EENT - Eyes, Ears, Nose & Throat

OBJECTIVES
At the end of the lecture-discussion, the students
are expected to:
a. Identify the parts of the eye, ears, nose and
S7 Sciera

throat;
b. describe the functions of the anatomy of the vea centralis
Pupil
EENT; tral depression)

c. discuss diagnostic tests with corresponding

nursing responsibilities appropriately;
d. identify applicable nursing diagnosis to patients
with EENT problems;
iscuss
d indications, side effects and nursing

[E
terventions of common pharmacologic agents;
scribe common disorders of the EENT; Suspensory ligaments

umerate correct etiologies of the disorders;

Right Eye (viewed from above)

]
Layers of the Eye
h. discuss the alterations to physiologic functions secsdary
to the EENT problems; I. External Layer
i. enumerate correct types or classifications of EENT a. sclera
problems; b. cornea
j. identify the manifestations in connection with the c. corneoscleral
physiologic alterations; junction
k. discuss applicable medical management;
I. provide rationales of each of the medical management 11. Middle Layer
identified; a. choroid
m. identify appropriate surgical interventions ; b. ciliary body
n. discuss pre-operative and post-operative nursing c. Iris
management;
o. provide health teachings applicable to the EENT disorder; 111. Inner Layer

�:�lily
a. retina
preventive and rehabilitative interventions.

co •
Eyes
I. EXTERNAL LA YER
ANATOMY OF THE EYE
a. SC LERA -- opaque white tissue @
I. Eyelids and Eyelashes b. CORNEA -- dense transparent layer
II. Conjunctiva - the "window of the eye
a. Palpebral Conjunctiva
-pink; lines inner surface of eyelids c. CORNEOSCLERAL JUNCTION - also known as
b. Bulbar Conjunctiva LIMBUS
-white with small blood vessels; - transitonal zone through w/c aqueous
covers anterior sclera humor leaves the eye
Ill. Lacrimal Apparatus
-consists of lacrimal glands and
ducts
IV. Meibomian Glands
V. Ciliary Glands
II. MIDDLE LAYER ['"" *Macula - yellow spot near the center of the retina
- Vascular & heavily - responsible for central vision
pigmented Inberuslr meshed
laterior chmb Fovea - small pit; an indentation in the center of
a.CHOROID Schlemts eaol the macula
- dark brown pigmented
membrane tis Optic disk
- lines most of the sclera & is - creamy pink to white depressed area in the retina
attached to the retina
- contains many blood vessels - called "blind spot"

b. CILIARY BODY Vitreous humor

- connects the choroid with the - jell-like substance that maintains the shape of the
iris eye
- secretes aqueous humor
which gives the eye its shape

Acute Macular Degeneration

FLOW of the AQUEOUS HUMOR y
MUSCLES of the EYE

Extraocular muscles
•rectus muscles
•oblique muscles
·levator palpebrae

c.lRIS �
Colored portion
Located behind the cornea and in front of
the lens
Has a central opening called PUPIL
pupil - control the amount of light that
enters the eye Sensory nerve –Optic Nerve
darkness -- dilatation (mydriasis)
light- constriction (miosis) Motor
lens - lies behind the ins
- bends the rays of light entering – Oculomotor
through the pupil
-Trochlear -

- Abducens

[INNER LAYER
a. RETINA
NERVES of the EYE
made up of sensory receptors that transmit
impulses to the optic nerve A. CRANIAL NERVE II
Contains blood vessels & 2 type of photoreceptors:
- optic nerve (nerve of sight)
rods -- work at low light & for peripheral visions
cones - active at bright levels & provide color &
central vision B. CRANIAL NERVE Ill, IV, VI
- innervate the muscles around
the eye
 UNCTIONS
of the EYE r? TONOMETRY

n Refraction -- the process of bending light rays -Measures IOP by

to focus an image in the brain determining the amount
II. Accommodation -- ability of the eye to focus of force needed to
specifically for close objects indent a portion of the
Ill. Pupillary constriction - ability of the pupils of anterior globe
the eye to regulate light that enters the eye Principle: a soft eye is
easier to indent than a
ofVISIO�N---�� :' hard eye
ASSESSMENT e Normal1OP 11-21 mm

•
- appearance of the eye, symmetry, color
.# Hg

a. exopthalmus
-proptosis; protusion of the eyeball
.
b. enopthalmos
-sunken eyeballs. \
c. ptosis IV. EXTRAOCULAR MUSCLE FUNCTION
-drooping of eyelids

- Superor Reeta
111

J. roe
-- check for similarity of shape, size & ufenot Rectus
Ill
Superior Oblue
f
laferot Rectus
Ill
reaction
a. lsocoria - equal pupil size
b. Anisocoria - 1 pupil larger than the
Figure 2.4: Te action and nerve supply of the
other extr aoc ular muscles.

