Ch. 26. URT Disorders

Upper Respiratory Tract Disorders
Dr. Mohammad Alhawajreh

 Intended Learning Outcomes
 PH.I.1: Relate anatomy and physiology of the rhinitis, sinusitis,
pharyngitis, laryngitis, Tonsillitis, adenoiditis, peritonsillar abscess
disorders, epistaxis, and laryngeal cancer to commonly occurring
disorders and risk factors for these disorders.
 PH.I.1: Describe the pathophysiology of these disorders, relating their
manifestations to the pathophysiologic process.
 H.P.M.1: Compare and contrast of these disorders according to cause,
incidence, and clinical manifestations
 H.P.M.1: Describe the diagnostic findings of these disorders.
 S.E.E.2/PH.I.1/PH.I.2:Discuss nursing implications for medications and
other interdisciplinary care measures to treat these disorders.
 Intended Learning Outcomes
 S.E.E.2/Describe surgical procedures used to treat these disorders,
and their implications for patient care and recovery.
 S.E.E.2/P.S.I.1: Identify health-promotion activities related to reducing
the incidence of these disorders, describing the appropriate
population and setting for implementing identified measures.
 PH.I.1: Describe the nursing management of patients with these
disorders
 PH.I.1: Use the nursing process as a framework for the care of the
patient with these disorders.
 S.E.E.2/PH.I.1: Explain essential components of discharge
planning/teaching for the patient diagnosed with these disorders
Nursing Care of Patients with Upper
Airway Disorders
• Upper airway disorders may be minor, treated outside
health care setting
– Or may be acute, severe or life threatening
• Require good assessment skills, understanding of variety
of disorders that affect upper airway, impact those
disorders may have on patient.
• Seldom require hospitalization.
• Nurses working in community settings or long-term care
facilities may encounter patients who have these
infections. Thus, it is important for the nurse to recognize
the signs and symptoms and to provide appropriate care
• Patient teaching is important aspect of care
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Specific Disorders
• Allergic and nonallergic rhinitis.

• Sinusitis: acute, chronic
• Pharyngitis: acute, chronic
• Tonsillitis, adenoiditis
• Peritonisillar abscess
• Laryngitis

Specific Disorders
• Allergic Rhinitis: inflammation of mucous lining the

nose. Examples: such as hay fever (It often occurs with
other conditions, such as allergic conjunctivitis, sinusitis,
and asthma).
• When untreated, many complications may result, such as
allergic asthma, chronic nasal obstruction, chronic otitis
media with hearing loss, anosmia (absence of the sense
of smell.)
• Each year, attacks begin and end at about the same
time.

Pathophysiology
• ingestion or inhalation of an antigen

• Reaction of the nasal mucosa, edema formation,
leukocyte (eosinophil infiltration).
• Histamine production , as the major mediator of allergic
reaction , vasodilatation to increase capillary
permeability.

Clinical manifestations:
• nasal congestion; clear, watery nasal discharge;

intermittent sneezing; and nasal itching. Itching of the
throat and soft palate, Drainage of nasal mucus into the
pharynx initiates multiple attempts to clear the throat
and results in a dry cough or hoarseness. Headache, pain
over the paranasal sinuses, and epistaxis.
• Allergic rhinitis may affect quality of life by also

producing fatigue, loss of sleep, and poor concentration.

Assessments and diagnostic findings
• Physical examination, and diagnostic test results.

• nasal smears, peripheral blood counts
• Medical management
• AVOIDANCE THERAPY:
- remove the allergens that act as precipitating factors.
- Simple measures and environmental controls are often
effective in decreasing symptoms. Examples include use
of air conditioners, air cleaners, humidifiers and
dehumidifiers, and smoke-free environments.

Assessment and management con,d
• Pharmacological therapy
- Antihistamines: Blocking the action of histamine such as
oral antihistamines.
• Adrenergic Agents. Adrenergic agents, vasoconstrictors of
mucosal vessels nasal drops and spray as decongestants.

Non-allergic rhinitis
• Causes: Nonallergic rhinitis may be caused by a variety

of factors, including environmental factors such as
changes in temperature or humidity, odors, or foods;
infection; age; systemic disease; drugs (cocaine) or
prescribed medications; or the presence of a foreign
body.
• Drug-induced rhinitis is associated with use of
antihypertensive agents and oral contraceptives and
chronic use of nasal decongestants.

