Soap Note Nurse Practitioner Otitis Externa

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Disorders of the Eyes, Ears, Nose, and Throat

Page 2 of 57 Practicum I: Adult Health—Adults & Gerontology

2 Week 2 Lectures

Common Eye Disorders

Visual Disturbances

Visual disturbances can include gradual or sudden vision changes, full or partial loss of vision, blind spots, and change in visual acuity, including color vision. It is important to determine whether there was pain associated with the vision change. Did the pain occur with, occur before, or persist with the vision change? Was there any trauma associated with the vision change? Does anything make the vision change better or worse? Has this been a gradual or an abrupt change? Were there any new medications or a change in routine?

The examination should begin with your inspection of the patient's face and, in particular, his or her eyes. Follow this with an assessment of vision acuity—the Snellen test with use of any prescription lenses (if used) is preferred.

The next step is assessment of extraocular movement and pupil reaction. Note the red reflex and then proceed to fundoscopic examination, if possible. The patient may be extremely photophobic, or cataracts may be present that prevent full fundoscopic examination. Be alert for any changes that signify other disease processes, such as hypertension, diabetes, or neurological conditions.

The following table shows common eye disorders that may be seen in an adult patient. Keep in mind that you may have to refer the patient for further testing and evaluation on the basis of your findings.

Common Eye Disorder

Signs and Symptoms

Evaluation Treatment Plan

Cataracts Chief Complaints:

 Blurred vision.

 Haziness in the visual field.

 Gradual decrease in visual acuity.

 Halos around light.

 Increase in glare when driving at night.

Cataracts may be visualized with a normal eye exam, but early cataracts are best detected through a dilated eye examination.

Refer the patient for ophthalmology evaluation and possible cataract extraction. Remind the patient to have an annual eye examination.

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Chronic Open-Angle Glaucoma: Chronic open-angle glaucoma is the most common form of glaucoma, or the increased intraocular pressure that compresses the optic nerve. The resulting neuropathy of the optic nerve leads to alteration in vision. African Americans, diabetics, adults aged thirty-five years and older, and those with a family history of chronic open-angle glaucoma are at higher risk of developing glaucoma.

Patient Presents:

 Gradual alteration of vision.

 Can be quite advanced before the patient notices any visual symptoms, such as peripheral vision loss.

Assess peripheral visual fields and perform fundoscopic examination. The cup-to-disk ratio is increased, as is the intraocular pressure, in a patient with chronic open- angle glaucoma.

Ophthalmology should be consulted for evaluation and initiation of a treatment plan. Remind your patient that an annual eye examination is part of health maintenance.

Acute Closed- Angle Glaucoma: Acute closed-angle

Patient Presents:

 Abrupt onset of severe, unilateral eye pain that may

The pupil may be fixed and somewhat dilated accompanied by infection of the eye. Edema of the

Acute closed- angle glaucoma requires an immediate referral to an ophthalmologist

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glaucoma often presents with acute changes in vision. There may be only a transient increase in the intraocular pressure, yet it results in significant symptoms during the time of the event. These symptoms may resolve by the time the patient is evaluated. Do not dilate the patient's eyes if there is a history of unilateral eye pain and visual changes. The dilation of the eye may exacerbate the intraocular pressure.

be associated with photophobia, headaches, or nausea.

 May complain of halos around lights and blurred vision.

cornea is common, with a hazy or dewdrop appearance.

for evaluation and treatment. The goal is to provide treatment as soon as possible in order to preserve vision.

Amaurosis Fugax: "It's like a shade has been pulled down over my eye. It lasts a few minutes . . . then it's

Chief Complaints:

 Unilateral "shade being drawn down over the eye," this symptom may last from a few seconds

If you are able to assess the patient during the episode, you may be able to visualize a whitening of the retina with a bright-red fovea. Fundoscopic

A referral is needed for a further workup and treatment of the patient.

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gone." This is the presentation of amaurosis fugax. This transient ischemia of the retina is a warning sign of an impending stroke. There are four general sources for amaurosis fugax: emboli, insufficient vascular supply to the retina, arterial spasms, and other idiopathic means.

to several minutes, and the resolution is the "shade going back up," just as it descended.

 There is no pain associated with amaurosis fugax.

examination may show you hemorrhages, tiny emboli or aneurysms, and vessel changes. These changes may be seen outside the acute episode. Assess for carotid bruits and any neurological changes or weakness. An electrocardiogram (ECG), a carotid ultrasound, and computed tomography (CT) should be considered, as well as a complete blood count (CBC), a comprehensive metabolic profile, and the erythrocyte sedimentation rate (ESR), for assistance in diagnosing the patient.

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Retinal Disorders

Eye Disorders

Eye Disorders Signs and Symptoms

Evaluation Treatment Plan

Retinal Detachment:

 Usually precipitated by some type of trauma to head or eye, it may be spontaneous as a result of diabetic retinopathy.

 Requires an immediate referral and evaluation by an ophthalmologi st.

Chief Complaints:

 Vision change, such as an increase in the number of floaters, flashing scotomas, or flashing lights.

 Retinal detachment may increase over time.

 As detachment enlarges symptoms escalate.

An afferent pupil defect may be present if the defect is large, with the affected retina having a wrinkled, gray appearance.

This is an optical emergency, and the patient must be referred immediately to an ophthalmologist for further evaluation and treatment.

Macular Degeneration:

 The loss of vision from macular atrophy or macular hemorrhage.

 Considered an age-related medical

Patient Presents:

 Loss of may be subtle or abrupt.

 Typically unilateral.

 Vision may become blurred.

 Patient may

Fundoscopic examination may display soft or hard exudates on the macula and alteration in pigmentation of the macula (white spots, or hypopigmentation), or hemorrhage. Diabetic patients often have neovascularization

If you suspect macular degeneration in a patient, refer the patient immediately to an ophthalmologist for further testing and diagnosis.

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problem. experience full vision loss.

and microaneurysms.

An ophthalmologist will conduct detailed testing of the central vision, along with an Amsler grid evaluation.

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Reddened Eye

Conjunctivitis

When a patient presents with a reddened eye, the examination should begin with general observation and end with evaluation for any type of trauma. Is the patient experiencing edema of the eye or eyelid? Is drainage present? If so, what color is the drainage? Are there any obvious signs of trauma? Is there a lesion present on the eye or eyelid? If so, what does the lesion look like? Is it firm, soft, long, short, large, small, draining, intact, vesicular, or purulent? Are the symptoms associated with photophobia?

Perform an examination of the eyelids, sclera, and conjunctiva. Note any changes that may be present, including foreign bodies or lesions. Note the pupils, including size and reaction to light. Fundoscopic examination would be helpful, provided the patient is able to tolerate the light. You should consider a full examination of the head, ears, nose, and throat to see whether there are other symptoms present.

If you suspect an unusual infection, consider a culture of the exudates from the affected eye. A Wood's lamplight for use with fluorescein staining is helpful when a corneal abrasion or foreign body is a possibility. If a foreign body is present, the patient should be referred immediately to an ophthalmologist for evaluation and treatment.

Red Eye Signs and Symptoms Evaluation Treatment Plan

Conjunctivitis:

 Most common presentation.

 Allergic, viral, or bacterial or chemical reaction.

 Bacterial infection may follow a viral infection or be associated with sinusitis or otitis media, especially in children.

 Allergic conjunctivitis

Patient Presents:

 Red eye.

 Itching, discharge, and general discomfort.

 Bacterial conjunctivitis: yellow-green eye discharge and the eye matted shut.

 Viral conjunctivitis: excessive tearing (epiphora).

 Allergic

Note the symptoms, both primary and associated; color of the discharge; any foreign bodies; any lesions; or other sources of symptoms. Consider a culture of the exudates, if warranted.

Viral conjunctivitis will not require specific treatment other than warm compresses to alleviate discomfort, patient education on preventing the spread of conjunctivitis to the opposite eye and to others, good hand-washing technique, and general comfort measures.

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is very common and may be related to the change of seasons, such as spring and fall.

conjunctivitis: Mild scleral erythema, cobblestoning, paleness of the lower eyelid, and ocular pruritus.

Bacterial conjunctivitis may be treated with eyedrops, such as polymyxin or ciprofloxacin. Consider a culture and sensitivity testing if bacterial conjunctivitis is present. Allergic conjunctivitis may be treated with over-the- counter eyedrops, antihistamines, or other allergy treatments, such as avoidance or a referral to an allergy specialty practice.