PERRLA - Pupil Equally Round

& Reactive to Light &
Accommodation
r-:. TEST FOR COLOR VISION

ISHIHARA CHART
Use of polychromatic plates
- Each eye is tested separately
- Sensitive for the diagnosis of red/green blindness

TEST: https://www.color-blindness .com/ishihara-338-plates-cvd-

test/#pretty
Photo

Ill. VISUAL ACUITY TEST RESULT: https //picassciences files wordpress .com2015/01/1shihara38.pdf
- measures the client's distance & near vision •
SNELLEN CHART/ ILLETERATE E CHART

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 DIAGNOSTIC TESTS for the EYE
I. FUNDOSCOPY
% used to examine the
health of the retina and
vitreous humor
pupils should be
dilated prior to the
procedure
Set ophthalmoscope 6
Ill. SLIT LAMP
allows examination
of the anterior ocular
structures under
microscopic
magnification
help detect disorders
of the anterior

-. . inches away from pt's

eye
portion of the eye

Look for REDREFLEX

that indicates reflection
• in the retin:\,

qED - ORANGE REFLEX

/ ,, IV. CORNEAL STAINING
• Consist of placing fluorescein or other topical dye into
conjunctival sac
A blue light is directed in the eye
The dye outlines the corneal irregularities that are not visible.

3. Osmotic Diuretics - used for reduction of IOP or • �

ocular surgery "
~rowoe1RY - Mannitol (Osmitrol); Glycerin (Glycerol)
..Measures oP by
4. Ophthalmic anti-infectives - used for treatment of
determining the amount ophthalmic infections
of force needed to - eg. Tobramycin (Tobramycin, Tobrex); Gentamycin
indent a portion of the (Garamycin, Genoptic); Bacitracin (AK-Tracin)

anterior globe 5. Ophthalmic steroid anti-inflammatories- to relieve pain;

Principle: a soft eye is suppress other inflammatory processes of the
easier to indent than a conjunctiva, cornea, lid, and interior segment of the
globe
hard eye �
e Normal loP - 11-21 mm
Hg
l

a - Oexamethasone (Maxidrex, Oecadron);

Fluorometholone (FML, Flarex)

6. Carbonic anhydrase inhibitors - used in combination

regimen to treat glaucoma and postoperative rise in
IOP.
7
- Acetazolamide (Diamox); Methazolamide
(Neptazane)
 CONSIDERAToNs CON.JuNcTvITIS
GENERAL
A. Inflammatory
1. Advise the patient to follow the directions exactly. - d/t allergens
2.If the condition worsens or does not improve, notify the - non-contagious
physician. Treated with vas0constrictors/ corticosteroid
3. If multiple drugs are ordered, wait 5 minutes between them.
4. After administering ophthalmic solutions, apply gentle pressure Get
to inner canthus for approximately 1minute to decrease absorption B. Infectious
and systemic effects - d/t staph, chlamydia, Neisseria
- contagious
5. If patient has both an ophthalmic drops and ointment, instill first
Treated w/ broad spectrum antibiotics
the drops before the ointment.
6. Teach the patient or a family member the correct technique for
drug administration S/Sx. Itching, burning or scratchy eyelids
Redness
7. Emphasize that patients should never share eye medications
Conjunctival edema
Excessive tearing
Discharge

�LEPHARITIS
Inflammation of the eyelid margins
S/Sx: Itchy, red, burning eyes, flaking,
purulent discharges
EYE DISORDERS T. topical/eye drops antibiotics
Do warm compress

HORDEOLUM (STYE)
Chalazion
Acute suppurative infection of the follicle of
an eyelash
Usually d/t Staph
S/Sx. redness and pain, lump/ swelling of
the eyelid, purulent discharges
Tx. Antibiotics/ I&D
Do warm compress 4-5x a day

