1. Nose Sinus, and Throat Disorders
Chapter 53
Nose Sinus, and Throat Disorders 1

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

3. Anatomy and Physiology of the Nose, Sinuses, and Throat
External nose
Internal nose
Sinuses
Maxillary, frontal, ethmoid, and sphenoid
Throat
The external nose is made up of bone, cartilage, and mucous membrane.
Only the upper one third of the external nose has a bony skeleton; the remainder is shaped by cartilage.
The internal nose is divided by the nasal septum, a thin wall that creates two passages.
What are the openings on each side of the septum called?
The internal nose is well supplied with blood by branches of the internal and external carotids.
The sinuses are spaces in the bones of the skull; they are lined with mucous membrane and filled with air.
The throat consists of the nasopharynx, oropharynx, and the larynx. 3

4. Figure 53-1 4

5. Figure 53-2 5

6. Health History Chief complaint and history of present illness
Obtain detailed description of the patient’s complaints
Past medical history
Previous streptococcal infections; sinus infections; surgery on the nose, sinuses, or throat; known allergies; and current and recent medications 6

7. Health History Review of systems
Presence of nasal discharge (amount, color), obstruction, bleeding, sneezing, snoring, throat pain or soreness, hoarseness, aphonia (loss of voice), and earache
An altered sense of smell or facial pain should be noted 7

8. Physical Examination
External nose examined for size, shape, color, and lesions
If drainage, note amount, color, and consistency
Examiner listens for abnormal breath sounds and notes whether the patient is breathing through the nose or the mouth
Patency of the nostrils determined by gently closing one naris at a time and instructing the patient to breathe through the other naris
The sinuses are assessed indirectly
The nurse’s examination of the nose and sinuses is usually confined to inspection of the external nose and palpation over the paranasal sinuses.
What is transillumination? 8

9. Physical Examination
Examiner palpates over the frontal and maxillary sinuses for tenderness or pain
Inspect throat at the back of the oral cavity
Mucous membranes and tonsils inspected for redness, swelling, drainage, lesions
Inspection and palpation of the neck may reveal enlarged lymph nodes
A nasal speculum and a lighted scope are used to observe the mucosa of the nasal cavity.
How is the sense of smell assessed? 9

10. Age-Related Changes in the Nose, Sinuses, and Throat
Nasal obstruction more common because of the softening of the cartilage of the external nose
Mucous membrane thinner; produces less mucus
Epistaxis (nosebleed) more common in older people
Decline in the sense of smell as people age
Tissues of larynx are drier and less elastic in older adult
Weakened esophageal sphincter allows gastric contents to flow back into the throat when the patient lies down
Some older people report having a watery or “runny” nose when eating spicy or hot foods.
What side effects should older people who are on drugs to treat nasal congestion be assessed for?
The older person may fail to detect smoke or gas in the home or may neglect personal hygiene owing to failure to notice body odors.
Some people complain of a constant tickling sensation that causes them to clear the throat frequently. 10

11. Diagnostic Tests and Procedures
Throat culture
Isolate and identify infective organisms
Laryngoscopy
Inspection of the larynx to aid in diagnosis of abnormalities or to remove foreign bodies
A throat culture usually is done when streptococcal sore throat (“strep throat”) is suspected.
What is the difference in a direct and indirect laryngoscopy? 11

12. Figure 53-3 12

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

14. Care of the Patient Having Nasal Surgery
Assessment
Pain, pressure, anxiety, and dyspnea
Monitor vital signs to detect signs of excessive blood loss
Number of dressings saturated and the frequency of changes
Bleeding from the nasal cavity may flow into throat and be swallowed although the dressing remains dry
Check back of throat for bleeding; be alert for frequent swallowing
Inspect vomitus and stool for blood (bright red or “coffee ground” emesis and red, maroon, or black stools)
Patients often have nasal packing in place with a moustache dressing to absorb drainage.
If the patient is unable to close the mouth for an oral temperature, what other routes may be used? 14

