Review A & P of ear, nose and throat
Ear, Nose and Throat examination
Common diseases/conditions of Ear, Nose, and
Perform ear irrigation
REVIEW OF A & P
Hearing and Balance
Three parts outer, middle, and inner ear
The outer & middle ear; hearing
The inner ear; both hearing & equilibrium
Receptors for hearing & balance
Lighten the skull.
Warm and moisten the air.
Resonance chambers for speech.
Produce mucus that drains into the nasal
Examination of ENT
Inspection: deformities, lesions, and discharge,
as well as size, symmetry, and angle of
attachment to the head
Direct palpation: pain, tenderness
Otoscopic Exam: ext. auditory canal & tympanic
membrane:- redness, perforation, exudate, blood,
Gross Auditory Acuity: one ear at a time;
Voice/Whisper, Weber and Rinne tests are done
Testing Gross Auditory Acuity
Voice/Whisper Test: One ear occluded,
examiner whispers softly 1-2 feet away from the
unconcluded ear, out of pt’s sight.
Normal: can correctly repeat word.
Weber Test: Tests bone conduction.
Vibrating tuning fork placed on the pt’s mid-
Normal: sound heard equally in both ears or as
Conductive hearing loss:- sound heard better in the
Rinne Test: Distinguishes btwn conductive &
sensorineural hearing loss.
Examiner places stem of vibrating turning fork on
mastoid process & counts till pt. can no longer hear;
then immediately near the canal and counts till pt.
can no longer hear.
Normal: air conduction > bone conduction.
Conductive hearing loss:- bone conduction ≥ air
Sensorineural hearing loss:- air conduction > bone
1. Sinuses in direct communication with
2. Bacterial or viral infection of sinuses
3. Inflammation, (or tumors, polyps, trauma)
cause ostia obstruction
4. Ostia obstruction impede normal air & mucus
5. Mucus stagnates, further growth of bacteria
causing eve further inflammation/ swelling
Mainly based on Hx. & Clinical Presentation
X-ray, sinoscopy, ultrasound, CT, and MRI (chronic
A confirmatory diagnosis is by obtaining cultures
by sinus puncture or endoscopy.
Depends on cause, from Hx & physical exam.
Tx. focuses on symptom relief.
Most common: Antihistamine/decongestant
Leukotriene modifiers (Montelukast)]
Mast cell stabilizer (Cromolyn)
Tx. Goal is to shrink the nasal mucosa, relieve
pain, & treat infection (if present/ suspected)
Observation without the use of antibiotics
Antibiotic of choice: Amoxicillin OR Amoxicillin-
For Penicillin allergy: Cotri-moxazole (Septrin)
For Resistance: High dose Amoxicillin-clavulanate;
NURSING MANAGEMENT and PREVENTION
Teaching on self-care is the basis of nursing
Avoid or reduce exposure to allergens/irritants
Correct use/administration of meds/ following the
recommended antibiotic regimen
Controlling the environment at home and at work
Early Tx. & home remedies: saline nasal sprays/
Signs of complications: headache; neck stiffness;
Treated through the use of supportive
Increased fluid intake
Analgesics e.g. PCM
Penicillin (Augmentin, X-pen, benzathine)(first-line
Consider corticosteroids e.g dexa
Indications for tonsillectomy and adenoidectomy.
1. Recurrent throat infections:
≥ 7 ep. in 1 yr
5 ep./yr. for 2 yrs.
3 ep. /yr. for 3yrs.
