By A.B.Sani MED-SURGE (E.N.

T) KKB SON KT
OBJECTIVES:
At the end of this lesson, students will be able to:

 Recall and relate the structures and functions of the ear, nose, and throat with their
condions.
 Understand the Techniques for assessing the ear, nose, and throat
 Identify and solve Nursing diagnoses appropriate for ear, nose, and throat disorders
 Be familiar with Common ear, nose, and throat disorders and treatments.
Introduction

 The aim of Ear, Nose and Throat Care is to provide clients with an understanding of the
problem that are associated with Ear, Nose and Throat and also to provide you solutions
to these problems.
 An otorhinolaryngology nurse:
 Also known as an ear, nose and throat nurse
 Cares for patients with diseases or injuries of the ear, nose, throat, head, or neck.
 Often referred to as ENT nurses, otorhinolaryngology nurses assist in the treatment
of both acute and chronic conditions, including ear infections and allergies,
laryngitis, sinusitis, tonsillitis, sleep apnea and injuries such as broken bones.
 ENT nurses treat all ages of patients, from infants to the elderly, with a sizable
pediatric patient population.
 Collect specimens from the affected area and record symptoms and vital signs, which
are then used in pinpointing a diagnosis.
 Also assist with treatments, such as administering medications, educating patients
about home care for their conditions, and providing support for patients undergoing
medical and surgical procedures that concern the head and neck.
Roles and Duties of an Otorhinolaryngology Nurse
1. Conduct assessments of patients' ears, nose, throat, head and/or neck, including the
use of tongue depressors, otoscopes, and various lights and mirrors
2. Collect samples from affected areas and record symptoms and medical histories
3. Administer medications and educate patients on how to care for their conditions or
injuries at home
4. Assist in surgical procedures, prep patients for surgery and care for patients during
recovery
ASSESSMENT OF THE EARS, NOSE, THROAT AND MOUTH
HISTORY OF PRESENT ILLNESS AND REVIEW OF SYSTEMS
The following characteristics of each symptom should be elicited and explored: Onset
(sudden or gradual), Chronology, Current situation (improving or deteriorating), Location,
Radiation, Quality, Timing (frequency, duration), Severity, Precipitating and aggravating
factors, Relieving factors, Associated symptoms, Effects on daily activities, Previous
diagnosis of similar episodes, Previous treatments, Efficacy of previous treatments
CARDINAL SYMPTOMS
Characteristics of specific symptoms should be elicited, as follows.
Ears
o Recent changes in hearing o Tinnitus
o Itching o Vertigo
o Earache o Ear trauma, including Q-tip use
o Discharge o Pain
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
Nose
– Nasal discharge or postnasal – Sinus pain, pressure
drip – Itching
– Epistaxis – Nasal trauma
– Obstruction of airflow
Mouth and Throat
– Dental status – Dysphagia (difficulty
– Pain swallowing)
– Oral lesions – Hoarseness or recent voice
– Bleeding gums change
– Sore throat
Neck
– Pain – Enlargement of glands
– Swelling
Other Associated Symptoms
– Fever – Nausea and vomiting
– Malaise
PAST MEDICAL HISTORY (SPECIFIC TO ENT)
– Seasonal allergies, allergies – ENT surgery
– Frequent ear or throat – Audiometric screening results
infections indicating hearing loss
– Rhinosinusitis – Prescription or over-the-counter
– Trauma to head or ENT area medications used regularly
FAMILY HISTORY (SPECIFIC TO ENT)
– Others at home with similar symptoms – Asthma
– Seasonal allergies – Hearing loss
PERSONAL AND SOCIAL HISTORY (SPECIFIC TO ENT)
– Feeding methods (breast or bottle), – Crowded living conditions
bottle propping – Poor personal hygiene
– Frequent exposure to water – Dental hygiene habits
(swimmer’s ear) – Exposure to cigarette smoke, wood
– Use of foreign object to clean ear smoke or other respiratory toxins
– Insertion of foreign body in ear – Recent air travel
REVIEW OF SYSTEMS
Obtain a history about other relevant systems for the presenting concern. This may include
information about the eyes, central nervous system, gastrointestinal system and/ or
respiratory system organs.
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT

Nose
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT

PHYSICAL EXAMINATION
– Apparent state of health – Activity level – Emotional reaction to
(for example, appearance (spontaneous activity or parent (or caregiver) and
of acute illness) lethargy) examiner
– Hydration status – Mental status (whether – Hygiene
– Degree of comfort or alert and active) – Posture
distress – Degree of cooperation, – Difficulty with gait or
– Colour (flushed or pale) consolability balance
– Character of cry (in – Nutritional status (obese
infants < 6 months old) or emaciated)

SAFETY TIP
It may be necessary patient or client to be restrained. For example;
Lay the client in a supine position and have the relative hold the client’s arms extended, and
stand in a position close to the sides of the head.
This will limit side-to-side movements while you are examining ENT structures.
EARS
Inspection

– External ear: position (in relation to perforation, scarring, air bubbles, fluid
eyes) level
– Low-set or small, deformed auricles – Check mobility of the eardrum using a
may indicate associated congenital pneumatic otoscope (if available);
defects, especially renal agenesis decrease may indicate acute otitis
– Pinna: lesions, abnormal appearance or media
position – Estimate hearing by producing a loud
– Canal: discharge, swelling, redness, noise (for example, by clapping hands)
odour, wax, foreign bodies for an infant or young client (which
– Eardrum: colour, light reflex, should elicit a blink response) or by
landmarks, bulging or retraction, performing a watch or whisper test for
an older patient.
NB: Perform tympanometry (if equipment available).
Clinical tip: For the best view of the eardrum in a client e.g. less than 6 years old, pull the
outer ear downward, outward and backward.
Palpation
– Tenderness over tragus or mastoid process
– Tenderness on manipulation of the pinna
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
NOSE
Inspection
– External: inflammation, deformity, – Transilluminate sinuses to check for
discharge, bleeding dulling of light reflex in patient > 6
– Internal: colour of mucosa, edema, years
deviated septum, polyps, bleeding – Nasal vs. mouth breathing
points
Palpation
– Check for sinus and nasal tenderness (only in older patients who can cooperate and
provide a response)
Percussion
– Check for sinus and nasal tenderness (only in older patient who can cooperate and
provide a response)
MOUTH AND THROAT
Inspection
– Lips: colour uniformity (light to dark pink), lesions, symmetry of lips
– Oral mucosa and tongue: breath odour, colour, lesions of buccal mucosa, palate, tongue
– Gums: redness, swelling, caries
– Teeth: caries, fractures
– Throat: colour, tonsillar enlargement, exudates, uvula midline
NECK
Inspection
– Symmetry – Redness
– Swelling – Enlargement of thyroid
– Masses – Active range of motion
Palpation
– Tenderness, enlargement, mobility, contour and consistency of masses
– Thyroid: size, consistency, contour, position, tenderness
LYMPH NODES OF THE HEAD AND NECK
Palpation
Massage to palpate for Tenderness, enlargement, mobility, contour and consistency of nodes.
– Pre- and post-auricular nodes – Submaxillary
– Anterior and posterior cervical nodes – Submandibular
– Tonsillar – Occipital
COMMON PROBLEMS OF THE EARS, NOSE AND THROAT
FOREIGN BODY IN THE NOSE

 Patient frequently put foreign bodies in their nostrils.