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

16. Disorders of the Nose, Sinuses, Throat, and Larynx16

17. Sinusitis
Inflammation of the sinuses, most often the maxillary and frontal sinuses
Most common organisms are Staphylococcus pneumoniae, Haemophilus influenzae, Diplococcus, and Bacteroides
Signs and symptoms
Pain or a feeling of heaviness over the affected area
Purulent drainage from the nose
When maxillary sinuses affected, pain may seem like a toothache
Headache is common, especially in the morning
Fever may be present; white blood cell count may be elevated
What may cause sinusitis?
Chronic sinusitis is a permanent thickening of the mucous membranes in the sinuses after repeated infections. 17

18. Sinusitis Complications Medical diagnosis and treatment
Chronic sinusitis, meningitis, brain abscess, osteomyelitis, and orbital cellulitis
Medical diagnosis and treatment
Diagnosis
Sinus radiographs, CT; sinus aspiration or nasal endoscopy
Treatment
Antibiotics, decongestants, nasal corticosteroids, analgesics, and antipyretics
Twice-daily hot showers, increased fluid intake, humidifier
Functional endoscopic sinus surgery (FESS); Caldwell-Luc procedure
The possibility of brain infection exists because of the location of the sinuses in the skull.
When should neurologic complications be suspected?
Antibiotics are prescribed for acute sinusitis.
Other drugs that may be ordered to improve drainage or to relieve symptoms include decongestants, nasal corticosteroids, analgesics, and antipyretics. 18

19. Care of the Patient Having Sinus Surgery
After FESS, able to return to work in 4-5 days
Saline nasal sprays ordered to prevent crusting and promote healing
After the Caldwell-Luc procedure, the semi-Fowler’s position is recommended to prevent swelling and promote drainage
Apply cold compresses as ordered during the first 24 hours
Provide gentle oral care to avoid injury to the incision
Chronic sinusitis sometimes is treated surgically.
Underlying problems that might be treated surgically include deviated septum, nasal polyps, and hypertrophy of turbinates. 19

20. Care of the Patient Having Sinus Surgery
Nasal packing is usually left in place until the first postoperative day
Antral packing is left in place for 36 to 72 hours
Caution the patient to avoid blowing the nose or straining, which could cause bleeding and tissue damage
Three to 5 days after the Caldwell-Luc procedure, nasal saline sprays may be ordered to moisten the nasal mucosa 20

21. Nasal Polyps
Swollen masses of sinus or nasal mucosa and connective tissue that extend into the nasal passages
Exact cause is unknown, but patients often have a history of allergic rhinitis or infections
The size of the polyps may be reduced by removing allergens or treating the allergic response
Corticosteroids inhaled nasally may be prescribed
Surgical removal under local anesthesia, however, is often necessary
Nasal polyps tend to recur 21

22. Care of the Patient Having Nasal Polyp Surgery
Often in an outpatient surgical facility, so patient teaching before discharge is especially important
Advise patient not to take aspirin because it increases the risk of bleeding and because some patients are allergic to aspirin 22

23. Allergic Rhinitis “Hay fever”: acute (seasonal) or chronic (perennial)
Follows exposure to a substance (allergen) that causes an allergic response
A reaction to the release of chemicals, including histamine, that cause vasodilation and increased capillary permeability
Fluid leaks from capillaries; causes swelling of nasal mucosa
Occasionally these changes are triggered by overuse of decongestant nose drops or sprays
Acute allergic rhinitis often from exposure to pollens
The chronic form is more likely due to allergens that are continuously in the environment 23

24. Allergic Rhinitis Signs and symptoms Medical diagnosis
Nasal obstruction; sneezing; clear nasal discharge; frontal headache; and itchy, watery eyes
Nasal mucosa is often pale, but it can be red or bluish
Medical diagnosis
Made on the basis of a detailed history
With chronic symptoms, the patient may be instructed to keep a diary describing all episodes
This can help identify possible allergens 24

