NCLEX: Ear, nose, and throat disorders

Ear, nose, and throat disorders: A look at ear, nose, and throat disorders

Focus topic: Ear, nose, and throat disorders

Because ear, nose, and throat (ENT) conditions can cause pain and severely impair a patient’s ability to communicate, they require careful nursing assessment and, in many cases, recommendations for follow-up treatment. For example, you may need to refer a patient with a hearing loss to an audiologist for further evaluation or refer a patient with rhinitis to a doctor for hypersensitivity testing.

Ear, nose, and throat disorders: Anatomy and physiology

Focus topic: Ear, nose, and throat disorders

To perform an accurate physical assessment, you’ll need to understand the anatomy and physiology of the ear, nose, and throat. Let’s look at each of them.

Ear, nose, and throat disorders: Ear

Focus topic: Ear, nose, and throat disorders

The ear, a sensory organ, enables hearing and maintains equilibrium. It’s divided into three main parts — the external ear, the middle ear, and the inner ear.

Ear, nose, and throat disorders

Ear, nose, and throat disorders: Let’s start outside

Focus topic: Ear, nose, and throat disorders

The external ear is made up of the skin-covered cartilaginous auricle (pinna) and the external auditory canal. The tympanic membrane (eardrum) separates the external ear from the middle ear at the proximal portion of the auditory canal.

Ear, nose, and throat disorders: Three in the middle

Focus topic: Ear, nose, and throat disorders

The middle ear, a small, air-filled cavity in the temporal bone, contains three small bones — the malleus, the incus, and the stapes.

Ear, nose, and throat disorders: Enter the inner labyrinth

Focus topic: Ear, nose, and throat disorders

This cavity leads to the inner ear, a bony and membranous labyrinth, which contains the vestibule, the semicircular canals (the vestibular apparatus), and the cochlea.

Ear, nose, and throat disorders: How we hear here

Focus topic: Ear, nose, and throat disorders

The auricle picks up sound waves and channels them into the auditory canal. There, the waves strike the tympanic membrane, which vibrates and causes the handle of the malleus to vibrate too. These vibrations travel from the malleus, to the incus, to the stapes, through the oval window and the fluid in the cochlea, tothe round window.

Ear, nose, and throat disorders: Hearing hair

Focus topic: Ear, nose, and throat disorders

The membrane covering the round window shakes the delicate hair cells in the organ of Corti, which stimulates the sensory endings of the cochlear branch of the acoustic nerve (cranial nerve VIII). The nerve sends the impulses to the auditory area of the temporal lobe in the brain, which then interprets the sound.

Ear, nose, and throat disorders: Nose, sinuses, and mouth

Focus topic: Ear, nose, and throat disorders

Not only is the nose the sensory organ for smell, but it also warms, filters, and humidifies inhaled air. The sinuses are hollow, air-filled cavities that lie within the facial bones. They include the frontal, sphenoidal, ethmoidal, and maxillary sinuses. The same mucous membrane lines the sinuses and the nasal cavity. Consequently, the same viruses and bacteria that cause upper respiratory tract infections also infect the sinuses. In addition to aiding voice resonance, the sinuses may also warm, humidify, and filter inhaled air, although this role hasn’t been firmly established.

Ear, nose, and throat disorders: Open wide

Focus topic: Ear, nose, and throat disorders

The lips surround the mouth anteriorly. The soft palate and uvula (a small, cone-shaped muscle lined with mucous membrane that hangs from the soft palate) border it posteriorly. The mandibular bone, which is covered with loose, mobile tissue, forms the floor of the mouth; the hard and soft palates form the roof of the mouth.

Ear, nose, and throat disorders: Throat

Focus topic: Ear, nose, and throat disorders

Located in the anterior part of the neck, the throat includes the pharynx, epiglottis, and larynx (voice box). Food travels through the pharynx to the esophagus. Air travels through it to the larynx. The epiglottis diverts material away from the glottis during swallowing and helps prevent aspiration.