 Occasionally, the foreign body (anything from a pea to a small bead or toy part) obstructs
the airway or becomes embedded, possibly causing significant infection.
HISTORY
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
 Generally unilateral
 History of purulent rhinorrhea and difficulty with breathing through the affected nostril
 Typically, the relative may said that a very foul smell is emanating from the client
 Fever and other systemic features are uncommon
PHYSICAL FINDINGS

 Obvious mucopurulent discharge, generally unilateral

 Nasal blockage may be so severe that adequate visualization of the foreign body is
impossible
 Suction may be necessary to visualize the foreign body
 It is important to explore the opposite nostril and ears for other foreign bodies.
DIFFERENTIAL DIAGNOSIS

 Sinusitis
 Rhinitis
 Nasal polyps
COMPLICATIONS

 Sinus infection
 Epistaxis
 Other ENT infections
DIAGNOSTIC TESTS

 None
MANAGEMENT
Goals of Treatment

 Remove foreign body

 Prevent recurrence
Nonpharmacologic Interventions

 Nurse must be cautious to not displace the foreign body posteriorly or into the airway.
 It is not recommended to attempt removal of a foreign body beyond that dictated by
common sense.
 The client will become increasingly frightened and the procedure increasingly
difficult.
 Attempt to remove clearly visible foreign bodies and do not attempt to remove foreign
bodies that cannot be seen.
 Visible foreign bodies can be removed by:
 Using a suction catheter
 Using a cerumen loop (curette)
 Using a nasal speculum and forceps,
 Ask the client to exhale forcibly through the nostril containing the foreign body
while the opposite nostril is occluded. This technique may be difficult for the very
young patient.
 Providing oral positive pressure.
 Have the client sit or stand, depending upon their preference.
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
 Occlude the unaffected side of the nose and instruct the parent to firmly seal their
mouth over the client’s mouth and give a short, sharp puff of air into the client’s
mouth.
 This technique has the advantage that it does not require physical restraint.
 If a foreign body is embedded with granulation tissue, consultation with an ENT
specialist and removal under general anesthesia may be necessary.
 Educate the parents or caregiver about the problems associated with foreign bodies,
particularly the risk of aspiration and the need to remove foreign bodies under general
anesthetic.
EARACHE
OVERVIEW
 Caused by disorders of the external and middle ear from allergies, infection, obstruction,
or trauma
 Ranges from a feeling of fullness or blockage to deep boring pain or stabbing pain
 Also known as otalgia
History
 Ask about the onset and description of the pain.
 Inquire about recent head cold or problems with the mouth, sinuses, or throat.
 Find out about aggravating and alleviating factors.
 Ask the patient about itching, drainage, ringing noises, dizziness, vertigo, nausea,
vomiting, and fever and whether he has pain when he opens his mouth.
 Ask about recent airplane travel, travel to high altitudes, and scuba diving.
 Obtain a medical history, including incidence of head colds or problems with the eyes,
mouth, teeth, jaw, sinuses, and throat, including allergies.
 Obtain a drug history, including over-the-counter medications.
Physical Assessment
 Inspect the external ear for redness, drainage (serous or purulent), swelling, or
deformity.
 Apply pressure to the mastoid process and tragus to check for tenderness.
 Using an otoscope, examine the external auditory canal for lesions, bleeding or other
discharge, impacted cerumen, foreign bodies, tenderness, or swelling. (See Using an
otoscope.)
 Examine the tympanic membrane.
 Perform tests for hearing loss.
 Obtain vital signs.
 Obtain a sample of drainage for testing.

TOP TECHNIQUE: USING AN OTOSCOPE

When the patient reports an earache, use an otoscope to inspect the ear structures closely.
Follow these techniques to obtain the best view and to ensure the patient's safety.
CHILD YOUNGER THAN AGE 3
To inspect a young child's ear, grasp the lower part of the auricle and pull it down and back
to straighten the upward S curve of the external canal. Then gently insert the speculum into
the canal no more than ½″ (1.3 cm).
ADULT
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
To inspect an adult's ear, grasp the upper part of the auricle and pull it up and back to
straighten the external canal. Then insert the speculum about 1″ (2.5 cm). Also use this
technique for children age 3 and older.

Causes
Medical
1. Abscess, Extradural: Severe earache is accompanied by persistent ipsilateral
headache, malaise, hearing loss, and recurrent mild fever.
2. Barotrauma, Acute:Earache ranges from mild pressure to severe pain with hearing
loss and dizziness. Tympanic membrane ecchymoses or bleeding into the tympanic
cavity may also occur.
3. Cerumen Impaction: Signs and symptoms include a blockage or a sensation of
fullness in the ear accompanied by partial hearing loss, itching, dizziness, and tinnitus
(ringing in the ear).
4. Chondrodermatitis Nodularis Chronica Helicis: Small, painful, indurated areas
develop along the upper rim of the auricle. Lesion may have a central core with scaly
discharge.
5. Frostbite: Burning or tingling pain may occur in the ear, followed by numbness. Ear
appears mottled and gray or white and turns purplish as it warms.
6. Furunculosis
 Infected hair follicles in the outer third of the ear canal may produce severe,
localized ear pain from a pus-filled furuncle.
 Pain is aggravated by jaw movement and relieved by rupture or incision of the
furuncle.
 Other signs and symptoms include pinna tenderness, swelling of the auditory
meatus, partial hearing loss, and a feeling of fullness in the ear canal.
7. Herpes Zoster Oticus
 Burning or stabbing pain typically occurs with the ear vesicles.
 Other signs and symptoms include hearing loss; vertigo; transitory, ipsilateral,
facial paralysis; partial loss of taste; tongue vesicles; and nausea and vomiting.
8. Mastoiditis, Acute: Dull ache behind the ear is accompanied by low-grade fever and
purulent discharge. Eardrum appears dull and edematous and may perforate, and soft
tissue near the eardrum may sag.
9. Ménière Disease: A sensation of fullness in the affected ear, severe vertigo, tinnitus,
and sensorineural hearing loss may occur with this condition.
Other signs and symptoms include nausea, vomiting, diaphoresis, and nystagmus.
10. Middle Ear Tumor: Deep, boring ear pain and facial paralysis are late signs. Hearing
loss and facial nerve dysfunction may develop.
11. Otitis Externa, Acute
 Initially, pain is mild to moderate and occurs with tragus manipulation.
 Later, ear pain intensifies, causing the affected side of the head to ache.
 Other signs and symptoms include fever; sticky yellow or purulent discharge;
partial hearing loss; a feeling of blockage; itching; swelling of the tragus,
external meatus, and external ear canal; reddened eardrum; lymphadenopathy;
dizziness; and malaise.
12. Otitis Media, Acute: Acute serous otitis media may cause a feeling of fullness in the
ear, hearing loss, and a vague sensation of top-heaviness. Acute suppurative otitis
media involves severe, deep, throbbing ear pain, hearing loss, and fever.
13. Petrositis
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
Infection of the temporal bone, resulting from acute otitis media, produces deep
ear pain with headache and pain behind the eye.
 Other signs and symptoms include diplopia, loss of lateral gaze, vomiting,
sensorineural hearing loss, vertigo, and, possibly, nuchal rigidity.
14. Temporomandibular Joint Infection
 Ear pain is referred from the jaw joint.
 Pain is aggravated by pressure on the joint with jaw movement and may radiate
to the temporal area or entire side of the head.
Nursing Considerations

 Give an analgesic, as prescribed.

