Disorder of the Throat

• Pharyngitis
• Laryngitis
• Tonsilitis
• Tumor of the larynx
 Pharyngitis
Pharyngitis is an inflammation of the pharynx,
including palate, tonsils, and posterior wall of
the pharynx, most commonly caused by acute
infection, usually transmitted through
respiratory secretions.
Streptococcal pharyngitis (strep throat) and
rhinoviruses (the common cold) are frequent
causes.
Inflammation of the throat is called pharyngitis.
Types:
• Acute
• chronic
 Acute pharyngitis
• Acute pharyngitis is an inflammation or
infection in the throat, usually causing
symptoms of a sore throa.t
 Pathophysiology
• Most cases of acute pharyngitis are caused by viral
infection.
• When group A beta-hemolytic streptococcus, the most
common bacterial organism, causes acute pharyngitis, the
condition is known as strep throat
• The body responds by triggering an in flammatory response
in the pharynx. This results in pain, fever, vasodilation,
edema, and tissue damage, manifested by redness and
swelling in the tonsillar pillars, uvula, and soft palate.
• A creamy exudate may be present in the tonsillar pillars.
• Uncomplicated viral infections usually subside promptly,
within 3 to 10 days after the onset.
 Pathophysiology and Etiology
• Acute bacterial pharyngitis is usually caused
by group A beta-hemolytic streptococci
(streptococcal pharyngitis). Peak age-group for
streptococcal pharyngitis is 5 to 18, but it may
occur in all age-groups.
• Other bacterial causes include Haemophilus
influenzae, Moraxella catarrhalis,
Corynebacterium diphtheriae (diphtheria),
Neisseria gonorrhoeae (gonorrhea), and other
groups of streptococcus.
• Transmission of N. gonorrhoeae is through oral
contact with genital secretions; it is a sexually
transmitted disease.
• Viral pharyngitis is common and causes include
rhinovirus, adenovirus, parainfluenza virus,
coxsackievirus, coronavirus, and others.
• More chronic causes are irritation from postnasal
drip of allergic rhinitis and chronic sinusitis,
chemical irritation, and systemic diseases.
 Clinical Manifestations
• For acute bacterial infections, abrupt onset of
sore throat and fever (usually above 101°F
[38.3° C] in streptococcal pharyngitis).
– Throat pain is aggravated by swallowing.
– Pharynx appears reddened with edema of uvula;
tonsils enlarged and reddened; pharynx and
tonsils may be covered with exudate
• Varying degrees of sore throat, nasal
congestion, fatigue, and fever with other
bacterial and viral causes.
• Swollen, palpable, and tender cervical lymph
nodes in most cases.
 Diagnostics
• Throat culture or rapid streptococcal antigen
detection test to rule out streptococci. Rapid
strep tests provide results within 5 minutes.
• Throat culture on Thayer-Martin medium or
gonococcal antigen detection test to rule out
gonococcal pharyngitis if genital gonococcal
infection or positive sexual contact is suspected.
• Viral testing is not practical, and viral causes are
self-limiting.
 Management
• For streptococcal pharyngitis, penicillin V (Pen-
Vee K) 250 mg qid orally for 10 days or penicillin
G benzathine (Bicillin) in a single intramuscular
dose of 2.4 million units appears to shorten
duration of symptoms and prevents rheumatic
fever.
• Erythromycin for patient who is allergic to
penicillin.
• Other penicillins, macrolides, and cephalosporins
are also used.
 Nursing Interventions and Patient
Education
• Advise patient to have any sore throat with fever
evaluated, especially in the absence of cold
symptoms.
• Encourage compliance with full course of
antibiotic therapy, despite feeling better in
several days, to prevent complications.
• Advise lukewarm saline gargles and use of
antipyretic/analgesics as directed to promote
comfort.
• Encourage bed rest with increased fluid intake
during fever.
 Complications
• Acute rheumatic fever
• Peritonsillar abscess/cellulitis
• Acute glomerulonephritis
• Scarlet fever
• Sinusitis, otitis media, mastoiditis
 Laryngitis
• Laryngitis, an inflammation of the larynx,
often occurs as a result of voice abuse or
exposure to dust, chemicals, smoke, and other
pollutants or as part of a URI.
• It also may be caused by isolated infection
involving only the vocal cords.
• Laryngitis is also associated with
gastroesophageal reflux (referred to as reflux
laryngitis).
 Causes
• Laryngitis is very often caused by the pathogens
that cause the common cold and pharyngitis; the
most common cause is a virus, and laryngitis is
often associated with allergic rhinitis or
pharyngitis. Bacterial invasion may be secondary.
• The onset of infection may be associated with
exposure to sudden temperature changes, dietary
deficiencies, malnutrition, or an
immunosuppressed state.
• Viral laryngitis is common in the winter and is
easily transmitted to others.
 Clinical manifestation
• Signs of acute laryngitis include hoarseness or aphonia
(complete loss of voice) and severe cough.
• Chronic laryngitis is marked by persistent hoarseness.
• Other signs of acute laryngitis include sudden onset
made worse by cold dry wind.
• The throat feels worse in the morning and improves
when the patient is indoors in a warmer climate.
• At times, the patient presents with a dry cough and a
dry, sore throat that worsens in the evening hours.
• If allergies are present, the uvula will be visibly
edematous.
 Management
• Management of acute laryngitis includes resting
the voice, avoiding irritants (including smoking),
resting, and inhaling cool steam or an aerosol.
• If the laryngitis is part of a more extensive
respiratory infection caused by a bacterial
organism or if it is severe, appropriate
antibacterial therapy is instituted.
• The majority of patients recover with
conservative treatment; however, laryngitis tends
to be more severe in elderly patients and may be
complicated by pneumonia
• For chronic laryngitis, the treatment includes
resting the voice, eliminating any primary
respiratory tract infection, eliminating
smoking, and avoiding secondhand smoke.
• Topical corticosteroids, such as
beclomethasone dipropionate (Vanceril), may
be given by inhalation.
• proton pump inhibitors such as omeprazole
given once daily for reflux problem
 Nursing management
• Instructs the patient to rest the voice and to maintain a
well-humidified environment.
• expectorant agents for secretion
• Daily fluid intake of 2 to 3 L to thin secretions.
• Instructs the patient about the importance of taking
prescribed medications, including proton pump
inhibitors, and using continuous positive airway
therapy at bedtime, if prescribed for obstructive sleep
apnea.
• It is important to report continued hoarseness after
voice rest or laryngitis that persists for longer than 5
days because of the possibility of malignancy.
 TONSILLITIS

