Hearing Acuity Gross Assessment Should be performed in a quiet room -test the patients ability to hear your whispered

or spoken voice or the ticking of a watch Precise Assessment -Audioscopy- uses an audioscope 40 dB intensity Frequency: 510, 1000,2000,4000 cycles per second (Hz) -done with special equipment (audiometer) Test one ear at a time while masking the hearing in the other ear To mask an ear, have the patient place a finger on the ears tragus & push it quickly in and out of the auditory meatus. WATCH TICKING TEST - Hold a watch a few inches away from the patients ear - Move the watch slowly away from the ear and ask the patient to say now when ticking can no longer be heard - Document the distance from the watch to the ear from the point where ticking stopped being heard. WHISPERED WORD TEST - Stand 1-2 feet behind the client so they can read your lips - Instruct client to place one finger on tragus of left ear to obscure sound - Whisper word with 2 distinct syllables towards clients right ear. - Ask client to repeat word back - Repeat test for left ear - Client should correctly repeat two syllable word Whispered words & watch ticking test consist mainly of high-frequency sound

& so are not easily heard by people with sensorineural hearing loss. HEARING ASSESSMENT Tuning Fork Test - Measure the air conduction (AC) and bone conduction (BC) of sound o ACwhen sound waves are transmitted through the air into the auditory canal and so to the eardrum, middle ear and inner ear o BC- transmission of sound waves through the cranial bones and inner ear. * AC is normally more sensitive than BC 2 types 1. Weber 2. Rinne test WEBER TEST 1. Distinguishes between conductive and sensorineural hearing. Strikes a 512 Hz tuning fork softly 2. Place the vibrating fork on the middle of the clients head 3. Ask client if the sound is heard better in one ear or the same in both ears. 4. If hearing is normal, the sound is symmetrical with no lateralization Sound localizes toward the poor ear with a conductive loss Sound localizes toward the good ear with a sensorineural hearing loss. RINNE TEST 1. Test compares air and bone conduction on hearing , Strike 512 Hz tuning for softly 2. Place vibrating fork on the base fo the mastoid bone 3. Ask the client to tell you when the sound is no longer heard.

4. Note the time interval and immediately move the tuning fork to the auditory meatus 5. Ask the client to tell you when the sound is no longer heard. 6. Note the time interval and findings. -N or (+) Rinne AC >BC -AbN or (-) Rinne AC<BC TUNING FORK TEST SCHWABACH TEST - Examiners ear is assumed to be normal - Tuning fork placed near pinna of subject - Confirmed by the examiner when sound is no longer heard - Results: o Prolonged: conductive loss o Diminished: sensorineural loss ROMBERG TEST - Done to test client equilibrium - Have client stand with arms at side and feet together - Have client perform initially with eyes open and then with eyes closed - Client should maintain position for 20 seconds with only minimal swaying AUDIOMETRY - Measure of hearing acuity - Frequency o Highness or lowness of sound o The higher the frequency, the higher the pitch - Intensity o Expressed in decibels (dB) o Normal threshold -0 dB (51% of the time) o Painful for persons with normal hearing-100dB PURE TONE AUDIOMETRY

Pure tones presented at frequencies for hearing, speech, music and other common sounds Tested both for AC (earphones) and BC (bone oscillator) Result is recorded as an audiogram

Instruct the client o Objective of the test is to determine the softest sound that will elicit a response (threshold) o Tones will be presented that will sound like bells or tuning forks o Upon hearing- client should raise hand or press button on presenting side. o When sound is no longer heard client lowers hand or releases button o Test better ear first SPEECH AUDIOMETRY Speech reception threshold- minimum loudness to repeat simple words. Uses a series of simple recorded words spoken at various volumes into headphones worn by the patient being tested The patient repeats each word back to the audiologist as it is heard. And adult with normal hearing will be able to recognize and repeat 90-100% of the words. SPEECH DISCRIMINATION Tests ability to distinguish similar sounds or words with similar sounds Assesses understanding of speech Uses 25-50 monosyllabic words phonemically balanced with equal difficulty 30-40 dB above speech reception threshold TYMPHANOMETRY