25. Allergic Rhinitis Medical treatment Nursing care
Desensitizing injections may be advised to decrease the patient’s reaction to the offending allergens
The drugs used to treat allergic rhinitis are primarily antihistamines and decongestants
Nursing care
Patients with allergic rhinitis are usually outpatients
The nurse who works in a clinic or physician’s office may need to reinforce teaching about desensitization and drug therapy
Allergy Testing
The allergist applies solutions of common allergens to the skin.
The allergens are applied in a specific pattern so that the patient’s reaction to them can be assessed individually.
Desensitizing Injections
Patients often call these injections “allergy shots.”
The injections are composed of dilute solutions of the allergens to which the person reacts.
The strength of the solution is gradually increased as the patient’s tolerance grows.
What drugs are commonly used to treat allergic rhinitis? 25

26. Acute Viral Coryza The common cold
Can be caused by any of some 30 viruses
It is contagious and spread by droplet infection
Signs and symptoms
Fever, fatigue, nasal discharge, and sore throat
Complications
Otitis media, sinusitis, bronchitis, and pneumonia
Who has a high risk of complications? 26

27. Acute Viral Coryza Medical treatment Prevention Nursing care
Antihistamines, decongestants, and antipyretics
Prevention
Best accomplished by avoiding people with colds
Nursing care
Primarily public education about prevention and about drugs prescribed for treatment
Encourage patients to rest and to drink plenty of fluids
Medical management of the common cold is primarily directed at relief of symptoms.
Why is acute viral coryza not usually treated with antibiotics?
People with colds are most contagious during the first 2 or 3 days after symptoms appear.
The very young, the very old, and those with weakened immune systems especially should be protected from exposure. 27

28. Tumors Signs and symptoms Medical diagnosis Nasal obstruction
Bloody discharge from one nasal passage
Lesions on the external nose typically begin as small, painless ulcers that do not heal
Medical diagnosis
Diagnosed by taking a biopsy of the tumor or removing the entire tumor for examination
Tumors can be benign or malignant.
Sinus malignancies are more common among people in certain occupations—notably furniture makers.
External nasal tumors are usually either basal cell or squamous cell carcinomas.
The earlier a malignancy is detected and treated, the better the chances of survival.
What sites do carcinomas in the nasopharynx usually metastasize to? 28

29. Tumors Medical treatment Nursing care
Combination of surgery, radiation therapy, and chemotherapy
Surgical procedures may be extensive and disfiguring, depending on the site and extent of the cancer
Reconstructive surgery or prostheses may be needed
Nursing care
Patient may be especially anxious and fearful of disfigurement or even death
Be supportive and encourage the patient to ask questions and express concerns
Why are benign tumors usually removed even thought they do not metastasize? 29

30. Deviated Nasal Septum
Nose divided into two passages by a cartilaginous wall called the septum
In most adults, septum is slightly deviated, meaning it is off center
Minor deviations cause no symptoms and require no treatment
Major deviations, however, can obstruct the nasal passages and block sinus drainage
Headaches, sinusitis, and epistaxis
Treatment: submucosal resection/nasal septoplasty
What are two major complications of submucosal resection? 30

31. Epistaxis
Nosebleed; from trauma, clotting disorders, dryness, inflammation, and hypertension
First aid
The patient should sit down and lean forward
Direct pressure should be applied for 3 to 5 minutes
Medical treatment
Nasal balloon catheter
Nasal packing
Complications
Infection, blockage of the eustachian tube, and airway obstruction
The nose has an abundant blood supply that permits it to bleed easily.
When should pressure not be applied to the nose?
An ice pack or a cold compress can be applied to the nose regardless of whether facial trauma has occurred.
Once the bleeding stops, advise the patient not to blow the nose for several hours because this may trigger renewed bleeding. 31

32. Figure 16-7 32

33. Figure 53-5 33

34. Epistaxis Assessment Interventions
Inspect the nose and back of the throat for obvious bleeding and observe for frequent swallowing
Level of consciousness and vital signs to detect signs of hypovolemia
Document allergies and major illnesses
Interventions
Decreased Cardiac Output
Anxiety
Risk for Injury and Infection
If a nasal balloon catheter or nasal packing has been placed, what assessments should be made? 34

