Family Nurse Practitioner I 471 HEENT

Family Nurse Practitioner I 471 HEENT B.

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Ear disorders 1. 1. Otitis media 2. 2. Otitis externa 3. 3. Cerumenosis 4. 4. Cholesteatoma 5. 5. Foreign body C. Nose/sinus disorders 1. 1. Rhinorrhea 2. 2. Allergic rhinitis 3. 3. Polyps 4. 4. Foreign body 5. 5. Epistaxis 6. 6. Sinusitis Mouth/throat/neck disorders 1. 1. Dental problems 2. 2. Pharyngitis 3. 3. Epiglottitis 4. 4. Lymphadenitis 5. 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: o Obstruction (cerumen) o Mass loading (acute otitis media) o Stiffness (of tympanic membrane) o Discontinuity (perforation of tympanic membrane)  Sensory – deterioration of cochlea caused by noise trauma, ototoxicity, and aging (presbycusis)  Testing for hearing loss o Weber – tuning fork on forehead  Conductive – sound is heard in (lateralized to) the impaired ear  Sensorineural – sound is heard in the good ear o 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 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 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 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 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 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

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Assessment: Foreign body Plan: Extract the foreign object o Make only one attempt at removal; if unsuccessful, refer o Do NOT irrigate if foreign body is a vegetable or a wood object, as it may expand and make removal more difficult o Do NOT irrigate if perforation of the TM is suspected o If an insect is in the ear, it must be killed by filling the ear canal with mineral oil or alcohol before removal. o Dislodge ticks by filling the canal with 70% alcohol and then remove o 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 o Bacteria (most common = Pseudomonas aeruginosa; others = proteus mirabilis, Staphyloccus aureus, and Streptococcus pyogenes) o 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)

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o Herpetic viral infections o Dermatoses (seborrheic dermatitis, atopic dermatitis [eczema]) o Chemical irritants (used in hair dyes and sprays) o Foreign bodies Risk Factors o Chemical irritants o Anything altering the pH of the ear canal (swimming in pools or bodies of fresh or salt water) o Impacted cerumen (may create environment more conducive to microbial growth) o Mechanical irritation (from hearing aids) o Trauma (cotton tip applicators, bobby pins, matchsticks) o Foreign bodies (including insects) o Anatomic factors (narrow ear canals, sharp angles in the curve of the canal, excessive hair) Differential Diagnosis o Seborrheic dermatitis o Atopic dermatitis o Osteomyelitis of the temporal bone o Cholesteatoma o Mastoiditis o Suppurative otitis media o Osteoma (from excessive swimming in cold water) o Exostoses (from excessive swimming in cold water) o Neoplasm Management o Depends upon the causative factors o Pain management (OTC meds, heating pad, may need stronger med) o Cleansing of debris from external auditory canal  Gentle irrigation with warmed saline or 2.5% acetic acid solution, or with gentle suctioning o 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 o Severe OE may require hospitalization for systemic antibiotics and appropriate pain management o 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

o 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

Subjective

Objective

Assessment Plan

Case #1   Unilateral hearing loss   Afebrile   Stuffiness/fullness in ear; pain rarely   Recent URI or allergy

Case #2   Unilateral hearing loss   Fever   Deep ear pain; otic discharge   Recent URI   Vertigo, tinnitus, nausea, vomiting   TM: retracted; may be amber   TM: full/bulging; or yellow-orange in color injected; pink-gray to red discharged with perforation   Bony landmarks prominent; visible air/fluid level behind TM   Bony landmarks and light reflex absent   Nasal/oral mucosa may be injected or edematous Serous otitis media Acute otitis media (AOM)   Topical decongestants   Systemic antibiotics*, analgesics, antipyretics,   See patient in 4-6 weeks 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-lactamaseresistant 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; greenyellow 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 antihistaminedecongestant 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.

