CHAPTER 43. Otorhinolaryngological Care
Donna R. Mcewen
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Identify the pathophysiological ear, nose, throat, and head and neck conditions requiring surgical interventions.
2. Describe surgical procedures with the preanesthesia, perianesthesia, and postanesthesia problems encountered in the ear, nose, throat, and head and neck patient and the nursing interventions required in the management of these problems.
3. Identify possible complications that can arise after ear, nose, throat, and head and neck procedures.
I. ANATOMY AND PHYSIOLOGY
A. Ear
1. Structure and function
a. Anatomy of ear (organ of hearing and equilibrium; Figure 43-1)
(1) Outer ear
(a) Visible portion consists of skin-covered flap of cartilage known as auricle or pinna.
(i) Collects sound waves
(ii) Directs sound waves to external acoustic meatus
(b) Auditory canal—external acoustic meatus
(i) Extends to tympanic membrane (eardrum)
(c) Tympanic membrane
(i) Thin, transparent, pearly gray, cone-shaped membrane
(ii) Stretches across the ear canal
(iii) Separates the middle ear (tympanic cavity) from the outer ear
(d) Nerve supply
(i) Auriculotemporal branch of the trigeminal nerve
[a] General sensory
[b] Innervates tympanic membrane, external acoustic meatus, anterior auricle
(2) Middle ear
(a) Structure
(i) Ossicles
[a] Malleus (hammer)
[1] Largest of the three ossicles
[b] Incus (anvil)
[1] Middle ossicle
[c] Stapes (stirrup)
[1] Innermost ossicle
(ii) Eustachian tube
[a] Channel connecting the tympanic cavity and the nasal part of the pharynx through which air reaches the middle ear
(b) Function
(i) Ossicles form a chain from tympanic membrane to the oval window.
(ii) Transmits vibrations to inner ear, conducting sound to the inner ear
(3) Inner ear
(a) Cochlea—spiral-shaped, forms the anterior part of the labyrinth of the inner ear; contains three compartments
(i) Scala vestibuli
[a] Part of the cochlea above the spiral lamina, which divides the canal
(ii) Scala tympani
[a] Part of the cochlea below the spiral lamina
(iii) Cochlear duct (scala media)
[a] Canal between the scala tympani and scala vestibuli
(b) Organ of Corti
(i) Organ lying against the basilar membrane in the cochlear duct
(ii) Contains special sensory receptors for hearing
(iii) Consists of neuroepithelial hair cells that respond to vibration from the ossicles, converting mechanical energy to electrochemical impulses
(c) Vestibular labyrinth—controls equilibrium
(i) Utricle
[a] Larger of the two divisions of the membranous labyrinth of the inner ear
(ii) Saccule
[a] Smaller of the two divisions of the membranous labyrinth of the vestibule
[b] Communicates with the cochlear duct by way of the ductus reuniens
(iii) Semicircular canals
[a] Description: three canals—anterior, lateral, and posterior
[b] Passages in the inner ear
[c] Located in the bony labyrinth
[d] Functions: control sense of balance
[e] Respond to movement of head
[f] Can cause feeling of dizziness or vertigo after spinning
[g] Motion sickness results from unusual movements of the head that result in stimulation of the semicircular canals.
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| FIGURE 43-1 ▪
The ear.
(From Thibodeau GA, Patton KT: Anatomy and physiology, ed 7, St Louis, 2010, Mosby.)
