S7

EENT - Eyes, Ears, Nose & Throat

are expected to:

OBJECTIVES
OBJECTIVES
At the end of the lecture-discussion, the students

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;
indications, side effects and nursing

[E
iscuss
d
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
Layers of the
the Eye
Eye
h. discuss the alterations to physiologic functions secsdary
secsdary
to the EENT problems; I. External Layer
i.i. enumerate correct types or classifications of EENT a. sclera
problems; b.
b. cornea
j. identify the manifestations in connection with the c. corneoscleral
physiologic alterations; junction
k. discuss applicable medical management;
I.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
a. retina

�:�lily preventive and rehabilitative interventions.

co •
co •
Eyes
I.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
 r?
n
UNCTIONS
of the EYE TONOMETRY
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
Hg

- appearance of the eye, symmetry, color

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.

r-:.
PERRLA - Pupil Equally Round
& Reactive to Light &
TEST FOR COLOR VISION
Accommodation
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 •

se'
SNELLEN CHART/ ILLETERATE E CHART

•
E
II E +
au m 3
Eu E = 4
•••••
••••• ••
·•
7
 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

a
hard eye � - Oexamethasone (Maxidrex, Oecadron);
l
e Normal loP - 11-21 mm Fluorometholone (FML, Flarex)
Hg

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,

EYE DISORDERS
purulent discharges
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

EYE .Instruct the child to avoid rubbing the 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

comea"an
Keratectomy (PT)
-mar re@ore

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

ril .
Defect in refraction – Ametropia
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

5 5
center

ternalwrsir Myopia

0 0-
tperopa

Corneal Curvature Problem – Astigmatism

Length of the eye – Hyperopia

Strength of Lens – Presbyopia

 TYPES of Refractive Errors -
6¢-·
opa
Eye Shape with y IV. PRESBYOPIA
I. MYOPIA
Old sight
Near-sightedness

o---
Inability to accommodate for near
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
Tr•_•_:-w-
• t_
i_h b_r_oca-
i -;;-e_n_•
l __
--=:::;1"!!!!!11..

l
Normal Vision Myopj% we

@w
h...of e-

@) 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

/suwoEss
Nomad Vision Farsighted Vision
l

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

#is%ks
Provide emotional support for
recent visual impairment
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)

@ml el
/ ti. CLOSED ANGLE GLAUCOMA
.Aka: narrow-angle glaucoma or acute

es
a. Manual expression
glaucoma
b. Phacoemulsification -Less common

vs>
It. Intracapsular cataract extraction (ICCE) -Movement of the iris against the cornea
narrows or closes the chamber angle,
obstructing the outflow of AH
Causes sudden onset of unilateral eye pain

7
with B0V and possibly nausea and
he vomiting
•• Reas.mo
4.of

NURSING INTERVE�N- ._s

PRE-OP NURSING CARE
__
Instruct measures to prevent increased 1OP
Closed angle is more dangerous
(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.
jbp
¢

• Administer medications as prescribed to loer ¢ trauma, inflammation, or tumor

a. MIOTICS: ¢ 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

G
ex: Epinephrine Slit-lamp exam
Goni0scopy
�GERY,
Peripheral Iridectomy; Trabeculectomy; Iridotomy

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

• Maintain on CBR
./ Sealing retinal break(y Cryosurgery
Diathermy
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
RISK FACTORS
-A medical EMERGENCy
• 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

eoRMS of AMD
Double vision
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 TREATMENT
from the choroid to retinal
epithelium Glasses
rapid onset Eye patch
development of abnormal Eye muscles exercise
blood vessels around the

zzc +z
Surgery
macula

MELANO�
J

"
OCULAR J
CANCER of the EYE
Melanocytes produce the dark-
Scotomas (blind spots in visual •• coloured pigment melanin
l
field)
found in many places in our
Metamorphopia (distortion of vision) 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

i
black dot in the middle. The central Ultraviolet (UV) rays
black dot is used for fixation (a place Dysplastic naevus syndrome
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
NURSING INTERVENTIONS Ultrasound
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