 Apply heat to relieve discomfort.
 Instill eardrops, as prescribed.
 Don't probe the ear canal if a foreign body is present. Remove a foreign body only if
it's sticking out or is easily accessible.
Pediatric Pointers
 Common causes of earache in children are acute otitis media and insertion of foreign
bodies that become lodged or cause infection.
 In a child not old enough to speak, ear tugging and crying in conjunction with fever,
night-waking, and poor feeding may indicate an earache.
Patient Teaching

 Be sure to include the patient's family or caregiver in your teaching, when

appropriate.
 Teach the patient or caregiver how to instill eardrops correctly.
 Explain the importance of taking prescribed antibiotics correctly and for the full term.
 Explain ways to avoid vertigo.
 Instruct the patient or caregiver about ways to avoid ear trauma and to prevent
recurrence of otitis media.
 Remind patients and caregivers not to insert anything into the ears, including cotton-
tipped applicators.
OTITIS EXTERNA
Overview

 Acute or chronic inflammation or infection of the external ear canal or auricle

 With treatment, usually subsides within 7 days
 Classifications:
 Acute diffuse—most common form
 Acute localized—associated with infected hair follicle
 Chronic—lasts longer than 6 weeks
 Eczematous—associated with dermatologic conditions
 Necrotizing (malignant)—deeper infection of tissues next to the auditory nerve
 Otomycosis—fungal infection of the ear canal
 If severe and chronic, may reflect an underlying disorder, such as diabetes mellitus,
hypothyroidism, or nephritis
 Also known as external otitis, OE, and swimmer's ear
Pathophysiology
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
 A reduction in cerumen occurs due to excessive water exposure, leading to drying of
the canal and pruritus.
 Pruritus leads to probing of the canal and subsequent skin breakdown, allowing an
entrance site for organisms.
 Colonization by the infecting organism leads to external ear canal inflammation.
Causes

 Bacteria (common) and fungi (less common)

 Occasionally, dermatologic conditions, such as seborrhea and psoriasis
 Trauma or excessive moisture that predisposes the canal to infection
Risk Factors

 Absence of cerumen or cerumen impaction

 High humidity
 Swimming in contaminated water
 Use of a hearing aid
 Cleaning of the ear canal with a cotton-tipped applicator, bobby pin, finger, or other
object
 Exposure to dust, hair care products, or other irritants
 Regular use of earphones, earplugs, or earmuffs
 Chronic drainage from a perforated tympanic membrane
 History of eczema, allergic rhinitis, or asthma
 Comorbidities, such as diabetes mellitus
 Prior radiation therapy
Incidence

 OE is most common in the summer but can occur any time of the year.
 It affects all ages and both sexes equally.
Complications

 Necrotizing OE
 Mastoiditis
 Chondritis of the auricle
 Cellulitis
 Central nervous system infection
Assessment
History

 Pain in the auditory external canal

 Repeated exposure to ear trauma, cotton swab use, water (moisture), or earphones,
earplugs, or earmuffs
 Allergic response to hair spray, dye, or other hair care products
 Mild to severe ear itching or pain that is aggravated by moving the jaw, clenching the
teeth, opening the mouth, or chewing
 Fungal OE may be asymptomatic
 Complaints of plugging in the ear or hearing loss
 Otalgia
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
 Itching
 Fullness or pressure in the ear
 Tinnitus
 Foul-smelling ear discharge
Physical Findings

 Swollen, inflamed external auditory canal with narrowing

 Increased pain on palpation of the tragus or with traction applied to the pinna
 Ear discharge that may be foul-smelling and yellow to green after being initially clear
and odourless
 Thick, red epithelium in the canal with chronic OE
 Itching on palpation or manipulation
 Periauricular adenitis
 Cellulitis of the face or neck
 Lymph node enlargement (ipsilateral)
Diagnostic Test Results
Laboratory

 Culture of discharge and microscopic examination shows the causative organism.

Diagnostic Procedures

 Audiometric testing may reveal partial hearing loss.

 Otoscopy reveals a swollen external ear canal, periauricular lymphadenopathy and,
occasionally, regional cellulitis.
Treatment
General

 Cleaning of debris from the canal under direct visualization

 With mild chronic OE, use of specially fitted earplugs for showering and swimming
 Drying of the ears with a hairdryer
Diet

 No restrictions
Activity

 Avoidance of exposing the affected ear to water for 7 to 10 days

 Once water activity has resumed, keeping head above water until symptoms have
resolved
 Medications
 Acetic acid (2%) with hydrocortisone otic solution
 Analgesics, such as acetaminophen, ibuprofen, or acetaminophen with codeine (for
moderate pain)
 Antibiotic-corticosteroid eardrops, such as neomycin sulfate-polymyxin B-
hydrocortisone, betamethasone dipropionate, gentamycin sulfate, ciprofloxacin-
dexamethasone, gentamicin-betamethasone dipropionate, or ofloxacin (otic)
 Antifungal eardrops, such as clotrimazole
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
 Oral antibiotics if lymphadenopathy is present, the external ear is swollen, or
temperature is greater than 101° F (38.3° C); IV antibiotics for necrotizing OE
Surgery

 Excision and abscess drainage for necrotizing OE or complications of OE

Nursing Considerations
Nursing Interventions

 Clean and dry the ear gently and thoroughly.