Corneal Abrasion:

 Scratching or abrasion of the cornea, typically by a foreign body i.e.: contact lens.

 Other possible sources of abrasion include sand, dirt, chemicals, and physical scratches,

Chief Complaints:

 Eye may feel scratched, painful or burning.

 Photophobia and excessive tearing and difficulty opening the eye.

 Onset of discomfort is typically immediately

The eye is usually diffusely erythematous with excessive clear tearing noted. There may be mild edema. You may perform fluorescein staining to look for the scratch—the scratch should be highlighted by the stain. Fundoscopic

You may patch the eye for twenty-four hours to allow eye rest; do not allow use of contact lenses until the abrasion is fully healed, but use topical antibiotics or ointment. Suggested eyedrops are sodium sulfacetamide, erythromycin

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such as from an animal, powder, etc.

after exposure. examination findings should be normal. No lymph node enlargement of preauricular nodes should be present (preauricular nodes are often enlarged in viral conjunctivitis). Diagnostic tests other than fluorescein staining and fundoscopic examination are not necessary.

ointment, ciprofloxin, and ofloxacin. Reevaluate the eye in twenty- four hours to note improvement. Corneal ulcers may develop if the abrasion does not heal quickly. Reevaluate every twenty- four hours until healed.

Subconjunctival Hemorrhage:

 A benign rupture triggered by sneezing, coughing, rubbing of the eye, or some type of trauma.

Patient Presents:

 Painless, unilateral, abrupt hemorrhage of the sclera of the eye.

 No loss of vision, pain, drainage, or photophobia.

 Normal eye exam.

Inspect both eyes for abnormal findings. Inquire about recent history, especially any trauma that may have occurred. Ask about current medications, especially blood thinners, which increase the risk of hemorrhage. Has there been any recent trauma that the

No specific treatment is required, it may be uncomfortable to wear contact lenses because of the hemorrhage. Patching or eyedrops are not necessary except for comfort. If eyedrops are desired, use a lubricating eyedrop compared with an allergy or "get the red out" solution. The

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patient can remember? How long ago was the hemorrhage noticed?

hemorrhage will eventually be reabsorbed. If the patient is taking blood thinners, perform tests to evaluate the medication therapeutic levels. For example, if the patient takes warfarin, draw a Prothrombin Time (PT) and International Normalized Ratio (INR) to check levels.

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Eye Lesions

Eye Lesions Signs and Symptoms

Evaluation Treatment Plan

Hordeolum or Sty:

 Result from a blocked meibomian or Zeis gland.

 May be a type of staphyloco ccal infection.

 Painful lesion, typically found on the eyelid margin.

Chief Complaints:

 Burning sensation.

 Edema of the eye.

 Onset may be abrupt or gradual.

 Duration up to several weeks.

Use gloves to examine the affected eye. Do not transfer material or expose the other eye. Invert the eyelid with a sterile cotton- tipped applicator swab for further evaluation. Note the location, size, and color of the lesion. Consider Herpes Zoster or Herpes Simplex as a differential diagnosis for the hordeolum.

Educate the patient on the importance of preventing cross contamination of the opposite eye. Good hand- washing technique is a must. The patient may use warm, moist compresses for up to twenty minutes at a time. A topical antibiotic ointment, such as erythromycin, may be used three times daily for five days.

Chalazion:

 A sterile, localized growth of benign granulomat ous tissue on the

Patient Presents:

 A firm, reddened nodule that usually points inward toward the

Examine by inverting the eyelid with a sterile cotton- tipped applicator swab.

The best treatment is early intervention with warm compresses. The chalazion may spontaneously resolve, or it may

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eyelid as a result of a blocked meibomian gland.

 Growth is an inflammato ry response to the blocked gland.

conjunctiva.

 Typically slow, appearing over a number of months or even years.

 No vision change, except in the presence of significant edema of the eyelid.

 Be painless but irritating or annoying to the patient.

Edema of the eyelid may be present depending on the size and acuity of the lesion. No drainage should be noted. Vision should be intact unless the eyelid is so edematous that the patient cannot see.

not resolve at all, even after a number of years. If vision is impaired, the lesion is painful, or the patient desires its removal, a referral to an ophthalmologist is indicated. If there is any question as to whether the lesion is benign, an immediate referral to an ophthalmologist is warranted.

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Inflammation of the Eye

Inflammation of the Eye Signs and Symptoms Evaluation Plan of Treatment

Keratitis:

 Inflammation of the cornea.

 May result in blindness if not treated appropriately.

 Triggered by infections, ischemia, exposure to chemical irritants, corneal abrasions, foreign bodies, dry eyes or conjunctivitis.

 May lead to corneal ulcers, opacity, and total loss of vision in the affected eye.

Patient Presents:

 Acute ocular pain or just the sensation of a foreign body in the affected eye.

 Vision changes may occur as the keratitis progresses.

Note any flushing or discoloration of the eye. Gray infiltrates may be present on examination of the cornea. Fluorescein staining may reveal ulcerations of the cornea with ulcerative keratitis.

An immediate referral to ophthalmology is indicated for this emergency situation.

Scleritis:

 Inflammation of the sclera.

 Often associated with chronic autoimmune diseases, such as sarcoidosis, systemic lupus erythematous, and rheumatoid arthritis.

Patient Presents:

 Vision is not usually affected.

 Scleritis may be very painful.

 Photophobia is more likely to be present in scleritis.

Erythema associated with scleritis may appear so red that it is more purplish. Inflammatory nodules and engorged vessels may be present on assessment of the sclera. A visual

The patient should be referred to an ophthalmologist for further diagnosis and treatment.

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 Self-limiting in nature but may contribute to cataracts or glaucoma in the future.

acuity change may be present when the scleritis has progressed.

A CBC, an ESR, and ANA should be ordered. If the patient has not been previously diagnosed with an autoimmune disease process, consider a rheumatoid arthritis panel as well.

Episcleritis:

 Inflammation of the episclera.

 Not associated with chronic autoimmune diseases.

 Self-limiting in nature but may contribute to cataracts or glaucoma in the future.

Patient Presents:

 Vision is not usually affected.

 Episcleritis is not associated with pain.

Presentation is lighter red than sceleritis. Episcleritis is localized but may also have engorged vessels and nodules.

A CBC, an ESR, and ANAs should be ordered. If the patient has not been previously diagnosed with an autoimmune disease process,

The patient should be referred to an ophthalmologist for further diagnosis and treatment.

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consider a rheumatoid arthritis panel as well.

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Eye Pain

Eye pain may be associated with traumatic injury, acute angle-closure glaucoma, retinal detachment, or other problems that require immediate treatment. The history and physical for eye pain and an erythematous eye are very similar.

Chemical Burns

Signs and Symptoms

You must first note whether the pain is related to a chemical injury, exposure, or burn. If a chemical insult has occurred, you must irrigate the eye thoroughly before continuing the history and physical.

After the irrigation is complete, ask the patient about the pain onset, surrounding circumstances, associated signs and symptoms, quality, quantity, and alleviating factors. Was the onset abrupt or gradual in nature? Is the pain deep, diffuse, or more superficial? What quality of pain is present—dull, sharp, stabbing, aching, throbbing, nagging, etc.? Is there any discharge, vision change, erythema, or photophobia associated with the pain?

Evaluation

Evaluate the face for bullae, erythema, or other indications of a chemical burn. There may be significant edema of the eye or face to the point that the patient cannot hold the eye open without assistance. Remember that acid burns may not penetrate the eye itself but alkali burns will penetrate the eye structure. Pain, excessive tearing, edema, and photophobia may impair assessment of the injured eye.

Treatment

It is very important that the causative chemical be identified as soon as possible so that appropriate treatment may be initiated. Treatment will include appropriate decontamination measures that are indicated by the causative chemical.

Herpes Zoster

Herpes Zoster may be found along any dermatome of the body. The fifth cranial nerve or the ophthalmic branch of the fifth cranial nerve may be affected by Herpes Zoster.

Signs and Symptoms

The presentation of Herpes Zoster often begins with a nasal lesion. A prodrome of several days may include malaise or neuralgia, followed by vesicular development. Pain may range from minor to severe; fever and fatigue are also associated with the illness. Vision may be altered, and photophobia may be present, along with mild edema.

