Chapter 53

1. Chapter 53 Nose Sinus, and Throat Disorders

2. Learning Objectives • Describe the nursing assessment of the nose, sinuses, and throat. • Identify nursing responsibilities for patients undergoing tests or procedures to diagnose disorders of the nose, sinuses, or throat. • Describe the nurse’s role when the following common therapeutic measures are instituted: administration of topical medications, irrigations, humidification, suctioning, tracheostomy care, and surgery. • Explain the pathophysiology, signs and symptoms, complications, and medical or surgical treatment of selected disorders of the nose, sinuses, and throat. • Assist in developing nursing care plans for patients with disorders of the nose, sinuses, or throat.

3. Anatomy and Physiology of the Nose, Sinuses, and Throat Nose External nose Internal nose Sinuses Maxillary, frontal, ethmoid, and sphenoid Throat

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6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

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13. Therapeutic Measures Nose drops Nasal and throat irrigations Humidification Suctioning Tracheostomy care Nasal surgery

14. 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)

15. Care of the Patient Having Nasal Surgery Interventions Decreased Cardiac Output Acute Pain Impaired Gas Exchange Disturbed Body Image

16. Disorders of the Nose, Sinuses, Throat, and Larynx

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

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34. 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

35. 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

36. 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

37. Pharyngitis Complications Acute glomerulonephritis and rheumatic fever Medical diagnosis Throat culture and a complete blood count

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. Tonsillitis Medical diagnosis Complete blood count, throat culture and sensitivity, and a test for infectious mononucleosis

45. 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

46. Tonsillitis Complications Peritonsillar abscess Surgical treatment Tonsillectomy and adenoidectomy

47. 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

48. Care of the Patient Having a Tonsillectomy Interventions Decreased Cardiac Output Ineffective Airway Clearance Acute Pain Ineffective Therapeutic Regimen Management

49. 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

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