Clinical manifestations
• Rhinorrhea (excessive nasal drainage, runny nose), nasal

congestion, nasal discharge (purulent with bacterial
rhinitis), nasal itchiness, and sneezing.
• Headache may occur, particularly if sinusitis is also
present.
• Medical management: depends on the cause, which may
be identified in the history and physical examination. The
examiner asks the patient about recent symptoms as well
as possible exposure to allergens in the home,
environment, or workplace. If symptoms suggest a
bacterial infection, an antimicrobial agent will be used.

Medical management
• Antihistamines are administered for sneezing, itching,

and rhinorrhea. Oral decongestant agents are used for
nasal obstruction. In addition, intranasal corticosteroids
may be used for severe congestion, and ophthalmic
agents are used to relieve irritation, itching, and redness
of the eyes.

Teaching patients
• The nurse instructs the patient with allergic rhinitis to

avoid or reduce exposure to allergens and irritants, such
as dusts, molds, animals, fumes, odors, powders, sprays,
and tobacco smoke.
• The patient is instructed about the importance of
controlling the environment at home and work. Saline
nasal or aerosol sprays may be helpful in soothing
mucous membranes, softening crusted secretions, and
removing irritants.

VIRAL RHINITIS (COMMON COLD)
• often is used when referring to an upper respiratory tract

infection that is self-limited and caused by a virus (viral
rhinitis).
• Different viruses known to produce the signs and
symptoms of the viral rhinitis such as rhinovirus,
parainfluenza virus or coronavirus.
• Clinical manifestations: Nasal congestion, fever, chills,
rhinorrhea, sneezing, sore throat, and general malaise.

Medical management
• There is no specific treatment for the common cold or

influenza.
• Management consists of symptomatic therapy. Some
measures include providing adequate fluid intake,
encouraging rest, preventing chilling, increasing intake of
vitamin C, and using expectorants as needed. Warm salt-
water gargles soothe the sore throat and nonsteroidal
anti-inflammatory agents (NSAIDs) such as aspirin or
ibuprofen relieve the aches, pains, and fever in adults.
Antihistamines are used to relieve sneezing, rhinorrhea,
and nasal congestion. Topical (nasal) decongestant
agents may be used.

Nursing management
• Nursing management: patient’s education

• It is important to teach the patient how to break the
chain of infection. Hand washing remains the most
effective measure.
• To prevent transmission of organisms. The nurse teaches
methods to treat symptoms of the common cold and
preventive measures.

Sinusitis
• The sinuses, mucus-lined cavities filled with air that drain

normally into the nose.
• Sinusitis as a secondary infection: if their drainage is
obstructed by a deviated septum, nasal polyps or
tumours.
• Causes: Some individuals are more prone to sinusitis
because of their occupations. For example, continuous
exposure to environmental hazards such as paint,
sawdust, and chemicals may result in chronic
inflammation of the nasal passages.

Pathophysiology
• May develops as a result of an upper respiratory infection

such as an unresolved viral or bacterial infection, or an
exacerbation of allergic rhinitis.
• Nasal congestion, caused by inflammation, edema, and
transudation of fluid, leads to obstruction of the sinus
cavities.
• Dental infections also have been associated with acute
sinusitis [dental abcses or Sinus perforations during tooth
extraction] .

• facial pain or pressure over the affected sinus area, nasal

obstruction, fatigue, purulent nasal discharge, fever,
headache, ear pain[ sinus affect the pressure in the ear] ,
cough, a decreased sense of smell.
• Assessment and Diagnostic Findings:
• A careful history and physical examination are
performed. The head and neck, particularly the nose,
ears, teeth, sinuses, pharynx, and chest, are examined.
There may be tenderness to palpation over the infected
sinus area.

Assessment and Diagnostic Findings
cont.
• The sinuses are percussed using the index finger, tapping

lightly to determine if the patient experiences pain.
• Sinus x-rays may be performed to detect sinus opacity
[Dullness] .
• Computed tomography scanning (Ct-scan) of the sinuses
is the most effective diagnostic tool. It is also used to
rule out other local or systemic disorders, such as tumor,
fistula, and allergy.

Medical management
• The goals of treatment of acute sinusitis are to treat the

infection, shrink the nasal mucosa, and relieve pain.
• careful consideration is given to the potential pathogen
before antimicrobial agents are prescribed.
• First-line antibiotics include amoxicillin, erythromycin.
Second-line antibiotics include cephalosporins such as
cefuroxime axetil (Ceftin) Augmentin, Zithromax. .
• if left untreated, may lead to severe and occasionally life-
threatening complications such as meningitis, brain
abscess, ischemic infarction, and osteomyelitis.