Test determines the functionality of the tympanic membrane by observing its response to waves of pressure, and measuring the pressure. Assess mobility of eardrums Varies air pressure in the external auditory canal For middle ear pathologic-conditions. AUDITORY BRAIN STERM EVOKED RESPONSE (ABR) Represents the electrical response of the CN VIII and some portion of the brainstem which occurs 10-12 msec after an auditory stimulus is sensed by the inner ear Series of clicks are presented at 75 dB or 80 dB above threshold Results is similar to EEG- waves are interpreted Used in newborn hearing screening

- Patient should have adequate vision to follow visual targets - detects both central and peripheral disease of the vestibular system -Detects nystagmus or the vestibuleocular reflex -May be contraindicated in patients with history of previous seizures due to ocular stimulation with lights. CALORIC TESTING I-it is performed to evaluate acoustic nerve which provides hearing and balance. This test may be recommended 1. When someone is experiencing dizziness or vertigo 2. When there is hearing loss with suspected toxicity from certain antibiotics 3. With some anemias Caloric stimulation is performed to evaluate the acoustic nerve, which provides hearing and helps with balance. 4. When psychological causes or vertigo are suspected 5. To determine the presence or extent of brain damage in a comatose person LABORATORY TESTS Dix-Hallpike Test - make sure that the patient has no neck injury! -Pull patient to a supine position form a sitting position -Induces vertigo in patients with BPV -Nystagmus is evident within 5-10 sec BARANY CHAIR -swivel 360 degrees to check for stimulation of the vestibular system. At right, an astronaut at NASA undergoes a test on a Barany chair.

Other Ancillary Tests CT Scan- structures of the ear MRI- greater sensitivity to soft tissue changes Precautions for Vestibular tests Performed last because may induce nausea and vomiting Prior to test, patient should be advised to come in with companion Limit food intake prior to test Advice against driving after the test; arrange for transportation Have emesis basin, tissue/towel/drapes ready Hold patient in examination room until balance is regained Vestibular tests *Electronystamography Videonystagmography

or

STRUCTURES OF NOSE AND SINUSES -Nose is lined with respiratory mucosa, except the vestibule (lined with skin containing nasal hairs/ vibrissae) -Mucus secreted from respiratory mucosa is carried back into the nasopharynx by ciliary movements -nasal mucosa is normally redder than oral mucosa because the lining of the nasal cavities is very vascular -Blood carries moisture and heat to the mucosa -Nasal blood supply comes from the external and internal carotid systems. -air enter the nose through 2 nostrils (nares), separated by the nasal septum (composed of cartilage and bone) -Nasal cavities, located between the roof of the mouth and the frontal ethmoid, and sphenoid bones -On the lateral walls of each nasalcavity are three projections. Superior turbinate Middle turbinate Inferior turbinate The turbinate conchae increase the area of mucus membrane over which air passes Paranasal sinuses are airfilled cavities, lined with mucous membrane surrounding the nasal cavities Sinuses drain into the nasal cavities through opening in the grooves between the turbinates. Maxillary sinuses (antra)

Largest and most accessible Located on either side of the nose in the maxillary bones

-Frontal sinuses Lower forehead between and above the eyes

Sphenoid sinuses Rear of the nasal cavity Ethmoid sinuses Between the eyes and nose Olfactory cells Located in the olfactory membrane covering the roof of the nose and the floor of the anterior cranial fossa Nasolacrimal duct Small duct communicating indirectly with the lacrimal glands and the nose

FUNCTION OF NOSE AND SINUSES Principal functions: -olfaction (smelling) -Air conditioning (controlling air temp and humidity and removing particles before air enters the trachea, bronchi, and lungs). -Olfactory cells- neurons that divide into numerous hairlike processes in the olfactory membrane Axons form the cell bodies become the olfactory nerve, which passes to the olfactory center in the brain.