Ear, nose, and throat disorders

Ear, nose, and throat disorders: High jinx in the larynx

Focus topic: Ear, nose, and throat disorders

By vibrating exhaled air through the vocal cords, the larynx produces sound. Changes in vocal cord length and air pressure affect the voice’s pitch and intensity. The larynx also stimulates the vital cough reflex when a foreign body touches its sensitive mucosa. The most important function of the larynx is to act as a passage for air between the pharynx and the trachea.

Ear, nose, and throat disorders: Assessment

Focus topic: Ear, nose, and throat disorders

Now that you’re familiar with the anatomy and physiology of the ears, nose, and throat, you’re ready to assess them.

Ear, nose, and throat disorders: History

Focus topic: Ear, nose, and throat disorders

Before the interview, determine whether the patient hears well. If not, use his preferred technique to communicate.

Current health status

Document in the patient’s own words his chief complaint. Ask relevant questions, such as:

  • Have you recently noticed a difference in hearing in one or both ears?
  • Do you have ear pain? Is it unilateral or bilateral?
  • Do you have any drainage from one or both ears? What color is it? How often does it occur?
  • Do you have frequent headaches, nasal discharge, or postnasal drip?
  • Do you experience frequent or prolonged nosebleeds, difficulty swallowing or chewing, or hoarseness or changes in the sound of your voice?

Previous health status

To gather information about the patient’s past ENT health, inquire about previous hospitalization, drug therapy, or surgery for an ENT disorder or other relevant condition. Also, be sure to ask these questions:

  • Have you ever had an ear injury? Do you suffer from frequent ear infections?
  • Have you experienced ringing or crackling in your ears?
  • Have you had drainage from your ears or problems with balance, dizziness, or vertigo?
  • Have you had sinus infections or tenderness, allergies that cause breathing difficulty, or sensations that your throat is closing?

Family health status

Next, question the patient about possible familial ENT disorders. Ask whether anyone in the patient’s family has ever had hearing, sinus, or nasal problems.

Lifestyle patterns

To explore the patient’s daily habits that might affect the ears, nose, or throat, ask these questions:

  • Do you work around loud equipment, such as printing presses, air guns, or airplanes? If so, do you wear ear protectors?
  • Do you listen to loud music with headphones?
  • Do you smoke, chew tobacco, use cocaine, or drink alcohol? If so, to what extent?

Ear, nose, and throat disorders: Physical examination

Focus topic: Ear, nose, and throat disorders

You’ll primarily use inspection and palpation to assess the ears, nose, and throat. If appropriate, you’ll also perform an otoscopic examination.

Inspecting and palpating the ears

Examine ear color and size. The ears should be similarly shaped, colored the same as the face, sized in proportion to the head, and symmetrically placed. Look for drainage, nodules, and lesions. Cerumen is usually present and varies from gray-yellow to light brown and black.

Ear, nose, and throat disorders: Palpate pinna to process; then pull for pain

Focus topic: Ear, nose, and throat disorders

Palpate the external ear, including the pinna and the tragus, and the mastoid process to discover areas of tenderness, swelling, nodules, or lesions. Then gently pull the helix of the ear backward to determine whether the patient feels pain or tenderness.

Ear, nose, and throat disorders: Performing an otoscopic examination

Focus topic: Ear, nose, and throat disorders
Before examining the auditory canal and the tympanic membrane, become familiar with the function of the otoscope.

Assessing the nose

Inspect the nose for midline position and proportion to other facial features. To assess nasal symmetry, ask the patient to tilt his head back; then observe the position of the nasal septum. The septum should be aligned with the bridge of the nose. With the head in the same position, use a nasal speculum to inspect the inferior and middle turbinates, the nasal septum, and the nasal mucosa. Note the color of the mucosa, evidence of bleeding, and the color and character of drainage. The nasal mucosa is normally redder than the oral mucosa. Identify abnormalities such as polyps.