Chronic sinusitis
• Chronic sinusitis is an inflammation of the sinuses that

persists for more than 3 weeks in an adult and 2 weeks
in a child.
• Pathophysiology
• A narrowing or obstruction in the ostia of the frontal,
maxillary, and anterior ethmoid sinuses usually causes
chronic sinusitis, preventing adequate drainage to the
nasal passages (osteomeatal complex).
• Blockage that persists for greater than 3 weeks in an
adult may occur because of infection, allergy, or
structural abnormalities.

sinusitis

Pathophysiology
• This results in heavy secretions, an ideal medium for

infection.
• Immunocompromised patients, however, are at increased
risk for developing fungal sinusitis. Aspergillus fumigatus
[typically found in soil, species to cause disease in
individuals with an immunodeficiency ] is the most
common organism associated with fungal sinusitis.
• Clinical manifestations: impaired mucociliary clearance
and ventilation, cough (because the thick discharge
constantly drips backward into the nasopharynx. Chronic
hoarseness, chronic headaches, facial pain, a decrease in
smell and taste and a fullness in the ears.

• history and diagnostic assessment, including a computed

tomography scan of the sinuses or magnetic resonance
imaging (if fungal sinusitis is suspected), are performed
to rule out other local or systemic disorders, such as
tumor, fistula, and allergy.
• Nasal endoscopy may be indicated to rule out underlying
diseases such as tumors .
• Complications: uncommon, include severe orbital
cellulitis, thrombosis, meningitis, encephalitis, and
ischemic infarction.

Orbital cellulitis

Medical management
• Antimicrobial agents : Augmentin, Clarithromycin

(Biaxin), third-generation cephalosporins such as Ceftin,
The course of treatment may be 3 to 4 weeks.
Decongestant agents, antihistamines, saline sprays.
• Surgical management: When standard medical therapy
fails, surgery, usually endoscopic, may be indicated to
correct structural deformities that obstruct the ostia of
the sinus.
• Excising and cauterizing nasal polyps, correcting a
deviated septum, incising and draining the sinuses,
removing tumors

Nursing management
• The nurse teaches the patient how to promote sinus

drainage by increasing the environmental humidity
(steam bath, hot shower, and facial sauna), increasing
fluid intake, and applying local heat (hot wet packs).
• The nurse also instructs the patient about the
importance of following the medication regimen.
Instructions on the early signs of a sinus infection are
provided and preventive measures are reviewed.

ACUTE PHARYNGITIS
• Acute pharyngitis is an inflammation or infection in the

throat, usually causing symptoms of a sore throat.
• Pathophpysiology: viral infection or bacterial infection [A
beta-hemolytic streptococcus, the most common
bacterial organism, causes acute pharyngitis, the
condition is known as strep throat]. The body responds
by activating an inflammatory 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
exudates may be present in the tonsillar pillars.
• A beta-hemolytic streptococci is a more severe illness.

Strep throat

Complications
• include sinusitis, otitis media, peritonsillar abscess,

• In rare cases the infection may lead to bacteremia,
pneumonia, meningitis, rheumatic fever [rheumatic heart
disease (RHD)] , or nephritis.
• Clinical manifestations: The signs and symptoms of acute

pharyngitis include a fiery-red pharyngeal membrane and
tonsils, lymphoid follicles that are swollen and flecked
with white-purple exudate, and enlarged and tender
cervical lymph nodes and no cough. Fever, malaise, and
sore throat also may be present.

• Rapid screening tests for streptococcal antigens , throat

cultures are used to determine the causative organism,
• Nasal swabs and blood cultures may also be necessary
to identify the organism.
• Pharmacological therapy: If a bacterial cause is
suggested or demonstrated, penicillin is usually the
treatment of choice. For patients who are allergic to
penicillin or have organisms that are resistant to
erythromycin, cephalosporins (clarithromycin and
azithromycin) may be used. Antibiotics are administered
for at least 10 days to eradicate the infection from the
oropharynx.

Pharmacologic therapy con,d
• Analgesic medications, as prescribed. For example,

aspirin or acetaminophen[NSAIDs] (Tylenol) can be taken
at 3- to 6-hour intervals.
• Codeine [Opiates] , hydrocodone bitartrate (Hycodan)

[used in severe pain] , may be required to control the
persistent and painful cough that often accompanies
acute Pharyngitis.

