Family Nurse Practitioner I 471

HEENT

B.    Ear disorders 

1. Otitis media

2. Otitis externa

3. Cerumenosis

4. Cholesteatoma

5. Foreign body

C. Nose/sinus disorders

1. Rhinorrhea

2. Allergic rhinitis

3. Polyps

4. Foreign body

5. Epistaxis

6. Sinusitis

D.    Mouth/throat/neck disorders

1. Dental problems

2. Pharyngitis

3. Epiglottitis

4. Lymphadenitis

5. Mononucleosis

EARS

Screening recommendations

• Not recommended on a routine basis until the age of 65 UNLESS the patient is exposed to excessive noise (occupation)

Screening basics

• May use hand held audioscope
• Keep environment quiet
• 25dB – check at 1000, 2000, and 4000 hertz. No response to one is a fail
• 40dB – check at 1000, 2000, and 4000 hertz. No response to one is a fail
• Whispered voice and finger rub are not recommended by experts

Test Results

• Normal hearing – (0-20dB) whisper
• Mild loss – (20-40 dB) soft voice
• Moderate loss (40-60 dB) normal voice
• Severe loss (60-80 dB) loud voice
• Profound loss (80dB+) shout

Hearing Loss

• Conductive – dysfunction of external or middle ear (impairment of sound vibrations to inner ear) due to:
• Obstruction (cerumen)
• Mass loading (acute otitis media)
• Stiffness (of tympanic membrane)
• Discontinuity (perforation of tympanic membrane)
• Sensory – deterioration of cochlea caused by noise trauma, ototoxicity, and aging (presbycusis)
• Testing for hearing loss
• Weber – tuning fork on forehead
• Conductive – sound is heard in (lateralized to) the impaired ear
• Sensorineural – sound is heard in the good ear
• Rinne – tuning fork on mastoid behind ear, then held out from canal
• Conductive – (BC = AC or BC > AC)
• Sensorineural – (AC > BC)

Tinnitus

• Abnormal head or ear noises
• If persistent, usually there is a sensory hearing loss.
• Intermittent periods of high pitched tinnitus is common among normal hearing adults

Cerumenosis: Excessive secretion of cerumen

· Cerumen disimpaction = removing cerumen from the ear canal

o Indications

§ To visualize TM to facilitate dx/tx of otitis or other ear disease

§ For relief of dizziness, pressure sensation, or tinnitus

§ To enhancing auditory acuity if ear is totally obstructed by cerumen

§ A normal change of aging is decreased activity of the cerumen glands, causing reduced moisture. Dry cerumen is more likely to become impacted

o Contraindications/Precautions

§ If purpose to help visualize the TM for signs of infection, do not irrigate. Instead, attempt to remove the wax plug with a cerumen spoon.

§ Do not irrigate if:

· Suspected TM perforation

· History of recent middle ear surgery

· Tympanostomy tubes in place

· History of multiple previous episodes of OM

§ To avoid accidental TM perforation, gentle pressure and irrigation should be used slowly.

§ Irrigating solution should be warm to prevent caloric stimulation.

§ Irrigating stream should be aimed at the superior wall of the ear canal instead of at the cerumen plug to avoid compaction of the plug against the TM

§ Caution with struggling child: potential for damage to ear canal or TM with otoscope, cerumen spoon or curette

· Use papoose board or immobilization device fashioned from sheets

· Older child may require one person assigned to each limb and a fifth to control the head

o Patient Preparation/Education

§ If possible, use wax softening ear drops for 3-5 days before procedure (Debrox, Cerumenex)

§ Advise patient that he may feel pressure, dizziness, or vertigo during the procedure

§ Patient should alert NP if pain or discomfort occurs

o Procedure

§ Ear syringe or Water Pik on low setting

§ Irrigating solution should be 1:1 mixture of warm water and hydrogen peroxide

§ Basin

§ Protective drapes

o After irrigation

§ Consider having the patient mix 50% rubbing alcohol and 50% white vinegar and apply drops of it once a day after bathing to the ear canal for 2-3 days after the procedure to prevent otitis externa

§ Instruct patient to call or return if following occur: hearing loss, ear pain or fullness, discharge, tinnitus

§ Some people, especially the elderly, may require regular ear hygiene.

· Advise patient to use 2 drops of baby or mineral oil once or twice a week to soften wax so that it expels itself, or to purchase wax softening ear drops and use as directed on package.