≥ 2 wks of lost school or work
2. Peritonsilar abscess
3. Associated airway obstruction or sleep apnea
4. Malignancy (or suspicion of)-biopsy
5. Repeated attacks of purulent otitis media
Adenoidectomy done if adenoids are concurrently
Bleeding from nostril, nasal cavity or nasopharynx
Often self–limiting but may be severe & life-
60% of population with at least one nosebleed
6-10% will require medical treatment
Bimodal age distribution
High Incidence < 10 y/o
Second peak: 45-65 y/o
Bleeding usually arises from the nasal septum, which
is supplied by:
Anterior ethmoidal artery
Posterior ethmoidal artery
Superior labial artery
Anterior Nasal Cavity = Little’s Area
Nose has abundant blood supply that permits it to bleed
Posterior Nasal Cavity
Inspect the nose and back of the throat for obvious
bleeding and observe for frequent swallowing
Level of consciousness and vital signs to detect signs
Document allergies & major illnesses
Anterior or posterior rhinoscopy
CBC-Hb, platelet count etc.
Digital Pressure (Trotter’s Method)
1. Pt sits up
2. Head bent forward
3. Breath through open mouth
4. Pinch over Kiesselbach’s plexus for at least 15-20
Nasal Tampon inserted horizontally after
lubrication of pack with bacitracin or KY-Jelly and
then allowed to expand after saturation with normal
Balloon Catheter coated with lubricant & platelet
Soaked in water for 30 seconds then inserted into
the nose along the base of the nasopharynx.
Cuff inflated with air/water until it provides
Pack the nasal cavity with xeroform ribbon
gauze from the floor upwards in an accordion
fashion using a bayonet forceps leaving a four
inch tail on each end out of nares
Hot Water Irrigation
Complications of Packing
Failure to control bleeding
Toxic Shock Syndrome
Blockage of Duct drainage
Nasovagal Reflex (Controversial)
Obstructive Sleep Apnea
Removal can cause re-bleeding
Epistaxis is common complaint affecting 60% of
population at some point in lifetime
Key to evaluation is differentiation between anterior
and posterior bleeding source
Anterior = 90-95 % (from Kiesselbach’s plexus)
Posterior = 5-10% (from sphenopalantine artery)
Consider possible causes for epistaxis with recurrent or
difficult to control nosebleeds
Non-invasive techniques will stop the majority of
epistaxis (Trotter’s method, cautery, vasoconstrictive
Difficulty to control epistaxis may require nasal
Consider antibiotics while packing in place
Posterior nasal bleeds should all be hospitalized
Inflammation of the larynx
May be infectious or non-infectious;
Acute:- sudden onset.
Chronic:- persistent hoarseness.
Exposure to dust, chemicals, smoke, other pollutants
Descending URI. (pharyngitis): H. infuenzae; haemo lytic
streptococci or Staph. aureus.
GERD (reflux laryngitis).
Exposure to sudden temperature changes,
Dietary deficiencies, malnutrition,
NB: Most common cause is a virus. Bacteria are secondary.
Hoarseness or aphonia
Dry, irritating cough
Discomfort or pain in throat
Sore throat (worsens in the evening hours).
Malaise and fever if laryngitis has followed
viral infection of upper respiratory tract.
Vocal rest. This is the most important single
Avoidance of smoking and alcohol.
Steam inhalations e.g. oil of eucalyptus;
soothing and loosen viscid secretions.
Cough sedative:- To suppress troublesome
Antibiotics:-with 2˚infection; Ampicillin, 3rd gen
Analgesics. To relieve local pain and discomfort.
Steroids: laryngitis following thermal or chemical
DEVIATED NASAL SEPTUM
Top of the nasal cartilaginous ridge leans to the
left or the right, usually causing passage
Can result in poor drainage of the sinuses.
Alone, can go undetected for years; no need for
Many victims are unaware till some pain, or
Topical steroid medication
POST NASAL SPACE CARCINOMA
(NASOPHARYNGEAL CARCINOMA [NPC])
Most common ca. originating from nasopharyngeal
Usually at level of eustachian tube
Viral infections –EBV
Environmental influences e.g. carcinogens
Salted fish with Carcinogenic volatile nitrosamines
Hereditary; genetic susceptibility
Smoking & alcohol consumption
CANCER OF THE LARYNX
Approx ½ of all head & neck cancers.