Nursing management:
• NUTRITIONAL THERAPY
• A liquid or soft diet is provided during the acute stage of
the disease, depending on the patient’s appetite and the
degree of discomfort that occurs with swallowing.
Occasionally, the throat is so sore that liquids cannot be
taken in adequate amounts by mouth. In severe
situations, fluids are administered intravenously.
• Otherwise, the patient is encouraged to drink as much
fluid as possible (at least 2 to 3 L per day).

Nursing management cont.
• The nurse instructs the patient to stay in bed during the

febrile stage of illness and to rest frequently. Used
tissues should be disposed of properly to prevent the
spread of infection.
• It is important to examine the skin once or twice daily
possible rash, because acute pharyngitis may precede
some other communicable diseases (ie, rubella).
• Warm saline gargles or irrigations are used depending
on the severity of the lesion and the degree of pain
• Irrigating the throat properly is an effective means of
reducing spasm in the pharyngeal muscles and relieving
soreness of the throat.

Rubella or German measless

Nursing management cont’d
• Mouth care, A full course of antibiotic therapy.

• The nurse instructs the patient and family about the
importance of taking the full course of therapy and,
• informs them about the symptoms to watch for that may
indicate complications.

Chronic pharyngitis
• Chronic pharyngitis is a persistent inflammation of the
pharynx. It is common in adults who work or live in dusty
surroundings, use their voice to excess, suffer from
chronic cough, and habitually use alcohol and tobacco.
• Three types of chronic pharyngitis: • Hypertrophic:
characterized by general thickening and congestion of the
pharyngeal mucous membrane
• • Atrophic: probably a late stage of the first type (the
membrane is thin, whitish, glistening [shine], and at
times wrinkled).
• • Chronic granular characterized by numerous swollen
lymph follicles on the pharyngeal wall.

Clinical Manifestations
• Patients with chronic pharyngitis complain of a constant

sense of irritation or fullness in the throat, mucus that
collects in the throat and can be expelled by coughing,
and difficulty swallowing.
• Medical management: relieving symptoms, avoiding
exposure to irritants, and correcting any upper
respiratory, pulmonary, or cardiac condition that might
be responsible for a chronic cough.
• Nasal congestion may be relieved by short-term use of
nasal sprays or medications containing ephedrine
sulfate[relaxation of smooth muscle] .
• If there is a history of allergy, one of the antihistamine
antiinflammatory and analgesic properties.
TEACHING PATIENTS SELF-CARE
• To prevent the infection from spreading, the nurse

instructs the patient to avoid contact with others until the
fever subsides.
• Alcohol, tobacco, second-hand smoke, and exposure to
cold are avoided, as are environmental or occupational
pollutants if possible.
• The patient may minimize exposure to pollutants by
wearing a disposable facemask. The nurse encourages
the patient to drink plenty of fluids. Gargling with warm
saline solutions may relieve throat discomfort. Lozenges
will keep the throat moistened.

TONSILLITIS AND ADENOIDITIS
• The tonsils are composed of lymphatic tissue and are situated
on each side of the oropharynx.
• They frequently serve as the site of acute infection
(tonsillitis).
• Chronic tonsillitis is less common and may be mistaken for
other disorders such as allergy, asthma, and sinusitis.
• The adenoids or pharyngeal tonsils consist of lymphatic tissue
near the center of the posterior wall of the nasopharynx.
• Infection of the adenoids [a mass of lymphatic
tissue] situated posterior to the nasal cavity frequently
accompanies acute tonsillitis.Group A beta-streptococcus is
the most ommon organism associated with tonsillitis and
adenoiditis.
Clinical Manifestations
• Sore throat, fever, snoring [obstructive sleep apnoea],

and difficulty swallowing. Enlarged adenoids may cause
mouth breathing, earache, draining ears, frequent
headache colds [common cold], bronchitis, foul-smelling
breath, voice impairment, and noisy respiration.
• Infection can extend to the middle ears by way of the
auditory tubes and may result in acute otitis media,
which can lead to spontaneous rupture of the eardrums
and further extension of the infection into the mastoid
cells, causing acute mastoiditis. The infection also may
reside in the middle ear as a chronic, may cause
permanent deafness.

Mastoiditis

• Tonsillar site is cultured to determine the presence of

bacterial infection.
• in hearing loss the patient should be given a
comprehensive audiometric examination.
• Medical management: Tonsillectomy for recurrent
tonsillitis when medical treatment is unsuccessful and
there is severe hypertrophy, asymmetry, or peritonsillar
abscess that occludes the pharynx, making swallowing
difficult and endangering the airway (particularly during
sleep).
• Enlargement of tonsils is normal in children and decreaes
by age.

