest, fluids, analgesics, throat gargles or irrigations • Bed rest as long as patient has a fever • If oral intake is low, intravenous fluids• Soft/liquid diet because of painful swallowing • Humidifier to increase moisture in the room air • Antibiotics, usually penicillin or erythromycin, while

awaiting the results of the throat culture


Pharyngitis

• Prevention• People with poor resistance should avoid others

with upper respiratory infections • Good nutrition, adequate rest, avoidance of chilling,

and avoidance of inhaled irritants • People who have pharyngitis are contagious in the

early stages and should avoid contact with susceptible people


Pharyngitis

• Assessment • Throat pain, dysphagia, muscle and joint pain,

nausea and vomiting, and rash • Take the patient’s temperature, and inspect the

throat for redness and enlarged tonsils


Pharyngitis

• Interventions • Reinforce physician’s directions for drug therapy • Stress importance of completing prescribed

antibiotics • 2000-3000 mL fluids daily unless contraindicated • Advise patients that they are contagious at first and

should not be exposed to people with poor resistance


Tonsillitis

• Inflammation of tonsils/other throat lymphatic tissue

• Common in children but more severe in adults • Causes

• Usually bacterial, but sometimes caused by a virus • Causative organisms: streptococci, staphylococci,

H. influenzae, and pneumococci • The infection is contagious; spread by food or

airborne routes • Most cases run their course in 7 to 10 days • May have repeated infections that respond to

treatment or may have a chronic infection


Tonsillitis

• Signs and symptoms

• Sore throat, difficulty swallowing, fever, chills, muscle aches, and headache

• If swollen tissue blocks eustachian tubes, ear pain • Offensive breath odor often with chronic infection • The tonsils typically are enlarged and red • Purulent drainage/yellowish or white patches on

tonsils • Lymph nodes in the neck may be tender and

enlarged


Tonsillitis

• Medical diagnosis • Complete blood count, throat culture and sensitivity,

and a test for infectious mononucleosis


Tonsillitis

• Medical treatment • Antibiotic therapy for 7 to 10 days • Analgesics and anesthetic lozenges for pain and

antipyretics for fever • Warm saline gargles or irrigations to decrease

swelling and remove drainage • Rest and adequate fluids promote recovery and

decrease the risk of complications


Tonsillitis

• Complications• Peritonsillar abscess

• Surgical treatment • Tonsillectomy and adenoidectomy


Care of the Patient Having a Tonsillectomy

• Assessment• Frequently monitor responsiveness/vital signs • Inspect drainage from the mouth or vomited fluid for

blood • Excessive swallowing may indicate bleeding • Monitor respiratory effort and skin color to evaluate

oxygenation • Evaluate pain and dysphagia


Care of the Patient Having a Tonsillectomy

• Interventions• Decreased Cardiac Output• Ineffective Airway Clearance • Acute Pain • Ineffective Therapeutic Regimen Management


Obstructive Sleep Apnea

• Airway obstruction during sleep • The tongue and soft palate fall backward partially or

completely blocking the airway, causing apnea and hypopnea (abnormally slow, shallow breathing)

• Blood oxygen level falls; carbon dioxide level rises • Stimulate ventilation; cause the patient to arouse • Patient startles, snorts, and gasps causing the tongue

and soft palate to move forward so the airway is open


Figure 53-6



• Symptoms related to disrupted sleep pattern • Patient often irritable and sleepy during the day

• Sleeping partner may report loud snoring or

episodes of apnea • Symptoms can affect many aspects of life • Concentration and memory may be impaired • Hypertension and cardiac dysrhythmias • Diagnosis confirmed by polysomnography



• Conservative treatment: weight loss if obese, avoidance of sedatives and alcohol for 3-4 hours before bedtime

• Oral appliance that shifts mandible and tongue forward may be effective

• Serious symptoms are treated with nasal continuous positive airway pressure (CPAP)

• Surgical procedures: uvulopalatopharyngoplasty (UPPP or UP3), genioglossal advancement and hyoid myotomy (GAHM), and laser-assisted uvulopalatoplasty (LAUP)