 Use wet soaks on infected skin.
 Give prescribed drugs. Use a foam or gauze ear wick, as indicated, to help with
delivery of otic medications. Have the patient lie on the side for approximately 20
minutes, or insert a cotton ball into the ear canal for 20 minutes.
 Inspect the ear canal for drainage; note the color and characteristics of any drainage
present.
 Screen for and assess the patient's pain using facility-defined criteria that are
consistent with the patient's age, condition, and ability to understand.
 Treat the patient's pain, as needed and ordered, using nonpharmacologic,
pharmacologic, or a combination of approaches.
 Closely monitor a patient who is prescribed opioid treatment and is identified as being
at high risk for adverse outcomes.
 Reassess and respond to the patient's pain by evaluating the response to treatment and
progress toward pain management goals.
 With Hearing Loss
 Encourage discussion of concerns; reassure the patient that hearing loss from an
external ear infection is temporary.
 Face the patient when speaking; enunciate words clearly, slowly, and in a normal
tone.
 Allow adequate time for the patient to grasp what was said.
 Provide a pencil and paper to aid communication.
 Alert staff to the communication problem.
Monitoring

 Vital signs, especially temperature

 Auditory acuity
 Type and amount of aural drainage
 Pain level and effectiveness of interventions
 Response to treatment
 Associated Nursing Procedures
 Ear irrigation for foreign body or discharge removal
 Eardrop instillation
 External ear specimen collection
 Heat application
 Oral drug administration
 Pain assessment
 Pain management
 Safe medication administration practices, general Standard precautions
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
Patient Teaching
General

 Include the patient's family or caregiver in your teaching, when appropriate. Provide
information according to their individual communication and learning needs. Be sure
to cover: disorder, possible underlying causes, diagnostic testing, and treatment
 hand hygiene and daily ear cleaning, including the need to avoid frequent washing of
the ears with soap, which upsets the normal acidic pH of the ear canal
 importance of avoiding the use of cotton swabs to clear the ear canal
 use of otic antibiotics (if prescribed), including proper technique for administration
(tilting the head to the opposite shoulder, pulling the superior aspect of the auricle
upward, and instilling the number of drops into the ear canal)
 timing and technique for removing the ear wick, if indicated
 importance of warming eardrops in the hand before use and avoiding contamination
of the applicator tip during instillation
 pain management plan and potential adverse effects of pain management treatment
safe use, storage, and disposal of opioids, if prescribed
 need to wear earplugs when swimming and when a potential exposure of the ears to
water exists
 information that relief typically occurs within 48 hours of initiating therapy
 signs and symptoms of chronic infection
 steps for preventing recurrence (See Preventing otitis externa.)
 guidelines for returning to water activity after resolution of the infection (usually in 7
to 10 days; if the patient is an aquatic athlete, swimming may be allowed in 2 to 3
days if the patient can keep the head dry until the infection clears and wears well-
fitting earplugs)
 need to avoid using hearing aids and earphones, as appropriate, until the pain and
discharge have decreased
 use of acidifying drops in the ears after every exposure to water for patients with
recurrent OE
 importance of eliminating water from the ear canal after swimming or bathing to help
prevent recurrence; suggest the use of a blow dryer on a low setting after swimming
to dry the ear canal (as a possible preventive measure)
 importance of follow-up care within 3 days after starting treatment to determine the
effectiveness of therapy.
 Preventing otitis externa
 Teach the patient to follow these steps to help prevent the recurrence of otitis externa:
 Avoid potential irritants, such as hair care products and earrings.
 Refrain from frequent use of soap to clean the ear canal.
 Wear earplugs or keep the head above water when swimming, and instill two or three
drops of 42% acetic acid solution in 70% alcohol (diluted 50/50) into the ear after
swimming to toughen the skin of the external ear canal.
 Dry the ear with a towel or hair dryer on the lowest setting.
 Avoid cleaning the ears with cotton-tipped applicators and other objects.
 Avoid swimming in polluted or dirty water.
Discharge Planning

 Assess the patient's and family understands of the diagnosis, treatment, prognosis,
follow-up, and warning signs for which to seek medical attention.
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
 Identify the patient's and family's goals, preferences, comprehension, and concerns
about the diagnosis.
 Provide a list of prescribed drugs, including the dosage, prescribed time schedule, and
adverse reactions to report to the practitioner. Provide the patient (and family or
caregiver, as needed) with written information on the medications that the patient
should take after discharge.
 Assess the patient's and family's understanding of each prescribed medication,
including dosage, administration, expected results, duration, and possible adverse
effects.
 Assess the patient's ability to obtain medications; identify the party responsible for
obtaining medications.
 Instruct the patient to provide a list of medications to the practitioner who will be
caring for the patient after discharge; to update the information when the practitioner
discontinues medications, changes doses, or adds new medications (including over-
the-counter products); and to carry a medication list that contains all of this
information at all times in the event of an emergency.
 Ensure that the patient and caregivers receive contact information for medical support.
 Provide contact information for local support groups and services.
 Ensure that the patient or caregiver receives a copy of the discharge instructions and
that a copy is placed in the patient's medical record.
 Document the discharge planning evaluation in the patient's clinical record, including
who was involved in discharge planning and teaching, their understanding of the
teaching provided, and any need for follow-up teaching.
OTITIS MEDIA
Overview

 Inflammation of the middle ear, most commonly due to poor functioning of the
eustachian tube
 Recurrent when three episodes occur within 6 months or four or more episodes occur
within 1 year Categorized as follows:
1. Acute otitis media (OM): Disruption of eustachian tube patency of usually
less than 3 weeks OM with effusion: Infection resolves but fluid stays trapped
behind the eardrum, causing persistent inflammation
2. Chronic suppurative OM: Lasts longer than 2 weeks, with continued purulent
drainage through perforated tympanic membrane
Pathophysiology

 Dysfunction of the eustachian tube leads to relative negative pressure in the middle
ear space.
 This condition results in a lack of aeration and an accumulation of fluid, providing an
environment conducive to the growth of microorganisms.
 The disease process differs according to type of OM.
Chronic Suppurative OM

 Respiratory tract infections, allergic reactions, and position changes allow reflux of
nasopharyngeal flora through the eustachian tube and colonization in the middle ear.
Causes
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
 Bacteria, commonly Streptococcus pneumoniae, Haemophilus influenzae,
Staphylococcus aureus, and group A streptococcus
 Viruses, most commonly rhinovirus and respiratory syncytial virus
Risk Factors

 Smoking in the household

 Family history of middle ear disease
 Male sex
 Native American or Alaskan Native heritage
 Craniofacial abnormalities
 Eustachian tube dysfunction or obstruction
 Immune dysfunction
 Gastroesophageal reflux
Incidence

 Information about the incidence of OM in adults is uncertain.

 Acute OM is more common in males than in females.
 The disease is most common during the winter months, paralleling the seasonal
increase in viral and bacterial respiratory tract infections.
Complications

 Spontaneous rupture (perforation) of the tympanic membrane

 Persistent perforation
 Chronic OM
 Mastoiditis
 Meningitis
 Cholesteatomas
 Abscesses
 Septicemia
 Lymphadenopathy
 Leukocytosis
 Permanent hearing loss and tympanosclerosis
 Vertigo
 Labyrinthitis
 Paresis of facial nerve
Assessment
History

 Upper respiratory tract infection

 Allergies
 Severe, deep, throbbing ear pain
 Headache
 Dizziness and vertigo
 Nausea
 Vomiting
 Persistent ear infections
 Sensation of fullness in the ear
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
 Popping, crackling, or clicking sounds on swallowing or moving the jaw
 Perception of echo when speaking
 Tympanic Membrane Rupture
 Pain that suddenly stops
 Recent air travel or scuba diving
Physical Findings

 Sneezing and coughing (with upper respiratory tract infection)

 Mild to high fever
 Fluid draining from the ear canal
 Painless, purulent discharge (with chronic suppurative OM)
 Obscured or distorted bony landmarks of the tympanic membrane (with acute
suppurative OM)
 Tympanic membrane retraction (with the serous form)Clear or amber fluid behind the
tympanic membrane
 Blue-black tympanic membrane with hemorrhage into the middle ear
 Pulsating discharge (with tympanic perforation)
 Conductive hearing loss (varies with the size and type of tympanic membrane
perforation and ossicular destruction)
 Decreased eardrum motility (OM with effusion)
Chronic Suppurative OM

 Thickening and scarring of the tympanic membrane

 Decreased or absent tympanic membrane mobility
 Ear discharge
 Cholesteatoma
Diagnostic Test Results
Laboratory

 Culture and sensitivity tests of exudate show the causative organism.