PHYSIOLOGY OF SMELL -Turbulence from sniffing increases air flow in supper turbinates near olfactory mucosa FUNCTION OF NOSE AND SINUSES

-temp. is controlled by the enlargement and contraction of blood spaces or swell spaces in the erectile tissues in the turbinate bones. When inspired air is cold and dry water is absorbed by it from the nasal mucosa A blanket of serum and mucus covers the nasal mucosa surface As much as 1L of moisture can be evaporated from the nose during 24 hours of normal breathing Submucosal glands replenish the moisture Particle control is achieved by the mucous throughout the nose, sinuses, pharynx, trachea, bronchi, and bronchioles Airborne particles cling to this viscid blanket The mucous blanket secretions contain the enzyme lysozyme to combat microorganisms The beating action of cilia carries the blanket back toward the pharynx, where it is swallowed Any residual bacteria are then destroyed by gastric juice and HCL Sinus function is not definitely know Lighten the weight of the skull Give vocal resonance and timbre Produce mucus for the nasal cavity ASSESSMENT OF NOSE AND SINUSES History Examination of Nose, Nasopharynx and Paranasal Sinuses Smell assessment Diagnostic procedures

- (anteriorly) using a nasal sepeculum and (posteriorly) with a nasopharyngeal mirror Causes of nasal obstruction

Examination of Nasopharnyx Best examined with a mirror with the tongue depressed with a tongue blade or gauze Specialist may use a nasopharyngoscope to examine the nasopharynx Examination of Paranasal Sinuses Inspecting and plapating the soft overlying tissues Observing any nasal secretions Transillumination of the maxillary and frontal sinuses To more completely assess sinus conditions, sinus x-rays may be used Smell Assessment Senses of taste and smell are closely related Smell and Taste are affected by - Many conditions (viral infection, normal aging, head injury, local obstruction) - Medications( metronidazole, local anesthetics, some antibiotics, allopurinol, codeine, morphine, carbamazepine, lithium) Smell impairment - Hyposomia (decrease in smell sensitivity) - Anosmia (bilateral and complea absence of smell sensitivity) Have the patient identify various odors Test each nostril separately Have the patient sniff tubes (first with eyes open) Document whether the patient can o Perceive each odor o Identify each oder accurately

Examination of Nose External nose -symmetry, swelling, redness, lumps Nasal Chamber

 Smell is perceived mainly via Olfactory nerve (CN1) although some are perceived via the trigeminal nerves (CN V) Trigeminal irritants are perceived even by patient with anosmia Olfactory and Trigeminal Stimulants Olfactory - Coffee (instant powder) - Phenylethyl alcohol - Almod oil - Peppermint - Musk

temporary relief, the nose becomes more stuffy. Vasoconstrictors can be systematically absorbed and should not be used by hypertensive patients unless prescribed Some nasal medication may cause distressing symptom (restlessness, heart palpitations and tension) Oil-based solutions are of usually used since they interfere with normal ciliary action and may cause pneumonitis if aspirated

Trigeminal Ammonia Acetone Menthol

DIAGNOSTIC PROCEDURES - Nose and Throat cultures - X-ray - CT scan - MRI COMMON NASAL INTERVENTIONS Nasal Medications Drops, spray, aerosol (nebulizer) Most often instilled into the nose are vasoconstrictors (phenylephrine) used mainly to reduce nasal congestion Use only as prescribed to avoid rebound effect 0turbinate engorgement is controlled by ANS Vasoconstrictors stimulates sympathetic nerves, hence, compensatory relaxation of the turbinal vesssels occur after the medication has stopped This relaxation is accompanied by nasal stuffiness, thus, after a period of