35. Pharyngitis
Inflammation of the mucous membranes of the throat or pharynx
Usually is caused by a virus but sometimes by bacteria
Also can follow exposure to irritating substances in the environment
Usually occurs along with acute rhinitis or sinusitis.
When does pharyngitis most commonly occur? 35

36. Pharyngitis Signs and symptoms
Dryness, pain, dysphagia (difficulty swallowing), and fever
The throat appears red, and the tonsils may be enlarged
Compared with viral pharyngitis, bacterial pharyngitis has abrupt onset; characterized by abnormal blood cell counts, fever greater than
101° F, and muscle and joint pain
What additional signs of infection associated with beta-hemolytic streptococci may be observed? 36

37. Pharyngitis Complications Medical diagnosis
Acute glomerulonephritis and rheumatic fever
Medical diagnosis
Throat culture and a complete blood count
Patients with bacterial pharyngitis are more likely to have serious complications than those with viral pharyngitis.
When may signs of glomerulonephritis develop? Rheumatic fever? 37

38. Pharyngitis Medical treatment
Rest, fluids, analgesics, throat gargles or irrigations
Bed rest as long as patient has a fever
If oral intake is low, intravenous fluids
Soft/liquid diet because of painful swallowing
Humidifier to increase moisture in the room air
Antibiotics, usually penicillin or erythromycin, while awaiting the results of the throat culture
Obtain the culture specimen before the antibiotics are started.
How long will the course of antibiotic therapy continue? 38

39. Pharyngitis Prevention
People with poor resistance should avoid others with upper respiratory infections
Good nutrition, adequate rest, avoidance of chilling, and avoidance of inhaled irritants
People who have pharyngitis are contagious in the early stages and should avoid contact with susceptible people 39

40. Pharyngitis Assessment
Throat pain, dysphagia, muscle and joint pain, nausea and vomiting, and rash
Take the patient’s temperature, and inspect the throat for redness and enlarged tonsils 40

41. Pharyngitis Interventions
Reinforce physician’s directions for drug therapy
Stress importance of completing prescribed antibiotics
mL fluids daily unless contraindicated
Advise patients that they are contagious at first and should not be exposed to people with poor resistance
Fluids must be increased cautiously in the elderly because they do not adjust well to sudden changes in blood volume.
What symptoms should be reported to the physician? 41

42. Tonsillitis Inflammation of tonsils/other throat lymphatic tissue
Common in children but more severe in adults
Causes
Usually bacterial, but sometimes caused by a virus
Causative organisms: streptococci, staphylococci, H. influenzae, and pneumococci
The infection is contagious; spread by food or airborne routes
Most cases run their course in 7 to 10 days
May have repeated infections that respond to treatment or may have a chronic infection 42

43. Tonsillitis Signs and symptoms
Sore throat, difficulty swallowing, fever, chills, muscle aches, and headache
If swollen tissue blocks eustachian tubes, ear pain
Offensive breath odor often with chronic infection
The tonsils typically are enlarged and red
Purulent drainage/yellowish or white patches on tonsils
Lymph nodes in the neck may be tender and enlarged 43

44. Tonsillitis Medical diagnosis
Complete blood count, throat culture and sensitivity, and a test for infectious mononucleosis
What does an elevated white blood cell count suggest?
The culture and sensitivity identify the pathogenic organisms present and what antibiotics are likely to be effective.
A chest radiograph also may be ordered to assess for respiratory complications. 44

45. Tonsillitis Medical treatment Antibiotic therapy for 7 to 10 days
Analgesics and anesthetic lozenges for pain and antipyretics for fever
Warm saline gargles or irrigations to decrease swelling and remove drainage
Rest and adequate fluids promote recovery and decrease the risk of complications 45