 Complete blood count (CBC) with differential shows leukocytosis (if acute OM is due
to bacteria).
Imaging
Radiographic studies demonstrate mastoid involvement in complicated or persistent cases.
Diagnostic Procedures
Tympanometry detects hearing loss and evaluates the condition of the middle ear.
Audiometry shows the degree of hearing loss.
Pneumatic otoscopy may show decreased tympanic membrane mobility and identify redness,
bulging opacification, and perforation of the tympanic membrane.
WARNING!
Patients with unilateral serous otitis media should always undergo evaluation for a
nasopharyngeal-obstructing lesion such as carcinoma.
Treatment
General

 With acute serous OM, auto-insufflation (pinching the nose while gently exhaling)
several times per day (possibly the only treatment required)
 Concomitant treatment of the underlying cause
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
 Elimination of eustachian tube obstruction
Medications

 Antibiotic therapy, such as amoxicillin or (if allergic to penicillin) azithromycin as

first-line agents; cefdinir, cefpodoxime, cefuroxime axetil, amoxicillin-clavulanate
potassium, cefTRIAXone sodium, clarithromycin, erythromycin, or
sulfamethoxazole-trimethoprim as second-line agents
 Analgesics and antipyretics, such as acetaminophen, or analgesic eardrops such as
antipyrine-benzocaine
 Combination antibiotic and glucocorticoid solutions for tympanic membrane rupture
 Antibiotic eardrops (more effective in patients with tympanoplasty tubes and acute
OM)
Surgery

 Myringotomy and aspiration of middle ear fluid

 Myringoplasty
 Tympanoplasty
 Mastoidectomy
 Cholesteatoma excision
Nursing Considerations
Nursing Interventions

 Administer antipyretics and antibiotics, as ordered.

 Institute measures to reduce fever.
 Screen for and assess the patient's pain using facility-defined criteria that are
consistent with the patient's age, condition, and ability to understand.
 Treat the patient's pain, as needed and ordered, using nonpharmacologic,
pharmacologic, or a combination of approaches.
 Reassess and respond to the patient's pain by evaluating the response to treatment and
progress toward pain management goals.
 Encourage the patient to maintain adequate hydration.
 Allow the patient and family to verbalize feelings and concerns; answer all questions
and provide emotional support.
 Prepare the patient and family for possible surgery.
With Hearing Loss
 Offer reassurance, when appropriate, that hearing loss caused by OM is temporary.
 Provide clear, concise explanations.
 Administer prescribed medications, such as analgesic drops for pain and antibiotics.
 Face the patient when speaking, and enunciate clearly and slowly.
 Allow time for the patient to grasp what was said.
 Provide a pencil and paper.
 Alert the staff to the patient's communication problem.
 After Myringotomy
 Perform hand hygiene before and after ear care.
 Position the patient to maintain drainage flow.
 Place sterile cotton loosely in the external ear to absorb drainage and prevent
infection.
 Change the cotton when damp. Avoid placing cotton or plugs deep in the ear canal.
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
 Give prescribed analgesics.
Monitoring

 Pain level and effectiveness of interventions

 Excessive bleeding or discharge
 Auditory acuity
 Ability to communicate needs
 Postoperative status, including drainage and dressings
 Signs and symptoms of infection
WARNING!

 Watch for and immediately report pain and fever due to OM.
 Associated Nursing Procedures
 Eardrop instillation
 Fall management
 Fall prevention
 Heat application
 Oral drug administration
 Otic foreign body removal, assisting
 Pain assessment
 Pain management
 Safe medication administration practices, general
Patient Teaching
General
Include the patient's family or caregiver in your teaching, when appropriate. Provide
information according to their individual communication and learning needs. Be sure to
cover:

 disease, possible underlying causes, diagnostic testing, and treatment

 prescribed drug therapy, including drug name, dosage, route, frequency of
administration, duration of therapy, and expected results
 technique for administering eardrops, if prescribed
 possible adverse effects of drug therapy, such as gastrointestinal upset with
amoxicillin, and signs and symptoms of hypersensitivity
 importance of completing the entire course of antibiotic therapy as ordered
 need for adequate fluid intake
 information that symptoms of acute OM typically improve in 48 to 72 hours and that
OM with effusion after an acute episode usually resolves within 3 months
pain management plan and potential adverse effects of pain management treatment
use of fitted earplugs for swimming after myringotomy
 importance of notifying the practitioner if the tube falls out or if ear pain, fever, or
pus-filled discharge occurs
 measures to preventing recurrence (See Preventing otitis media.)
 importance of adhering to follow-up care, such as an otoscopic examination 4 weeks
after diagnosis of acute OM and monthly otoscopic or tympanometric examinations
until the condition resolves.
Preventing otitis media
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
Teach a patient who is recovering from otitis media at home (and the family, if appropriate)
about these important considerations to help prevent a recurrence:

 Recognition and early treatment of upper respiratory tract infections

 Promotion of eustachian tube patency achieved by performing auto-insufflation
several times per day, especially during airplane travel
 Avoidance of blowing the nose or getting the ear wet when bathing after
tympanoplasty
 Importance of completing prescribed antibiotics
Discharge Planning

 Assess the patient's and family understands of the diagnosis, treatment, prognosis,
follow-up, and warning signs for which to seek medical attention.
 Provide a list of prescribed drugs, including the dosage, prescribed time schedule, and
adverse reactions to report to the practitioner. Provide the patient (and family or
caregiver, as needed) with written information on the medications that the patient
should take after discharge.
 Assess the patient's and family's understanding of each prescribed medication,
including dosage, administration, expected results, duration, and possible adverse
effects.
 Assess the patient's ability to obtain medications; identify the party responsible for
obtaining medications.
 Instruct the patient to provide a list of medications to the practitioner who will be
caring for the patient after discharge; to update the information when the practitioner
discontinues medications, changes doses, or adds new medications (including over-
the-counter products); and to carry a medication list that contains all of this
information at all times in the event of an emergency.
 Ensure that the patient and caregivers receive contact information for medical support.
 Provide contact information for local support groups and services.
 Ensure that the patient or caregiver receives a copy of the discharge instructions and
that a copy is placed in the patient's medical record.
 Document the discharge planning evaluation in the patient's clinical record, including
who was involved in discharge planning and teaching, their understanding of the
teaching provided, and any need for follow-up teaching.
 Acute suppurative infection of the middle ear, often preceded by a viral upper
respiratory tract infection.
Tinnitus