§ Remind patient never to put anything in ear canal, especially commercial cotton tip applicators.

Foreign Body

• Most common between 2 and 4 years of age
• Subjective: Child may complain of pain, itching, buzzing (with an insect), a feeling of fullness in the ear, decreased hearing, discharge from the ear
• Objective: Foreign object or insect is visualized on otoscopic exam
• Assessment: Foreign body
• Plan: Extract the foreign object
• Make only one attempt at removal; if unsuccessful, refer
• Do NOT irrigate if foreign body is a vegetable or a wood object, as it may expand and make removal more difficult
• Do NOT irrigate if perforation of the TM is suspected
• If an insect is in the ear, it must be killed by filling the ear canal with mineral oil or alcohol before removal.
• Dislodge ticks by filling the canal with 70% alcohol and then remove
• Method:
• If object does not completely occlude the canal, an ear loop, curette, or forceps can be used.
• If object is soft and unwedged, may irrigate with tepid water and a Water-Pik on low setting.
• May try inserting 18-gauge butterfly catheter tubing (needle cut off) into the canal behind the foreign body, allowing the pulsating water to help dislodge the object
• Best to remove objects using an otoscope with an operating head for visualization.

Otitis Externa (“swimmer’s ear”)

• Refers to a spectrum of conditions, ranging from a minor inflammation to an intensely painful and debilitating disease, which affect both children and adults.
• The inflammation of the epithelium of the external ear canal may extend from the pinna all the way to the TM
• In children, the pain of OE can result in irritability, shortened attention span, as well as disruption of sleep and recreational activities (swimming)
• Adults suffering from the discomfort of OE may experience time lost from work, loss of sleep, and the added financial burden of the cost of medical appointments and prescription meds.
• In its more severe, but rarely occurring form known as malignant or necrotizing otitis externa, this disease can have debilitating and life-threatening consequences.
• Etiology: the pH of the ear canal is normally acidic, which tends to inhibit the growth of microorganisms. Alteration in the pH of the ear canal can occur due to swimming in a pool where the pH is usually alkaline. It is thought that it is this alteration in pH, not the presence of microorganisms in the pool, that is generally responsible for creating a climate conducive to the growth of bacteria or fungi.
• Causative agents
• Bacteria (most common = Pseudomonas aeruginosa; others = proteus mirabilis, Staphyloccus aureus, and Streptococcus pyogenes)
• Fungi (more common in DM, transplant patients, AIDS patients, and those who have been on prolonged courses of antibiotics or steroid drops for bacterial OE)
• Herpetic viral infections
• Dermatoses (seborrheic dermatitis, atopic dermatitis [eczema])
• Chemical irritants (used in hair dyes and sprays)
• Foreign bodies
• Risk Factors
• Chemical irritants
• Anything altering the pH of the ear canal (swimming in pools or bodies of fresh or salt water)
• Impacted cerumen (may create environment more conducive to microbial growth)
• Mechanical irritation (from hearing aids)
• Trauma (cotton tip applicators, bobby pins, matchsticks)
• Foreign bodies (including insects)
• Anatomic factors (narrow ear canals, sharp angles in the curve of the canal, excessive hair)
• Differential Diagnosis
• Seborrheic dermatitis
• Atopic dermatitis
• Osteomyelitis of the temporal bone
• Cholesteatoma
• Mastoiditis
• Suppurative otitis media
• Osteoma (from excessive swimming in cold water)
• Exostoses (from excessive swimming in cold water)
• Neoplasm
• Management
• Depends upon the causative factors
• Pain management (OTC meds, heating pad, may need stronger med)
• Cleansing of debris from external auditory canal
• Gentle irrigation with warmed saline or 2.5% acetic acid solution, or with gentle suctioning
• Suspected bacterial OE can be treated with antimicrobial drops, which include polymyxin B, neomycin, and hydrocortisone combination, ofloxacin, and ciprofloxacin HC otic drops
• An ear wick may be inserted in the auditory canal to ensure that the med is applied to all the affected area
• Severe OE may require hospitalization for systemic antibiotics and appropriate pain management
• Refer to ENT if:
• facial paralysis, erythema, and swelling over the mastoid are present
• granulation tissue is observed in the canal
• unresolved fever and lymphadenopathy following initial tx.
• Recalcitrant OE
• If fungal infection: clean, debride, antifungals agent such as nystatin and clotrimazole topical solution

Otitis Media:

· Definition: an inflammation of the structures within the middle ear

· Serous otitis media: transudation of plasma from middle ear blood vessels leading to chronic effusion

· Acute otitis media ( = suppurative or purulent otitis media): an inflammation secondary to infection, typically of bacterial origin, that may present with or without effusion; Streptococcus pneumoniae and H. flu most common bacterial pathogens found in middle ear fluid

· Subacute otitis media: effusion lasts between 3 weeks and 3 months

· Recurrent otitis media: characterized by the clearance of middle ear effusions between acute episodes of otic inflammation

· Chronic otitis media: occurs when inflammation persists for more than 3 months and is typically related to TM perforation with either intermittent or persistent otic discharge

	Case #1	Case #2
Subjective	· Unilateral hearing loss · Afebrile · Stuffiness/fullness in ear; pain rarely · Recent URI or allergy	· Unilateral hearing loss · Fever · Deep ear pain; otic discharge · Recent URI · Vertigo, tinnitus, nausea, vomiting
Objective	· TM: retracted; may be amber or yellow-orange in color · Bony landmarks prominent; visible air/fluid level behind TM · Nasal/oral mucosa may be injected or edematous	· TM: full/bulging; injected; pink-gray to red discharged with perforation · Bony landmarks and light reflex absent
Assessment	Serous otitis media	Acute otitis media (AOM)
Plan	· Topical decongestants · See patient in 4-6 weeks	· Systemic antibiotics*, analgesics, antipyretics, topical otic analgesics · See patient in 72 hours if symptoms have not resolved; otherwise see patient after pharmacotherapy is complete

Antibiotics:

· Initial treatment of choice: amoxicillin, 250-500 po tid for 10 days

· If symptoms fail to improve within 2 days, or in communities where resistant organisms are prevalent, or for an immunocompromised patient, beta-lactamase-resistant antibiotics, such as trimethoprim-sulfamethoxazole (1 DS tab bid) or amoxicillin plus clavulanic acid (250-500 mg tid) or cefaclor (500 mg tid) X 10 days may be used.

Topical otic analgesics:

· Americaine or Auralgan Otic Solutions, 4-5 drops every 1-2 hours

For inflammation:

· Cortisporin otic suspension, 4 drops qid for 7-10 days

Cholesteatoma

· May result from chronic otitis media and chronic negative ear pressure

· An epithelial pocket or cystlike sac filled with keratin debris forms.

· The cyst, which is filled with a combination of epithelial cells and cholesterol, most commonly enlarges to occlude the middle ear.

· Enzymes formed within the sac cause erosion of adjacent bones, including the ossicles, and destroy them.

NOSE/SINUSES

Rhinorrhea: thin, watery discharge from the nose

Rhinitis: an inflammation of the nasal mucosa that is usually accompanied by edema and a profuse nasal discharge.

Rhinitis (nasal congestion)

	Allergic Rhinitis	Atrophic Rhinitis	Rhinitis medicamentosa	Vasomotor Rhinitis	Viral Rhinitis
Nasal mucosa	Pale, edematous	Crusted with mucous, blood	Dry, rubbery	Red to blue in color	Erythematous
Rhinorrhea	Watery	Thick postnasal drip	Watery	Watery; watery postnasal drip	Watery
Speech	Nasal	Normal	Nasal	Nasal	Nasal
Breathing	Forced mouth	Normal	Forced mouth	Forced mouth	Forced mouth
Other	Edematous nasal turbinates and pharyngeal tonsils; conjunctivitis, pruritis in nasal passages, conjunctiva, and roof of mouth; sneezing coughing; sore throat; usually seasonal paralleling pollen production	Nasal patency, foul odor in nose, epistaxis, impaired olfaction	Increased pulse and BP	Edematous nasal turbinates; rapid onset	Edematous nasal turbinates and pharyngeal tonsils; edematous erythematous laryngopharynx; malaise; headache; occasional fever, sneezing, coughing, sore throat. Symptoms for < 7-14 days; green-yellow purulent discharge with secondary bacterial infection
Treatment	Avoid exposure to allergens; Nonsedating antihistamines; Nasal decongestant sprays no longer than 3-4 days, topical saline spray. May need steroid nasal spray, but may require up to 2 weeks of use prior to relief.	Topical bacitracin ointment intranasally 2-3 X/day until crusting and foul odor gone. Expectorants, saline sprays. Postmenopausal women may be helped by systemic estrogens.	Immediately stop all topical decongestant use; problem resolves in 2-3 weeks. Oral antihistamine-decongestant med, short courses of nasal or systemic steroids (prednisone 40 mg tapered over 8-10 days)	Treat symptoms. Vaporizer, topical saline nasal sprays, Astelin spray (antihistamine), systemic decongestants, May need intranasal steroid med.	Treat symptoms. Acetaminophen for fever and H/A. Decongestants for rhinorrhea. Cough med.