Evaluation

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Note any lesions on or in the nose and along the cheek, orbital area, forehead, and scalp. Palpate for lymph nodes in the anterior and posterior cervical chain as well as preauricular and posterior auricular areas. Some patients may have excruciating pain long before vesicles develop.

Treatment

If you are suspicious of Herpes Zoster that affects the fifth cranial nerve, initiate treatment with an antiviral medication and pain medication, if indicated. If there is any ocular involvement with herpes zoster it is important that you urgently refer to an ophthalmologist in conjunction with your treatment.

Prevention

Remember that Herpes Zoster is preventable. The Centers for Disease Control (CDC) recommends that all adults over the age of 60 receive one dose of zoster vaccine unless they are immunocompromised, receiving immunosuppressive therapy, or have another contraindication to the vaccination. Review the CDC-Vaccines & Immunizations website frequently to stay up to date with current evidence and recommendations for vaccines.

http://www.cdc.gov/vaccines/

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Eye Discharge

Eye Discharge Signs and Symptoms Evaluation Plan of Treatment

Dacryocystitis:

 Infection of the lacrimal sac.

 More common in infants but may be seen in adults.

 Geriatric patients lose elasticity of the lacrimal ducts, impairing flushing by tears, thereby allowing infection to set in.

Patient Presents:

 Constant tearing is present if the lacrimal duct is completely occluded.

 Associated symptoms include: erythema of the conjunctiva of sclera as conjunctivitis or blepharitis.

The lacrimal sac is erythematous, edematous, and tender to palpation. Further palpation may produce purulent exudates from the sac.

Refer the patient to an ophthalmologist for evaluation. Treatment may include antibiotics and surgery to correct the inflamed duct.

Erythema Multiforme: Stevens-Johnson Syndrome:

 May be the result of an infection from Group A Beta- Hemolytic Streptococc us (GABHS) or Mycoplasma or a reaction to any medication.

Patient Presents:

 Purulent discharge.

 Painful conjunctivitis.

 Bullae and ulcers develop on the conjunctiva.

 Bullae and ulcers develop on the skin of the body.

 Hemorrhagic lesions on

Diagnosis is made by noting the signs and symptoms. Classic skin lesions of Stevens- Johnson syndrome include an erythematous, centered bullae surrounded by white areas. Other areas, such as the

This is a medical emergency; refer the patient to the nearest emergency room for intervention.

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 May not be able to identify specific causative factor.

 is the most severe presentation of erythema multiforme.

 May result in the patient's death.

mucous membranes.

 Patient presents acutely ill with malaise, fever, and arthralgias.

nose, mouth, vagina, anus, soles, and palms, may be affected with lesions as well.

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Ptosis

Ptosis Signs and Symptoms

Evaluation Plan of Treatment

Ptosis:

 May be a result of aging, or it can be congenital or acquired.

 Other causes include: Trauma, weighing down of the eyelid, a stroke, Bell's palsy.

 Myasthenia gravis often presents with ptosis of an eyelid.

 A more recent onset of ptosis may indicate the need for a more immediate referral.

Patient Presents:

 Note whether one or both eyes have been affected by drooping .

 How long has it been present, does it ever improve, how much is the vision affected, and is the vision truly due to the drooping ?

 Has any recent trauma occurred ?

 Is there a history of

Evaluate visual acuity first and then follow with inspection. Note the degree or severity of ptosis by identifying the level of the eyelid margin to the pupil or iris. You may measure the palpebral fissure to compare one eye with the other. Palpate the eyelids for edema and masses. Is there any erythema or discoloration noted? Evaluate the third cranial nerve and muscle function through extraocular movements. Conduct a general assessment of facial muscles and

Treatment is guided by the underlying problem and the degree to which vision is impaired. If the ptosis is self- limiting, such as in Bell's palsy, treat the causative process. A ptosis related to a stroke may not be reversible. Hooding of the eye may be treated through blepharoplasty or an eye lift. Refer the patient to an ophthalmologist for further evaluation.

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hyperten sion or risk for a stroke or myasthe nia gravis?

cranial nerves. Note pupillary reaction as well as shape and symmetry.

Mechanical Ptosis:

 Is created by a tumor, edema, or a growth.

 Examples include a hordeolum, a chalazion, a lacrimal duct tumor or blockage.

Patient Presents:

Senile involutional ptosis is found in patients with advanced age and is very common because of gravity, loss of facial adipose, and drying of the skin.

Evaluation and treatment are the same as those for ptosis.

Myasthenia gravis:

 Commonly presents with ptosis that is a result of decreased innervations of the muscles because of acetylcholine receptor malfunction.

 Ptosis-related myasthenia gravis is noted in women earlier than in men, typically between the ages of twenty to seventy

Patient Presents:

The patient may complain of intermittent episodes of diplopia as well as ptosis. These symptoms may be present in hyperthyroidism as well.

You may note that the patient attempts to open the opposite eye wider to compensate for the ptosis of the affected eye. Assess the patient by having him or her look upward or blink rapidly for an extended period. The ptosis should be accentuated

Myasthenia gravis should be formally diagnosed by a neurologist, who will then initiate a treatment plan. A stable patient may be cotreated after the treatment plan is established.

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years. and more pronounced during this time. Pupil reaction should not be affected by ptosis. The Tensilon test, typically performed by a neurologist, will definitively diagnose myasthenia gravis by exacerbating the muscle weakness for a brief time.

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Double Vision

Diplopia is noted when extraocular muscles do not work together in tandem and the patient sees double, or two of all objects. Neurological and muscular disorders may lead to diplopia.

Signs and Symptoms

Note the severity, duration, exacerbating and alleviating factors, and associated signs and symptoms, such as headaches and muscle weakness. Are there certain times or circumstances that seem to trigger the diplopia? Note alcohol consumption (how much and how often) and any substance use or abuse, including prescription, over-the-counter, or street drugs. Is there a history of neuromuscular, endocrine, or neurological diseases in the patient?

Evaluation

Visual acuity should be assessed first. Is the diplopia present when both eyes are used or when only one eye is used? Which eye has the diplopia? Note the corneal reflex and assess the pupils with the cover-and- uncover test. Note any lack of conjugate gaze when performing the six-cardinal-fields-of-gaze test.

Treatment

Refer the patient to ophthalmology for further evaluation. Consider CT or magnetic resonance imaging (MRI) of the brain to evaluate for a prior stroke or tumor.

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Proptosis and Exophthalmos

The anterior displacement of the eye is referred to as proptosis. "Exophthalmos" is the term used specifically to describe endocrinopathy-related proptosis, in particular proptosis associated with thyroid disorders (commonly associated with Grave's Disease).

Signs and Symptoms

The patient may present with symptoms of thyroid disease, such as weight loss, anxiety or nervousness, tachypalpitations, or fine tremors. The patient may be febrile from the hyperthyroidism or from infection. Dry eyes may be a complaint, in addition to the proptosis.

Evaluation

Perform a physical examination pertinent to the chief complaint. Note a CBC, a comprehensive metabolic panel (CMP), and a thyroid profile to include thyroid stimulating hormone (TSH) and free thyroxine (T4).

Perform a visual inspection of the conjunctivae and periorbital tissue. Inspect for conjunctival injection (scleral redness) and periorbital edema (which can occur with Grave's disease). Assess if the lids can close fully. If the lids cannot fully close this promotes drying. Perform range of motion of the eyes to assess extraocular muscle function, visual acuity, and color vision.

Treatment

Ophthalmology evaluation is needed to assess for any vision changes. Keep the eyes moist as drying may lead to ulceration. Consider CT of the brain, in addition to a thyroid workup to rule out other sources of the proptosis.

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Infectious Eye Disorders

Orbital and Periorbital Cellulitis

Periorbital cellulitis involves inflammation of the tissue surrounding the affected eye. It may result from either trauma or infection and more commonly affects the pediatric population. The typical age of onset is six months to two years, and onset may be associated with maxillary sinusitis.

Periorbital cellulitis affects the top one-third layer of tissue surrounding the eye. Orbital cellulitis involves all three layers of the tissue and is more involved than periorbital cellulitis.