Overview

Abnormal ringing, sizzling, buzzing, or humming in the ear

Classified as subjective (only the patient can hear the noise) or objective (the patient
and examiner can hear the noise) and as tinnitus aurium (the patient hears noise in his
ears) or tinnitus cerebri (the patient hears noise in his head)
 Usually associated with neural injury in the auditory pathway (See Common causes of
tinnitus.)
 Can be continuous or intermittent
Common causes of tinnitus
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
Tinnitus usually results from a disorder that affects the external, middle, or inner ear. Below
are some of its more common causes and their locations.
EXTERNAL EAR

 Ear canal obstruction by cerumen or a foreign body

 Otitis externa
 Tympanic membrane perforation

MIDDLE EAR

 Ossicle dislocation
 Otitis media
 Otosclerosis

INNER EAR

 Acoustic neuroma
 Atherosclerosis of carotid artery
 Labyrinthitis
 Ménière disease

History

 Ask about the onset and location of the sound as well as for a description.
 Inquire about other symptoms, such as vertigo, headache, or hearing loss.
 Take a health and drug history.

Physical Assessment

 Inspect the ears and examine the tympanic membrane using an otoscope.
 Perform the Weber and the Rinne tests to check for hearing loss.
 Auscultate for bruits in the neck.
 Examine the nasopharynx for masses that might cause eustachian tube dysfunction
and tinnitus.

Causes
Medical
Acoustic Neuroma

 Tinnitus in one ear precedes sensorineural hearing loss and vertigo in the same ear.
 Facial paralysis, headache, nausea, vomiting, and papilledema may occur.

Anemia

 Mild tinnitus may occur if anemia is severe.

 Other findings include pallor, weakness, fatigue, exertional dyspnea, tachycardia,
bounding pulse, atrial gallop, and a systolic bruit over the carotid arteries.

Atherosclerosis of the Carotid Artery

By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
 Constant tinnitus can be stopped by applying pressure over the carotid artery.
 Auscultation over the upper part of the neck, on the auricle, or near the ear on the
affected side may detect a bruit.
 Palpation may reveal a weak carotid pulse.

Cervical Spondylosis

 Osteophytic growths may compress the vertebral arteries, resulting in tinnitus.

 A stiff neck and pain aggravated by activity accompany tinnitus.
 Other findings include brief vertigo, nystagmus, hearing loss, paresthesia, weakness,
and pain that radiates down the arms.

Ear Canal Obstruction

 Tinnitus with conductive hearing loss, itching, blockage, and a feeling of fullness or
pain in the ear may occur.

Eustachian Tube Patency

 Tinnitus, audible breath sounds, loud and distorted voice sounds, and a sense of
fullness in the ear can occur.
 Use a pneumatic otoscope to see whether the tympanic membrane moves with
respiration.

Hypertension

 High-pitched tinnitus in both ears may occur with severe hypertension.

 Diastolic blood pressure over 120 mm Hg may also cause severe, throbbing headache;
restlessness; nausea; vomiting; blurred vision; seizures; and decreased level of
consciousness.

Intracranial Arteriovenous Malformation

 A large malformation may cause tinnitus accompanied by a bruit over the mastoid
process.
 Other findings include severe headache, seizures, and progressive neurologic deficits.

Labyrinthitis (Suppurative)

 Tinnitus occurs with sudden, severe attacks of vertigo, sensorineural hearing loss in
one or both ears, nystagmus, dizziness, nausea, and vomiting.

Ménière Disease

 Attacks of tinnitus occur with vertigo, a feeling of fullness or blockage in the ear, and
fluctuating sensorineural hearing loss for 10 minutes to several hours.
 Other findings include severe nausea, vomiting, diaphoresis, and nystagmus.

Ossicle Dislocation
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
 Tinnitus and sensorineural hearing loss occur.
 Possible bleeding from the middle ear may also occur.

Otitis Externa (Acute)

 If debris in the external ear canal invades the tympanic membrane, tinnitus may result.
 More typical findings include pruritus, foul-smelling purulent discharge, and severe
ear pain aggravated by manipulation of the tragus or auricle, teeth clenching, mouth
opening, and chewing.
 The external ear canal appears red and edematous and may be occluded by debris,
causing partial hearing loss.

Otitis Media

 Tinnitus and conductive hearing loss may occur.

 More typical findings include ear pain; a red, bulging tympanic membrane; high
fever; chills; and dizziness.

Otosclerosis

 The patient may describe ringing, roaring, or whistling tinnitus or a combination of

these sounds.
 Progressive hearing loss and vertigo may occur.

Presbycusis

 Presbycusis is hearing loss that occurs with age.

 Tinnitus and a progressive, symmetrical, sensorineural hearing loss in both ears,
usually of high frequency tones, occur.

Tympanic Membrane Perforation

 Tinnitus is usually the chief complaint in a small perforation; hearing loss, in a larger
perforation.
 Other findings include pain, vertigo, and a feeling of fullness in the ear.

Other
Drugs and Alcohol

 Alcohol, indomethacin (Indocin), and quinine sulfate may cause reversible tinnitus.
 Common drugs that may cause irreversible tinnitus include the aminoglycoside
antibiotics and vancomycin.
 Overdose of salicylates commonly causes reversible tinnitus.

Noise

 Chronic exposure to noise, especially high-pitched sounds, can damage the ear's hair
cells, causing temporary or permanent tinnitus and total hearing loss.

Nursing Considerations
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
 Take steps to communicate clearly with patients with hearing loss.
 Address safety concerns in patients with vertigo.
 A hearing aid may be used to amplify environmental sounds, thereby obscuring
tinnitus.

Pediatric Pointers

 Maternal use of ototoxic drugs during the third trimester of pregnancy can cause
labyrinthine damage in the fetus, resulting in tinnitus.

Patient Teaching

Be sure to include the patient's family or caregiver in your teaching, when appropriate.
 Educate the patient about strategies for adapting to the tinnitus.
 Provide information about avoidance of excessive noise, ototoxic agents, and other
factors that may cause cochlear damage.
 Teach the patient about the treatment plan.
 Prepare the patient for diagnostic testing.
Otorrhea
Overview

 Drainage from the ear

 May be bloody, purulent, clear, or serosanguineous
History

 Ask about the onset and description of drainage.