Sinusitis:

· An inflammation of the mucous membranes of one or more of the paranasal sinuses: frontal, sphenoid, anterior ethmoid, and maxillary, with the latter two sinuses most often affected

· Classifications:

· Acute – abrupt onset of infection

· Subacute – purulent nasal discharge persists despite therapy

· Chronic – occurs with episodes of prolonged inflammation

· Chronic sinusitis is classified by the U.S. Public Health Service as the most common chronic disease.

· Signs/symptoms of acute sinusitis

· Gradual onset, recurrent or chronic dull, constant pain over the affected sinuses (because of expanding purulent inflammation)

· Pain increases and becomes characteristically throbbing

· Pain is exacerbated by coughing and sudden head movements

· Frontal sinus pain may worsen with recumbency; maxillary sinus pain may worsen when erect; and ethmoidal sinusitis is associated with retro-orbital pain

· Nasal congestion, mucopurulent rhinorrhea, cough sore throat malaise, and fatigue.

· Acute sinusitis is strongly predicted by maxillary toothache, a poor response to nasal decongestants, and a colored nasal discharged.

· Headache is worse in the morning or when bending forward.

· Physical exam: purulent nasal secretions, total opacification of affected sinuses on transillumination, and highly erythematous nasal mucosa

· With subacute or chronic sinusitis, the patient complains of a persistent cough or coldlike symptoms lasting from several weeks to several months.

· Treatment: Antibiotic and symptomatic therapy is recommended for all forms of sinusitis to prevent disease progression and complications.

· For acute sinusitis treat 10-14 days (up to 21 days)

· For subacute and chronic sinusitis, treat up to 3-4 weeks

· Decongestant sprays or oral forms, topical steroids

Nasal Polyps

· If also has asthma, avoid ASA (triad of problems)

· Nasal steroid sprays

Foreign body in nose

· May note unilateral purulent (at times malodorous) rhinorrhea

· Common offenders include peas, marbles, beads, buttons

· Treatment

· Position head forward to prevent aspiration

· Suction nose, vigorous nose blowing (older), insert 8 Fr foley past object then inflate balloon and remove

· If too deep or failed attempts to remove, refer to ENT

Epistaxis

· = nosebleed; a hemorrhage from the nose

· most common ENT emergency

· 95% caused by rupture of small vessels that overlie anterior nasal septum, usually self-limiting

· 5% originate in posterior cavity and can be life-threatening

· Etiology

· Nasal trauma such as foreign body, forceful blowing, blunt trauma, penetrating trauma (a finger)

· URI

· Irritants (OTC nose sprays, cocaine)

· Mucosal drying in low humidity

· Septal deviation

· Vascular abnormalities

· Children: usually foreign body

· Older adults: usually spontaneous from dry or thinned mucosa

· Ask about use of anticoagulants, aspirin, nasal sprays

· Physical examination

· Include orthostatics and SaO2

· Examine anterior septum with nasal speculum with client sitting upright with head in “sniffing” position, not with neck extension

· Treatment

· If bleeding, try instilling 1 or 2 sprays of phenylephrine (Neo-Synephrine)

· If bleeding continues, topical 4% cocaine or cauterization (silver nitrate) is indicated

· If bleeding persists, nostril must be packed with ½-inch iodoform gauze lubricated with petroleum jelly or bacitracin or with commercial nose packs

· If packing is used, place client on short course of prophylactic antibiotics

· Client Education

· Avoid vigorous exercise and blowing nose for several days

· Avoid hot or spicy food and tobacco (may cause vasodilation)

· Avoid chronic use of nasal sprays; use petroleum jelly or bacitracin for dry mucosa

· F/U

· Anterior packing removed in 2-4 days

· Posterior packing removed in 3-5 days

· If bleeding recurs, perform H & H, repack the nose, and refer to ENT specialist.