Almost all are classified as squamous cell carcinoma.
Male gender (10:1)
Age 60 to 70 years
Occupational exposure to carcinogens
Nutritional deficiencies (riboflavin –B3)
Hoarse; harsh, raspy, low-pitched voice.
Persistent cough; pain & burning in the throat
when drinking hot liquids & citrus juices.
Lump felt in the neck.
Late symptoms: dysphagia, dyspnea, unilateral
nasal obstruction or discharge, persistent
hoarseness or ulceration, & foul breath.
Enlarged cervical nodes, weight loss, general
weight loss, & pain radiating to the ear may occur
ASSESSMENT AND DIAGNOSIS
Hx. of hoarseness
Physical exam: every case of hoarseness
should be examined by in(direct) laryngoscopy;
Biopsy (Dx, typing & staging)
CT, MRI, & PET scan
Goals:- cure, preserve effective swallowing,
voice, and avoidance of permanent
Tx options:- surgery, radio, chemo, or
Radiation ─excellent results in early-stage
Vocal cord stripping—used to treat dysplasia
Cordectomy—lesions limited to the middle 3rd of
the vocal cord
Laser surgery—Tx of early glottic cancers
Partial laryngectomy—early stages
Total laryngectomy—stage IV tumor or recurrence
Speech therapy: artificial larynx (electrolarynx)
Inflammation of middle ear by pyogenic organisms.
Common esp. in infants & children of lower socio-
URTI; Chronic rhinitis and sinusitis
Recurrent fevers i.e. measles, diphtheria, whooping
Tumours of nasopharynx
Packing of nose or nasopharynx for epistaxis.
Via eustachian tube
Via External ear
Most common organisms in infants & children
are Strep. pneumoniae (30%), Haem. influenzae
(20%) & Moraxella catarhalis (12%).
PATHOPHYSIOLOGY & CLINICAL
Runs through the following stages:
1. Tubal occlusion: Oedema & hyperaemia with
blockage of eustachian tube
Deafness (conductive) and earache
2. Pre-suppuration: pyogenic organisms invade
tympanic cavity worsening hyperaemia with
Deafness & tinnitus (adults); high fever;
Antibacterial therapy:- ampicillin, amoxicillin
Decongestant nasal drops:- Ephedrine drops; Oral
Ear toilet:- dry-mopping or a moistened wick
Myringotomy:- Incising the bulging drum to
Note: All cases should be carefully followed till
membrane returns to its normal appearance; conductive
Tympanostomy tube- for removal of loculated
Recurrent infections increase risk of permanent
Take full-course of antibiotics
Pain & fever management
Control allergies & upper respiratory congestion.
Avoid blowing or holding nose closed when
Prevent fluid pooling back to the eustachian tube;
-elevate infant’s head while feeding
-don’t allow infant to fall asleep with a bottle.
Avoid swimming or water in the ears (use
Inflammation of mucosal lining mastoid antrum and
bony walls of the mastoid air cell system.
Usually accompanies or follows acute otitis media.
Associated with high virulence or lowered host
Children are more affected
Mostly caused Beta-haemolytic streptococci
1. Infection + inflammation of periosteal lining.
2. Pus cannot be effectively drained
3. Pus accumulates under tension.
4. Hyperaemia & engorgement causes dissolution of
Ca2+ (hyperaemic decalcification).
5. Destruction of mastoid air cells & cavity; pus-filled.
6. Pus may break through mastoid cortex & on to
Fever; persistent or recurrent
Ear discharge; profuse & increases in
Sagging of poster superior meatal wall.
Tympanic perforation. dull & opaque
Swelling over the mastoid.
Conductive hearing loss always present.
HEARING LOSS AND
Hearing impairment is common among older
TYPES OF HEARING LOSS
Occurs in the middle ear
Sound cannot be conducted from outer to inner
Impacted cerumen; foreign bodies.