INFECTIOUS
& NURSING CARE

INFLAMMATORY .Instruct in infection control measures

Administer antibiotic or antiviral
.Administer antihistamines
CONDITIONS .Child should be kept home from school until
antibiotic eye drops have been administered for 24
hrs
of the Instruct in the use of cool compresses
wear dark glasses for photophobia
.Instruct the child to avoid rubbing the eye
EYE .DIC use of contact lenses & to obtain new lenses to
eliminate the chance of re-infection
.Instruct patient that eye make-up should be
discarded & replaced
sere altered without the presence of any
inflammation, infection or other eye
Signs and Sympto
Cloudy or blurry vision
Watery eyes
Dry eyes
Glare
disease Photophobia
Runs in families Pain
Foreign body sensation
TYPES: Corneal erosions
I. Epithelial : epithelial layer of the cornea
Management
Diagnostic Test Hypertonic eye drops/ ointment
a. Meesman: occasional 'foreign body'
• Slit lamp examination Antibiotic
sensation at adulthood Special contact lenses
b. Epithelial membrane (COGAN'S Bandage contact lenses
dystrophy).painful 'foreign body' sensations Rigid contact lenses
and temporary blurring after 30 Surgery
c. Reiss buckler. light sensitivity and Corneal transplant
'foreign body' sensations Phototherapeutic
Keratectomy (PT)
-mar re@ore comea"an
II. Stromal Dystrophies
a. Granular. grey-ish dots can be seen
through a microscope. Vision may be
lost at 50
b. Macular : Irregular, cloudy areas
appear in both corneas which gradually
merge together. Light sensitive, sight lost
at 20-30 years old
REFRACTIVE ERRORS
c.Lattice: 'foreign body' sepsation and
a slight deterioration in vision. Under a
microscope, very fine, overlapping lines
will be seen in the cornea

Normal Refraction – Emmetropia

Defect in refraction – Ametropia

ril . Endothelium: innermost layer of the cornea
a. Fuch's: more common in women, unlikely to metropia
be inherited
a state where refractive error is present, or when distant points are no
- begins at 40 painless deterioration of vision and
longer focused properly to the retina
glare
- next stage, painful episodes due to tiny blisters
on the cornea, which will gradually disappear as
ETIOLOGY:
the vision gets worse Corneal curvature
Length of the eye
b. Keratoconus Strength of the lens
- conical or cone-shaped cornea
- rarely appears until puberty or older vs4o4 OsOm0ems
- Cornea becomes stretched and thins at its
center

5 5
ternalwrsir Myopia

0 0-
tperopa

Corneal Curvature Problem – Astigmatism

Length of the eye – Hyperopia

Strength of Lens – Presbyopia

 TYPES of Refractive Errors
I. MYOPIA
opa
Eye Shape with y IV. PRESBYOPIA
-
Old sight

6¢-·
Near-sightedness
Inability to accommodate for near

o---
Has excessive refractive strength vision due to loss of elasticity of the
Focuses light in front of the retina crystalline lens
Treat with CONCAVE lens
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Normal Vision Myopj% we --=:::;1"!!!!!11..

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@) Pt’s with presbyopia usually have Hyperopia

suRGERY
1. LASIK ( Laser in situ Keratomileusis)- uses an
excimer laser to cul/ reshape the cornea
11. HYEPEROPIA
Far-sightedness 2. ICR ( lntrastromal Corneal Ring) - are small
Focuses light at the back of the retina devices implanted to correct vision
Treat with CONVEX lens
¢ 3. Phakik lntraocular Lens -- lens that are made of
plastic/ silicone; implanted permanently

Nomad Vision Farsighted Vision

/suwoEss l

ls a condition of lacking visual perception

Ill. ASTIGMATISM
J Defined as a BCVA (best corrected visual acuity) of 201400 to no
light perception

TYPES of blindness:
Unequal curvature of the cornea a. Total blindness -- No light perception and no usable vision
Treat with special leni1 b. Functional blindness -- has light perception but no usable vision
c. Legally blind -- central visual acuity for distance of 20/200

Nursing Management
Assess how visual impairment can
affect normal functioning
Provide emotional support for
recent visual impairment