Ear, nose, and throat disorders: Palpate me tender

Focus topic: Ear, nose, and throat disorders

Next, palpate the nose, checking for painful or tender areas, swelling, and deformities. Evaluate nostril patency by gently occluding one nostril with your finger and having the patient exhale through the other.

Ear, nose, and throat disorders

Ear, nose, and throat disorders: Assessing the sinuses

Focus topic: Ear, nose, and throat disorders

To assess the paranasal sinuses, inspect, palpate, and percuss the frontal and maxillary sinuses. (The ethmoidal and sphenoidal sinuses lie above the middle and superior turbinates of the lateral nasal walls and can’t be assessed.) To assess the frontal and maxillary sinuses, first inspect the external skin surfaces above and to the side of the nose for inflammation or edema. Then palpate and percuss the sinuses. If the nose and sinuses require more extensive assessment, use the techniques of direct inspection and transillumination.

Ear, nose, and throat disorders

Assessing the mouth and throat

Use inspection and palpation to assess the mouth and throat. First, inspect the patient’s lips. They should be pink, moist, symmetrical, and without lesions. Use a tongue blade and a bright light to inspect the oral mucosa. Have the patient open his mouth; then place the tongue blade on top of his tongue. The oral mucosa should be pink, smooth, moist, and free from lesions and unusual odors.

Ear, nose, and throat disorders: Past the teeth, past the gums

Focus topic: Ear, nose, and throat disorders

Next, observe the gums (gingivae). They should be pink and moist and should have clearly defined margins at each tooth. Inspect the teeth, noting their number and condition and whether any are missing or crowded.

Ear, nose, and throat disorders: Next stop, the tongue

Focus topic: Ear, nose, and throat disorders

Next, inspect the tongue. It should be mid line, moist, pink, and free from lesions. It should move easily in all directions, and it should lie straight to the front at rest.

Ear, nose, and throat disorders: Uvula and oropharynx and tonsils — Oh, my!

Focus topic: Ear, nose, and throat disorders

Inspect the back of the throat (oropharynx) by asking the patient to open his mouth while you shine the penlight on the uvula and palate. You may need to insert a tongue blade into the mouth to depress the tongue. The uvula and oropharynx should be pink and moist, without inflammation or exudates. The tonsils should be pink and shouldn’t be hypertrophied. Ask the patient to say “Ahhh.” Observe for movement of the soft palate and uvula. The uvula should be centered at the mid line.

Ear, nose, and throat disorders: Palpation station

Focus topic: Ear, nose, and throat disorders

Finally, wearing clean gloves, palpate the lips, tongue, and oropharynx. Note lumps, lesions, ulcers, or edema of the lips or tongue. Assess the patient’s gag reflex by gently touching the back of the pharynx with a cotton-tipped applicator or the tongue blade. This should produce a bilateral response.

Ear, nose, and throat disorders: Diagnostic tests

Focus topic: Ear, nose, and throat disorders

Tests to determine the presence of ENT disorders should cause your patient little discomfort. These tests include auditory screening tests, audiometric tests, and cultures.

Ear, nose, and throat disorders: Auditory screening tests

Focus topic: Ear, nose, and throat disorders

Several tests can help you screen for hearing loss. The first test, the voice test, is a crude method and must be used with other auditory screening tests. Two other screening tests, the Weber and Rinne tests, help detect conductive or sensorineural hearing loss.

Voice test

For the voice test, have the patient occlude one ear with his finger. Test the other ear by standing behind the patient at a distance of 1 to 2 (30 to 60 cm) and whispering a word or phrase. A patient with normal acuity should be able to repeat what was whispered.

Weber test

The Weber test evaluates bone conduction. Perform the test by placing a vibrating tuning fork on top of the patient’s head at mid line or in the middle of the patient’s forehead. The patient should perceive the sound equally in both ears.

