CARE OF CLIENTS WITH NOSE

AND THROAT DISORDERS

BY:
SOFIA IRENE M. BRIONES, RN, MAN
 ANATOMY OF THE NOSE
 The nose is the organ of smell, with receptors from
cranial nerve I (olfactory) located in the upper areas.
 SEPTUM
 The upper one third of the nose is composed of bone; the
lower two thirds are composed of cartilage, allowing
limited movement.
 The ANTERIOR NARES (nostrils or external openings
into the nasal cavities) are lined with skin and hair.
 The POSTERIOR NARES are openings from the nasal
cavity into the nasopharynx.
 TURBINATES
 CILIA (hair like projections)
 SINUSES
 The PARANASAL SINUSES are air-filled
cavities within the bones that surround the
nasal passages.
 Lined with ciliated membrane, the purposes
of the sinuses are to provide resonance
during the speech and to decrease the
weight of the skull.
 These are located in the frontal, ethmoid,
maxillary and sphenoid bones.
 PHARYNX
 Or THROAT, is a passageway for both
the respiratory and digestive tracts. It
is located behind the oral and nasal
cavities.
3 DIVISIONS OF PHARYNX
1. NASOPHARYNX – located behind the nose, above the
soft palate. It contains the adenoids and the opening of the
Eustachian tube.
 ADENOIDS (pharyngeal tonsils)
 EUSTACHIAN TUBE
2. OROPHARYNX – located behind the mouth, below the
nasopharynx. It extends from the soft palate to the base of
the tongue and is used for breathing and swallowing.
 PALATINE TONSILS
3. LARYNGOPHARYNX – located behind the larynx and
extends from the base of the tongue to the esophagus. At
this point, the passageway divides into the larynx and the
esophagus.
 LARYNX
 Located above the trachea, just below the throat at the base of
the tongue.
 Composed of several cartilages:
 THYROID CARTILAGE is the largest is commonly called the
“Adam’s apple”.
 CRICOID CARTILAGE which contains the vocal cords lies below the
thyroid cartilage. The CRICOTHYROID MEMBRANE is located
below the level of the vocal cords and joins the thyroid and cricoid
cartilage.
 CRICOTHYROIDECTOMY (or cricothyrotomy), an opening is made
between the thyroid and cricoid cartilage, and results in tracheostomy.
 Inside the larynx are two pairs of vocal cords:
 FALSE VOCAL CORDS

 TRUE VOCAL CORDS

 GLOTTIS

 EPIGLOTTIS
ASSESSMENT OF THE NOSE AND SINUSES
PHYSICAL ASSESSMENT
1. Inspect the client’s external nose for deformities or tumors,
and inspect the nostrils for symmetry of size and shape.
2. To observe the interior nose, ask the client to tilt head back for
a penlight examination.
3. Inspect for color, swelling, drainage and bleeding.
4. Check for nasal septum for bleeding, perforation or deviation.
5. Occlude one nares at a time to check whether air moves
through the non-occluded side easily.
6. Palpate the nose and paranasal sinuses to detect tenderness or
swelling.
7. Transillumination (passage of strong light) of the sinuses may
be used to detect sinusitis.
 ASSESSMENT OF THE PHARYNX, TRACHEA
AND LARYNX
1. Assessment of the pharynx begins with inspection of the external structure
of the mouth.
2. To examine the posterior pharynx, use a tongue depressor to press down
one side of the tongue at a time (to avoid stimulating the gag reflex).
3. As the client says “ah”, observe the rise and fall of the soft palate and uvula
and inspect for color and symmetry, evidence of discharge (postnasal
drainage), edema, or ulceration and tonsillar enlargement or inflammation.
4. Inspect the neck for symmetry, alignment, masses, swelling, bruises and the
use of accessory neck muscles in breathing.
5. Palpate lymph nodes for size, shape, mobility, consistency, and tenderness.
 Tender nodes