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 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

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 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
Deteksi Gangguan Pendengaran Sejak Bayi Selasa, 1 November, 2005 oleh: Siswono

Deteksi Gangguan Pendengaran Sejak Bayi Gizi.net - Deteksi gangguan pendengaran dan ketulian sebaiknya dilakukan sejak bayi. Deteksi bisa dilakukan orangtua secara sederhana, misalnya dengan memperdengarkan sumber bunyi ke bayi dan mengamati ada atau tidak respons bayi terhadap suara. Hal tersebut diutarakan dr Jenny Bashiruddin SpTHT, Jumat (28/10) di Jakarta. Menurut dia, tidak semua kasus gangguan pendengaran sejak bayi diketahui. Pasalnya, tidak semua orangtua memeriksakan gangguan pendengaran yang dialami bayi. Data dari Pusat Kesehatan Telinga dan Gangguan Komunikasi Departemen THT-FKUI, misalnya, pada tahun 1999-2003 tercatat 2.579 kasus tuli berat pada kedua telinga. Sebagian besar (45,29 persen) ketulian itu diketahui pada saat berusia 1 sampai 3 tahun. Sekitar 24,42 persen diketahui pertama sekali pada usia 5 tahun atau lebih. Hanya 6,13 persen yang terdeteksi sebelum berusia 1 tahun. Dijelaskan, ada dua tipe gangguan pendengaran bayi sejak lahir. Pertama, gangguan pendengaran yang disebabkan kerusakan bagian dalam telinga atau rumah siput (koklea). Kerusakan ini tidak bisa kembali normal sehingga si penderita harus memakai alat bantu dengar sepanjang hidupnya. Kedua, gangguan pendengaran konduksi, yaitu gangguan yang terjadi pada telinga bagian luar dan tengah. Untuk gangguan tipe ini, ujarnya, bisa dilakukan operasi untuk memulihkan pendengaran. Dengan kemajuan teknologi, kata Jenny, saat ini upaya mengatasi gangguan pada koklea dilakukan dengan implan koklea. Metode ini sudah bisa dilakukan di Indonesia, namun hanya di rumah sakit tertentu. Selain itu, biayanya pun mencapai ratusan juta rupiah sehingga tidak semua orang yang mengalami gangguan pendengaran bisa melaksanakan implan koklea. Risiko Tinggi Jenny menjelaskan, ada beberapa indikasi yang perlu diketahui orangtua untuk mendeteksi gangguan pendengaran pada bayinya. Misalnya, bayi tetap tidur lelap, sekalipun di sekitarnya ada suara atau bunyi yang keras. Demikian juga kalau bayi berusia enam bulan belum bisa mengoceh dan tidak memberi respons bila ada bunyi.

"Di Indonesia deteksi gangguan pada bayi baru lahir belum menjadi program, sehingga tidak semua kasus tercatat. Di rumah sakit, deteksi gangguan pendengaran dilakukan dengan pemeriksaan emisi otoakustik, yang kemudian dilanjutkan dengan pemeriksaan automated brainstem evoked response audiometry," ujarnya. Disebutkan, deteksi terhadap gangguan pendengaran dan ketulian sudah harus dimulai sebelum bayi ke luar dari rumah sakit atau saat berusia dua hari. Sedangkan bayi yang lahir di tempat lain, sebaiknya dideteksi paling lambat saat berusia 1 bulan. Diagnosis terhadap ketulian hendaknya sudah dipastikan sebelum bayi berusia 3 bulan dan pemasangan alat bantu dengar sudah dimulai sejak usia 6 bulan. Lebih jauh dikatakan, ada beberapa hal yang membuat seorang bayi berisiko tinggi mengalami gangguan pendengaran dan ketulian. Seperti, bayi dengan berat badan lahir kurang dari 1.500 gram, ibu hamil yang memakai obat bersifat toksik, seperti obat tuberkulosis dan antibiotik, serta ibu hamil yang mendapatkan kemoterapi. Selain obat, hal lain yang membuat bayi berisiko tinggi mengalami gangguan pendengaran adalah ada riwayat meningitis karena bakteri, bayi kuning (kolestasis), dan bayi yang memakai ventilator lebih dari lima hari. " Bila bayi mengalami tiga dari hal-hal tersebut maka kemungkinan mengalami ketulian lima puluh sampai enam puluh kali dibanding bayi yang tidak berisiko. Bahkan dari hasil penelitian, bayi yang dirawat di neonatal intensive care unit (NICU), sepuluh kali lipat berisiko mengalami ketulian dibanding yang tidak dirawat di NICU," ucap Jenny. Ditambahkannya, 0,1 persen penduduk Indonesia mengalami ketulian sejak lahir. Sedangkan di negara maju 1 sampai 3 kasus tuli per seribu kelahiran hidup. Menurut Organisasi Kesehatan Dunia (WHO), ada 2,1 persen atau sekitar 120 juta dari penduduk dunia mengalami gangguan pendengaran. Dari jumlah itu sebanyak 25 juta orang berada di Asia Tenggara. (N-4) Sumber: http://www.suarapembaruan.com