46. Tonsillitis Complications Surgical treatment Peritonsillar abscess
Tonsillectomy and adenoidectomy
A peritonsillar abscess is an infection of the tissue surrounding the tonsil.
What is the immediate treatment of a peritonsillar abscess?
Tonsillectomy is usually recommended under the following conditions:
Repeated tonsillitis in a year, especially if caused by beta-hemolytic streptococci
Presence of a peritonsillar abscess
Malignancy of the tonsil
Airway obstruction by enlarged tonsils or adenoids
Evidence that the patient is a carrier of the diphtheria organism
Hearing loss associated with otitis media due to enlarged tonsils 46

47. Care of the Patient Having a Tonsillectomy
Assessment
Frequently monitor responsiveness/vital signs
Inspect drainage from the mouth or vomited fluid for blood
Excessive swallowing may indicate bleeding
Monitor respiratory effort and skin color to evaluate oxygenation
Evaluate pain and dysphagia 47

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

49. Obstructive Sleep Apnea
Airway obstruction during sleep
The tongue and soft palate fall backward partially or completely blocking the airway, causing apnea and hypopnea (abnormally slow, shallow breathing)
Blood oxygen level falls; carbon dioxide level rises
Stimulate ventilation; cause the patient to arouse
Patient startles, snorts, and gasps causing the tongue and soft palate to move forward so the airway is open 49

50. Figure 53-6 50

51. Obstructive Sleep Apnea
Symptoms related to disrupted sleep pattern
Patient often irritable and sleepy during the day
Sleeping partner may report loud snoring or episodes of apnea
Symptoms can affect many aspects of life
Concentration and memory may be impaired
Hypertension and cardiac dysrhythmias
Diagnosis confirmed by polysomnography 51

52. Obstructive Sleep Apnea
Conservative treatment: weight loss if obese, avoidance of sedatives and alcohol for 3-4 hours before bedtime
Oral appliance that shifts mandible and tongue forward may be effective
Serious symptoms are treated with nasal continuous positive airway pressure (CPAP)
Surgical procedures: uvulopalatopharyngoplasty (UPPP or UP3), genioglossal advancement and hyoid myotomy (GAHM), and laser-assisted uvulopalatoplasty (LAUP) 52

53. Figure 53-7 53

54. Laryngitis Inflammation of the larynx
Causes: upper respiratory infections, voice strain, smoking, alcohol ingestion, and inhalation of irritating fumes
Signs and symptoms
Hoarseness, cough, and scratchy or painful throat
Aphonia: absence of sound production; “losing” his or her voice
Medical diagnosis
Patient’s history and symptoms
Throat culture
The physician may use a laryngeal mirror to examine the larynx for color, edema, and growths such as polyps and tumors. 54

55. Laryngitis Medical treatment
Voice rest is advised, meaning that the patient should not talk
Removal of the irritant 55

56. Laryngitis Assessment
Document severity, how long it has persisted, and factors that to aggravate or precipitate it
Information about the patient’s occupation and hobbies may provide clues to the cause of the laryngitis
Take the patient’s temperature and describe respiratory status to detect possible infection 56

57. Laryngitis Interventions
Pad and pencil or Magic Slate for communication
Sign over the bed noting that patient should not speak
Notice on the intercom at the nurse’s station that the patient cannot (or should not) speak
Discourage smoking
An environment with a constant temperature
Teach patients that irritants can lead to laryngitis
Recognize irritants in the home and workplace and know how to protect themselves from harm
Why is voice rest prescribed? 57

58. Laryngeal Nodules
Benign masses of fibrous tissue result primarily from voice overuse but can follow infections
Singers and public speakers prone to development of nodules
The only symptom is hoarseness
Nodules are surgically removed under local or general anesthesia
The removal of nodules is usually fairly simple, but they may recur if the voice is again misused.
What interventions are necessary postoperatively? 58

59. Laryngeal Polyps
Swollen mass of mucous membrane attached to vocal cord
Can cause continuous or intermittent hoarseness, depending on its location and attachment
In heavy smokers, masses may develop on both cords
A procedure called stripping of the vocal cords is necessary to treat this condition
Unless patient continues smoking, condition usually does not return
Voice rest prescribed if polyps removed 59