 Malignant nodes

6. Gently palpate the trachea for position, mobility, tenderness and masses.
7. Many lung disorders cause the trachea to deviate from the astinal mass and
neck tumors push the trachea away from the affected area.
8. The larynx is usually examined by a specialist with a laryngoscope.
 An abnormal voice, especially hoarseness
DISORDERS OF THE NOSE AND PARANASAL SINUSES

EPISTAXIS
 Nosebleed is a common problem

 Nosebleeds may occur as a result of trauma,

hypertension, blood dyscrasia (e.g. leukemia),

inflammation, tumor, decreased humidity, nose
blowing, nose picking, chronic cocaine use, and
procedures such as nasogastric suctioning.
 Men are usually affected more often other than

women. Older adults tend to bleed most often from

the posterior portion of the nose.
 COLLABORATIVE MANAGEMENT

ASSESSMENT
 The client often reports that the bleeding

started after sneezing or blowing the nose.

 Document the amount and color of the blood

and take the vital signs.

 Ask the client about the number, duration and

causes or previous bleeding episodes. Record

this information in the client’s medical record.
 INTERVENTIONS
 Position the client upright and leaning
 Reassure the client and attempt to keep him quiet.
 Apply direct lateral pressure to the nose for 5 minutes, and
apply ice or cool compresses to the nose and face if possible.
 Maintain standard and body substance precautions.
 If nasal packing is necessary, loosely pack both nares with
gauze.
 To prevent re-bleeding from dislodging clots, instruct the client
not to blow the nose for several hours after the bleeding stops.
 Seek medical assistance if these measures are ineffective or if
the bleeding occurs frequently.
 Posterior nasal bleeding is an emergency.
 RHINITIS
 An inflammation of the nasal mucosa, and can be caused by an
infection (viral or bacterial) or contact with allergens.
 ALLERGIC RHINITIS, often called hay fever or allergies.
 CHRONIC RHINITIS occurs either intermittently with a no
seasonal pattern or continuously.Other causes of rhinitis include
a “rebound” nasal congestion from overuse of nose drops or
sprays (rhinitis medicamentosa) and chronic inhalation of
cocaine.
 ACUTE VIRAL RHINITIS (coryza, common cold) is caused by
any one of at least 200 viruses. It spreads from person to
person by droplets from sneezing or coughing. It is most
contagious in the first 2 to 3 days after symptoms appear.
 COLLABORATIVE MANAGEMENT
ASSESSMENT
 In both acute and chronic allergic rhinitis, the

presence of the allergens - a release of natural

chemicals (histamines )from white blood cells in the
nasal mucosa = local blood vessel dilation and capillary
leak = edema and swelling of the nasal mucosa.
 The resulting symptoms include headache, nasal

irritation, sneezing, nasal congestion, rhinorrhea

(watery drainage from the nose) and itchy watery
eyes.
 Viral or bacterial invasion of the nasal passages - sore

dry throat and a low grade fever.

 INTERVENTIONS
 Administration of antihistamines and
decongestants.
 Antipyretics are given if with fever.
Antibiotics are given only bacterial rhinitis.
 Rhinitis caused by overuse of nasal drops or
sprays is treated by discontinuing the
offending drug.
 Steroid nasal sprays are used to decrease the
rebound nasal congestion.
 COMPLEMENTARY AND ALTERNATIVE THERAPY

 Instruct the client about importance of rest (8 to 10

hours a day) and fluid intake of at least 2000 ml/day.
 Humidifying the air helps to relieve congestion.
 Teach the client to reduce the risk of spreading the
cold.
 Instruct the client to avoid close contact with people
who are more susceptible to infection.
 The client with recurrent allergic rhinitis can have
allergy testing to determine the cause.
 Uncomplicated cold subsides within 7 to 10 days.
 SINUSITIS
 An inflammation of the mucous membrane of one or more of the
sinuses.
 Swelling can obstruct the flow of secretions from the sinuses,
which may then become infected. The disorder follows rhinitis.
 In chronic sinusitis, the mucous membrane is permanently
thickened from repeated inflammation.
 The most common organisms causing sinus infection are
Streptococcus pneumoniae, Hemophilus influenzae, Diplococcus
or Bacteroides.
 Sinusitis most often develops in the maxillary and frontal
sinuses. Complications include cellulites, abscess and meningitis.
 Transillumination of the affected sinus is decreased. Other
diagnostic tests for sinusitis include sinus x-rays, endoscopic
examination and computed tomography.
 COLLABORATIVE MANAGEMENT