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• Tonsils are defined as the masses of lymphatic
tissue that are located in the each side of the
oropharynx.
• The tonsils act as a filter to protect the body
from bacterial invasion via the oral cavity and
also to produce white blood cells.
 INTRODUCTION
➢Tonsillitis is the inflammation of the tonsils,
typically of acute onset.

➢It is a type of pharyngitis.

➢This condition is contagious & commonly

caused by viral infection; when caused by
the bacterium Group A beta hemolytic-
streptococcus, it is referred to as strep
throat.
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 • Infection of the adenoids(pharyngeal
tonsils)i.e.adenoiditis frequently
accompanies acute tonsillitis.

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 Causes
• Viral infection
• Adenovirus,rhinovirus,influenza,Epstein-
Barr virus,herpes simplex virus,
cytomegalovirus and even HIV.
• Bacterial infection
• Group A ß-hemolytic streptococcus
(GABHS),Staphylococcus(less common),
Chlamydia pneumoniae,Bordetella pertusis,
Corynebacterium diphtheriae,Neisseria
gonorrhoeae.

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 Pathophysiology
• Under normal circumstances, as viruses and
bacteria enter the body through the nose and
mouth,they are filtered in the tonsils.

• Within the tonsils,WBCs of the immune system

destroy the viruses or bacteria by producing
inflammatory cytokines like phospholipase
A2,which also lead to fever.

• The infection may also be present in the throat &

surrounding areas,causing inflammation of the
pharynx.
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 Clinical features
• Sore throat
• Red,swollen tonsils
• Pain in swallowing
• Fever /chills
• Headache
• Malaise
• White pus filled spots on the tonsils
• Swollen lymphnodes in the neck

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 • Pain in the ears/neck
• Furry tongue
• Difficulty ingesting and swallowing
meal/liquid intake
• Halitosis
• Loss of appetite
• Weight loss
• Mouth breathing/noisy respiration
• Voice changes/impairment
• Abdominal pain
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 Diagnosis
• History is obtained to rule out related or
systemic condition.
• A thorough physical examination.
• Tonsillar site is cultured to determine the
presence of bacterial infection.

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 Treatment
• Treatments to reduce the discomfort from
tonsillitis include:

• Pain & fever reducing medications such as

paracetamol(acetaminophen) and
ibuprofen.

• Warm salt water gargle, lozenges or warm

liquids

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• When tonsillitis is caused by a virus,the length
of illness depends on which virus is inolved.

• Usually, a complete recovery is made within

one week;however,symptoms may last for up
to two weeks.

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 Antibiotics
• If the tonsillitis is caused by group A
streptococcus,then antibiotics are
useful,usually penicillin or amoxicillin.

• In acute setting,cephalosporins,
erythromycin are considered.

• For beta-lactamase producing bacteria;

clindamycin or amoxicillin-clavulanate are
used.

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 Surgery
• Chronic cases may be treated with
tonsillectomy(surgical removal of tonsils).

• Children have had only a modest benefit

from tonsillectomy(most children normally
have large tonsils ,which decrease in size
with age).