A peritonsillar abscess
• A peritonsillar abscess is a collection of purulent exudates

between the tonsillar capsule and the surrounding
tissues, including the soft palate.
• Clinical Manifestations: a raspy voice, odynophagia (a
severe sensation of burning, squeezing pain while
swallowing), dysphagia, earache, marked swelling of the
soft palate.
• Assessment and Diagnostic Findings: Aspiration of
purulent material (pus) by needle aspiration is required
to make the appropriate diagnosis. Culture for aspirated
materials.

A peritonsillar abscess

Medical management
• Antibiotics (usually penicillin) are extremely effective in

controlling the infection in peritonsillar abscess. If
antibiotics are prescribed early in the course of the
disease, the abscess may resolve without needing to be
incised.
• The abscess may also be incised and drained. These
procedures are performed best with the patient in the
sitting position to make it easier to expectorate the pus
and blood that accumulate in the pharynx. Most cases
need tonsillectomy.

Nursing management
• Considerable relief may be obtained by the use of topical

anesthetic agents and throat irrigations or the frequent
use of mouthwashes or gargles, using saline or alkaline
solutions at a temperature of 105°F to 110°F (40.6°C to
43.3°C). The nurse instructs the patient to gargle at
intervals of 1 or 2 hours for 24 to 36 hours.
• Liquids that are cool or at room temperature are usually
well tolerated.

Rhinitis and Sinusitis

Pharyngitis

Question
• Tell whether the following statement is true or false:

• Acute pharyngitis of a bacterial nature is most commonly
caused by group A, beta-hemolytic streptococci.

Answer
• True.
• Rationale: Acute pharyngitis of a bacterial nature is most
commonly caused by group A, beta-hemolytic
streptococci.

Potential Complications
• Sepsis
• Meningitis
• Peritonsillar abscess
• Otitis media
• Sinusitis

Laryngitis
• Larynx is a cartilaginous epithelium-lined structure that

connects the pharynx and the trachea it also called voice
organ. The major function of the larynx is vocalization. It
also protects the lower airway from foreign substances
and facilitates coughing.

Laryngitis [Conts]
• 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 an upper
respiratory tract infection.
• The cause of infection is almost always a virus.
• Laryngitis is usually associated with allergic rhinitis or
pharyngitis.
• The onset of infection may be associated with exposure
to sudden temperature changes, dietary deficiencies,
malnutrition, and an immunosuppressed state. Laryngitis
is common in the winter and is easily transmitted.

• hoarseness or aphonia
• severe cough
• Medical management : resting the voice, avoiding
smoking, resting, and inhaling cool steam or an aerosol.
• If laryngitis due to 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.

Medical management
• For chronic laryngitis, the treatment includes:

• resting the voice, eliminating any primary respiratory
tract infection, eliminating smoking, and avoiding
second-hand smoke [70 toxic materials].
• Topical corticosteroids, such as beclomethasone
dipropionate (Vanceril) inhalation, may also be used.

WHY CATCHING VIRUSES IN WINTER
• -We spend more time indoors in the winter, meaning that we’re in
closer contact with other people who may be carrying germs.
• Misting up the windows with their coughs and sneezes-
• POPULAR: idea concerned our physiology: the cold weather wears
down your body’s defenses against infection. In the short days of
winter, without much sunlight, we may run low on Vitamin D, which
helps power the body’s immune system, making us more vulnerable
to infection.
• What’s more, when we breath in cold air, the blood vessels in our
nose may constrict to stop us losing heat. This may prevent white
blood cells (the warriors that fight germs) from reaching our mucus
membranes and killing any viruses that we inhale, allowing them to
slip past our defenses unnoticed. (It could be for this reason that we
tend to catch a cold if we go outside with wet hair.)

Nursing Process: Care of Patients with
Upper Respiratory Infections -
Assessment
• Health history
• Signs and symptoms: headache, cough, hoarseness,
fever, stuffiness, generalized discomfort and fatigue
• Allergies
• Inspection of nose, neck, throat
– Include palpation of lymph nodes

Question
• What should the nurse palpate when assessing for an

upper respiratory tract infection?
A.Neck lymph nodes
B.Nasal mucosa
C.Tracheal mucosa
D.All of the above

Answer
• A. Neck lymph nodes

• Rationale: The nurse should palpate the neck lymph
nodes along with the trachea and the frontal and
maxillary sinuses when assessing for an upper
respiratory tract infection. The nurse should inspect the
nasal and tracheal mucosa when assessing for an upper
respiratory tract infection.