#3
A ticking watch is used to test the
high-frequency sounds DIAGNOSTIC TESTS FOR THE EAR
The examiner holds a ticking watch
about 5 inches from each ear & I. Audiometry
asks the client if the ticking is heard - 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
Ill. TUNING FORK TEST responses are plotted on a graph known
A. Weber Test as an audiogram
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

B. Rinne Test Audiologists – Interprets the result for audiometry

Useful in distinguishing between conductive
and sensorineural hearing lo
(+)Rinne test a Air conduction » Bone
Conduction
(.)Rinne test = Bone conduction Air
conduction IL Otoscopic exam
(+)Conductive leaning Loss
GUIDELINES
the speculum is never blindly introduced into the
external canal
tilt the head slightly away & hold the otoscope upside
YOU GOTTA KNOW THAT! down as if it were a large pen
visualize the external canal while slowly inserting the
speculum

Ex: tuning fork is placed on the mastoid and then moved Normal
External canal - colored, intact, w/out lesions
outside of both the right and left ear. The patient says they Eardrum - shiny, transparent, opaque or
pearly gray; mobile
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 Adult – Pull up
the fork better in their right ear. What is the diagnosis? Neonates – Pull down
RINNE normal for both ears (AC > BC)
Ill. ELECTRONYSTAGMOGRAPHY (ENG)
WEBER -- localized to the right (sensorineural loss, left) - electroencephalographic recordings of eye
movements that provide objective
documentation of induced and spontaneous
nystagmus
- used to evaluate the oculomotor and
vestibular systems to differentiate the cause
of vertigo, tinnitus, and hearing loss of
unknown origin

C/Iif patient has had prior neck injury.

Evaluates oculomotor and Vestibular System

 NURSING CONSIOERATIONS Ill. MIXED HEARING LOSS

- Client has both sensorineural and

e avoid a heavy meal before the procedure conductive healing loss
avoid caffeine and/or alcohol - 48 hours before the
procedure Etiology: IV. PRESBYCUSIS
medications that may affect the vestibular system Encephalitis
Stroke - Associated with aging
(sedatives, antianxiety agents, antihistamines, and - Leads to degeneration or atrophy of the
medications ordered for dizziness)- w/held for up neoplasm in the brain
ganglionic cells in the cochlea and a loss of
to5days before the procedure elasticity of the basilar membranes
- Leads to compromise of the vascular
supply to the inner ear
• Blaferal hearing loss especially high
frequency tones
Etiology
Age related changes
Lifelong exposure to loud noises
Avoid heavy meal might cause vomiting Ototoxic drugs
Disease process
Avoid alcohol as it may alter the result
COMMON MANIFESTATIONS
Complaints that their hearing is good but
others mumble
Leaning or turning one ear toward the

EAR
speaker
May fail to follow directions, speak while
others are speaking. or turn the radio/TV up
very loud

DISORDERS rritability and even hostility not unusual

Some become very suspicious of others
because they cannot hear what is being
said
Otalgia (ear pain), dizziness, and tinnitus
with certain types of disorders

tearing Aid Styles

HEARING LOSS MANAGEMENT

Hearing loss is any degree of 1. Hearing aids - are battery operated
impairment of the ability to instruments that make sounds louder
apprehend sound Hearing loss range (dB 2. Cochlear implants - permits direct
Degree of hearing loss
Disruption of the sound wave HL) neural stimulation of the auditory
path Normal 10to 15
Decibel (dB)- unit of nerve, bypassing damaged hair cells
measuring loudness
Slight 16 t0 25 3. Surgery
Mild 26 to 40 Tympanoplasty - reconstruction of
Moderate 41 to 55 diseased or deformed middle ear
Moderately severe 56 to 70 components
Severe 71 to 90 Stapedectomy - removal of footplate
Profound 91+ of stapes and insertion of graft or
Source: Clark, J. G.(1981) Uses and abuses of prosthesis
hearing loss classification. Asha, 23, 493--500