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B. Nose
1. Structure and function
a. Anatomy of nose (organ of respiration and olfaction; Figure 43-2)
(1) External
(a) Upper—formed by nasal bones and maxilla
(b) Lower—formed by connective tissue
(c) Nares—separated by columella, formed from nasal cartilage
(d) Nasal septum
(i) Nasal cartilage
(ii) Vomer bone
(iii) Perpendicular plate of ethmoid bone
(2) Internal—nasal cavity
(a) Nares (nostrils)
(i) External opening of the nasal cavity
(b) Choanae
(i) Paired openings between nasal cavity and oropharynx
(c) Nasopharynx
(i) Part of the pharynx above the soft palate
(d) Eustachian tube
(i) Narrow channel that connects tympanum with nasopharynx
(e) Paranasal sinuses
(i) Arranged in four pairs
[a] Maxillary
[b] Frontal
[c] Sphenoid
[d] Ethmoid
(f) Nasal duct
(i) Extends from the lower part of the lacrimal sac to the inferior meatus of the nose
(ii) Channel through which tear fluid is conveyed into the cavity of the nose
(g) Turbinate bones
(i) Extend horizontally along the lateral wall of the nasal cavity
(ii) Separate the middle meatus of the nasal cavity from the inferior meatus
(h) Nasal septum
(i) Separates the nasal cavity into two fossae
(i) Nerve supply
(i) Trigeminal nerve
[a] Cranial nerve V
[b] General sensory, motor
[c] Face, teeth, mouth, nasal cavity
(ii) Cranial nerve I (olfactory)
[a] Special sensory
[b] Nerve of smell
(j) Other nerves to consider
(i) Cranial nerve II (optic)
[a] Special sensory
[b] Nerve of sight
[c] Can be damaged in endoscopic sinus surgery
(k) Arterial blood supply
(i) Internal maxillary
(ii) Anterior ethmoid
(iii) Sphenopalatine
(iv) Nasopalatine
(v) Pharyngeal
(vi) Posterior ethmoid
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| FIGURE 43-2 ▪
Lateral wall of nose, showing superior, middle, and inferior turbinates.
(From Monahan FD, Sands JK, Neighbors M, et al: Phipps medical-surgical nursing, ed 8, St Louis, 2007, Mosby.)
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C. Throat
1. Structure and function
a. Anatomy of oral cavity
(1) Mouth
(a) Lips
(b) Buccal cavity
(c) Lingual cavity
(i) Tongue
(ii) Hard palate
(iii) Soft palate
(2) Pharynx (Figure 43-3)
(a) Throat
(i) Nasopharynx
[a] Lies posterior to the nose and above the level of the soft palate
[b] Provides passageway for air
[c] Contains opening of the eustachian tubes
(ii) Oropharynx
[a] Extends from soft palate to the hyoid bone
[b] Provides passageway for both air and food
(iii) Laryngopharynx
[a] Extends from the hyoid bone to the lower border of the cricoid cartilage
[b] Continues with the esophagus
[c] Anterior entrance of the larynx is the epiglottis.
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| FIGURE 43-3 ▪
Sagittal section of head showing pharynx and larynx.
(From Monahan FD, Sands JK, Neighbors M, et al: Phipps medical-surgical nursing, ed 8, St Louis, 2007, Mosby.)