Middle ear disease (otitis media)
Impaired inner ear or vestibulocochlear nerve
Congenital & hereditary factors
Noise trauma during a period of time
3. MIXED HEARING LOSS
Both conductive & sensorineural losses.
Surgery can correct conductive loss but
sensorineural loss remains.
Able to hear sound but not to understand
4. CENTRAL & FUNCTIONAL HEARING
Problem along the pathway from the inner ear
to the auditory region or in the brain itself.
Unable to understand or put meaning to incoming
Positive family Hx of deafness.
Functional may be from emotional/psychologic
No organic cause can be identified.
Psychologic counseling may help.
TEST YOUR KNOWLWDGE!
Conductive hearing loss is initially detected by:
a) A negative Rinne test
b) A positive Rinne test
Test Normal Conductive loos SN loss
Rinne AC> BC
BC > AC
Weber Equal Lateralised to the
Lateralised to the
RISK FACTORS FOR HEARING
a) Prolonged exposure to high-intensity sound
b) Repeated, chronic ear infections
c) Prenatal problems of rubella & eclampsia
d) Premature birth
e) Ototoxic medications: aminoglycosides,
f) Female with family history of otosclerosis
i. Asking others to speak up
ii. Answering questions inappropriately
iii. Not responding when not looking at the
iv. Straining to hear
v. Cupping hand around ear
vi. Showing irritability with others who do not
vii. Increasing sensitivity to slight increases in
ix. Speech problems: deterioration of present speech
or delayed speech development.
Hearing aids: most effective with conductive loss.
Stapedectomy: for otosclerotic lesions
Cochlear implants: for profound sensorineural hearing
1. Teach client how to care for hearing aid
Keep the hearing aid dry
Avoid using hair spray, cosmetics, or oils around
Always have extra batteries
At night, turn off & open the battery compartment
Avoid exposing it to extreme temperatures
Clean ear mold part with a mild soap & water
Clean any debris or cerumen
Have it professionally cleaned every 3 to 6
2. To prevent complications after stapedectomy
Appropriate pre-op teaching about post-op
Dressing change as appropriate.
Assess client for dizziness; maintain safety
Position Pt. on side with head of bed slightly
Instruct client not to blow nose
Administer analgesics, antibiotics
Instruct that hearing may not improve till edema
3. Advice on discharge:
Keep the ear dry for 4 to 6 week after surgery.
Avoid flying for at least a month after surgery
Report unusual sensations or feelings in the ear
& any ear drainage.
Notify health care provider if vertigo occurs
ASSISTIVE DEVICES & TECHNIQUES
Hearing Aids. Fitted by an audiologist or
speech/hearing specialist. Many types.
Speech/lip Reading. Pt. uses speech-associated
visual cues like gestures & facial expression to
help clarify the spoken message.
Sign language. It is a visual-spatial language that
involves facial features such as eyebrow motion &
ASSISTIVE DEVICES & TECHNIQUES
Cochlear Implant. Electronic hearing device that
stimulates inner ear nerves. Used incase of
Assisted Listening Devices. Direct amplification
devices, amplified telephone receivers, alerting
flash systems, infrared amplifying systems, & a
combination of FM receiver & hearing aid.
A routine procedure to remove excess ear wax
(cerumen) or foreign materials from the ear.
Too much wax can cause blockage, resulting in
earaches, ringing in the ears, or temporary
Lukewarm water is squirted into the ear canal, by
a machine that squirts water at the right
This dislodges the softened plug which then falls
out with the water.
Impacted cerumen; Often works if the plug has been
softened e.g olive oil ear drops.
Previous complications following irrigation.
Hx of ear surgery
Cleft palate (even if repaired).
Current ear infection or within six weeks.
Recurrent otitis externa.
Current or previous perforated eardrum
A 20-year-old man, a member of a college
swim team, has recurrent external otitis—his
episode in the past 6 weeks. He is being
treated at an ENT clinic.
Devise an evidence-based practice teaching
plan for this patient.