60. Cancer of the Larynx
Factors: exposure to smoke or other noxious fumes, alcohol consumption, vocal strain, and chronic laryngitis
Malignant tumors can develop throughout the larynx: above the glottis, on the vocal cords, or below the vocal cords
Most malignancies are squamous cell carcinomas
Cancer of the larynx accounts for more than 10,000 new cancers each year.
It causes approximately 4000 deaths yearly and is increasing in frequency.
Cancer of the larynx is most common in men of what age?
The cure rate is highest for patients with tumors that are confined to the vocal cords. 60

61. Cancer of the Larynx Signs and symptoms
Early symptoms include persistent hoarseness or sore throat and ear pain
Later signs and symptoms are hemoptysis and difficulty swallowing or breathing 61

62. Cancer of the Larynx Prevention Stop smoking and drinking alcohol
The public also should be educated to recognize the signs and symptoms of laryngeal cancer and seek prompt medical attention 62

63. Cancer of the Larynx Medical diagnosis
Confirmed by study of a tissue sample obtained during a laryngoscopy
Radiographs, CT scans, and MRI to define the extent of the cancer 63

64. Cancer of the Larynx Medical treatment
Surgery, radiotherapy, chemotherapy, or a combination
Surgery: from simple removal of the tumor to extensive procedures, such as laryngectomy and modified or radical neck dissection
A laryngectomy can be total or partial
Voice preserved with hemilaryngectomy or supraglottic laryngectomy; total laryngectomy causes permanent loss of the natural voice
Radiotherapy alone can cure some small cancers that have not spread to surrounding tissues.
What is brachytherapy?
Chemotherapy may be administered as palliative treatment, before surgery to reduce tumor size, or postoperatively to reduce the risk of metastasis. 64

65. Figure 53-8 65

66. Care of the Patient Having a Total Laryngectomy
If patient will lose the ability to speak, information about other means of communication should be available
Listen compassionately and accept the patient’s expressions of anger or despair
A total laryngectomy will require that the patient breathe through the trachea
. The physician and speech therapist can advise the patient about appropriate alternatives for speech.
What structures are removed with a total laryngectomy? 66

67. Care of the Patient Having a Total Laryngectomy
Complications
Salivary fistula, carotid artery blowout, tracheal stenosis
Assessment
Patient’s level of consciousness
Ask about pain and observe for signs of discomfort
Measure vital signs at frequent intervals
Continuous electrocardiogram monitoring and pulse oximetry to assess oxygenation and circulation
Fluid intake and output, wound drainage 67

68. Care of the Patient Having a Total Laryngectomy
Interventions
Ineffective Airway Clearance
Anxiety
Decreased Cardiac Output
Acute Pain
Risk for Injury
Imbalanced Nutrition: Less Than Body Requirements
Impaired Verbal Communication
Ineffective Coping
Risk for Infection
Ineffective Therapeutic Regimen Management 68

69. Figure 53-10 69

70. Care of the Patient Having a Supraglottic Laryngectomy
Care like that for total laryngectomy except the tracheostomy is temporary, the voice is not lost, and swallowing is more problematic
Enteral feedings may be needed for a long time, so begin to instruct the patient in self-feeding
Be alert for signs and symptoms of this complication: increased pulse and respiratory rates, dyspnea, cough, crackles and rhonchi, fever, wheezing, and frothy, pink sputum
Keep a suction machine readily available
The patient with a supraglottic laryngectomy is at increased risk for aspiration pneumonia.
What swallowing techniques may be taught? 70

71. Care of the Patient Having a Partial Laryngectomy
Temporary tracheostomy for 2 to 5 days
IV fluids and enteral feedings are ordered at first
Patients have considerable difficulty swallowing when oral nourishment is resumed
To prevent aspiration, seat the patient upright, with the head flexed slightly forward
Semisolids easier to manage than thin liquids
Suction machine should be on hand 71