Instilling Nose Drops Direct nose drops toward the problem area by positioning the patient in such a way that the drops flow toward the affected area Support the persons head with one hand Observe the persons reaction to the medication Ask the patient to remain still for at least 5 mins after the drops are instilled and to breathe through the mouth Solution can drain into the posterior nose give the person a basin to expectorates solution running into the oropharynx and motuh Have tissues available to wipe excess solution from the external nares and face Nasal Aerosol Also used to diffuse medication over the noses inner surface Usually self-administered Shake aerosol before use Tilt head back Occlude one nostril and insert tip into other nostril and administer one dose of medication

 Nasal Irrigation Occasionally prescribed to clean the nose Normal saline solution is most commonely used Usually self-administered for chronic nasal conditions Aspiration is a potential hazard Nasal Packs Made of small petroleum gauze or small cotton ball soaked in epinephrine Inserted by a physician Explain procedure to patient Take and document the patients VS periodically through the procedure Assist the physician while inserting the packing Help the patient into a comfortable sitting position Encourage patient to breath through the mouth Tell the patient to expectorate any blood accumulating in the nasopharynx and not to swallow it Airway obstruction can occur if a posterior nasal pack accidentally slips out of place When packing is removed, tell patient not to blow the nose for 48 hrs. because of danger of bleeding Nursing intervention for PostNasal Surgery patients Remind the patient to - Breathe through the moth (because of nasal packing) - Do not blow the nose - Spit out drainage accumulating in the nasopharynx After sinus surgery, If GA is given, turn the patient on to the side to prevent aspiration of bloody drainage before consciousness returns. Ineffective airway clearance

Breather through mouth Periodically assess nasal packings Elevate head Do not blow nose Patients mouth may become dry and develop an unpleasant taste and odor due to mouth breathing blood and post nasal discharges. Alteration in comfort due to pain and anxiety - Nasal surgery is not usually painful but may be uncomfortable because of the packing - Ice packs or cold compress may be prescribed to reduce pain and edema - Pain may be reduced by promoting drainage - Help the person to relax Alteration in nutrition, less than body requirements due to difficulty swallowing - Give fluids as prescribed (usually liquid diet) - Be sure that gag reflex has returned before giving oral liquids - Oral hygiene before meals may improve the persons appetite - Encourage fluid intake COMMON NASAL AND SINUS DISORDER Rhinitis Common cold Allergic rhinitis Non-allergic vasomotor rhinitis Nasal polyps Hypertrophied turbinates Foreign bodies Nosebleed (epistaxis) Deviated nasal septum Nasal Fx Infected an Hypertrophied adenoids Sinusitis

 Epistaxis - Nosebleed - May occur spontaneously or result form diease or trauma - Minor trauma is the most common cause - More severe causes o Severe trauma o Deviated or perforated nasal septum o Acute sinusitis o Local cancer o HPN, sclerotic blood vessels, acute rheumatic fever, leukemia Emergency care for Anterior Nosebleed - Position client upright and leaning forward - Reassure and reduce anxiety - Apply direct lateral pressure to the nose for 5 minutes - Apply ice or cold compress to the nose if possible - To prevent re-bleeding, instruct to avoid blowing the nose - Seek medical assistance if persistent Nasal Polyp - Benign, grapelike clusters of mucous membrane and connective tissue - Gradually form from recurrent,, localized swellings of the nasal sinus mucosa - Once fully developed, they appear as smooth pale tumors with pedunculated bases - Usually multiple and insensitive to touch - Most common site in the nose is the middle meatus - Most frequently develop in people who have allergic rhinitis - Symptoms of nasal obstruction occur when the polyps become large enough to obstruct the airways - Large persistent polyps are surgically removed (polypectomy)