#is%ks
Orient to the environment
Sight guide technique (e.g. Contact
and grasp)
 CATARACTS
, GLAUCOMA
A group of disorder that ail
, r
have increased intraocular
- Is an opacity or cloudiness of the normally pressure , leading to damage to the optic nerve
transparent crystalline lens structure with resulting visual field loss.
- lens protein dries out and forms crystals
Maybe caused by ocular inflammation or injury,
CAUSES trauma, infection, hereditary predisposition
Senile -- associated w/ aging
Congenital - may be hereditary Normal IOP: 12-20 mmHg
Traumatic - associated with injury
Secondary - sequelae of systemic vii tug
4cataract
disease, drug ingestion

IDiagnostic When optic nerve is damaged it is permanent

Exams
Standard ophthalmic exam
TYPES of Glaucoma
Visual acuity test
Eye movement and peripheral vision
I. OPEN ANGLE GLAUCOMA
Color blindness A.k.a: chronic, simple or wide-angle glaucoma
Most common
Pupil dilation Bilateral & asymptomatic in early stage
Tonometry Reduced outflow of AH
Slit-lamp exam .The fluid cannot leave the eye at the same rate
it is produced, IOP gradually increases
l First s/sx is cloudy vision, lessened
accommodation, loss of peripheral vision
Medical Management
CLOSED ANGLE GLAUCOMA

@ml
I. Extracapsular cataract extraction (ECCE) / ti. CLOSED ANGLE GLAUCOMA
a. Manual expression el .Aka: narrow-angle glaucoma or acute
glaucoma

es
b. Phacoemulsification -Less common
-Movement of the iris against the cornea

vs>
It. Intracapsular cataract extraction (ICCE)
narrows or closes the chamber angle,
obstructing the outflow of AH
Causes sudden onset of unilateral eye pain
with B0V and possibly nausea and

NURSING INTERVE�N- ._s

PRE-OP NURSING CARE
__
Instruct measures to prevent increased 1OP
7 he
••
4.of

Closed angle is more dangerous

vomiting
Reas.mo

(avoid heavy lifting, bending lower than waist, reading)

Administer pre-op eye medications including mydriatics & Late stage open angle glaucoma can cause pain
cycloplegics as prescribed ex. Atropine

POST-OP NURSING CARE

Elevate the head of the bed 30-45 degrees
SIGNS and SYMPTOMS 1111111
Turn the client to the back or un-operative side
Pharmacologic: antibiotic-steroids: TobraDex, C-lean post-operative eye EARLY
Acetaminophen A-nalgesics • Elevated IOP
No aspirin due to clotting effects. T-obradex • Diminished accommodation
Instruct measures to prevent or decrease [0 A-void lying on operative
Wear glasses during the day until the pupils side LATE
responds to light R-eport complications Progressive loss of peripheral
Eyeshield at night or while sleeping. A- void bending & stooping vision tunnel vision" followed by a
For minor pain: ice or heat as prescribed. The use of eyeshield loss of central vision ltrmt
Shower or bathing is allowed Vision worsening in the evening
Care of the dressings. A-vise hygiene Symptom

Stool softeners with difficulty adjusting to dark

Instruct to report pain with nausea and vomiting. rooms
Blurred vision
Halos around white lights.
Frontal headaches Av.nod
Photophobia Symptom.
Increased lacrimation

h
 '] [CAUSES
MANAGEMENT
• For acute glaucoma: treat as medical emergenc ¢ degenerative changes in the retina or vitreous.
• Administer medications as prescribed to loer
a. MIOTICS:
jbp ¢

¢
trauma, inflammation, or tumor
diabetic retinopathy
Ex: Pilocarpine myopia and loss of a lens from a cataract (aphakia)

b. CARBONIC ANHYDRASE INHIBITORS: SIGNS and SYMPTOMS

Ex: Acetazolamide Sense of curtain being drawn
Flashes of light
e. BETA-BLOCKERS: , black spots or floaters
• blurred vision
ex: Timolol; Betaxol»»l • loss of a portion of the visual field
use cautiously to patient with Asthma and CHF.
d. SYMPATHOMIMETICS:
DIAGNOSTIC EXAMS
drug of choice to patient with asthma and CHF Ophthalmoscopy
ex: Epinephrine Slit-lamp exam
�GERY,
Peripheral Iridectomy; Trabeculectomy; Iridotomy
Goni0scopy