Signs and Symptoms

The patient complains of eye pain and has swelling of the eyelid and erythema of the conjunctiva. There will be significant swelling of the tissue, but the eye will remain grossly normal and easily visualized. With orbital cellulitis, there will be more significant swelling and the eye may not be grossly visualized because of the swelling. The distinguishing factors between periorbital cellulitis and orbital cellulitis are: patients with orbital cellulitis will have ophthalmoplegia (pain with eye movements) and proptosis. It is important that orbital cellulitis is treated aggressively as it can quickly lead to loss of vision or possibly death.

Treatment

Most patients with periorbital cellulitis can be managed on an outpatient basis with oral antibacterials. With orbital cellulitis, the patient will need parental antibiotics and hospitalization. The most common types of bacteria causing both periorbital and orbital cellulitis include Staphylococcus aureus, (including Community-Acquired Methicillin-Resistant Staph Aureus [CA-MRSA] Streptococcus pneumoniae, other streptococci, and anaerobes).

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Ear Disorders

Otalgia

Otalgia, or ear pain, in the adult patient is more likely to be a secondary symptom from a primary problem, such as Eustachian Tube Dysfunction with allergic rhinitis or sinusitis, dental caries, or an abscess, among others. The patient may have primary otitis media or otitis externa, but these are more common in children than in adults.

Signs and Symptoms

Note the basic information regarding the chief complaint. Where does it hurt? What does it feel like? How long has it been a problem? Does anything make it better or worse? Are there any other associated signs and symptoms? Has the patient taken any medications—prescription or over-the-counter drugs—for these symptoms? When does the complaint seem to be better or worse? In other words, note the location, quality, quantity, severity, timing, duration, and onset or triggers. Also note any associated symptoms, such as sinus congestion. Inquire about recent travel, such as air travel, altitude changes, and deep-sea diving.

Evaluation

Inspect the external ear first and then move onto palpation and manipulation of the external ear. An otoscopic evaluation of the ear canal and then of the tympanic membrane should be performed. Note any erythema, drainage, cerumen, or signs of trauma. Are the ear canal and the tympanic membrane still intact? What color is the drainage, and where is it coming from exactly? Is a cone of light present on the tympanic membrane? Are there any signs of scarring or perforation? A hearing acuity screen should be performed. You may consider a CBC as well as culture and sensitivity if any purulent drainage is present and the clinical picture warrants such diagnostics. Note the difference between normal cerumen, purulent drainage, clear drainage, and exudates from dermatitis, including atopic or psoriatic eczema.

Acute Otitis Externa

Inflammation or infection of the external ear canal is also known as swimmer's ear. Acute otitis externa (AOE) can occur from trauma from aggressive cleaning of the ear with foreign objects, such as cotton- tipped applicator swabs, bobby pins or hairpins, tips of keys, paper clips, etc. Pseudomonas and Staphylococcus aureus are common findings in otitis externa. Keep in mind that in patients with compromised immune systems, necrotizing otitis can begin and move as far as the temporal bone, creating damage that may not be repaired.

Signs and Symptoms

Pain with manipulation of the auricle or tragus as well as itching are primary symptoms. There may be a sensation of stuffiness or fullness in the ear canal. A detailed history, including recent travel, history of tympanic membrane perforations, previous ear infections, prior ear surgery, and water exposure is helpful.

Evaluation

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Purulent drainage or clear drainage may be present. The entire ear canal may not be visible because of edema and errythema. There may be cheesy-like exudates, clear drainage or fluid, and purulent drainage. You may perform a culture, if desired.

Treatment

Treatment involves cleaning the ear canal. In the clinical setting using a 1:1 solution of water and hydrogen peroxide at body temperature will allow for the removal of debris and possibly visualization of the tympanic membrane. Topical antibiotics have a high cure rate in most cases. Oral antibiotics are usually only necessary in immunocompromised patients and those with deep tissue infection. Antibiotic ear drops, such as polymyxin, ciprofloxacin, and levofloxacin, may be useful. Caution the patient regarding the use of foreign objects to clean the ear canal. If significant edema is present, you may insert an ear wick into the ear canal in order to ensure that the medication reaches its desired goal.

Otitis Media

Acute otitis media (AOM) is a viral or bacterial infection of the middle ear. Viruses are more commonly the pathogens seen with AOM, and antibacterials are often overprescribed. There is suppurative effusion of the middle ear as a result of the lack of drainage by the Eustachian tube. Bacterial AOM is most frequently caused by Streptococcus pneumoniae. AOM is more common in children because of the number of viral infections they have, in addition to the horizontal placement of the Eustachian tube. In some children, AOM may become chronic and require an ear, nose, and throat (ENT) referral for possible placement of pressure equalization (PE) tubes.

The onset of AOM is associated with ear pain (otalgia) and decreased hearing. Some patients may also have a fever and lymphadenopathy. AOM is typically one sided and drainage may be present if the tympanic membrane has ruptured. With AOM the tympanic membrane is red, opacified, bulging, and immotile. Patients with AOM may also have conductive hearing loss (recall that you can demonstrate conductive hearing loss with both the Rinne's and Weber's test).

For adults with AOM it is recommended that empiric treatment is started with amoxicillin if there is no penicillin allergy. Penicillin provides adequate coverage for the most common bacteria that cause AOM including S. pneumoniae, H. influenzae, and M. catarrhalis. Adults that do not demonstrate improvement within 48–72 hours should be re-evaluated for treatment failure.

AOM with effusion refers to clear serous fluid behind the tympanic membrane from Eustachian tube dysfunction and fluid creation from either allergies or viral illness. Nasal steroids can be useful in decreasing the swelling in the nose and relieving the pressure on the Eustachian tube.

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Barotrauma and Mastoiditis

Barotrauma

Barotrauma is defined as an injury of the ear from a change in atmospheric pressure.

Signs and Symptoms

The symptoms of barotrauma may not appear for up to twenty-four hours after the change in atmospheric conditions. Significant ear pain, pressure, loss of hearing, tinnitus, sinus symptoms, and headaches may be associated with barotrauma.

Evaluation

The tympanic membrane appears inflamed or red but usually is intact. A perforation may be possible. Assess for vertigo and benign positional vertigo symptoms. Perform a brief neurological examination to look for any other associated symptoms.

Treatment

No specific measures may be performed other than patient education and supportive, comfort measures.

Mastoiditis

Mastoiditis is the infection of the mastoid bone—normally a complication of severe otitis media. Although uncommon, mastoiditis is more likely to occur in children and has severe consequences including osteomyelitis, cerebellar abscess, and bacterial meningitis.

Signs and Symptoms

There is ear pain that radiates and is often present for weeks. The pain may be described as severe and deep seated, being worse at night. Fever may be present.

Cardinal signs and symptoms include posterior ear pain and/or local erythema over the mastoid bone, edema of the pinna, or a posteriorly and downward displaced auricle.

Evaluation

Note hearing loss, if any, especially on the affected side of the face. Edema, erythema, and tenderness may be found on examination of the mastoid bone. It is important that you promptly obtain a CT scan with mastoid views.

Treatment

A referral to an ENT specialist is indicated for confirmatory diagnosis and treatment.

Foreign Bodies

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A foreign body in the ear is typically thought of as a pediatric diagnosis, but adults can do silly things too! Do not put anything in your ear smaller than your elbow. Leave the cleaning to the professionals. Foreign bodies may include cerumen, cotton-tipped applicator swabs, insects, and even small spiders. What goes in really needs to come out, especially if it is a foreign body. Consider irrigation, use of small forceps, and a referral for further treatment, if necessary.

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Otorrhea and Cholesteatoma

Otorrhea (Ear Discharge)

Drainage from the ear may come from different sources but is always a warning sign of some problem. Further investigation is always needed.

Signs and Symptoms

Consider the color of the drainage: is it clear, brown, red, dark red, golden, thick, or thin? Purulent discharge is often a sign of infection or the presence of a foreign body. Serosanguinous discharge after a head injury indicates a cerebrospinal fluid (CSF) leak or a skull fracture.

Evaluation

First, look for simple problems. Assess the outside and then the inside of the ear. Is there otitis externa or otitis media present that would account for the symptoms? Is there a foreign body that can be removed? Did the patient experience any recent trauma? Compare both ears, starting with the nonaffected ear and then the affected ear. What is different between the two ears? What is alike? Has there been a spontaneous rupture of the tympanic membrane from infection or trauma? If you suspect a CSF leak, check the fluid for glucose. A CSF leak is a risk for meningitis, and an immediate referral is indicated, provided the patient is stable enough to be referred.