 Find out about pain, tenderness, vertigo, or tinnitus.
 Obtain a medical history, including incidence of recent upper respiratory infection or
head trauma, cancer, dermatitis, or immunosuppressant therapy.
Physical Assessment

 Inspect the external ear, and apply pressure on the tragus and mastoid area to elicit
tenderness; then insert an otoscope.
 Observe for edema, erythema, crusts, or polyps.
 Inspect the tympanic membrane, noting color changes, perforation, absence of the
normal light reflex, or a bulging membrane.
 Test hearing acuity and perform Weber and Rinne tests.
 Palpate the neck and preauricular, parotid, and postauricular areas for
lymphadenopathy.
 Test the function of cranial nerves VII, IX, X, and XI.
 Obtain vital signs.
Causes
Medical
Allergy
 Tympanic membrane perforation may cause clear or cloudy otorrhea, rhinorrhea, and
itchy, watery eyes.
 Other signs and symptoms include nasal congestion and an itchy nose and throat.
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
Aural Polyps
 Foul, purulent, blood-streaked discharge may occur, possibly followed by partial
hearing loss.
Basilar Skull Fracture

 Otorrhea may be clear and watery and show a positive reaction on a glucose test, or it
may be bloody.
 Other signs and symptoms include hearing loss, cerebrospinal fluid or bloody
rhinorrhea, periorbital raccoon eyes, mastoid ecchymosis (Battle sign), cranial nerve
palsies, decreased level of consciousness, and headache.
Dermatitis of the External Ear Canal
 With contact dermatitis, vesicles produce clear, watery otorrhea with edema and
erythema of the external ear canal.
 With infectious eczematoid dermatitis, otorrhea is purulent with erythema and
crusting of the external ear canal.
 With seborrheic dermatitis, otorrhea has greasy scales and flakes.
Mastoiditis

 Thick, purulent, yellow otorrhea becomes increasingly profuse.

 Related signs and symptoms include low-grade fever and dull aching and tenderness
in the mastoid area.
 Conductive hearing loss may develop.
Myringitis, Infectious

 Small, reddened, blood-filled blebs or blisters rupture, causing serosanguineous

otorrhea.
 In the chronic form, purulent otorrhea, pruritus, and gradual hearing loss occur.
 Other signs and symptoms include severe ear pain and tenderness over the mastoid
process.
Otitis Externa

 The acute form usually causes purulent, yellow, sticky, foul-smelling otorrhea.
 Related acute signs and symptoms include edema, erythema, pain, and itching of the
auricle and external ear; severe tenderness with movement of the mastoid, tragus,
mouth, or jaw; tenderness and swelling of surrounding nodes; partial conductive
hearing loss; and low-grade fever and headache ipsilateral to the affected ear.
 The chronic form usually causes scanty, intermittent otorrhea that may be serous or
purulent as well as edema and slight erythema.
Otitis Media
 With acute otitis media, rupture of the tympanic membrane produces bloody, purulent
otorrhea and conductive hearing loss that worsens over several hours.
 With acute suppurative otitis media, otorrhea may accompany signs and symptoms of
upper respiratory infection, dizziness, fever, nausea, and vomiting.
 With chronic otitis media, otorrhea is intermittent, purulent, and foul-smelling and is
accompanied by gradual conductive hearing loss, pain, nausea, and vertigo.
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
Trauma
 Bloody otorrhea may occur and may be accompanied by partial hearing loss.
Tumor

 A benign tumor of the jugular glomus may cause bloody otorrhea.

 Related signs and symptoms include throbbing discomfort, tinnitus that resembles the
sound of the patient's heartbeat, progressive stuffiness of the affected ear, vertigo,
conductive hearing loss, and, possibly, a reddened mass behind the tympanic
membrane.
 Squamous cell carcinoma of the external ear causes purulent otorrhea with itching;
deep, boring pain; hearing loss; and, in late stages, facial paralysis.
 Squamous cell carcinoma of the middle ear causes blood-tinged otorrhea that occurs
early and is accompanied by hearing loss of the affected side; pain and facial paralysis
are late signs.
Nursing Considerations

 Apply a warm moist compress, heating pad, or hot water bottle to the ear.
 Use cotton wicks to clean the ear or to apply topical drugs. Avoid inserting anything
directly into the ear canal.
 Keep eardrops at room temperature; instillation of cold eardrops may cause vertigo.
 If the patient has impaired hearing, make sure that he understands what's explained to
him.
Pediatric Pointers
 Perforation of the tympanic membrane from otitis media is the most common cause of
otorrhea in infants and young children.
 Children may insert foreign bodies into their ears, resulting in infection, pain, and
purulent discharge.
 Because the auditory canal of a child lies horizontal, the pinna must be pulled
downward and backward to examine the ear (see Examining a child's ear).
Respirations (stertorous)
Overview

 Are characterized by harsh, rattling, or snoring sound

 Result from the vibration of relaxed oropharyngeal structures during sleep or coma,
causing partial airway obstruction
 Alcohol or sedatives before bed and sleeping in a supine position increase
oropharyngeal flaccidity; these allow the relaxed tongue to slip back into the airway

Action Stat!

Check the patient's mouth and throat for edema, redness, masses, or foreign
objects. If edema is marked, take vital signs, including oxygen saturation levels.
Observe for signs and symptoms of respiratory distress, such as dyspnea,
tachypnea, the use of accessory muscles, intercostal muscle retractions, and
cyanosis. Elevate the head of the bed 30 degrees to help ease the patient's breathing
and reduce edema. Administer supplemental oxygen, and prepare for intubation,
tracheostomy, or mechanical ventilation, as needed. Insert an I.V. catheter for fluid
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT

and drug access, and begin cardiac monitoring.

History

 Ask the patient's sleeping partner about his snoring habits.

 Find out about factors that decrease snoring.
 Inquire about sleep talking and sleepwalking.
 Ask about signs of sleep deprivation, such as personality changes, headaches, daytime
somnolence, and decreased mental acuity.
Physical Assessment

 Perform a complete respiratory assessment.

 Examine the head, nose, and throat.
 If you detect stertorous respirations while the patient is sleeping, observe his
breathing pattern for 3 to 4 minutes.
 Watch for periods of apnea and note their length.
Causes
Medical
Airway Obstruction
 With partial obstruction, stertorous respirations may be accompanied by wheezing,
dyspnea, tachypnea, intercostal retractions, and nasal flaring.
 In complete obstruction, the patient abruptly loses the ability to talk and displays
diaphoresis, tachycardia, and inspiratory chest movement but absent breath sounds;
severe hypoxemia rapidly ensues, resulting in cyanosis, loss of consciousness, and
cardiopulmonary collapse.
Obstructive Sleep Apnea

 Loud and disruptive snoring is a major characteristic, commonly affecting people who
are obese.
 Snoring alternates with periods of sleep apnea, which usually ends with loud gasping
sounds.
 Alternating tachycardia and bradycardia, ankle edema, and hypertension may occur.
 Sleep disturbances such as somnambulism and talking during sleep may occur.
 Other relevant findings may include a generalized headache, dry or sore throat,
feeling tired and unrefreshed, daytime sleepiness, depression, hostility, morning
sleepiness, and decreased mental acuity.
Pickwickian Syndrome (Obesity Hypoventilation Syndrome)
 Characteristics include obesity, daytime hypoventilation, and sleep-disordered
breathing.
 Obstructive sleep apnea with disruptive snoring and disturbed sleep at night results
from excessive fatty tissue surrounding the chest muscles.
 Related signs and symptoms include excessive sleepiness during the day, dyspnea,
lack of energy, flushed face or bluish tinge to the face, elevated blood pressure, and
enlarged liver.
Other
Procedures
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
 Endotracheal intubation, suction, or surgery may cause significant palatal or uvular
edema, resulting in stertorous respirations.
Nursing Considerations

 Give a corticosteroid or an antibiotic, as prescribed.