ASSESSMENT
 Manifestations of sinusitis include nasal

swelling and congestion, headache, facial

pressure, pain, tenderness to touch over
the involved area, low-grade fever,
cough and purulent or bloody nasal
drainage.
 INTERVENTIONS
 Treatment includes the use of broad-spectrum antibiotics
(e.g. amoxicillin), analgesics for pain and fever,
decongestants, steam humidification, hot and wet packs
over the sinus area and nasal irrigations.
 Instruct the client to increase fluid intake to more than
10 glasses of water or juice per day unless other medical
problem requires fluid restriction.
 CALDWELL-LUC PROCEDURE an incision is made under
the upper lip into maxillary sinus. The infected mucosa is
removed.
 ENDOSCOPIC SINUS SURGERY - inspection of the
sinuses through a sinus endoscope with the client under
general anesthesia.
 NASAL POLYPS
 Are benign grapelike clusters of mucous
membrane and connective tissue.
 They often occur bilaterally and are
caused by irritation to the nasal mucosa
or sinuses, allergies or infection. If
polyps become too large, airway
obstruction may result.
 COLLABORATIVE MANAGEMENT

ASSESSMENT
 Manifestations of nasal polyps include

obstructed nasal breathing, a change in

the character of nasal discharge and a
change in speech quality.
 INTERVENTIONS
 Surgery is the treatment of choice for nasal polyps.
 BENIGN NASAL POLYPS are treated with nasally
inhaled steroids and surgical removal (POLYPECTOMY).
 INVERTING PAPILLOMA is a rare, benign lesion that
erodes nasal and facial bones and is often first
diagnosed as a benign polyp.
 JUVENILE ANGIOFIBROMAS are cellularly different
from other polyps. These tumors often occur in
adolescents males and may resolve spontaneously when
adulthood is reached. When the lesions are local, they
can be removed by nasal surgery.
 NASAL FRACTURE
 Nasal fracture often results from
injuries received during falls, sports
activities, motor vehicle accidents or
physical assaults.
 Displacement of either bone or cartilage
can cause airway obstruction or
cosmetic deformity and is a potential
source of infection.
 COLABORATIVE MANAGEMENT

ASSESSMENT
 Document any nasal problem, including

deviation, maligned nasal bridge, and a

change in nasal breathing, crepitus (dry,
crackling sound) on palpation, midface
bruising and pain.
 Blood or clear fluid rarely drains from one

or both nares. The presence of drainage

could indicate a skull fracture.
 INTERVENTIONS
 Simple closed reduction of nasal fracture
within the first 24 hours after injury.
 Treatment focuses on pain relief and local
cold compresses to decrease swelling.
 RHINOPLASTY is a surgical reconstruction of
the nose for cosmetic purposes and to
improve airflow.
 NASOSEPTOPLASTY or submucous resection,
straightens a deviated septum when chronic
symptoms or discomfort occur.
 DISORDERS OF THE THROAT
TONSILLITIS
 An inflammation and infection of the tonsils

and lymphatic tissues located on each sides of

the throat.
 Tonsillitis is a contagious airborne infection.

The infection is usually more severe when it

occurs in adolescents or adults.
 ACUTE TONSILLITIS usually lasts 7 to 10

days and is usually caused by bacteria. The

most common organism is Streptococcus.
 COLLABORATIVE MANAGEMENT
ASSESSMENT
 key features of Acute tonsillitis
 sudden onset of a mild to severe sore throat

 fever

 muscle aches

 chills

 Dysphagia, odynophagia (painful swallowing of food)

 Pain in the ears

 Headache

 Anorexia

 Malaise

 “Hot potato” voice (thickened voice of poor quality)