G
Black spots means bleeding
NURSING MANAGEMENT
.
.
.
.
.
Maintain on CBR
Administer meds as ordered

Provide emotional support

Avoid mydriatics
"
Assist according to degree of visual impairment
liMMEDIATE NURSING CARE
Provide bedrest
Cover both eyes with patches to prevent further
detachment
Speak to the client before approaching /
Position the client's head as prescribed
. Prepare patient for surgery Protect the client from injury

__
Avoid jerky head movements
Minimize eye stress
Prepare the client for surgical procedure as prescribed

0
NURSING MANAGEMENT
...___ ']
./
SURGICAL MANAGEMENT
Sealing retinal break(y Cryosurgery
Diathermy
• Maintain on CBR Laser Therapy _ _
• Administer meds as ordered Scleral "
• Assist according to degree of visual impairment
• Provide emotional support
• Avoid mydriatics
. Prepare patient for surgery
MACULAR DEGENERATION (AMD)

RETINAL DETACHMENT 7
- occurs when the layers of the retina separate because of
Age-related macular degeneration is
a medical condition that results in a
loss of vision in the cenler of lhe visual
field (the macula) because of damage
accumulation of fluid between them lo lhe relina
- also occurs when both retinal layers elevate away from the - the most common cause of
choroid as a result of a tumor irreversible central vision loss in persons
over 60
TYPES:
- PARTIAL RETINAL DETACHMENT
. COMPLETE RETINAL DETACHMENT

-A medical EMERGENCy
RISK FACTORS
•
• Related to retinal aging
Affected by genetics
g term exposure to UV lights
peropia
rette smoking
 =
STRABISMUS (DOUBLE VIS1ow
OCULAR MELANOMAS
- called "SQUINT EYE" or "CROSSED EYE"
CANCER of the EYE kt- acondition in which the eyes are not aligned because of lack of
muscle coordination of the extraocular muscles
Melanocytes produce the dark-
• 7rmar In young infant but should not be present after about age
coloured pigment melanin 4 months
found in many places in our
body, including the skin, hair, CAUSES care ADULT
and lining of the Internal unknown - Diabetes
organs, including the eye. - congenital rubella - traumatic brain
• cerebral palsy injury
- retinopathy of prematurity - injuries to the
- traumatic brain injury eye
ETIOLOGY - hemangioma near the eye -stroke
Unknown
Ultraviolet (UV) rays Other risk factors: family history, farsightedness
Dysplastic naevus syndrome

JE=to
Ocular melanocytosis

Double vision
eoRMS of AMD Uncoordinated eye movements
Loss of depth perception
I. Dry (non-exudative)
abnormal accumulation of
yellowish colored extracellular
deposits drusen in the retinal
DIAGNOSTIC EXAM
pigment epithelium Retinal exam
Slow onset Ophthalmic exam
Macular cells start to atrophy Visual acuity
Neurological exam
Before
II. Wet (exudative)
owth of new blood vessels
from the choroid to retinal
TREATMENT «·
epithelium Glasses
rapid onset Eye patch
development of abnormal Eye muscles exercise
blood vessels around the
Surgery
macula

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MELANO�
OCULAR J
Scotomas (blind spots in visual
field)
Metamorphopia (distortion of vision)
l ••
CANCER of the EYE
Melanocytes produce the dark-
coloured pigment melanin
found in many places in our
body, including the skin, hair,
and lining of the internal
organs, including the eye.
"
DIAGNOSTIC EXAM
AMSLER GRID TEST ETIOLOGY
- a pattern of intersecting lines with a Unknown
black dot in the middle. The central Ultraviolet (UV) rays
Dysplastic naevus syndrome

i
black dot is used for fixation (a place
Ocular melanocytosis
eye to stare at).