POSTOPERATIVE NURSING MANAGEMENT

TYPES OF HEARING LOSS Antibiotics as prescribed.
Bed rest may be maintained for the first 24 hours or longer.
I. CONDUCTIVE HEARING LOSS
Analgesics, antiemetics, and antihistamines are given as
- occurs when sound waves are blocked to needed.
the inner ear fibers because of external ear The patient is positioned to promote drainage but maintain
or middle ear disorders
. Reversible some immobility.
Manifestations: Elevate head of bed.
Etiology: Sound is perceived as distant or faint
Otosclerosis (decreased sensitivity) Encourage the patient to move slowly.
Complain that hearing is worse while Wash hands before ear care, and instruct patient not to touch
Changes in eardrum such as bulging
eating crisp or crunchy foods
Obstructed external ear canal ear.
Perforated tympanic membrane
Dislocated ossicle Diagnostic Tests: Take care not to get dressing or ear wet.
Ottis media Weber test = lateralization on Packing may be removed up to 6 days postoperatively.
Ottis externa affected ear Report and teach patient to report any manifestations of
Rinne test = BC > AC
infections

In cochlea High Pitch usually is damaged first when

there is sensorineural Loss
OTITIS EXTERNA
--- %.
-..
=±±EE:::±EE=-
MANAGEMENT
M-easures to open Eustachian
Infected Small Incision
infective inflammatory or allergic Middle Ear in Ear Drum
responses involving the #=ENEE tube

- · en _. .. ,
structure of the external auditory -myringotomy
canal or the auricles Eradicate the cause
SWIMMER'S EAR"
more common in children and D-decongestant & Anti-histamine
adolescents Es I-nstruct to avoid colds &
4$ barotraumas
'gt'i A-nalgesics

. • .·i?
le
Blocked
eustachian
the

Myringotomy – Surgical Procedure

CAUSES
causative agents. bacteria
(Pseudo, Proteus, E.coli,
Staph) & fungi (Candida 8
Aspergillus)
swimmer's ear". water
collects in the ear canal
cuts or abrasions in the lining
of the ear canal ( eg. cotton
swab injury)
dermatologic conditions
(seborrhea, eczema, and
contact dermatitis)
MANAGEMENT
E-ear wicking
X-urgery: debridement
T-horough cleaning
E-steroids
R-elieve edema
N-SAID'%
A-ntibiotics
OTITIS MEDIA
infection of the middle ear
occurring as a result of a
blocked eustachian tube, which
prevents normal drainage
a common complication of an
acute respiratory infection
primary causative agents: H.
influenzae, Strep, Staph, E.coli
infants & children are more
prone
main causes:
Allergy
Infection
blockage of the eustachian
tube and nutritional
deficiency.
SIGNS AND SYMPTOMS
first symptom: the ear will feel
full, and it may itch
pain
Skin becomes red, swollen, &
tender
Yellowish discharge
Fever
Lymphadenopathy
Excessive swelling of the
canal lead to conductive
hearing toss
NOTE moisture and irritation
will prolong course of the
problem
showering or swimming: use an ear plug
(one that is designed to keep water out), or
use cotton with Vaseline on the outside.
cotton swabs should be avoided
hearing aid should be left out as much as
possible until swelling and discharge stops.
suctioning of the ear canal helps to keep it
open, remove debris, and decrease
bacterial counts.
Analgesic for Children is Acetaminophen
NURSING CARE
Apply heat locally for 20 minutes 3x a day
Administer analgesics, antipyretics, antibiotics
{amoxicillin, clarithromycin, cefuroxime)
Ears should be kept clean & dry
Use earplugs for swimming
Instruct the client that cotton-tipped applicators
should not be used to dry ear
Instruct the client that irritating agents such as hair
products or headphones should be discontinued
Prepare for myringotomy
First line of anitbiotics is Amoxycilin
MASTOIDITIS
- infection of the mastoid air cells
secondary disorder resulting from
untreated otitis media
- caused by Strep. pneumoniae & H
influenzae
- most often affects children
SIGNS AND SYMPTOMS
Dull, post-auricular pain/
swelling
» Cellulitis of area involved
Low-grade fever
Anorexia
» Tender & enlarged lymph
nodes
DIAGNOSTIC EXAMS
Otoscopic exam: reddened, dull, thick,
immobile tympanic membrane with or
without perforation
Xray: shows bone destruction