Upper Respiratory Infections - Diagnosis
• Ineffective airway clearance

• Acute pain
• Impaired verbal communication
• Deficient fluid volume
• Deficit of knowledge related to prevention, treatment,
surgical procedure, postoperative care

Upper Respiratory Infections - Planning
• Maintenance of patent airway

• Relief of pain
• Maintenance of effective communication
• Normal hydration
• Knowledge to how to prevent upper airway infections
• Absence of complications

Interventions
• Interventions to maintain patent airway

• Promote comfort
– Analgesics
– Gargles for sore throat
– Use of hot packs for sinus congestion[relieve any
pressure you might be feeling in your sinuses] or ice
collar to reduce swelling, bleeding post tonsillectomy
and adenoidectomy.
– http://www.wikihow.com/Get-Rid-of-Sinus-
Congestion [ How to get rid of sinus congestion]
Interventions (cont’d)
• Rest
• Refrain from speaking, use alternative communication
• Encourage liquids; 2 to 3 L a day, appropriate foods
• [This will thin out your mucus and can help prevent
sinuses blockages, and thereby ease pressure]

Patient Education
• Prevention of upper airway infections

• Emphasize frequent hand washing
• When to contact health care provider
• Need to complete antibiotic treatment regimen
• Annual influenza vaccine for those at risk

Epistaxis
• Epistaxis: hemorrhage from the nose due to rupture

of tiny, distended vessels in the mucous membrane of
any area of the nose
• Sites of bleeding
– Most common: anterior septum
• Can be serious problem resulting in significant blood loss.

Causes of epistaxis
• Different causes include: trauma, infection, inhalation of

illicit drugs[narcotics], cardiovascular diseases, blood
dyscrasias, nasal tumors, low humidity, a foreign body in
the nose, and a deviated nasal septum.
• DX: nasal speculum or headlight may be used to
determine the site of bleeding in the nasal cavity
• Management: Initial treatment may include applying
direct pressure.
• pinch the soft outer portion of the nose against the
midline septum for 5 or 10 minutes continuously. While
you do this, breathe through the mouth].

Medical management cont’d
• The patient sits upright with the head tilted forward to

prevent swallowing and aspiration of blood.
• In anterior nosebleeds, the area may be treated with a
silver nitrate applicator or electrocautery.
• Topical vasoconstrictors, such as adrenaline cocaine
(0.5%), and phenylephrine may be prescribed.
• If bleeding is occurring from the posterior regions,
cotton pledgets soaked in a vasoconstricting solution may
be inserted into the nose to reduce the blood flow and
improve the examiner’s view of the bleeding site.

Medical management cont’d
• Suction may be used to remove excess blood and clots

from the field of inspection.
• When the origin of the bleeding cannot be identified, the
nose may be packed with gauze saturated with
petrolatum jelly or antibiotic ointment; a topical
anesthetic spray and decongestant agent may be used
prior to inserting the gauze packing, or a balloon-inflated
catheter may be used .The packing may remain in place
for 48 hours or up to 5 or 6 days if necessary to control
bleeding.

Posterior Packing with 10F foley catheter

Nursing Management
• The nurse monitors the vital signs, control of bleeding,

and provides tissues and an emesis basin to allow the
patient to expectorate any excess blood.
- It is common for patients to be anxious in response to a
nosebleed.
- Blood loss on clothing and handkerchiefs can be
frightening, and the nasal examination and treatment are
uncomfortable.
• Assuring the patient in a calm, efficient manner that
bleeding can be controlled can help reduce anxiety.

Patient’s teaching
• Discharge teaching includes reviewing ways to prevent

epistaxis
- avoiding forceful nose blowing, tension.
- - Adequate humidification may prevent drying of the
nasal passages.
- The nurse instructs the patient how to apply direct
pressure to the nose with the thumb and the index finger
for 15 minutes in the case of a recurrent nosebleed.
- If recurrent bleeding cannot be stopped, the patient is
instructed to seek additional medical attention.