Ear, nose, and throat disorders: Lateral means loss

Focus topic: Ear, nose, and throat disorders

If the patient has a conductive hearing loss, the sound will lateralize to the ear with the conductive loss because the sound is being conducted directly through the bone to the ear. With a sensori neural hearing loss in one ear, the sound will lateralize to the unimpaired ear because nerve damage in the impaired ear prevents hearing.

Ear, nose, and throat disorders: Normal is negative

Focus topic: Ear, nose, and throat disorders

Document a normal Weber test by recording a negative lateralization of sound — that is, sound heard with equal volume in both ears.

Rinne test

The Rinne test compares bone conduction to air conduction in both ears. To administer this test, strike the tuning fork against your hand and place it over the patient’s mastoid process. Ask him to tell you when the tone stops, and note this time in seconds.

Ear, nose, and throat disorders: Tuning in

Focus topic: Ear, nose, and throat disorders

Next, move the still-vibrating tuning fork to the opening of his ear without touching the ear. Ask him to tell you when the tone stops. Note the time in seconds.

Ear, nose, and throat disorders

The patient should hear the air-conducted tone for twice as long as he hears the bone-conducted tone. If he doesn’t hear the air-conducted tone longer than he hears the bone-conducted tone, he has a conductive hearing loss in the affected ear.

Ear, nose, and throat disorders: Audiometric tests

Focus topic: Ear, nose, and throat disorders

Audiometric tests include acoustic immittance tests and pure tone audiometry. Audiologists perform these tests to confirm hearing loss.

Acoustic immittance tests

Immittance tests help diagnose middle ear disorders, lesions in the seventh (facial) or eighth (acoustic) cranial nerve, and eustachian tube dysfunction. They also can help verify a labyrinthine fistula and identify nonorganic hearing loss. Acoustic immittance tests evaluate middle ear function by measuring sound energy’s flow into the ear (admittance) and the opposition to that flow (impedance). Acoustic immittance tests include tympanometry and acoustic reflex testing.

Ear, nose, and throat disorders: Rising resistance

Focus topic: Ear, nose, and throat disorders

Tympanometry is the indirect measurement of mobility (compliance) and impedance (resistance of the tympanic membrane and ossicles of the middle ear). It’s performed by subjecting the external auditory canal and tympanic membrane to positive and negative air pressure.

Ear, nose, and throat disorders: That’s intense

Focus topic: Ear, nose, and throat disorders

Acoustic reflex testing measures the change in admittance produced by contraction of the stapedial muscle as it responds to an intense sound. A stimulation in one ear causes reaction in both ears.

Ear, nose, and throat disorders: Nursing considerations

Focus topic: Ear, nose, and throat disorders

  • Instruct the patient not to move, speak, or swallow while admittance is being measured.
  • Tell him not to startle during the loud tone, reflex-eliciting measurement.
  • Ask him to report discomfort or dizziness (which occurs rarely).
  • Explain that the probe forms an airtight seal in the ear canal and may cause discomfort but that it won’t harm the ear.

Pure tone audiometry

Performed with an audiometer in a soundproof booth, pure tone audiometry provides a record of the thresholds (the lowest intensity levels) at which a patient can hear a set of test tones through earphones or a bone conduction (sound) vibrator. Comparison of air and bone conduction thresholds can help identify a conductive, sensorineural, or mixed hearing loss but won’t indicate the cause of the loss.

Ear, nose, and throat disorders: Nursing considerations

Focus topic: Ear, nose, and throat disorders

  • Make sure the patient has had no exposure to unusually loud noises in the past 16 hours.
  • For bone conduction testing, remove the earphones and place the vibrator on the mastoid process of the better ear (the auricle shouldn’t touch the vibrator).
  • It’s important that the ear canals be free from cerumen before audiologic testing begins.

Ear, nose, and throat disorders: Cultures

Focus topic: Ear, nose, and throat disorders

Nasopharyngeal and throat cultures can identify various pathogens related to ENT disorders.