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(3) Tonsils
(a) Types
(i) Palatine tonsils
[a] Pair of oval-shaped structures
[b] Size of almonds
[c] Partially imbedded in mucous membrane
[d] One on each side of the throat
(ii) Lingual tonsils
[a] Below palatine tonsils
[b] At base of tongue
(iii) Pharyngeal tonsils (adenoids)
[a] Located in upper rear wall of oral cavity
[b] Fair size in childhood, shrink after puberty
(b) Functions
(i) Part of the lymphatic system
(ii) Assist in filtering the circulating lymph of bacteria and other foreign material that may enter body through mouth or nose
(c) Nerve supply
(i) Middle and posterior branches of the maxillary and glossopharyngeal nerves
(ii) Cranial nerve X (vagus)
[a] Parasympathetic, visceral, afferent, motor, general sensory
[b] Supplies sensory fibers to ear, tongue, pharynx, and larynx
[c] Supplies motor fibers to pharynx, larynx, and esophagus
(d) Blood supply
(i) External carotid branch (ascending palatine branch of facial artery)
(4) Larynx
(a) Thyroid cartilage
(i) Shield-shaped cartilage
(ii) Produces prominence on neck (“Adam’s apple”)
(b) Hyoid bone
(i) Horse-shaped bone
(ii) Situated at the base of the tongue, just below the thyroid cartilage
(c) Cricoid cartilage
(i) Ringlike cartilage
(ii) Forms lower and back part of larynx
(d) Epiglottis
(i) Lidlike cartilage structure
(ii) Hangs over the entrance to the larynx
(e) Arytenoid cartilages
(i) Jug-shaped cartilage of the larynx
(f) Corniculate cartilages
(i) Two small conical nodules of yellow elastic cartilage
(ii) Articulate with the arytenoid cartilages
(g) Cuneiform cartilage
(i) Elongated yellow elastic cartilage in the aryepiglottic fold
(h) Glottis
(i) Vocal apparatus of the larynx
(ii) Consists of true vocal cords (vocal folds) and opening between them
(i) Nerve supply
(i) Superior laryngeal nerve
[a] Motor, general sensory, visceral afferent, parasympathetic
[b] Cricothyroid muscle and inferior constrictor muscles of the pharynx, mucous membrane of back of tongue and larynx
(ii) Recurrent laryngeal nerve
[a] Parasympathetic, visceral afferent, motor
[b] Tracheal mucosa, esophagus, cardiac plexus
(5) Thyroid gland
(a) Located in anterior portion of the neck
(b) Consists of right and left lobes united by isthmus
(c) Vascular supply: superior and inferior thyroid arteries
(d) Nerves in proximity
(i) Recurrent laryngeal nerve
(ii) Superior laryngeal nerve
II. GENERAL NURSING CONCERNS
A. Preoperative concerns (see Chapter 15)
1. Medical history assessment
2. Nursing assessment
a. Chief complaint
b. Medications
(1) Allergies
(2) Current medications patient is taking, including over-the-counter and herbal medications
(3) Use of aspirin, nonsteroidal anti-inflammatory medications, or medications containing aspirin (increased risk of bleeding)
(4) Hormone therapy
(5) Preoperative medications
c. Patient’s understanding of surgical procedure and expected outcomes
d. Patient’s psychosocial status
e. Preexisting sensory deficits
3. Usual laboratory and radiological evaluations
a. Complete blood cell count
b. Electrolytes based on patient history
c. Urinalysis
d. Coagulation studies
e. Availability of designated blood products, type and crossmatch
f. Electrocardiogram
g. Chest radiograph
h. Radiograph of sinuses, neck, mastoid
i. Computed tomography
j. Magnetic resonance imaging
k. Pregnancy test for menstruating females
4. Preoperative instructions
a. Surgical procedure
b. Operative site verification
c. Expected outcomes
d. Environment
e. Alterations in lifestyle
f. Self-care
g. Suctioning
h. Deep breathing
i. Pain management
B. Intraoperative concerns
1. Nursing assessment
a. Assess respiratory status.
b. Determine patient’s comfort.
c. Identify positioning needs.
d. Establish priorities.
e. Reinforce preoperative teaching.
(1) Orient to perioperative environment.
(2) Instruct patient in postoperative dressings.
f. Determine patient’s anxiety or apprehension.
g. Operative site verification
2. Aseptic technique
3. Skin and tissue integrity
4. Correct counts
5. Medications given
6. Intake and output
7. Blood loss
8. Patient’s condition at time of transfer to post anesthesia care unit (PACU)
C. Postanesthesia concerns: phase I
1. Nursing assessment
a. Respiratory status
b. Cardiovascular status
c. Neurological status
d. Psychosocial status
2. Report from anesthesiologist or certified registered nurse anesthetist and/or operating room nurse
a. Procedure, extent of surgery; complications
b. Anesthetic agents and medications administered
c. Blood loss and fluid replacement
d. Placement of drains, packing
e. Pertinent history, allergies
3. Pain status
4. Intake and output
5. Patient’s position
6. Presence or absence of nausea
7. Patient’s ability to communicate
8. Integrity of dressings and incision
9. Patient’s temperature
10. Drainage from surgical site
D. Postanesthesia concerns: discharge from phase I
1. Patient
a. Conscious and able to maintain airway
b. Able to maintain oxygen saturation greater than 92% after 15 minutes breathing room air without being stimulated
c. Remains in this condition for 30 to 45 minutes after:
(1) Extubation
(2) Administration of narcotic or narcotic antagonist
2. No active bleeding from operative site or drains
E. Postanesthesia concerns: phase II
1. Prepare for discharge (criteria and policies vary among facilities).
a. Ensure adequate pain control.
b. Validate ability to retain fluids and maintain hydration status.
c. Validate patient’s ability to urinate or return to previous level of urinary status.
d. Assist patient with changing from hospital gown to personal clothing if necessary.
e. Provide discharge instructions to patient and caregiver.
f. Ensure that the patient is accompanied by responsible adult at discharge.
F. Pediatric otolaryngology patients
1. Special considerations
a. Preoperative concerns (see Chapter 11)
(1) Fear of separation, pain, injury, death: establish trust, reassure patient.
(2) Child’s feelings of “loss of control”: allow child to choose flavoring for anesthetic induction mask.
(3) Anxiety and fear of child and parents: prepare child and parents.
b. Intraoperative concerns
(1) Airway management: increased risk of laryngospasm and vomiting if anesthesia is induced while crying
(2) Maintenance of body temperature (pediatric patient loses temperature faster than adult): keep patient covered with warm blankets, insulated drapes, convection or forced air warming blanket to prevent loss of body heat.
c. Postoperative concerns
(1) Maintenance of body temperature: use of warm blankets, insulated drapes, keep patient covered to prevent further heat loss and restore body temperature.
(2) Increased risk for bleeding related to postoperative crying: administer pain medication as needed, provide reassurance to child and parents, allow family visitation postoperatively.
(3) Fluid balance (pediatric patient dehydrates easier than adult): encourage fluid intake postoperatively, monitor intravenous (IV) fluids and output.
III. SURGICAL PROCEDURES
A. Ear
1. Myringotomy with or without tympanostomy tubes
a. Purpose
(1) Relieves pressure and allows for drainage of purulent or serous secretions from middle ear
(2) Aerates middle ear
(3) Relieves eustachian tube obstruction (thick, mucoid fluid)
(4) May be short-term or long-term
b. Description
(1) Small incision made into posteroinferior aspect of tympanic membrane
(2) Polyethylene tube can be inserted into eardrum.
c. Indications
(1) Acute otitis media unresponsive to antibiotics
(2) Bulging tympanic membrane
(3) Multiple episodes of acute otitis media along with chronic otitis media
d. Preoperative concerns
(1) Frequently performed on children
(a) Preoperative medication provided in oral form
(b) Usually performed under mask anesthesia; no IV access established
e. Intraoperative concerns
(1) General anesthetic essential for children to ensure accurate incision of tympanic membrane and placement of tube
(2) Parents may be present in OR for induction of pediatric patients, depending on institutional policy and practice.
f. Postanesthesia priorities
(1) Phase I
(a) Standard phase I activities as previously described
(i) Nurse-to-patient ratio—1:1 until consciousness and reflexes return for pediatric patients
(ii) Children may struggle against face tent; provide humidified oxygen by placing tubing near mouth and nose.
(b) Depending on setting and institutional policy, patient may bypass phase I.
(2) Phase II
(a) Standard phase II activities as previously described
(b) Reunite parents with child as soon as possible to alleviate separation anxiety.
(c) Discharge instructions
(i) Avoid getting ears wet.
(ii) Change cotton balls as directed by physician.
(iii) Discuss pain management techniques.
(iv) Advise parents that tubes may fall out naturally.
g. Psychosocial concerns
(1) Children may experience separation anxiety.