SIGNS AND,SYMPTOMS MANAGEMENT

Antibiotics
bulging & immobile tympanic » Surgery (myringotomy; mastoidectomy)
membrane
fullness in the ear
w/ slight hearing loss
vertigo COMPLICATIONS
pain - usually the first symptom Facial nerve injury; meningitis, brain
fever abscess; labyrinthitis
LABYRITHITIS MANAGEMENT
- an inflammation of the inner ear structure
called labyrinth (a maze of interconnected
TREATMENT:
sodium restricted diet
diuretics: hydrochlorothiazide to
<r nor vs
@€€N REN CRNTED
L
fluid-filled channels and canals)
CAUSES decrease pressure A MERRY-60-gbuNp
vestibular suppressants:
Usually follows a viral illness hill! -t[/]A
antihistamine, tranquilizers and
4
Trauma or injury to the head or ear lhymind anticholinergics
Bacterial infection (otitis media) avoid alcohol, caffeine and smoking
Allergies Stress Therapy
Alcohol abuse ENDOL YMPHATIC DRAINAGE &
A benign tumor of the middle ear INSERTION OF THE SHUNT (frst-line
Certain medications taken in high
surgical approach)
doses (Furosemide (Lasix). Aspirin,
LABYRINTHECTOMY
Phenytoin (Dilantin) at toxic levels)

NURSING CARE
MANIFESTATIONS
Help patient recognize aura so patient has time to prepare for an
COMMON SYMPTOMS :
vertigo DIAGNOSTIC EXAMS attack.
tinnitus Encourage patient to lie down during attack, in safe place, and lie still.
CBC
sensorineural hearing loss Rinne and Weber test Place pillow on each side of head.
Other symptoms : Have patient close eyes if this lessens symptoms.
Nystagmus Teach about medication therapy
Pain
Fever
MANAGEMENT Assist patient to identify specific triggers to control attacks.
- Remind the patient to move slowly.
ataxia Antibiotics; vestibular suppressants;
nausea, vomiting antiemetics
- Avoid noises and glaring, bright lights.
Mild sedation may help the patient relax - If there is a tendency to allergic reactions to foods, eliminate those
foods from the diet.

NURSING CARE
Otosclerosis
avoid turning the head quickly
OTOSCLEROSIS

:,
to help alleviate the vertigo
place on bed rest is a genetic disorder in which
assist to cope with anxiety that repeated reabsorption and
may be present because of the redeposition of abnormal bone �
frustration surrounding hearing gradually lead to fixation of
loss or loss of work stapedial footplate in the oval
window.
more common in women; 15-45
yrs. old

ENIERE's sYNDRowe =Sl

l

Chronic recurrent disorder of
the inner ear,
ENDOLYMPHATIC HYDROPS
refers to dilation of the
endolympathic system by either
overproduction or decreased
reabsorption of endolymphatic
ho
With remissions and
exacerbations
CAUSES
Any factor that increases
endolymphatic secretion in the
labyrinth
Viral & bacterial infections
Allergic reactions
Vascular disturbances
\
c
-- MANIFESTATIONS
Progressive hearing loss
PARACUSI WILLISII (patient hears
better in a noisy environment)
$_ w/ or w/out tinnutus MANAGEMENT
Pinkish discoloration
(SCHWARTZE'S SIGN) of the Medical therapy
� tympanic membrane
Rinne's test BC better than AC
Sodium fluoride therapy for 1-2
years
Weber's test: Increased sound in Calcium gluconate and Vit. D
affected ear Amplification -- hearing aid
Audiometry: Conductive hearing loss Surgery - partial stapedectomy
or mixed loss or complete stapedectomy with
MANIFESTATIONS prosthesis (fenestration)
Triad: tinnitus, unilateral
sensorineural hearing loss, & ACOUSTIC NEUROMA
vertigo
Nausea and Vomiting slow-growing tumor of the nerve
that connects the ear to the brain.
Depression
This nerve is located behind the
headache

4
ear right under the brain
High salt intake non-cancerous
Head trauma Vestibular Schwannoma
Smoking affects both men and women

ETIOLOGY
. Genetic (neurofibromatosis type 2)
ene pus pressure on ha0al en
 MANAGEMENT
MANIFESTATIONS Acoustic

.
If object is visible: use tweezers
Neuroma If insect instill 2 drops of mineral oil