Treatment

Treat the otitis media or otitis externa or remove the foreign body. A ruptured tympanic membrane or a CSF leak requires further attention from an otolaryngologist.

Cholesteatoma

A cholesteatoma is a growth of epithelial tissue in the middle ear. This is a surgical problem, and the patient must be referred for evaluation.

Signs and Symptoms

The patient often presents with discharge or drainage from the ear, fullness, or loss of hearing. In addition, possible dizziness and pain may be noted.

Evaluation

Drainage within the ear canal, as well as granulated tissue, may be present. The drainage is often purulent and possibly malodorous. You may be able to visualize the cholesteatoma behind the tympanic membrane.

Treatment

There is a risk of permanent damage and hearing loss from a lack of treatment. A referral is indicated for further evaluation and possible surgical intervention by an otolaryngologist.

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Hearing Loss

Hearing loss may be associated with the aging process, with symptoms typically beginning during the sixth decade of life. Traumatic hearing loss may be caused by an injury or repetitive loud-noise exposure. A mechanical obstruction may be a foreign object or cerumen. Hearing loss may be classified as conductive, nerve, or central loss.

Hearing loss can be either conductive or sensorineural (mixed). Sensorineural hearing loss typically occurs as a result of damage to the cochlear structure. Conductive hearing loss occurs as a result of the decreased transmission of sound through the external auditory canal to the middle ear.

Signs and Symptoms

Note onset and then progression of hearing loss. Is this an acute or a chronic problem? Does it involve one or both ears? How does it affect the patient's ability to communicate? Are there any associated signs and symptoms, such as tinnitus, pain, or discharge? Note any over-the-counter and prescription medications that may be ototoxic. Inquire about recent trauma.

Evaluation

The whisper test may be used to evaluate general hearing loss or ability. An audiogram is necessary to thoroughly evaluate hearing ability. You may use a tuning fork to note sensorineural or conductive hearing loss (Weber and Rinne tests).

Treatment

Refer the patient to an audiologist or an otolaryngologist for further testing and treatment, provided the hearing loss is not related to a mechanical obstruction, sinusitis, or otitis media or otitis externa, which may be treated by a nurse practitioner.

Cerumen Impaction

Cerumen impactions are usually found in young children and older adults. Evidence suggests that unless the impaction is causing pain, itching, fullness, or difficulty with hearing the best intervention for cerumen in the ear canal is no intervention at all. If the cerumen is causing a problem first attempt a trial of cerumenolytic agents. If there has been no success with the cerumenolytic agents the provider can irrigate the canal with tepid sterile water or saline diluted 1:10 with hydrogen peroxide. If irrigation is unsuccessful and you are skilled at mechanical removal methods you may consider it as an alternative. Be careful as you attempt to remove the obstruction. Most offices have soft plastic earwax curettes that are effective in wax removal however these can cause small abrasions to the external auditory canal. If there is a chief complaint of ear pain, the tympanic membrane must be visualized. Note any trauma to the ear canal walls, and the tympanic membrane should not be injured during the removal. Older adults are likely to have repetitive issues with cerumen impactions and should be evaluated with each visit. Make sure to take a few minutes and review (and save) the clinical practice guideline related to cerumen impaction. Clinical practice guidelines will serve to guide you in providing evidence based care not only in your practicums but also in your future practice.

http://www.aafp.org/dam/AAFP/documents/patient_care/clinical_recommendations/RecToBOD-020810-Attachment-2-CerumenImpaction-Jan2010Cluster.pdf

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Hearing Loss Signs and Symptoms

Evaluation Treatment Plan

Presbycusis:

Age-related sensorineural hearing loss. Symptoms may not be noted until the sixth decade, but initial injury begins in early adulthood. Exposure to noise pollution and genetic predisposition may increase the risk.

The patient notes a gradual onset of hearing loss. Inquire about any family history of hearing loss, noting the age at diagnosis, the diagnosis, and the treatment plan.

Diagnosis of presbycusis is one of exclusion. Rule out other sources of the hearing loss, perform audiometric testing, and confirm the diagnosis. Note the degree of hearing loss. Higher- frequency tones are usually the first to be lost.

Refer the patient to an audiologist or an otolaryngologist for further testing and treatment.

Otosclerosis:

The bony structures of the ear become sclerosed, leading to gradual hearing loss. This problem is more prominent in females and the Caucasian population. A family history of otosclerosis increases the risk of developing this hearing loss. The middle-ear bones lose their vibratory abilities, therefore leading to

The usual presentation is painless loss of hearing. Tinnitus may be noted. The loss is typically bilateral in nature.

The physical examination, with the exception of audiometric testing, is usually noncontributory.

Refer the patient for audiometric testing. Lower frequencies are typically the first to be lost. Surgical intervention has been successful.

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hearing loss.

Acoustic Neuroma:

A benign tumor that attacks the acoustic nerve, or the eighth cranial nerve. Symptoms are usually noted after the third decade of life.

Unilateral hearing loss, tinnitus, and vertigo may be the presenting signs and symptoms. The symptoms often depend on the size of the neuroma. Headaches, facial pain, nausea, and vomiting, as well as lethargy, may be associated symptoms.

Audiogram findings are consistent with early hearing loss, while the rest of the examination is normal.

A referral to an otolaryngologist is needed for definitive diagnosis and initiation of a treatment plan. An acoustic neuroma responds well to surgery and radiation treatment. An MRI is helpful in diagnosis.

Meniere's Disease:

Meniere's disease is associated with increased fluid in the labyrinth of the ear, resulting in increased pressure within the labyrinth.

Severe vertigo, tinnitus, and hearing loss. The vertigo is recurrent but, fortunately, intermittent in nature. The hearing loss may also be transient but does progress over time. A sensation of ear fullness may be noted as a prodrome to a Meniere's episode. Nausea and vomiting may be associated with the vertigo symptoms.

The symptoms and findings for Meniere's disease and an acoustic neuroma are very similar. An MRI of the brain and head is recommended for further diagnostic testing.

A referral to an otolaryngologist is important for further diagnostic testing and setting of a treatment plan.

Tinnitus: Tinnitus is not Take a thorough Refer the patient

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A persistent ringing in the ears that is not attributable to other sources is called tinnitus. Ototoxic drugs are the most likely culprit in the onset of tinnitus, especially in the elderly.

limited to a ringing noise but rather a variety of sounds, including chirping, whistles, buzzing, etc. Symptoms tend to be noted bilaterally and will persist, although at different levels of annoyance.

history, noting prescription and over-the-counter medications. Document any exposure to repetitive noise pollution or loud noises as well as chemical agents. Tinnitus may be a work-related or a recreational problem. Are there any other ear problems in the patient's history, including Meniere's disease? Note any serous otitis media, symptoms of Eustachian tube dysfunction, and allergic rhinitis. Hearing loss is typical but dependent on the level of the tinnitus noise.

to an otolaryngologist for further evaluation, including audiometry testing and a treatment plan.

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Epistaxis

Epistaxis or nosebleeds may occur at any time and at any age. The nosebleed may be bright red and may vary in volume, and it should respond to application of pressure or cold packs. Epistaxis may be related to medication, trauma, allergies, tumors, or other medical problems.

Signs and Symptoms

The presentation of epistaxis is self-explanatory. It is important to find out:

 How long has the patient been bleeding (this episode)?

 Have there been other episodes of epistaxis?

 What treatments or attempts have been made to staunch the blood flow?

 Were any of these attempts successful?

 What was the time frame between episodes?

 Is there any pertinent medical history such as blood disorders, hypertension, or other medical problems?

 Are there any other signs and symptoms, such as headache, chest pain, or cough, which accompany the epistaxis?

 Has the patient experienced any allergy or sinusitis symptoms?

 Has the patient experienced any trauma to the head or face recently?

 Has the patient been evaluated by another provider for these symptoms?

In addition, it is very important to ask about any medications that the patient is currently taking. This includes both prescription and over-the-counter medicines, nasal sprays, and street drugs.

Evaluation

The physical exam should begin with an inspection of the outer structure of the nose:

 Are there signs of obvious trauma, such as ecchymosis or other discoloration, edema, or disfiguration?

 Are there any skin lesions present?