(a) Allow for parent presence at induction if allowed by institutional policy.
(2) Allow child to assert control over situation when appropriate.
(a) Remain in pajamas or street clothes.
(b) Select flavor and scent of mask used for induction.
h. Complications
(1) Hearing loss
(2) Persistent otorrhea
(3) Chronic perforation
(4) Bleeding
(5) Premature tube extrusion
2. Tympanoplasty
a. Purpose
(1) Improve hearing.
(2) Prevent recurrent infection.
b. Description
(1) Refers to a variety of reconstructive surgical procedures performed on deformed or diseased middle ear components
(2) Some tympanoplasties carried out in two stages
(a) First procedure removes diseased tissue; second procedure involves reconstruction of hearing and middle ear function.
(3) Involves tissue grafts of cartilage, bone, fascia, skin, silicone, Teflon, or hydroxyapatite
(4) Types of tympanoplasty
(a) Type I (myringoplasty): repair of tympanic membrane
(b) Type II: graft rests on incus.
(c) Type III: graft attaches to head of stapes.
(d) Type IV: graft attaches to footplate of stapes.
c. Indications
(1) Defects in tympanic membrane
(2) Necrotic destruction of ossicles
(3) Cholesteatoma (epidermal pocket or cystlike sac filled with keratin debris)
(4) Chronic drainage from ear canal
(5) Conductive hearing loss
(6) Trauma
d. Preoperative concerns
(1) Hearing deficits may be present; adjust communication methods as appropriate.
(2) Shampoo hair morning of surgery or night before surgery.
(3) Advise patient that postoperative hearing may be diminished initially because of packing and dressing.
e. Intraoperative concerns
(1) Allow patient to wear hearing aids (if present) to the operating room (OR) to enhance communication.
(2) Involves use of microscope for work on minute, delicate structures
(3) Postauricular (behind ear) and/or endaural (through ear canal) approach used to expose structures of middle ear
(4) Facial nerve monitoring may be used.
(5) Positioning involves tilting OR bed at an angle to provide optimum exposure to operative ear; may cause pressure injury to dependent structures.
f. Postanesthesia concerns
(1) Phase I
(a) Standard phase I activities as previously described
(b) Elevate head of bed at least 30° to minimize eustachian tube edema; clarify positioning with surgeon for specific instructions.
(c) Position with operative ear upward to prevent pressure and graft displacement.
(d) Assess facial nerve function. Report any impairment to the surgeon. Assess facial symmetry by asking patient to:
(i) Smile enough to show teeth.
(ii) Wrinkle forehead.
(iii) Pucker lips.
(iv) Wrinkle nose.
(v) Squeeze eyelids shut.
(vi) Stick out tongue.
(e) Prepare to treat nausea, vomiting, vertigo.
(f) Avoid excess motion; transfer patient slowly and smoothly to minimize vertigo.
(2) Phase II
(a) Standard phase II activities as previously described if patient discharged to home
(b) Discharge instructions
(i) Avoid getting ears wet.
(ii) Avoid sudden turning; encourage slow, smooth motion.
(iii) Sneeze with mouth open to avoid pressure on eustachian tubes.
(iv) Gentle nose blowing only
(v) Noises such as popping and/or cracking may be heard in the ear by the patient and are considered normal.
g. Psychosocial concerns
(1) Anxiety related to hearing loss
h. Complications
(1) Facial nerve injury
(2) Hearing loss caused by drill trauma to ossicles
3. Stapedectomy
a. Purpose
(1) Restoration of stapes bone function
b. Description
(1) Removal of diseased stapes and replacement with prosthetic graft
c. Indications
(1) Treatment of otosclerosis, a condition of unknown etiology characterized by the formation of spongy bone around the round window, which causes stiffening and hardness of the stapes
d. Preoperative concerns
(1) Hearing deficits may be present; adjust communication methods as appropriate.