MANIFESTATIONS
blurred vision ., ----•.../ -
MANAGEMENT . flashing lights and shadows.
_:change in iris color
1.Laser macular photocoagulation · red and/painful eye MANAGEMENT
2. photodynamic therapy (PDT) · loss of peripheral vision
3. Pegaptanib Radiotherapy
4. Ranibizumab DIAGNOSTIC EXAMS Surgery
5. green leafy vegetables with lutein Transpupillary thermothera
Ophthalmoscopy
Ultrasound
NURSING INTERVENTIONS MRI/CT scan
Discuss strategies/modifications to carry out usual activities.
Assist with self-care activities.
Engage support people in assistance with patient activity.
Advise patient to memorize environment while some vision is intact.
Use side rails as needed, and make sure that patient can call for
help if needed
Rest eyes as needed. Enucleation – removal of whole eye
 ANATOMY of the EAR

OCULAR
EMERGENCIES
•

Out«r f

DIVISONS of the EAR

%ow to ms sve l OUTER (EXTERNAL) EAR
. Apply cold compress for about 15 minutes to reduce swelling and pain
a Aunicle (pinna)
and help prevent bleeding
- collects sound waves

CHEMICAL BURNS b. External auditory canal

Immediately flush eye with water, normal saline or ophthalmic irrigation - glands secrete cerumen which provides
solution for minimum of 15-20 minutes protection
• Using fingers to keep eye open as wide as possible. - transmits sound waves to tympanic
membrane
FOREIGN BODIES
Never rub a speck or particle in the eye.
Have the client look upward, expose the lower lid, wet a cotton-tipped Tympanic membrane (eardrum)
applicator with sterile normal saline, & gently twist the swab over the - barrier between external ear and middle
particle & remove it ear
Blink several times to let particle move out. - transmit vibrations to middle ear
If specks remains, keep eyes closed.

HYPHEMA
Management: bedrest in semifow1ers position. II MIDDLE EAR
Avoid sudden movements for 3-5 days
Eye patch and shields. a Ossicles 4
It may resolve in 5-7 days. - contains 3 small bones
Cycloplegic medications to rest the eyes injured. + malleus (/hammer)
+ lncus f anvil)
+ Stapes (stirrup)
- oval window' an opening between the
Hyphema - Pulling or collection of blood inside the eye middle and inner ear

b. Eustachian tube
- connects nasopharynx and middle ear
- equalizes pressure on both sides of
eardrum, drainage channel r+#;
...

EAR Ill INNER EAR

- filed with pen/ymph and endolymph

a Vestibule
- entrance spa0e next to oval window

b Cochlea
- has the organ of Corti, receptor and
organ of hearing
- contains hair cells that detect vibration
from sound and stimulate the 8 cranial
nerve

c. Semicircular canals
- organ of balance

Vestibule – Kinetic WEquilibrium

Cochlea – Hearing

Semicircular Caanls – Dynamic Equilibrium

Assessment IV. VESTIBULAR ASSESSMENT OF THE EAR
ROMBERG' TEST
sa screening test for balance

(-Pomberg = client remains erect with slight

I. VOICE TEST (WHISPER TEST) swaying

Ask the client to block one external (+)Romberg presence of significant swaying
canal
The examiner stands 1-2 ft away &
quickly whispers a statement
The client is asked to repeat the
whispered statement
Each ear is tested separately

II. WATCH TEST

A ticking watch is used to test the

#3
Ill. TUNING FORK TEST
A. Weber Test
Uses bone conduction to test lateralization of
sound
Useful in detecting unilateral hearing loss
Normal sound is heard equally in both ears
Conductrve hearing loss affected ea
Sensorineural hearing loss unaffected ear
high-frequency sounds
The examiner holds a ticking watch
about 5 inches from each ear &
asks the client if the ticking is heard
DIAGNOSTIC TESTS FOR THE EAR
I. Audiometry
- measures hearing acuity
the patient wears earphones and signals to
the audiologist when a tone is heard
audiometric evaluations are performed in a
soundproof room
responses are plotted on a graph known
as an audiogram

B. Rinne Test
Useful in distinguishing between conductive
and sensorineural hearing lo
(+)Rinne test a Air conduction » Bone
Conduction
(.)Rinne test = Bone conduction Air
conduction
(+)Conductive leaning Loss

YOU GOTTA KNOW THAT!

Ex: tuning fork is placed on the mastoid and then moved
outside of both the right and left ear. The patient says they
are able to hear the fork better when it is held in the air
next to both ears The physician strikes the tuning fork and
placed it on the patients head. The patient says they hear
the fork better in their right ear. What is the diagnosis?

RINNE normal for both ears (AC > BC)

WEBER -- localized to the right (sensorineural loss, left)