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Eyes, Ears, Nose and Throat for the Advance Practice Nurse
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Slide 1Primary Care: The Art and Science of Advanced Practice
Nursing, 3rd Edition
Copyright © 2011 F.A. Davis Company
Chapter 8
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Common Complaints
Dry eye
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Common Complaints (cont’d)
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Lid Pathology: Blepharitis
Occasionally seen in those with trisomy 21
Tends to affect people with psoriasis, seborrhea, eczema,
allergies, and lice infestations
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Blepharitis (cont’d)
Ulcerative form
Involves the lash follicle and the meibomian glands of the
eyelid
May be pustules at the base of the hair follicles that may crust
and bleed
Lashes become thin and break easily
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Hordeolum
Hordeolum (stye): an acutely presenting, erythematous, tender lump
within the eyelid
External hordeolum: inflammation/infection of the eyelid margin
affecting the hair follicles of the eyelashes
Internal hordeolum: inflammation/infection of the meibomian
glands
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Chalazion
A granulomatous infection of a meibomian gland, presenting in the
form of painless swelling on the eyelid
Initially may be tender and erythematous before evolving into a
nontender lump
Blepharitis is frequently associated with chalazia
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Dry Eye
Sjögren’s syndrome
May reflect a more local infectious process, as in some forms of
conjunctivitis
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Dye Eye (cont’d)
Certain medications: anticholinergic agents, beta-adrenergic
blockers, and antihistamines
Aging, especially women during menopause
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Treatment for Dry Eye
Elimination of offending systemic medications
Use of artificial tear substitutes, lubricants, gels, and
ointments
Possibly eyelid therapy
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Treatment for Dry Eye (cont’d)
Level 2 treatment (if prior level not effective)
Ocular lubricants, nonpreserved artificial tear substitutes, and
anti-inflammatory agents such as topical cyclosporine A, topical
corticosteroids, or topical/systemic omega-3 fatty acids
Cyclosporine ophthalmic emulsion (RESTASIS®) for chronic dry
eye
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Treatment for Dry Eye (cont’d)
Level 3 treatment (when levels 1 and 2 fail)
Autologous serum, special contact lenses, and permanent punctual
occlusion
Level 4
Grafting of mucous membranes
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Red Eye/Conjunctivitis
Conjunctivitis: inflammation of the conjunctiva covering the front
of the eye
Common causes
Sexual transmission and ophthalmia neonatorium
Herpes simplex (HSV) I
Allergy
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Conjunctivitis: Diagnostic Tests
Dilated pupil exam for proptosis, optic nerve dysfunction,
decreased visual acuity, diplopia, or anterior chamber
inflammation
Fluorescein staining to rule out corneal involvement or
keratitis
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Cataracts
Other causes of cataracts: congenital, metabolic, and traumatic
etiologies
Excessive exposure to sunlight (ultraviolet B rays) without
protective lenses over time
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Glaucoma
Glaucoma: progressive damage to the optic nerve, resulting in optic
nerve atrophy and blindness, most typically associated with
elevated intraocular pressure
Open-angle
Angle-closure (closed-angle, or narrow-angle glaucoma)
Primary or secondary (associated with an ocular condition or a
systemic process)
Also a congenital form
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Glaucoma Treatment
Open-angle glaucoma
Laser or surgical treatment if not controlled by medication
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Glaucoma Treatment (cont’d)
Acetazolamide (Diamox)
Laser iridotomy or peripheral iridectomy
Bedrest should be maintained until the attack is broken
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Diabetic Retinopathy
Ophthalmologist must do yearly retinal eye exam on all
diabetics
Three stages
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Diabetic Retinopathy (cont’d)
Microaneurysms, intraretinal hemorrhage, macular edema, and lipid
deposits
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Management of Diabetic Retinopathy
First goal for patients at risk for microvascular complications,
including diabetic retinopathy, is prevention
The only pharmacologic agent found to slow the progression of
diabetic retinopathy is Lisinopril, an angiotensin-converting
enzyme (ACE) inhibitor
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Macular Degeneration
“Dry”: a slow progressive atrophy and degeneration of the
retina
“Wet”: age-related; new blood vessels develop under the retina in
the macula, causing a sudden distortion or loss of central
vision
Refer immediately to an ophthalmologist
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Macular Degeneration (cont’d)
If vision is less than 20/20, do “pinhole” test
Vision that corrects with the pinhole test implies an uncorrected
refractive error
Funduscopic exam is normal in patients with refractive errors
Yellow round spots (drusen): indicative of early macular
degeneration
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Management of
Macular Degeneration
No treatments for the initial stage of early disease
In the intermediate stage of the disease, high-dose antioxidant
vitamins and zinc supplements possibly help
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Tinnitus
Risk factors
Hearing loss, labyrinthitis, Ménière’s disease, otitis media or
externa, otosclerosis, ear-canal blockage (from ear wax or a
foreign body)
History of high or low blood pressure, head trauma, anemia,
hypothyroidism, hyperthyroidism, or allergies
Chronic exposure to noise
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Management of Tinnitus
Learning to cope with tinnitus is necessary