 To reduce palatal and uvular inflammation and edema, provide cool, humidified
oxygen.
 Monitor the patient's respiratory status.
 Prepare the patient for diagnostic tests such as laryngoscopy and sleep studies.
Pediatric Pointers

 The most common cause of stertorous respirations in children is nasal or pharyngeal

obstruction from tonsillar or adenoid hypertrophy or the presence of a foreign body.
Geriatric Pointers
 Encourage the patient to seek treatment for sleep apnea or significant hypertrophy of
tonsils or adenoids.
Patient Teaching

 Be sure to include the patient's family or caregiver in your teaching, when

appropriate.
 Discuss the underlying condition, diagnostic tests, and treatment options.
 Discuss the importance and methods of weight loss.
 Explain the setup and use of a continuous or bilevel positive airway pressure device.
 Teach the patient how to elevate his head while sleeping.
 Give information and recommend a smoking cessation program if the patient smokes.
Facial pain
Overview

 May result from various neurologic, vascular, or infectious disorders

 May be referred from the ears, nose, paranasal sinuses, teeth, neck, and jaw
 Typically paroxysmal and intense
History

 Ask about onset, description, location, intensity, quality, and duration, including any
possible precipitating factors related to the pain.
 Determine what alleviates or aggravates the pain.
 Ask about sensitivity to hot, cold, or sweet liquids or foods.
 Obtain a medical and dental history, noting incidence of previous head trauma, dental
disease, and infection.
Physical Assessment

 Inspect the ear for vesicles and changes in the tympanic membrane.
 Inspect the nose for deformity or asymmetry and characterize any secretions.
 Palpate the sinuses for tenderness and swelling.
 Inspect the oral cavity and evaluate oral hygiene.
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
 Have the patient open and close his mouth as you palpate the temporomandibular
joint for tenderness, spasm, locking, and crepitus.
 Assess cranial nerves V and VII. (See Major nerve pathways of the face.)
Major nerve pathways of the face
Cranial nerve V has three branches. The ophthalmic branch supplies sensation to the
anterior scalp, forehead, upper nose, and cornea. The maxillary branch supplies sensation to
the midportion of the face, lower nose, upper lip, and mucous membrane of the anterior
palate. The mandibular branch supplies sensation to the lower face, lower jaw, mucous
membrane of the cheek, and base of the tongue.

Cranial nerve VII innervates the facial muscles. Its motor branch controls the muscles of the
forehead, eye orbit, and mouth.
Causes
Medical
Angina Pectoris
 Jaw pain may be described as burning, squeezing, or feeling tight.
 Pain may radiate to the left arm, neck, and shoulder blade.
Dental Caries

 Caries in the mandibular molars can produce ear, preauricular, and temporal pain.
 Caries in the maxillary teeth can produce maxillary, orbital, retro-orbital, and parietal
pain.
Herpes Zoster Oticus

 Severe pain localizes around the ear, followed by the appearance of vesicles in the
ear.
 Eye pain may occur with corneal and scleral damage and impaired vision.
Multiple Sclerosis
 Facial pain may resemble that of trigeminal neuralgia.
 Pain is accompanied by jaw and facial weakness.
 Other signs and symptoms include visual blurring, diplopia, and nystagmus; sensory
impairment; generalized muscle weakness and gait abnormalities; urinary
disturbances; and emotional lability.
Ocular Glaucoma

 Periorbital pain appears late.

 Other signs and symptoms include loss of peripheral vision, reduced visual acuity
(especially at night), and seeing halos around lights.
Postherpetic Neuralgia

 Burning, itching, prickly pain occurs that worsens with contact or movement and
persists along any of the three trigeminal nerve divisions.
 Mild hypoesthesia or paresthesia and vesicles affect the area before the onset of pain.
Sinusitis, Acute
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
 Acute maxillary sinusitis produces pressure, fullness, or burning pain over the
cheekbone and upper teeth and around the eyes that worsens with bending over.
 Acute frontal sinusitis produces severe pain above or around the eyes that worsens
when the patient is in a supine position.
 Acute ethmoid sinusitis produces pain at or around the inner corner of the eye.
 Acute sphenoid sinusitis produces a persistent, deep-seated pain behind the eyes or
nose or on the top of the head that increases with bending forward.
Sinusitis, Chronic
 Chronic maxillary sinusitis produces a chronic toothache or a feeling of pressure
below the eyes.
 Chronic frontal sinusitis produces a persistent low-grade pain above the eyes.
 Chronic ethmoid sinusitis is characterized by nasal congestion and discharge and
discomfort at the medial corners of the eyes.
 Chronic sphenoid sinusitis produces a persistent low-grade, diffuse headache or retro-
orbital discomfort.
Sphenopalatine Neuralgia

 Deep, boring pain occurs below the ear and may radiate to the eye, other ear, cheek,
nose, palate, maxillary teeth, temple, neck, shoulder, or back of head.
 Attacks bring increased tearing and salivation, rhinorrhea, a sensation of fullness in
the ear, tinnitus, vertigo, taste disturbance, pruritus, and shoulder stiffness or
weakness.
Temporal Arteritis

 Pain occurs behind one eye or in the scalp, jaw, tongue, or neck.
 A typical episode consists of a severe throbbing or boring temporal headache with
redness, swelling, and nodulation of the temporal artery.
Temporomandibular Joint Syndrome

 An intermittent severe, dull ache or intense spasm, usually on one side, radiates to the
cheek, temple, lower jaw, or ear.
 Other signs and symptoms include trismus (lockjaw); malocclusion; and clicking,
crepitus, and tenderness of the joint.
Trigeminal Neuralgia

 Paroxysms of intense pain shoot along the three branches of the trigeminal nerve.
 Pain may be triggered by touching the nose, cheek, or mouth; being exposed to hot or
cold environments; consuming hot or cold foods or beverages; or even smiling and
talking.
Nursing Considerations

 Assess for changes in the character and location of the pain.

 Give drugs for pain, as prescribed.
 Apply direct heat or give a muscle relaxant, as prescribed.
 Provide a humidifier, vaporizer, or decongestant to relieve nasal or sinus congestion.
Pediatric Pointers
By A.B.Sani MED-SURGE (E.N.T) KKB SON KT
 Look for subtle signs of pain, such as facial rubbing, irritability, or poor eating habits.
Patient Teaching

 Be sure to include the patient's family or caregiver in your teaching, when

appropriate.
 Teach the patient about triggers to avoid.
 Explain which signs and symptoms to report.
 Teach the patient about prescribed medications, dosage, and possible adverse effects.
 Teach the patient about appropriate nonpharmacologic methods to treat pain if
appropriate.
 Instruct the patient about proper oral hygiene measures if dental caries are a cause.