\
z.
Common symptoms:
If not insect do not instill mineral oil
• Hearing loss (progressive)
Irrigation is contraindicated if eardrum is
. Tinnitus
perforated, foreign vegetable bodies,
Vertigo
insects
Less common symptoms include:
DON TS
Difficulty understanding speech

£.-?
Do not push your finger into the ear when you
Headache suspect some foreign body in the ear
Numbness in the face or one ear Do not put oil into the ear unless you are sure the
Pain in the face or one ear foreign body is an insect

@'/
Sleepiness Do not shake the head of the child who has foreign
Vision problems body in the ear

A-Z
Weakness of the face Do not attempt to clean your ears with cotton
swabs sticks or the match sticks

DIAGNOSTIC EXAMS EAR TRAUMA MANIFESTATIONS

MRI CAUSES lacerations
a blow to the head contusions
Head CT
Audiogram
MANAGEMENT automobile accidents hematomas
Burns abrasions
Electronystagmography
Surgical removal of the tumor foreign bodies lodged in the ear erythema
Auditory Brainstem Response
Stereotactic radiosurgery canal blistering
Caloric Test
cold temperatures conductive hearing loss
repeated trauma to the ear can
cause hypertrophy, also known
as cauliflower ear ( common
with BOXERS)
numbness, pain, and paresthesia
of the auricle.

DIAGNOSTIC EXAMS NURSING DIAGNOSIS

IMPACTED CERUMEN Imaging studies Acute pain related to inflammation or
Audiometric trauma
a condition wherein earwax has built up in the
oar canal and cause blockage Whisper test Disturbed sensory perception:
Rinne and Weber test auditory related to altered sensory
RISK FACTORS reception
improper cleaning Risk for injury related to self-cleaning
older adult of external ear
patients wth hearing aids MANIFESTATIONS
bony growths secondary to osteophyte or Deficient knowledge related to lack of
Hearing loss
oste0ma
A feeling of fullness, or blocked ear f cerumen Information on preventive ear care
has become impacted
Tinnitus
Otoscopic examination reveals cerumen
blocking the ear canal

DIAGNOSTIC EXAMS
Audiometric testing
Hearing acuity
• Whisper voice, Rinne, and Weber tests

MANAGEMENT
rnigation NOSE and
THROAT
Aural suction
instrumentation with the use of ceruren
curette

NOTE DO NOT attempt to irrigate ear or

instill anything into the external canal f
eardrum may be perforated

FOREIGN BODIES
Anything that may be lodged in the ear canal
intentionally or accidentally

HIGH RISKS
Adults - insects
+ 9months and up Children - small objects
 ANATOMY OF THE NOSE A
-. .
Consists of bone and
cartilage; air enters
through 2 openings/
we wt cwt
fir l eec. Set
-
l nostrils (nares)
DISORDERS OF
THE NOSE
1
' FUNCTION
Olfaction - (CN I) smelling
Air-conditioning -
controlling air temperature
and humidity, removing
articles before air enters
..
;
+,
4u

to the trachea, bronchi 4

" and lungs

ANATOMY OF THE SINUSES

RHINITIS
Paranasal sinuses (frontal,
sphenoid, maxillary, ' - Inflammation of the nasal mucosa
ethmoid)
Air-filled cavities lined with TYPES
mucous membranes I. Acute viral rhinitis or common colds
FUNCTIONS - dlt rhinovirus, parainfluenza virus,
Reduce the weight of the coronavirus, respiratory syncytial
skull virus (RSV), influenza virus, and
To produce mucus adenovirus
'-" To influence voice quality
+· (resonating chambers)
,,
, ,

ANATOMY OF THE PHARYNX

«
Pharynx
pharynx - commonly called
the throat; divided into II. Allergic rhinitis or hay fever
3 regions: nasopharynx, - ls the most common form of
oropharynx, respiratory allergy presumed to be
laryngopharynx mediated by an immediate
4 Nasopharymx
Functions:
Respiratory function - Oro pharynx
immunologic reaction
- maybe: seasonal (pollens from grass,
receives air from the
trees, flowers) or perennial
nasal cavity l]Laryngopharmx
+ Digestive function - (domestic animal, hair, wool, house
dust. foods, newspaper, tobacco,
receives air, food and
fluids from the oral etc.)
cavity
b"
MANIFESTATIONS
ANATOMY OF THE LARYNX Edema
Headache
Larynx - commonly called the Swelling of the nasal
voice box/glottis; mucosa
passageway for air bet. the Congestion
pharynx above and the Fever
trachea below Sneezing
Function: essential in human hinorrhea
speech Cough