Nasopharyngeal culture
A nasopharyngeal culture isolates and identifies pathogens in nasopharyngeal secretions. For this test, a specimen is obtained, streaked onto a culture plate, and left alone for organisms to grow. Sensitivity testing of the cultured pathogens can then help to determine appropriate antibiotic therapy.

Ear, nose, and throat disorders: Nursing considerations

Focus topic: Ear, nose, and throat disorders

  • Ask the patient to cough before you begin collecting the specimen. Then have him sit with his head tilted back.
  • Using a penlight and a tongue blade, inspect the nasopharyngeal area.
  • Next, gently pass the sterile swab through the nostril and into the nasopharynx, keeping the swab near the septum and floor of the nose. Rotate the swab quickly and remove it.
  • Take care not to injure the nasal mucosa and cause bleeding.

Throat culture

A throat culture primarily isolates and identifies group A betahemolytic s treptococci (Streptococcus pyogenes).This allows early treatment of pharyngitis and can help prevent aftereffects, such as rheumatic heart disease and glomerulonephritis. A throat culture also screens for other pathogens.

Ear, nose, and throat disorders: Isolate and identify

Focus topic: Ear, nose, and throat disorders

This test involves swabbing the throat, streaking a culture plate, and allowing the organisms to grow so that pathogens can be isolated and identified.

Ear, nose, and throat disorders: Nursing considerations

Focus topic: Ear, nose, and throat disorders

  • Before beginning ordered antibiotic therapy, obtain the throat specimen. With the patient in a sitting position, tell him to tilt his head back and close his eyes. With the throat well illuminated, check for inflamed areas using a tongue blade.
  • Next, use a sterile swab to swab the tonsillar areas from side to side, including inflamed or purulent sites. Don’t touch the tongue, cheeks, or teeth with the swab.
  • Finally, you’ll need to immediately place the swab in the culture tube. If you’re using a commercial sterile collection and transport system, crush the ampule and force the swab into the medium to keep the swab moist.

Ear, nose, and throat disorders: Treatments

Focus topic: Ear, nose, and throat disorders

Here’s practical information about the most common drugs and surgical procedures used to treat ENT disorders.

Ear, nose, and throat disorders: Drug therapy

Focus topic: Ear, nose, and throat disorders

Drugs used to treat ENT disorders include antihistamines and decongestants as well as anti-infective agents and corticosteroids. The route of administration depends on the disorder:

  •  The nasal route is used for relief of seasonal or perennial rhinitis and nasal congestion.
  • The systemic route is used for relief of inflammation and nasal congestion and to treat infection.
  • The otic is the route of choice for external ear infections, cerumen removal, pain from otitis media, and inflammation of the external ear. Instruct the patient using ear drops to lie on his side with the affected ear up for 15 minutes to promote absorption.

Ear, nose, and throat disorders: Surgery

Focus topic: Ear, nose, and throat disorders

Surgical treatment of ENT disorders includes the Caldwell-Luc procedure and tonsillectomy and adenoidectomy.

Caldwell-Luc procedure

The Caldwell-Luc procedure, a surgical approach to the maxillary sinus, permits visualization of the antrum, promotes sinus drainage, and allows access to infected sinuses when an intra nasal approach isn’t possible because of suppuration or inflammation. It’s usually used to treat chronic sinusitis that doesn’t respond to other treatments. This procedure also halts persistent epistaxis, provides a tissue sample for histologic analysis, and supplements other treatments such as ethmoidectomy.

Ear, nose, and throat disorders: Patient preparation

Focus topic: Ear, nose, and throat disorders

Before the procedure, take these steps:

  • Tell the patient to expect considerable swelling of his cheek and numbness and tingling on his upper lip.
  • Explain that his maxillary sinus and nose may be packed. Let him know that nasal packing is removed after 24 hours and antral packing is removed after 48 to 72 hours.