Inspect the intranasal passages. Are both sides responsible for the bleeding or is it unilateral? Note any internal nasal lesions. Keep in mind that external lesions may extend inward, especially skin cancers. A common place to find a skin cancer is on the tip of the nose or on the side of the nares. Squamous cell carcinoma is commonly found in the nasopharyngeal area. Basal cell carcinomas may occur as well. A basal cell carcinoma may present as a lesion that will not heal, ulceration, or even as a "button" on the tip

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of the nose. Squamous cell carcinoma is often asymptomatic until late in the disease, then as unilateral pain or congestion.

Make note of any erythema, pallor, or discharge that may be found within the nasal passages. Note any dryness or irritation. The patient with persistent allergic rhinitis will have a "cobblestone" appearance to the mid-turbinate region and may experience mild nosebleeds or bloody nasal discharge from the dry mucosa.

Symptoms of intranasal drug use include ulceration or friability of the nasal mucosa along with dilatation of the pupils, tachycardia, restlessness, personality changes, and hypertension. These are a few signs of drug use. Note that age, sex, race, educational level, and socioeconomic status are not among the symptoms. You must ask about any type of drug use and understand that the patient may not respond truthfully to this question.

Note any signs of trauma, especially the ones that would alert you to a possible abusive situation. Women and the elderly are at risk for abuse and may not be forthcoming about the perpetrator. Look for other signs of abuse or recurrent visits for unexplained "accidents."

Treatment

Consider plain sinus films or a CT of the face with attention to the nose, if warranted. If you are concerned that there may be a tumor, consider a MRI. Bloodwork is not ordered routinely for epistaxis. A CBC may be ordered in the cases of massive blood loss. Coagulation studies are only recommended in patients taking anticoagulants. If other signs in addition to epistaxis are present providers may order additional testing such as hepatic function testing.

While preparing to examine the patient with active epistaxis you will want to intervene immediately and may achieve hemostasis while doing so. The below mentioned steps can be taken in order to help the patient:

 Have the patient blow their nose to remove any blood clots.

 Spray the affected nares with 2 sprays of oxymetazoline.

 Have the patient pinch the nasal alae (the wings of the nose) against the nasal septum and hold continuously (no peeking) for 10 minutes.

The use of over-the-counter nasal decongestant sprays should be limited due to possible side effects, including rebound nasal congestion.

For persistent bleeding, providers trained in cautery may attempt cautery of the damaged vessel. Nasal packing is also an option, but an immediate referral to an otolaryngologist is recommended for nasal packing. If the epistaxis is a recurrent problem, refer to an otolaryngologist. Note that some patients may experience epistaxis during seasonal changes such as when the heat is turned on and the home environment is suddenly much drier.

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Any patient whom you feel may have a malignant lesion should be referred immediately for additional workup by an otolaryngologist. Consider a plastic surgeon, dermatologist, or otolaryngologist for known skin cancer evaluation and treatment.

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Common Nose Disorders

Nasal Congestion or Drainage

Nasal congestion is the most common nasal complaint in most practices. The spring and fall are common times to experience allergic rhinitis, while winter is a more likely time to have viral upper respiratory infections. Children may experience ten viral syndromes in a season starting in September when school starts, and the spread of viruses becomes more likely indoors. Some patients will experience allergy symptoms in the summer or even year-round. Indoor allergens in the winter include exposure to mammals, indoor mold, and dust mites. You must learn to distinguish between allergic rhinitis and upper respiratory infections.

Signs and Symptoms

Inquire as to when the symptoms began, how severe the symptoms have been, and exactly what symptoms have been present. Is fever present? If so, to what maximum degree? What is the color of the sinus drainage or congestion? Ask the same for sputum. Note any associated signs and symptoms. A viral presentation is often associated with malaise and low-grade fever early on, followed by congestion. The patient with a viral upper respiratory illness (or common cold) generally feels well except for the congestion.

Bacterial presentation begins slowly, then escalates, with fever being secondary and having discolored drainage, sputum, and cough.

Sinusitis will be accompanied by a frontal headache, ear pain or fullness, fever, malaise, pharyngitis, and purulent sinus drainage. The presence of maxillary pain without drainage should be suspicious for dental problems rather than sinusitis.

Evaluation

As with all examinations, begin with inspection of the external features of the nose, face, ears, and throat. You may choose to transilluminate the sinuses, if desired. Do percuss the sinuses for tenderness and palpate for fullness of the sinuses. The preauricular, posterior auricular, and cervical chain should be palpated for lymph node enlargement. Note the appearance of the tympanic membranes, including any distension, erythema, or drainage from the ears. Scarring or signs of previous perforation may be noted in older patients. The chest should be auscultated for wheezing, rales, or rhonchi. Note any decrease in breath sounds, as well as prolonged expiratory phase or fibrotic crackles.

The presence of honey-colored drainage from the sinuses after trauma to the head should be evaluated immediately as it may be secondary to a skull fracture.

Treatment

Decongestants, cough suppressants, and antihistamines can be used for symptomatic relief of a viral illness. The bacterial infection will require antibiotic treatment and cough suppressants as indicated. The use of antihistamines in the elderly should be implemented with caution as well due to interactions, dry

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mouth, and somnolence. Rest and fluids are always appropriate for an upper respiratory infection along with good hand-washing techniques.

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Atopic Disorders

Allergic Rhinitis

Allergic symptoms account for over 2.5% of all outpatient visits in primary care. Environmental allergies may be seasonal or perennial in nature; usually, they are worse in the spring and fall, and may increase or decrease as a person ages. A person may become "desensitized" to a particular allergen through allergy injections or by chronic long-term exposure. A person may experience "sensitization" over a period of time through repeated exposure to a particular allergen. The patient who has become sensitive to an allergen over a period of time will have an allergy response when exposed to the particular allergen(s). The sensitization results in the production of immunoglobulin E (IgE) and can be tested using skin prick testing. This results in a Type I hypersensitivity disorder with both immediate- and late-phase reactions. Seasonal allergies rarely present for the first time in the older population unless there has been an environmental change such as moving to a new geographical area or having a new pet. In older adults with new onset rhinitis symptoms consider other possible diagnoses such as vasomotor or atrophic rhinitis.

Signs and Symptoms

Frequent sneezing, cough, clear sinus drainage, and itchy, watery eyes are all symptoms of allergies. Patients may report nasal obstruction, nasal itching, and postnasal drip. Fatigue is a common complaint for a person with allergies but not fever. Pharyngitis may be present from postnasal drip. The patient may complain of ear fullness due to Eustachian tube dysfunction.

Evaluation

The nasal mucosa is often boggy and pale in appearance; a cobblestone effect may be noted in the mid- turbinate region. In the presence of allergies, the drainage should be clear to white, not discolored. The tympanic membranes may be distended but clear, not erythematous. The sinuses should not feel full or tender to palpation. Infraorbital edema and darkening (allergic shiners) may be present due to subcutaneous venodilation. Dennie-Morgan lines or accentuated lines below the lower lids may be present. Often patients may have a visible transverse nasal crease caused by repeated pushing up of the nose tip (the allergic salute).

Treatment

Allergy avoidance behaviors, environmental changes, and pharmacology are used to provide relief from allergic rhinitis in most cases. In refractory cases immunotherapy may be used. The single most effective method for the maintenance treatment of allergic rhinitis is the use of intranasal glucocorticoids. Intranasal antihistamines may also be used if needed. For patients who are not controlled with intranasal glucocorticoids a second generation anti-histamine may be added. Remember that antihistamines may not be well tolerated in the elderly. Review all medications, both prescription and over-the-counter, before initiating therapy. Review recent changes in the patient's home and work settings. Check if there are any new pets, new carpet, new plants, etc. Has the patient been exposed to a known allergen? Check if the patient is using any new medications, soaps, detergents, lotions, makeup, perfumes, etc.

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Discuss the signs and symptoms of allergies versus an acute infection with your patient. Make sure that the patient understands the differences between each problem and to notify you of any changes. A referral to an allergy specialty practice may be necessary to co-manage the patient with a more severe atopic presentation.

Loss of Smell

The loss of smell may be secondary to nasal congestion, infection, use of medications, an age-related finding, or even a tumor.

Signs and Symptoms

The patient may present with a complete loss of smell, or perhaps only certain smells have been affected. Ask if other symptoms, such as sinus congestion, drainage, hearing loss, facial or neck pain, etc., have been noted. Inquire about fever as well.