..@r
Itching
Mucus production

r
Vop vew
Af44

MANAGEMENT
Antihistamine
Antipyretics
Nasal decongestants

•
Rest and hydration
Desensitization

j�·
' 'I .
',
 NURSING MANAGEMENT
SINUSITIS e
Monitor vital signs and assist with control of

Inflammation of the mucous • bleeding. �

Provides tissues and an emesis basin to allow the
membrane of 1 or more patient to expectorate any excess blood.
sinuses eview ways to prevent epistaxis: avoiding
May accompany or follow forceful nose blowing, straining, high altitudes.
rhinitis Adequate humidification to prevent drying of the
Caused by Diplococcus, Strep, nasal passages.
H. Influenzae Instruct the patient how to apply direct pressure
MANIFESTATIONS to the nose in the case of a recurrent nosebleed.
- Nasal swelling - Congestion If recurrent bleeding cannot be stopped, the ',
- Purulent nasal discharge - Headache patient is instructed to seek additional medical ',,""
4
' . -
-
-
Fever
Facial pain
Fatigue
-
-
-
Cough
Ear pain
Anosmia
attention.

NASAL POLYPS
benign, grape like clusters of

• MANAGEMENT mucous membrane & loose

connective tissue
Most often seen in patients with
allergic rhinitis
r Antibiotics - Forms gradually from recurrent
swelling of the nasal mucosa
eg.:amoxicillin(Amoxil), Complication: airway obstruction
sulfamethoxazole (Bactrim, Septra),
azithromycin (Zithromax),
clarithromycin (Biaxin), ciprofloxacin
(Cipro) MANIFESTATIONS
I'decongestants Nose feeling blocked
Anosmia
Runny nose
antihistamines Headache or pain

r antral irrigation: Caldwell-Luc Rhinoscopy shows a grayish

grape-like mass in the nasal MANAGEMENT
Cortisone therapy
cavity
procedure - permanent CT scan of the sinuses will - Polypectomy
show opaque (cloudy) spots
opening for drainage where the polyps are
NOTE: Nasal polyps may rec'·

Disorders of the Throat

NURSING CARE
1. methods to promote drainage:
d inhaling steam <
TONSILITIS
increase fluid intake Inflammation & infection of
d applying local heat the tonsils
2. stress the importance of following the recommended
d/t Strep, Staph, H.
antibiotic regimen
3. discourage swimming and diving while patient has URTI lnfluenzae
4. avoid people who has URTI Prone to Rheumatic fever
5. maintain strict hand-washing habits

EPISTAXIS
- Nose bleeding difficulty swallowing MANAGEMENT
ear pain Antibiotic therapy, warm
Causes: fever, chills saline gargles, analgesics-
trauma, HPN, blood dyscrasias, headache antipyretics
tumor, inflammatory reactions, sore throat Apply ice collar to severe
otic barotrauma, nasal sprays, tenderness of the jaw and sore throat
vigorous nose blowing and nose MANAGEMENT throat Oral care
picking Apply direct pressure
redness and swelling of the Soft/liquid diet, hydration
(Kiesselbach's area)
Types: Cautery
tonsils and surrounding Discourage spicy/sweet
a. Anterior - easier to treat Nasal packing tissues with patches upon foods
b. Posterior - more severe Cottonball with epinephrine inspection Bed rest with increase OFI '
bleeding voice changes, loss of voice Tonsillectomy
d
LARYNGITIS
. «
Inflammation of the
-.J
,,.,i..,.�
mucous membrane of
the larynx

=le!
caused by viruses,
exposure to irritating

ti1
inhalants, pollutants,
chemical agents,
alcohol, smoke, VO<>!mds
overuse of voice

MANIFESTATIONS
l
acute hoarseness
dry cough
Dysphagia MANAGEMENT
aphonia (voice loss)
fever voice rest
steam inhalation

c=, Hydration
Lozenges

:8
+
« antibiotics e, u
4