Treatment of Epistaxis
• Topical vasoconstrictors
– Adrenaline
– Cocaine
– Phenylephrine
• Packing of nasal cavity or balloon catheter

Control of Epistaxis

Nursing Care of Patients with Epistaxis
• Assessment of bleeding
• Monitor airway, breathing
• Vital signs
• Reduce anxiety
• Patient teaching
– Avoid nasal trauma, nose picking, nose blowing
– Air humidification
– Pressure on nose to stop bleeding; if bleeding does
not stop in 15 minutes, seek medical attention
Cancer of the Larynx
• Larynx is is a cartilaginous epithelium-lined structure that
connects the pharynx and the trachea it also called voice
organ. The major function of the larynx is vocalization. It
also protects the lower airway from foreign substances and
facilitates coughing.
• Categories
– Supraglottic: false vocal cords above vocal cords
– Glottic: true vocal cords [the opening between the vocal
cords in the larynx]
– Subglottic: below vocal cords
• Epiglottis—a valve flap of cartilage that covers the
opening to the larynx during swallowing
10
10

incidence of laryngeal cancer
• It represents less than 1% of all cancers.

• occurs about four times more frequently in men than in
women, ( most commonly in persons 50 to 70 years of
age.
• The incidence of laryngeal cancer continues to decline,
but the incidence in women versus men continues to
increase.
• Each year in the United States, approximately 9,000 new
cases are discovered, and 3,700 persons with cancer of
the larynx will die (American Cancer Society, 2002).

Causes of laryngeal cancer
• Carcinogens that have been associated with the

development of laryngeal cancer include tobacco and
alcohol.
• Exposure to asbestos, mustard gas, wood dust, cement

dust, tar products, leather, and metals [lead, mercury].

Other causes
• Straining the voice

• Chronic laryngitis
• Nutritional deficiencies (riboflavin)
• History of alcohol abuse
• Familial predisposition
• Age (higher incidence after 60 years of age)
• Gender (more common in men)
• Race (more prevalent in African Americans)
• Weakened immune system

• Hoarseness of more than 2 weeks’ duration is noted early

in the patient with cancer in the glottic area. The voice
may sound harsh.
• Affected voice sounds are not early signs of subglottic or
supraglottic cancer.
• The patient may complain of a cough or sore throat that
does not go away and pain.
• and burning in the throat, especially when consuming hot
liquids or citrus juices. A lump [swelling] may be felt in
the neck.
• Later symptoms include dysphagia, dyspnea (difficulty
breathing), unilateral nasal obstruction.

Medical Diagnosis
• Diagnosis made by history, physical exam, laryngoscopic

exam, biopsy.
• Tumors staged by TMN classification.
• CT, MRI, to assess tumor extent and stage, to determine
reoccurrence.
• Positron emission tomography (PET scan) may also
beused to detect recurrence of a laryngeal tumor after
treatment.
• It also provide information about biologic activity of
malignant cells; help distinguish between benign and
malignant processes and responses to treatment.

Places of Laryngeal cancer
• A malignant growth may occur in three different areas of

the larynx:
• the glottic area (vocal cords), supraglottic area (area
above.
• the glottis or vocal cords, including epiglottis and false
cords),and
• subglottis (area below the glottis or vocal cords to the
cricoid).
• Two thirds of laryngeal cancers are in the glottic area

Medical management
• Treatment of laryngeal cancer depends on the staging of

the tumor, which includes the location, size, and
histology of the tumor and the presence and extent of
cervical lymph node involvement.
• Treatment options include surgery, radiation therapy,and
chemotherapy.
• Small glottic tumors, stage I and II, with no infiltration to
the lymph nodes are associated with a 75% to
95%survival rate.
• Patients with stage III and IV or advanced tumors have
a 50% to 60% survival rate and have a 50% chance of
recurrence.

Types of laryngectomy
• Partial laryngectomy : recommended in the early stages

of cancer, associated with a very high cure rate.
• • Supraglottic laryngectomy: indicated in the
management of early (stage I) supraglottic and stage II
lesions.
• • Hemilaryngectomy: is performed when the tumor
extends beyond the vocal cord, It may be used in stage I
glottic lesions. The airway and swallowing remain intact,
• • Total laryngectomy: is performed in the most advanced
stage IV laryngeal cancer, when the tumor extends
beyond the vocal cords, or for recurrent or persistent
cancer following radiation therapy.

Question
• Tell whether the following statement is true or false:

• An early sign of cancer of the larynx in the glottic are is
enlarged cervical nodes.

Answer
• False.
• Rationale: An early sign of cancer of the larynx in the
glottic are is affected voice sounds, not enlarged cervical
nodes.