Evaluation

Perform a general assessment of the ears, nose, and throat along with lymph nodes and the cranial nerves. If possible, perform a more in-depth smell test with several different everyday items. Findings regarding the loss of smell and mild cognitive impairment have been published by Wilson et al., 2007. The study noted that patients with loss of smell were more likely to develop mild cognitive impairment within five years than those who did not have impairment of the olfactory nerve. Some of the common smells that were not identified included leather, soap, and lilac.

Consider a CT or an MRI for further assistance with diagnosing the underlying problem.

Reference:

R.S,Wilson C.S, Amarasinghe S.P, Anderson J.M, Tjiang S.W.K (0)

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Mouth Disorders

Mouth Sores

Oral lesions may be painful and obvious, and they may even create difficulties with speech and food intake. Many lesions are self-limiting, such as ulcerations, whereas others may be dangerous, even life threatening, such as oral cancer. A thorough history and physical exam are indicated to provide accurate diagnoses and intervention.

Signs and Symptoms

Note the type of lesion, location, any drainage, pain, onset, duration, exacerbating or alleviating factors, possible treatments, and associated symptoms.

You can start with asking the patient the following questions:

 Was there a prodrome prior to the appearance of the lesion(s)?

 Any exposure to irritants?

 Has the patient experienced anything like this before? If yes, what was the diagnosis and treatment?

Aphthous ulcers may begin in childhood years but recur throughout the life span. These ulcers are usually small, shallow, and very painful. Triggers may include food allergies, stress, or even vitamin B12 deficiency. It is important to remember that these are not caused by a virus such as Herpes Simplex Type 1, another cause of painful mouth lesions.

Evaluation

The aphthous ulcer—a shallow erythematous base with mild edema—is usually less than 1 cm in width. The ulcer may be gray or pale yellow in appearance. Multiple ulcers or just a single ulcer may be present. The general rule is that the larger the ulcer, the greater the discomfort.

Treatment

You may encourage over-the-counter saline rinses or topical treatment for mouth ulcers. A topical steroid cream made in oral base may be prescribed with caution. Determining and avoidance of the offending food or fluid is the key to management.

Herpes Simplex

Herpetic lesions in and around the oral cavity may be secondary to Type 1 or Type 2 herpes.

Signs and Symptoms

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The presentation may be of intermittent outbreaks, especially after exposure to heat (usually the sun) or in times of increased stress or immunocompromise. The prodrome is usually tenderness or stinging sensation followed by edema at the localized response area. The lesions tend to reoccur at the same site.

Evaluation

Inspect the area of complaint for erythema, edema, and lesions. Herpes Simplex lesions are typically erythematous-based vesicles that may be singular or in a cluster, located on the vermillion border, around the nares, or in the mouth. Herpes Zoster has a similar appearance but will follow a dermatome. If you suspect zoster instead of simplex, note whether the affected dermatome involve the eye or eye area. If the eye may be or is affected, this requires immediate referral to an ophthalmologist.

Localized lymphadenopathy may be present upon palpation. A superinfection (cellulitis) may be noted from scratching or other irritation. The vesicles may range from early appearance—small erythematous papules, full vesicular appearance—to ruptured vesicles that are dry and rough in appearance. Zoster will follow a dermatome, while simplex remains in a small group in a specific location.

Diagnostic tests are not usually indicated; you may attempt to culture the vesicular drainage or draw a blood sample to evaluate for the presence of antibodies to Herpes Simplex Types 1 and 2.

Treatment

Evidence based treatment with anti-viral medication is available. It is important to check the CDC's website for periodic updates. Medication options include acyclovir and valacyclovir. Patients may also require pain control. Evidence does not support the use of topical therapy.

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Viral Mouth Diseases

Hand, Foot, and Mouth Disease

The source of hand, foot, and mouth disease (HFMD) is the coxsackievirus. This viral illness is commonly seen in children, but it may be seen in immunocompromised adults and the elderly as well.

Signs and Symptoms

The patient may present a prodrome of malaise and fever followed by small, clear vesicles, usually on the lips and in the mouth. The patient may not present for diagnosis until lesions have appeared elsewhere, such as the hands and feet. Complaints of pharyngitis or pain when eating or drinking may be noted. Fever may or may not be present at time of evaluation.

Evaluation

Inspect the lips, mouth, and oral cavity for presence of lesions. The vesicles rupture and form small, erythematous ulcerations on the mucosa and even on the posterior oropharynx. Lesions may be present on the palms of the hands, soles of the feet, and even on the buttocks. Localized lymphadenopathy may be present to palpation of the cervical chain. A rapid strep test may be performed, if available, to rule out strep throat.

Treatment

Treat the patient with rest, and for relief of pain, use acetaminophen or ibuprofen (if not contraindicated by other medications or medical diagnoses); ensure hydration. It is important to keep the patient, especially the elderly, well hydrated.

Candidiasis

Candida infections are common in patients who are immunocompromised, have received antibiotic therapy and steroid treatment, and use certain medications, or from other sources. Candida infections may be present on any part of the body, including the oral cavity. Candidiasis in the oral cavity is commonly referred to as thrush.

Infants may also have diaper candidiasis that is often confused with irritant diaper dermatitis. Candidiasis in the diaper area may also be present in the intertriginous folds as Candida grows in warm, moist, and dark environments. Having simultaneous oral candidiasis and diaper candidiasis is seen commonly in infants.

Signs and Symptoms

The patient may complain of a white "growth" on the tongue, painful swallowing (dysphagia), loss of taste, or discomfort. Ask about recent medication changes, daily medications such as steroids and corticosteroid metered-dose inhalers, or antibiotics. Patients with dentures are also at risk of developing candidiasis. Note if there is a reason that the patient may be immunocompromised.

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Evaluation

Inspect the affected area, noting any presence of plaque, erythema, or white exudates. Angular stomatitis may be present in the corners of the mouth, creating a cracked, dry, or erythematous lesion. Diagnosis can be confirmed with a potassium hydroxide (KOH) preparation or Gram stain.

Treatment

A topical oral antifungal such as nystatin suspension may be used as a swish, gargle, and spit treatment. Alternative treatments include fluconazole suspension or clotrimazole troches. Angular stomatitis may respond to over-the-counter miconazole therapy; apply a small amount to the corners of the mouth, twice daily for up to seven days.

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Painless Oral Lesions

Leukoplakia

Leukoplakia is defined as idiopathic white patches on the oral mucosa. These painless plaques have been linked to an increased risk for squamous cell carcinoma of the oral cavity. Chronic or recurrent trauma to the mucosa and the use of tobacco products (snuff, chewing, and smoking) and alcohol have been associated with an increased risk for leukoplakia.

Signs and Symptoms

Leukoplakia is painless; therefore, it is often found during a dental checkup or after examining one's oral cavity. The leukoplakia has a "stuck on" appearance and cannot be brushed or rubbed away as candidiasis can be.

Evaluation

Inspect the oral cavity and note the presence of the white plaques or patches inside. Some lesions may be raised or wart-like in appearance, but most are flat and smooth. A biopsy should be considered to rule out other processes such as malignancies. A referral to an oral surgeon is indicated for the biopsy.

Treatment

Referral to an oral surgeon should be made. The patient should follow up with the oral surgeon or dentist to monitor for changes in the leukoplakia.

Malignant Lesions of the Oral Cavity

Squamous cell carcinoma is the most common type of oral cancer. The lesions are often painless until very advanced, contributing to poor outcomes. Melanoma may affect the oral cavity, appearing as blue, black, or brown lesions.

If you are suspicious of any oral lesion, refer to an oral surgeon for biopsy as soon as possible.

Denture or Orthodontic Dermatitis

Patients who have dentures or orthodontic appliances may develop an irritation or allergy to the materials. The reaction may be painless or somewhat uncomfortable, ranging from a small erythematous patch to a callous formation. Examine the patient with the part in place, if possible, to see if adjustment would improve the problem. If the patient is experiencing a severe reaction, do not replace the appliance but refer for emergency intervention.

Ill-fitting dentures may be related to weight loss, weight gain, trauma, or even poorly made appliances. Make note of how well dentures fit as ill-fitting dentures may affect nutritional status and intake.