(2) Advise patient that postoperative hearing may be diminished initially because of packing and dressing.
e. Intraoperative concerns
(1) May be performed under local anesthesia with moderate sedation in adult patients
(2) Involves use of microscope
(3) May involve the use of the laser
(4) Profound intraoperative vertigo may be noted in patients under local anesthesia.
(5) Prosthesis fabricated from Teflon, stainless steel, or other synthetic material
f. Postanesthesia priorities
(1) Phase I
(a) Standard phase I activities as previously described
(b) Elevate head of bed at least 30° to minimize eustachian tube edema; clarify positioning with surgeon for specific instructions.
(c) Position with operative ear upward to prevent pressure and graft displacement.
(d) Nausea, vomiting, and vertigo should be anticipated.
(2) Phase II
(a) Standard phase II activities as previously described
(b) Discharge instructions
(i) Avoid getting ears wet.
(ii) Avoid sudden turning; encourage slow, smooth motion.
(iii) Sneeze with mouth open to avoid pressure on eustachian tubes.
(iv) Gentle nose blowing only
g. Psychosocial concerns
(1) Patient may report immediate improvement in hearing, but hearing may decrease postoperatively because of accumulation of drainage.
h. Complications
(1) If chorda tympani is removed to expose stapes and footplate, loss of taste to anterior two thirds of tongue will occur on the affected side.
(2) Facial nerve dehiscence
(3) Ossicular chain dislocation
(4) Perilymph leak
(5) Dizziness
4. Mastoidectomy
a. Purpose
(1) To eradicate infected or diseased mastoid air cells
b. Description
(1) Simple mastoidectomy
(a) Removal of mastoid air cells only
(2) Modified radical mastoidectomy
(a) Removal of mastoid cells, posterior and superior external bony canal walls
(b) Conversion of mastoid and epitympanic space into one common cavity
(3) Radical mastoidectomy
(a) Removal of mastoid cells, posterior wall of external auditory canal, remnants of tympanic membrane, ossicles (except stapes), and middle ear mucosa
(b) Removal of infected or diseased mucosa from middle ear orifice of the eustachian tube
(c) Conversion of middle ear and mastoid space into one cavity
c. Indications
(1) Acute or chronic infection
(2) Extension of cholesteatoma into mastoid cells
d. Preoperative concerns
(1) Hearing deficits may be present; adjust communication methods as appropriate.
(2) Advise patient that postoperative hearing may be diminished initially because of packing and dressing.
e. Intraoperative concerns
(1) Involves use of microscope
(2) Positioning involves tilting OR bed at an angle to provide optimum exposure to operative ear; may cause pressure injury to dependent structures.
f. Postanesthesia concerns
(1) Phase I
(a) Standard phase I activities as previously described
(b) Elevate head of bed at least 30°; clarify positioning with surgeon for specific instructions.
(c) Position with operative ear upward to prevent pressure.
(d) Assess facial nerve function. Report any impairment to the surgeon. Assess facial symmetry by asking patient to:
(i) Smile enough to show teeth.
(ii) Wrinkle forehead.
(iii) Pucker lips.
(iv) Wrinkle nose.
(v) Squeeze eyelids shut.
(vi) Stick out tongue.
(e) Prepare to treat nausea, vomiting, vertigo.
(f) Avoid excess motion; transfer patient slowly and smoothly to minimize vertigo.
(2) Phase II
(a) Standard phase II activities as previously described if patient discharged to home
(b) Discharge instructions
(i) Avoid getting ears wet.
(ii) Avoid sudden turning; encourage slow, smooth motion.
(iii) Sneeze with mouth open to avoid pressure on eustachian tubes.
(iv) Gentle nose blowing only
(v) Noises such as popping and/or cracking may be heard in the ear by the patient and are considered normal.
g. Psychosocial concerns
(1) Patient may report immediate improvement in hearing; hearing may decrease postoperatively from accumulation of drainage.
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