Avoidance of risk factors
Protective earplugs
Tinnitus-masking devices
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Otitis Media (OM)
Otitis media with effusion (OME): transudation of plasma from
middle ear blood vessels, leading to chronic effusion in the
absence of the signs and symptoms of acute infection
Acute otitis media (AOM): suppurative OM or purulent OM
Recurrent OM: the clearance of middle ear effusions between acute
episodes of otic inflammation
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
OM: Subjective Data
Stuffiness, fullness, and a loss of auditory acuity in the affected
ear only
Pain is rare; may describe popping, crackling, or gurgling sounds
when chewing, yawning, or blowing the nose
Rare vertigo
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
AOM Symptoms
Unilateral hearing loss
Possible dizziness (space disorientation), vertigo, tinnitus
(ringing in the ears), vomiting, or nausea
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Chronic OM Symptoms
History of repeated bouts of acute otitis media, followed by a
period of continuous or intermittent otorrhea lasting for more than
three months
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Objective Signs of OM
OME
Mucous membranes of nasal and oral cavities may be injected or
edematous
Eardrum may be dull but usually is not bulging, and eardrum
mobility typically decreases on pneumatic otoscopy
AOM
Tympanic membrane may be amber or yellow-orange, or may be injected
and pinkish gray to fiery red in color
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Chronic OM
Chronic, foul-smelling otorrhea—anaerobic bacterial infection
Chronic, grayish-yellow suppuration—cholesteatoma from the
degenerative products of invasive epithelialization
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Management of OM
Uncomplicated cases of OM: self-limited and require no specific
intervention
May need pain relief
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Management of OME
14- to 28-day course of antibiotic such as amoxicillin/clavulanate
(Augmentin), cefaclor (Ceclor), or trimethoprim-sulfamethoxazole
(Bactrim)
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Nonallergic Rhinitis
Vasomotor
Hormone-related
Atrophic (mostly in geriatric patients)
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Clinical Presentation
of Rhinitis
Viral rhinitis
Allergic rhinitis
Itching in the nasal passages, conjunctivae, and roof of the
mouth
Epiphoria (stringy, watery ocular discharge)
Sneezing, coughing, and a sore or burning throat
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Clinical Presentation
Watery rhinorrhea, nasal congestion, “nasal” speech, and forced
mouth-breathing
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Management of Rhinitis
Rhinorrhea may be treated with oral decongestants
Topical preparations
Dextromethorphan for persistent coughs
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Treatment for Allergic Rhinitis
Oral antihistamines: short-term treatment
Intranasal corticosteroids: long-term management
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Sinusitis
Acute: abrupt onset of infection and post-therapeutic resolution of
symptoms lasting no more than 4 weeks
Subacute: a purulent nasal discharge persists despite therapy,
lasting from 4 to 12 weeks
Chronic: episodes of prolonged inflammation with repeated or
inadequately treated acute infection lasting greater than 12
consecutive weeks
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Subjective Symptoms of Sinusitis
Gradual onset of symptoms
Recurrent or chronic dull, constant pain over the affected
sinuses
Pain increases and becomes characteristically throbbing
Maxillary sinusitis: pain over the cheeks and upper teeth—may
worsen when standing erect
Frontal sinusitis: pain over the eyebrows—may worsen with
recumbency
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Objective Signs of Sinusitis
A red, swollen nasal mucosa
A swollen pale mucosa with watery secretions, points to allergic
sinusitis or rhinitis
Objective
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Objective Signs of Sinusitis (cont’d)
Purulent secretions
Black or necrotic material—mucormycosis-related rhinorrhea in
immunocompromised patients
Ethmoid sinus involvement may result in chemosis (eyelid mucous
membrane edema), proptosis, conjunctival injection, extraocular
muscle palsy, or orbital fixation
Tenderness on palpation over the sinuses
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Management of Sinusitis
Since a vast majority of acute sinusitis cases are caused by
viruses, antibiotics are largely unhelpful
Antimicrobial therapy indicated for acute uncomplicated bacterial
sinusitis
Saline nasal spray
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Other Sinusitis Treatment
Increase fluid intake
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Medications for Sinusitis
Avoid nonprescription medicated nose drops and sprays
Use prescription nasal sprays for no more than 3 to 4 days at a
time
Expectorants such as guaifenesin to liquefy sinus secretions and
facilitate drainage
Anti-inflammatory topical steroids in nasal spray
preparations
Empiric antibiotic therapy for 7 to 10 days
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Temporomandibular Joint Disease (TMD)
A cluster of related disorders in the masticatory system
The most common presenting symptom is pain in the muscles of
mastication, the preauricular area, and/or the temporomandibular
joint
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Subjective Symptoms of TMD
Ear symptoms account for 28 percent of clinical presentations
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Management of TMD
Use a multidisciplinary approach
Goals for management: reduction or elimination of pain and
restoration of acceptable mandibular function
Adjustment in diet consistency, education, and alteration of oral
parafunctional habits
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Primary Care: The Art and Science of Advanced Practice Nursing, 3rd
Edition
Copyright © 2011 F.A. Davis Company
Other Treatment for TMD
Stress relief, pain control methods such as counseling, hypnosis,
biofeedback, and guided imagery
Pharmacotherapy