• Enlargement of tonsils is rarely an

indication for their removal.
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Tonsillectomy
Tonsillectomy is usually performed for recurrent
tonsillitis when medical treatment is unsuccessful
and there is severe hypertrophy,asymmetry or
peritonsillar abscesss that occludes the pharynx,
making swallowing difficult and endangering the
airway (obstructive sleep apnea), repeated attacks
of purulent otitis media; suspected hearing loss
due to serious otitis media that has occurred in
association with enlarged tonsils and adenoids;
and some other conditions, such as an
exacerbation of asthma or rheumatic fever.

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 Nursing care for tonsillectomy patient
• Continuous nursing observation is required in the immediate
postoperative and recovery period because of the significant risk
of hemorrhage after surgery.
• In the immediate postoperative period, the most comfortable
position is prone with the head turned to the side to allow
drainage from the mouth and pharynx.
• The nurse must not remove the oral airway until the patient’s gag
and swallowing reflexes have returned.
• The nurse applies an ice collar to the neck, and a basin and
tissues are provided for the expectoration of blood and mucus.

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• Bleeding may be bright red if the patient expectorates
blood before swallowing it . Often, however, the
patient swallows the blood, which immediately
becomes brown because of the action of the acidic
gastric juice.

• Hemorrhage is a potential complication after a

tonsillectomy and adenoidectomy.

• If the patient vomits large amounts of dark blood or

bright-red blood at frequent intervals, or if the pulse
rate and temperature rise and the patient is restless,
the nurse notifies the surgeon immediately.

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 • The nurse should have the following items ready for
examination of the surgical site for bleeding: a light, a mirror,
gauze, curved hemostats, and a waste basin.
• Occasionally, suture or ligation of the bleeding vessel is
required.
• In such cases, the patient is taken to the operating room and
given general anesthesia. After ligation, continuous nursing
observation and postoperative care are required, as in the
initial postoperative period.
• If there is no bleeding, water and ice chips may be given to the
patient as soon as desired. The patient is instructed to refrain
from too much talking and coughing because these activities
can produce throat pain.

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 Patient teaching on:
• Tonsillectomy and adenoidectomy usually do not require
hospitalization and are performed as outpatient surgery
with a short length of stay.
• Because the patient will be sent home soon after surgery,
the patient and family must understand the signs and
symptoms of hemorrhage.
• Hemorrhage usually occurs in the first 12 to 24 hours. The
patient is instructed to report frank red bleeding to the
physician.
• Alkaline mouthwashes and warm saline solutions are
useful in coping with the thick mucus and halitosis that
may be present after surgery.

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 • It is important to explain to the patient that a sore throat,
stiff neck, and vomiting may occur in the first 24 hours.
• A liquid or semiliquid diet is given for several days. The
patient should avoid spicy, hot, acidic or rough foods.
• Milk and milk products (ice cream and yogurt) may be
restricted because they may make removal of mucus more
difficult .
• The nurse explains to the patient that halitosis and some
minor ear pain may occur for the first few days.
• The nurse instructs the patient to avoid vigorous tooth
brushing or gargling, since these actions could cause
bleeding.

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 COMPLICATIONS
• Dehydration & kidney failure due to
difficulty swallowing,blocked airways due
to inflammation and pharyngitis due to the
spread of infection.

• An abscess may develop later to the tonsil

during an infection,typically several days
after the onset of tonsillitis,termed as
peritonsillar abscess(or quinsy).

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 • Unusually enlarged adenoids fill the space
behind the posterior nares ,making it
difficult for the air to travel from nose to
the throat & resulting in nasal obstruction.

• Infection can extend to the middle ears by

way of auditory(eustachian )tubes and may
result in acute otitis media leading to
spontaneous rupture of eardrum & further
extension of infection into mastoid cells
causing acute mastoiditis.
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 • The infection may also reside in the middle
ear as a chronic, low-grade ,smoldering
process that eventually may cause
permanent deafness.

• Rarely,the infection may spread beyond the

tonsil result in inflammation & infection of
the internal jugular vein giving rise to
spreading septicaemia infection (Lemierre’s
syndrome).

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• Endotoxins from tonsillitis caused by
Streptococcus pyogenes are associated with
the development of rheumatic fever and
glomerulonephritis.

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 PROGNOSIS
• Following acute tonsillitis,swelling subsides &
the tonsil returns to normal but repeated
infection may lead to chronic inflammation,
fibrosis and permanent enlargement.

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 REFERENCES
• Smeltzer, S. C., Bare, B. G., Hinkle, J. L. &
Cheever, K. H. (2010). Brunner & suddarth’s
textbook of medical-surgical nursing (12th ed).
Lippincott Williams & Wilkins: New Delhi,
India.

• Black, J. M. & Hawks, J. N. (2009). Medical-

surgical nursing (8th ed). Elsalvier India Pvt.
Ltd.: India.

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