Ear, nose, and throat disorders: Monitoring and aftercare

Focus topic: Ear, nose, and throat disorders

Immediately after surgery, take these steps:

  • Check for facial edema, and advise the patient to report adverse reactions such as paresthesia of his upper lip.
  • If the patient has packing in place, let him know how long it will be before the doctor removes it. If he has a drainage tube in place for irrigation, assist with irrigation and tell the patient that the tube will be removed in 3 to 4 days.
  • Assess the patient’s mouth frequently for bleeding.
  • Remind the patient not to touch the incision with his tongue or finger.
  • If the patient wears dentures, instruct him not to insert his upper plate for 2 weeks. Also, caution him not to brush his teeth, but rather to rinse his mouth gently with tepid saline solution or diluted mouthwash.
  • Until the incision heals, avoid giving foods that require thorough chewing.

Ear, nose, and throat disorders: Home care instructions

Focus topic: Ear, nose, and throat disorders

Before discharge, tell the patient to:

  • expect some drainage from his nose for a few days after surgery and to monitor the amount, color, and odor
  • call the practitioner if he notices bleeding or a foul smell or if drainage persists for more than 5 days
  • avoid rubbing or bumping his incision
  • avoid engaging in vigorous activity or blowing his nose forcefully for 2 weeks and to sniff gently if he needs to clear his nostrils.

Tonsillectomy and adenoidectomy

Tonsillectomy is the surgical removal of the palatine tonsils. Adenoidectomy is the surgical removal of the pharyngeal tonsils. These procedures were once routinely combined in an adenotonsillectomy to treat enlarged tonsils and adenoids. However, these procedures aren’t as common today. Instead, patients receive antibiotics to treat tonsils and adenoids enlarged by bacterial infection.

Ear, nose, and throat disorders: Still surgery sometimes

Focus topic: Ear, nose, and throat disorders

Even so, a patient may need either or both of these surgeries to resolve tonsillar tissue enlargement that obstructs the upper airway, causing hypoxia or sleep apnea. These procedures may also be used to relieve peritonsillar abscess, chronic tonsillitis, and recurrent otitis media.

Ear, nose, and throat disorders: Patient preparation

Focus topic: Ear, nose, and throat disorders

If a patient is scheduled for an adenoidectomy, evaluate whether he has nasal speech or difficulty articulating. If you note these problems, arrange for evaluation by a speech therapist.

Ear, nose, and throat disorders: Monitoring and aftercare

Focus topic: Ear, nose, and throat disorders

After surgery, take these steps:

  • Monitor vital signs closely for 24 hours, and watch for hemorrhage. Use a flashlight to check the throat and assess for bleeding. Remember, blood can seep down the back of the patient’s throat. Pay special attention to frequent swallowing; it may indicate excessive bleeding.
  • Take care not to dislodge clots: Make sure the patient doesn’t place straws or other utensils in his mouth. When ordered, start him on soft foods.
  • Expect some vomiting; even coffee-ground vomitus is the normal result of swallowed blood. However, notify the practitioner if you see bright red blood; this indicates that vomiting has induced bleeding at the operative site.
  • If the patient complains of a sore throat, provide cool compresses or an ice collar.

Ear, nose, and throat disorders: Home care instructions

Focus topic: Ear, nose, and throat disorders

Before discharge, instruct the patient to:

  • immediately report bleeding; explain that the risk of bleeding is greatest 7 to 10 days after surgery, when the membrane formed at the operative site begins to slough off
  • consume only liquids and soft foods for 1 to 2 weeks to avoid dislodging clots or precipitating bleeding
  • practice good oral hygiene by gently brushing his teeth but avoiding vigorous brushing, gargling, and irritating mouthwashes for several weeks
  • rest and avoid vigorous activity for 7 to 10 days after discharge
  • avoid exposure to persons with colds or other contagious illnesses for at least 2 weeks.

FURTHER READING/STUDY:

Resources:

Leave a Reply

Your email address will not be published. Required fields are marked *