MOUTH/THROAT/NECK

Pharyngitis/Tonsillitis

• Definition: Generalized inflammatory processes involving the pharynx (pharyngitis) and pharyngeal tonsils (tonsillitis). May occur independently of one another; often co-occur
• Etiology
• Infectious agents
• Most cases (30-50%) caused by URI viral agents (adenovirus, influenza virus A and B, coxsackievirus, rhinovirus, RSV)
• Other viral agents (Epstein-Barr virus, CMV, HSV)
• Exudative pharyngitis is commonly caused by bacterial agents, most commonly group A Streptococcus pyogenes (about 20% of all cases)
• Noninfectious causes
• Trauma
• Allergies
• Collagen vascular diseases (such as Kawasaki’s syndrome)
• Pemphigus
• Chemical or drug-induced damage (including smoking)
• Dehydration
• Epidemiology
• Viral pharyngitis most often seen in fall and winter months
• Occurs at any age; most frequently in ages 5-10 years

Differential Diagnosis: Pharyngitis

Diagnosis	Throat	Other
Candida	Sore	Dysphagia Thin, white, nonvesicular diffuse or patchy exudative ulcers on mucosa
Herpes simplex	Sore	Dysphagia Vesicular lesion on lips or in pharynx, oral cavity
Mononucleosis	Sore	Gradual onset Low-grade fever Occasional exudates Exanthem Posterior cervical lymphadenopathy Hepatosplenomegaly
Sinusitis	Mild soreness; worse on recumbency	Postnasal drip Fever Headache Painful sinuses Nasal discharge Nasopharyngeal edema
Allergic pharyngitis	Sore	Postnasal drip Sneezing Itchy, watery eyes Seasonal pattern Swollen pharynx with minimal redness
Viral laryngitis	Sore	Cough Rhinorrhea Occasional fever Malaise Headache Edematous, pale, boggy, slightly injected pharynx; no exudates
Streptococcal pharyngitis	Painful soreness	Fever above 101 degrees F Chills Malaise Headache Pain Edematous, erythematosus pharynx Mucosal exudates Enlarged tonsils Anterior cervical adenitis Scarlatiniform rash

Treatment:

• Symptomatic
• For throat pain
• Voice rest
• Humidification (humidifier)
• Saline nasal sprays
• Viscous xylocaine
• Warm salt-water solution gargle (1 tsp. Salt in 8 oz. Water)
• Zinc throat lozenges with vitamin C and Echinacea
• Acetaminophen or ibuprofen (for mild pain)
• For enlarged, tender cervical lymph glands
• Warm, moist compresses qid for 30-60 minutes/time
• For fatigue and malaise
• Limit physical activity until symptoms have subsided
• Bed rest if fever present
• To maintain nutritional intake
• Increase daily fluid intake to 8-12 glasses
• Water or nonacidic juices
• For dysphagia
• Liquid or soft-food diet (milkshakes, soups, high-protein diet drinks)
• For viral infections
• Treat symptomatically
• Amantadine, 100 mg po bid may also be prescribed
• For bacterial or fungal infections
• Appropriate antibiotic or antimycotic therapy
• For suspected streptococcal infections (check Rapid Strep, throat culture)
• Penicillin V potassium (Pen Vee-K) 250 mg tid or qid for 10 days or benzathine penicillin, 1.2 million units IM
• If allergic to PCN, order erythromycin 250 mg po qid for 10 days
• For noninfectious causes
• Minimize contact with the environmental irritant
• Treat symptomatically with a combination of antihistamines and decongests
• Tonsillectomy is recommended if the patient has any of the following: airway obstruction, more than 3 occurrences/year, mild dysphagia, history of rheumatic fever with heart damage; or if the tonsils remain chronically hypertrophied.

Mononucleosis

• See above table for symptoms
• Diagnosis: CBC, throat swab for rapid strep, throat culture, Monospot test, EBV IgM and IgG, Cold agglutinin titer, liver function tests
• Treatment: warm salt water gargles
• Activity: bed rest with gradual return to activity; no social contact until acute phase is over
• No physical activity, especially contact sports if an enlarged spleen is present
• F/U: recheck every 1-2 weeks
• If initial Monospot negative, repeat in 7-10 days
• If splenomegaly present, reevaluate patient prior to release for contact sports

Lymphadenitis

• Swelling/enlargement of lymph nodes
• Attempt to identify primary source of infection
• May be cat scratch fever, malignancy
• Initially treat with antibiotic; recheck in 10-14 days; if persists, consider referral