 Tonsils usually swollen and red with pus

 Tonsils may be covered a white or yellow exudates

 Purulent drainage may be expressed by pressing a tonsil

 Uvula visually edematous or inflamed

 Cervical lymph nodes usually tender and enlarged

 INTERVENTIONS
 Administration of antibiotics for 7 to 10 days (penicillin or
azithromycin).
 Warm saline throat gargles, analgesics, antipyretics and
lozenges with topical anesthetic agents may provide symptom
relief.
 Surgery is performed after the client has recovered from an
acute tonsillitis and no infection is present.
 Surgery may involve complete tonsil removal or a partial tonsil
removal without infection.
 Tonsillectomy and adenoidectomy is performed under general
anesthesia.
 After surgery, assess for airways clearance, provide pain relief
and monitor for excessive bleeding.
 PHARYNGITIS
 Or sore throat is a common
inflammation of the mucous membranes
of the pharynx.
 This condition often occurs with acute
rhinitis and sinusitis.
 COLLABORATIVE MANAGEMENT

ASSESSMENT
 The client with pharyngitis has throat

soreness and dryness, throat pain, pain

on swallowing (odynophagia), difficulty
in swallowing and fever.
 BACTERIAL PHARYNGITIS
VIRAL PHARYNGITIS
 Low-grade fever
 retracted or dull tympanic
membrane
 Scant or no tonsillar exudates
 Slight erythema of pharynx
and tonsils
 possible lymphadenopathy
 No rash
 No cough, rhinitis. mild
hoarseness, headache
 CBC usually normal
 WBC usually lower than
10,000/mm
 negative culture results
 onset is gradual
 High temperature 38.5 to 40
 retracted or dull tympanic membrane
 severe hyperemia of pharyngeal
mucosa, tonsils and uvula
 erythema of tonsils with yellow
exudates
 anterior cervical lymphadenopathy and
tenderness
 possible scariatiniform rash
 possible petechiae on chest or abdomen
or both
 No cough, voice characterized by pain
on voicing and slurred speech,
headache, arthralgia, myalgia
 CBC abnormal
 WBC usually >12,000/mm
 Throat culture results positive for beta-
hemolytic streptococcus
 Abrupt onset
 INTERVENTIONS
 Treatment includes rest, increased fluid intake, humidifying the air,
analgesics for pain, warm saline gargles and throat lozenges containing
mild anesthetics.
 Use of antibiotics. For streptococcal infection, oral penicillin or
cephalosporin is prescribed. If allergic to penicillin, azithromycin or
erythromycin.
 Stress the importance of completing the antibiotic prescription, even
when symptoms improve or subsides.
 Any client whose bacterial pharyngitis does not improve with
antibiotics should consider HIV testing.
 EPIGLOTTITIS complication of pharyngitis in adults, infection of the
epiglottis and supraglottic structures.
 Teach the client how to take her oral temperature accurately every
morning and evening until infection resolves.
 The client is not contagious 24 hours after antibiotic therapy.
 LARYNGITIS
 Inflammation of the mucous membrane lining the
larynx and may or may not include edema of the vocal
cords.
 Common causes include exposure to irritating
inhalants and pollutants (chemical agents, tobacco,
alcohol and smoke), overuse of the voice, inhalation of
volatile gases (eg. glue, paint thinner, butane), or
intubation
 An increasingly common cause of laryngitis is
GASTROESOPHAGEAL REFLUX (gerd)
 COLLABORATIVE MANAGEMENT

ASSESSMENT
 Assess the client for acute hoarseness, dry cough and

difficulty swallowing.
 Complete but temporary voice loss (aphonia) also may

occur.
 A laryngeal mirror is used to examine the larynx

visually and to identify inflammation, polyps, edema or

tumor.
 If suspicious lesions are present an x-ray, computed

tomography or fiberoptic laryngoscopic examination.

 INTERVENTIONS
 Voice rest, steam inhalations, increased fluid intake
and throat lozenges.
 Antibiotic therapy or bronchodilators .
 Inform the client and family about relief measures;
infection prevention; and avoidance of alcohol,
tobacco and pollutants.
 Preventive therapy
 Emphasize activities that place an added strain on the
larynx
 Speech therapy