Figure 53-7


Laryngitis

• Inflammation of the larynx • Causes: upper respiratory infections, voice

strain, smoking, alcohol ingestion, and inhalation of irritating fumes

• Signs and symptoms• Hoarseness, cough, and scratchy or painful throat • Aphonia: absence of sound production; “losing” his

or her voice

• Medical diagnosis • Patient’s history and symptoms• Throat culture


Laryngitis

• Medical treatment • Voice rest is advised, meaning that the patient

should not talk • Removal of the irritant


Laryngitis

• Assessment• Document severity, how long it has persisted, and

factors that to aggravate or precipitate it • Information about the patient’s occupation and

hobbies may provide clues to the cause of the laryngitis

• Take the patient’s temperature and describe respiratory status to detect possible infection


Laryngitis

• Interventions• Pad and pencil or Magic Slate for communication • Sign over the bed noting that patient should not

speak • Notice on the intercom at the nurse’s station that the

patient cannot (or should not) speak• Discourage smoking • An environment with a constant temperature• Teach patients that irritants can lead to laryngitis • Recognize irritants in the home and workplace and

know how to protect themselves from harm


Laryngeal Nodules

• Benign masses of fibrous tissue result primarily from voice overuse but can follow infections

• Singers and public speakers prone to development of nodules

• The only symptom is hoarseness • Nodules are surgically removed under local or

general anesthesia


Laryngeal Polyps

• Swollen mass of mucous membrane attached to vocal cord

• Can cause continuous or intermittent hoarseness, depending on its location and attachment

• In heavy smokers, masses may develop on both cords

• A procedure called stripping of the vocal cords is necessary to treat this condition

• Unless patient continues smoking, condition usually does not return

• Voice rest prescribed if polyps removed


Cancer of the Larynx

• Factors: exposure to smoke or other noxious fumes, alcohol consumption, vocal strain, and chronic laryngitis

• Malignant tumors can develop throughout the larynx: above the glottis, on the vocal cords, or below the vocal cords

• Most malignancies are squamous cell carcinomas



• Signs and symptoms • Early symptoms include persistent hoarseness or

sore throat and ear pain • Later signs and symptoms are hemoptysis and

difficulty swallowing or breathing



• Prevention • Stop smoking and drinking alcohol• The public also should be educated to recognize the

signs and symptoms of laryngeal cancer and seek prompt medical attention



• Medical diagnosis • Confirmed by study of a tissue sample obtained

during a laryngoscopy • Radiographs, CT scans, and MRI to define the

extent of the cancer



• Medical treatment • Surgery, radiotherapy, chemotherapy, or a

combination • Surgery: from simple removal of the tumor to

extensive procedures, such as laryngectomy and modified or radical neck dissection

• A laryngectomy can be total or partial • Voice preserved with hemilaryngectomy or

supraglottic laryngectomy; total laryngectomy causes permanent loss of the natural voice


Figure 53-8


Care of the Patient Having a Total Laryngectomy

• If patient will lose the ability to speak, information about other means of communication should be available

• Listen compassionately and accept the patient’s expressions of anger or despair

• A total laryngectomy will require that the patient breathe through the trachea



• Complications • Salivary fistula, carotid artery blowout, tracheal

stenosis

• Assessment• Patient’s level of consciousness • Ask about pain and observe for signs of discomfort • Measure vital signs at frequent intervals • Continuous electrocardiogram monitoring and pulse

oximetry to assess oxygenation and circulation • Fluid intake and output, wound drainage



• Interventions• Ineffective Airway Clearance • Anxiety • Decreased Cardiac Output • Acute Pain • Risk for Injury • Imbalanced Nutrition: Less Than Body

Requirements • Impaired Verbal Communication • Ineffective Coping • Risk for Infection • Ineffective Therapeutic Regimen Management


Figure 53-10


Care of the Patient Having a Supraglottic Laryngectomy

• Care like that for total laryngectomy except the tracheostomy is temporary, the voice is not lost, and swallowing is more problematic

• Enteral feedings may be needed for a long time, so begin to instruct the patient in self-feeding

• Be alert for signs and symptoms of this complication: increased pulse and respiratory rates, dyspnea, cough, crackles and rhonchi, fever, wheezing, and frothy, pink sputum

• Keep a suction machine readily available


Care of the Patient Having a Partial Laryngectomy

• Temporary tracheostomy for 2 to 5 days • IV fluids and enteral feedings are ordered at

first • Patients have considerable difficulty

swallowing when oral nourishment is resumed • To prevent aspiration, seat the patient upright,

with the head flexed slightly forward • Semisolids easier to manage than thin liquids • Suction machine should be on hand

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