Changes in Airflow with Total
Laryngectomy

Nursing Process: Care of a Patient with a
Laryngectomy - Assessment
• Health history
• Assess history of alcohol abuse
• Physical assessment
• Nutritional status
• Assess literacy, hearing, visual ability; may impact
communication
• Assess learning needs
• Assess patient, family coping, support systems

Laryngectomy - Diagnoses
• Deficit knowledge related to surgical procedure,

postoperative course
• Anxiety, depression
• Ineffective airway clearance
• Impaired verbal communication
• Imbalanced nutrition
• Disturbed body image
• Self-care deficit

Potential Collaborative Problems
• Respiratory distress
• Hemorrhage
• Infections
• Wound breakdown
• Aspiration

Laryngectomy - Planning
• Adequate level of knowledge (patient, family)

• Reduction of anxiety
• Maintenance of patent airway
• Effective means of communication
• Attaining optimum hydration, nutrition
• Improved body image, self-esteem
• Self-care management
• Absence of complications

Preoperative Teaching
• Instruction regarding type of procedure, resultant

changes (changes in speech, permanent loss of speech,
changes in airway)
• Include instruction regarding tubes used postoperatively
(drainage tubes, feeding tubes), provide general
preoperative teaching to prevent postoperative
complications

Preoperative Teaching (cont’d)
• Include planning for postoperative communication, long-

term speech rehabilitation
• Utilize collaborative approach
• Include physician, speech therapy, dietary, social work,
clinical nurse specialist, others as required

Anxiety and Depression
• Allow asking of questions, provide information

• Permit verbalization of feelings
• Interventions to reduce anxiety, promote comfort
• Reassuring manner
• Stay with patient during episodes of anxiety
• Relaxation techniques

Maintaining a Patent Airway
• Semi Fowler’s or high Fowler’s position to decrease

edema
• Monitor for signs, symptoms of respiratory distress
• Tracheostomy or laryngectomy tube assessment, care
• Care of stoma
• Suctioning
• Humidification of air
• Patient teaching

Communication
• Plan communication preoperatively

• Immediate postoperative communication
• writing, lip speaking, and communication or word boards
– Magic slate
• Speech rehabilitation, Esophageal Speech [compress
air into the esophagus and expel it, setting off a vibration
of the pharyngeal esophageal segment].
• Tracheoesophageal Puncture : a voice prosthesis[A
speech therapist teaches the patient how to produce
sounds].
TEP Voice Prosthesis

Potential for Aspiration
• Keep HOB elevated during, after tube feedings

• Check gastric residual when administering tube feedings
• When patient begins oral feeding, maintain upright bed
position during, after feedings
• Swallowing maneuvers to prevent aspiration
• Use of thickened liquids

Thank you
Any Questions ?

Ch. 26. URT Disorders

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Ch. 26. URT Disorders

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Upper Respiratory Tract Disorders

Dr. Mohammad Alhawajreh

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Allergic and nonallergic rhinitis.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Allergic Rhinitis: inflammation of mucous lining the

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• ingestion or inhalation of an antigen

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• nasal congestion; clear, watery nasal discharge;

• Allergic rhinitis may affect quality of life by also

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Physical examination, and diagnostic test results.

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Causes: Nonallergic rhinitis may be caused by a variety

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Rhinorrhea (excessive nasal drainage, runny nose), nasal

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Antihistamines are administered for sneezing, itching,

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• The nurse instructs the patient with allergic rhinitis to

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• often is used when referring to an upper respiratory tract

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• There is no specific treatment for the common cold or

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Nursing management: patient’s education

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• The sinuses, mucus-lined cavities filled with air that drain

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• May develops as a result of an upper respiratory infection

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• facial pain or pressure over the affected sinus area, nasal

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• The sinuses are percussed using the index finger, tapping

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• The goals of treatment of acute sinusitis are to treat the

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Chronic sinusitis is an inflammation of the sinuses that

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• This results in heavy secretions, an ideal medium for

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• history and diagnostic assessment, including a computed

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Antimicrobial agents : Augmentin, Clarithromycin

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• The nurse teaches the patient how to promote sinus

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Acute pharyngitis is an inflammation or infection in the

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• include sinusitis, otitis media, peritonsillar abscess,

• Clinical manifestations: The signs and symptoms of acute

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Rapid screening tests for streptococcal antigens , throat

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Analgesic medications, as prescribed. For example,

• Codeine [Opiates] , hydrocodone bitartrate (Hycodan)

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

• The nurse instructs the patient to stay in bed during the