Diagnostic tests

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

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 midline 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

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

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

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. (See Positioning the tuning fork.)

 

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

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

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

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.

Nursing considerations

  • 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.

Nursing considerations

  • 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.
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Ear, nose, and throat disorders: Cultures

Nasopharyngeal and throat cultures can identify various path ogens 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.

Nursing considerations

  • 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 betahemolytics 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

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

Nursing considerations

  • 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.

Treatments

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

Ear, nose, and throat disorders: Drug therapy

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 eardrops to lie on his side with the affected ear up for 15 minutes to promote absorption.

Ear, nose, and throat disorders: Surgery

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.

Patient preparation

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.

Monitoring and aftercare

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.

Home care instructions

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

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.

Patient preparation

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.

Monitoring and aftercare

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.

Home care instructions

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.
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