Nasal Fx - Nasal & nasopharyngeal bleeding - Disfiguring soft tissue edema around the nose after the injury - Apply ice bag and tightly hold the nose - Once edema occurs, wait for 2 or 3 days for the edema to subside before setting the Fx - Skull x-rays to rule out possible skull Fx - And identify the location of Fx and bone fragments - Reduced under anesthesia, displaced bone fragment are pushed into proper alignment and held in place with intranasal packing or external dressings or nasal splints Common Cold - Simple acute viral rhinitis (coryza) - Most common problem of the nose and sinuses - Inflammation of the nasal mucosa - Caused by filterable virus and is spread by droplet contact from sneezing - Contagious for the first two or three days - Causes o Rhinovirus, adenovirus, influenza, virus, parainfluenza virus, mycoplasma

Symptoms Burning or irritation in the nasopharynx Sneezing, chillness, copious nasal discharge, muscular aching, malaise, mild fever Headache for the first 2 days Nasal discharge becomes purulent and increasing nasal obstruction occurs A sore throat does not usually occur with a common cold Self-limited Treatment is symptomatic

No specific cure Antibiotics aer not indicated Secondary invasion of bacteria may complicate a common cold causing symptoms to persist and become worse

Allergic Rhinitis - Hay fever - Triggered by hypersensitivity reactions to airborne allergens - May be seasonal and acute or perennial and chronic S/sx - Sneezing, nasal obstruction, tearing, recurrent thin nasal discharge, frontal headache, itchiness of eyes and nose - Turbinates are typically hyperemic and edematous - Nasal mucosa appear smooth and glistening Treatment - Eliminate or limit intake of chocolate, milk, and eggs - Cover mattress and pillow with plastic - Do not touch domestic animals - Use non-allergenic cosmetics - Cover overstuffed furniture - Use antihistamines as prescribed - Install air condition in the house avoid wool bedding. Seasonal Allergic Rhinitis - Acute episodes lasting for several weeks and then disappears and recurs the same time the next year. - Usually caused by grass pollens, flowers or trees Chronic Rhinitis - Constantly present or may occur intermittently w/o any seasonal pattern over a period of many years - Often associated with allergic sinusitis

Sensitivity to contacts constantly present in our environment (domestic animal hair, dandruff, newspaper, wool, house dust, foods, tobacco) Less severe than seasonal allergic rhinitis but treatment is more difficult since it us usually hard to identify the allergen

Non-allergic Vasomoto rhinitis - Chronic, intermittent nasal obstruction or stuffiness often accompanied by nasal discharge - May result from stress, nervousness, tension, or some endocrine problems - Symptoms may be aggravated by changes in environmental changes in environmenta temp - Treatment o Sympathomimetics -RHINITIS OF PREGNANCY Nasal congestion resulting from estrogen-mediated mucosal engorgement -May occur with oral contraception > Rhinitis Medicamentosa/Druginduced -Rebound: nasl congestion from overuse of nose drops or sprays SINUSITIS - Inflammation of sinus producing an inflammatory mucosal change - Head pain and mucoid nsal discharge are often attributed to sinusitis - Causes: o Infection spread from the nasal passages to the sinuses o Blocked routes of normal sinus drainage - Purulent or non-purulent - Acute or chronic - Types (ethmoid, frontal, maxillary or sphenoid)

 ACUTE SINUSITIS - Caused by infection (pneumonia, influenza, rhinitis) passing into the sinuses via the nasal passages - Assessment o Malaise, lack of appetite, nausea, nasal obstruction, congestion o Purulent nasal discharge, fever pressure over the involved sinuses, pain -Tx o Relieve pain with analagesics o Promotes sinus drainage by adequate fluid intake, moist steam inhalation, mucolytics o Control infection o Increase resistance with rest, wellbalanced diet and reduced stress SINUSITIS -Surgery - Maxillary antral puncture and lavage - Caldwell-Luc procedure -FESS CHRONIC SINUSITIS - Repeated or sustained sinus infections cause the mucous membrane lining to become thickened - Difficult to treat and is directed at correcting underlying cause (remove polyp, eradicate dental infections, straighten deviated nasal septum and treat allergy) - S/sx o Lethargy, difficulty sleeping, chronic sough, chronic purulent nasal discharge, inability to smell, chronic sinus headache. The Pharynx Common passageway between the respiratory and digestive tracts Located behind the oral and nasal cavities

Anatomy of the Pharynx Nasopharynx -Located behind the nose, above the soft palate - Contains adenoids (pharyngeal tonsils) and openings of the Eustachian tube

Oropharynx Extends from the soft palate to the base of the tongue With palatin tonsils (faucial tonsils) Laryngopharynx Extends from the base of the tongue to the esophagus Critical dividing point between respiratory and digestive passages

Physiolgy of Pharynx Respiration Deglutition Voice resonance Articulation Deglutition 3 stages Voluntary movement of food from the mouth into the pharynx Transport of the food through the pharynx Passage of the bolus through the esophagus After mastication, food is positioned on the middle 3rd of the tongue Elevation of tongue and soft palate forces the bolus into the oropharynx Suprahyoid muscles contract, elevating the hyoid bone and larynx thus the opening the hypopharynx Intrinsic laryngeal muscles contract in a sphincter-like fashion to prevent aspiration A strong motion of tongue posterior,rly plunges the food inferiorly through the

oropharynx , a movement aided by the contraction of the superior and middle pharyngeal constrictors Peristalsis, assisted by gravity, moves the food down the esophagus and into the stomach

Anatomy of the Larynx Composed of 9 cartilages: 3 single, 3 paired Thyroid- Adams apple Cricoid-below the thyroid cartilage; contains vocal cords Arytenoid- attach at the back end of the vocal cords, for vocal cord movement Epiglottis- lead-shaped elastic cartilage guarding the glottis Corniculate Cuneiform Two pairs of vocal cords False True Physiology of the Larynx Protection of the airway Respiration Phonation - Adducted true vocal cords serve as a passive reed that vibrates when air is forced through them - Changes in shape, mass and tension of the true vocal cords produces different pitches - Loudness of voice proportional to the pressure in the subglottic airstream - Whispering due to escape of air between the abduction sphenoid without vibration of the tru vocal cords Assessment of the Throat History Physical Examination - Inspection

Palpation Procedures Indirect Laryngoscopy Endoscopy Radiographic X-ray CT scan MRI HISTORY Drug use Allergies Frequent URTI Occupational history Teachers Salesman TV and radio anchor Demographic Data Family History and Genetic Risk Cancers Maternal exposure to teratogenous or disease Personal History Smoking history

Current Health Problems Common complaints - Sore throat - Discharge in the throat - Sense of lump, fullness or swelling - Difficulty in swallowing

Physical examination -Perform PE in an adequately lighted area -have patient sit upright and leaning Slightly forward as if pushing the chin towards the examiner -Equipment Lights

 Inspection Observe for palate and uvula - Color - Symmetry - Evidence of discharge (postnasal) - Edema or ulceration - Tonsil enlargement and inflammation Observe neck - Symmetry - Alignment - Masses Palpation Gently palpate the neck - Position of the trachea - Massess - Lymph nodes Indirect Laryngoscopy Requires a mirror to view the larynx and hypopharynx Assess function of vocal cords or to obtain tissue for biopsy The mirror is placed against the soft palate May make patient anxious and uncontrollable Nursing Interventions - NPO several hours before procedure - Assess client for allergies to iodine, contrast media, or local anesthetics - Administer pretest medications (sedation) - Assess client for fear - After the procedure NPO until gag reflex - Encourage coughing - Assess VS q 15 min atleast 2 hr - After procedure and then q2 x 24 h - Assess client for bleeding - After procedure, administer lozenges or gargles as prescribed.

Pharyngitis -Pharyngitis is an inflammation of the Pharynx that frequently results in a sore throat - It may be caused by a variety of microorganisms.