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Mouth Pain without Obvious Lesions

Toothache

Signs and Symptoms

The patient will usually present with complaints of unilateral pain or "toothache." This pain may be made worse by chewing, eating hot- or cold-temperature food, or brushing the teeth.

Evaluation

The source of the pain may be noted upon simple inspection of the oral cavity. Dental caries, fracture, inflammation of the gingiva, periodontal disease, or other trauma, such as loss of a filling, may be visualized. Note any edema, erythema, and drainage near the site. Check to see if the affected tooth is loose. Cervical chain lymphadenopathy may be palpated.

Treatment

Consider referral to a dentist for x-rays and dental treatment. You may initiate antibiotic therapy for an abscess until the patient may be seen by the dentist.

Parotitis

Parotitis is the inflammation of the parotid glands. The salivary glands are often occluded by a stone, limiting or blocking the flow of saliva.

Signs and Symptoms

The patient may present with swelling of the jaw, typically in the parotid area(s). The edema is unilateral, associated with painful mastication and sometimes with fever. It may develop abruptly or over several days. Note that parotid gland swelling also occurs with other infections such as the mumps.

Evaluation

The parotid gland is obviously enlarged, tender to palpation, and possibly erythematous as well as edematous. Some restriction of opening the mouth may be noted due to discomfort and edema. Cervical chain lymphadenopathy may be present to palpation. It is important to evaluate the underlying cause of the parotid gland swelling and assess the overall clinical picture. Parotid gland swelling can have a variety of etiologies. Salivary stones, parotid gland infections, and the mumps all require different diagnostic testing and evidence based treatments.

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49 Week 2 Lectures

Diseases of the Throat

Pharyngitis

A complaint of pharyngitis is a common source for a primary care visit. Many episodes of pharyngitis are related to postnasal drip from allergies or self-limiting viral illnesses. Do not automatically assume that these are the reasons for the pharyngitis. Each patient must be evaluated and formally diagnosed.

Signs and Symptoms

You may ask about the type of pharyngitis the patient is experiencing with the help of the following questions:

 Is the pain mild or severe, aching or scratchy, and burning or mild?

 Has there been any other recent illness?

 Has there been any postnasal drip or anterior nasal discharge? If yes, then what is the color of the drainage or discharge? Any fever?

 Has the patient experienced any dysphagia or respiratory difficulty?

GABHS is associated with abrupt onset of severe pharyngitis, fever, nausea, vomiting, headache, and malaise. Cough and sinus drainage are not associated with GABHS.

Evaluation

Conduct a thorough examination of the ears, nose, throat, head, and neck by performing the following tasks:

 Check for any regional lymphadenopathy.

 You may incorporate assessment of the thyroid gland through palpation as well.

 Note any edema or erythema of the oropharynx.

 Is the trachea displaced or the thyroid gland enlarged?

 Can you visualize swallowing impairment? Is the patient swallowing their own secretions?

 Does the patient have trismus (inability to open the mouth greater than two finger widths)?

The Centor criteria is commonly used to clue into the diagnosis of GABHS infection. The likelihood of having GABHS increases with the number of criteria.

The Centor criteria include:

 Tonsillar exudates

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 Tender anterior cervical adenopathy

 Fever (can be by history)

 Absence of cough

Patients with 2 or less centor criteria are unlikely to have a GABHS infection and normally should not have diagnostic testing or antibiotic medication. In patients with 3 or more Centor criteria perform a rapid strep test to test for GABHS. Normally a throat culture and sensitivity are not needed unless the patient is at high risk for complications from infection (immunocompromised, chronic steroid use, poorly controlled diabetes).

A monospot test along with a CBC may be useful, if clinically indicated.

If the patient has GABHS, the rapid strep test or throat culture should be positive, whereas the monospot test should be negative. Patients with GABHS will have enlarged and tender anterior cervical nodes, and patients with a viral pharyngitis will have shotty posterior cervical nodes. The patient with GABHS may have a fine, reddish pink, and scarlatina rash across the body. This fine rash has a sandpaper-like feel upon palpation.

Treatment

Viral pharyngitis requires rest, fluids, and symptomatic relief with ibuprofen or acetaminophen depending upon the patient's medications or medical history. Make sure that the patient understands symptoms of infection and when to return for follow-up treatment.

Strep throat is usually responsive to antibiotic therapy such as penicillin or cephalosporins. Note any allergy responses to medications before prescribing. Ask what the allergic reaction was and when it occurred. Approximately 10% of patients who are allergic to penicillin may also be allergic to cephalosporins.

Mononucleosis

Mononucleosis is typically a result of the Epstein-Barr Virus (EBV). Possible adverse outcomes from mononucleosis include hepatitis, splenomegaly leading to splenic rupture, meningitis or encephalitis, and anemia.

Signs and Symptoms

The presentation of mononucleosis is a gradual onset of fatigue, malaise, myalgias, headache, and pharyngitis. The symptoms may precede the pharyngitis or may occur together.

Evaluation

The pharyngitis may be severe, prompting the evaluation. Regional and generalized lymphadenopathy is present on examination. The oropharynx is erythematous, tonsils (if present) tend to be enlarged, and greenish, white, or yellow exudates may be noted. Petechiae may be found on the palate in the mouth. A

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fine maculopapular rash may be palpated. Check for organomegaly, including enlargement of the liver and spleen.

The CBC should be evaluated; elevation of the white blood cell (WBC) count is common. Carry out liver function tests as well as the EBV panel.

Apositive EBV panel increases the possibility of developing Guillain-Barre syndrome. This is very rare. Please see the neurological chapter of your text for details.

Mycoplasma infections of the throat are common in children and may cause pharyngitis or tonsillitis. The onset of symptoms is slow and insidious with low-grade fever and dry cough. These infections respond to Macrolide antibiotics.

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Emergent Throat Disorders

Peritonsillar Abscess

Most peritonsillar abscesses (PTAs) occur in the adult population, whereas tonsillitis has a higher incidence in children. The most common cause of PTA is GABHS. PTA may also develop if the patient is under-treated with antibiotics for GABHS, such as in situations where the patient does not take all of the antibiotics as prescribed.

Signs and Symptoms

The patient presents gradual onset over several days of fever, malaise, and pharyngitis. The pain becomes severe and unilateral, and it is more difficult to breathe much less eat or drink.

Evaluation

The examination may be limited due to patient responsiveness to requests or to edema. Involuntary drooling from the mouth may be present. Tonsillar enlargement is often noted with or without purulent exudates or drainage. The patient may have a muffled voice, often called a "hot potato" voice. Consider a CT scan to assist with diagnosis.

Treatment

Monitor for airway impairment. Refer to an ENT specialist (or the emergency department if not available urgently) who can aspirate the abscess for culture or perform a therapeutic incision and drainage. Evaluate appropriate antibiotics for the patient.

Epiglottitis

The rare case of epiglottitis can occur in any age group. Be aware of this life-threatening problem and the need for urgent intervention and referral. The advent of the Haemophilus influenzae type B (HIB) vaccine in children has significantly decreased the number of cases of epiglottitis.

Epiglottitis should not be confused with laryngotracheal bronchitis (LTB) or spasmodic croup. This viral illness is much less severe and is self-limited. The patient will have a dry, barking cough at night. Parainfluenza and adenovirus are common pathogens. Exposing the child to a humid environment, such as a steamy shower, typically abates the cough.

Signs and Symptoms

The patient typically presents with abrupt onset of pharyngitis, fever, cough, and difficulty swallowing. This is a rapidly developing course of symptoms. The patient's voice sounds muffled, and uncontrollable drooling is present. There may be obvious signs of respiratory distress such as stridor or audible wheezing. The tripod position (sitting while leaning forward) is assumed automatically by the patient in an effort to maximize his or her airway.

Evaluation

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Note the above signs and symptoms. The patient appears acutely ill and in distress. Palpation of the larynx creates significant discomfort. If possible, assess oxygen perfusion by a pulse oximeter check on a finger. Note any cyanosis or stridor. Use oxygen, if necessary, to maintain adequate airway support.

Treatment

Monitor for complete airway obstruction while obtaining emergency transportation to the nearest emergency department. An otolaryngologist should be notified of the emergency situation in order to meet the patient in the emergency department for treatment. Do not hold the patient while trying to locate the ENT specialist—the patient is at high risk for loss of airway and must be transported immediately.

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54 Week 2 Lectures

Sinusitis

Sinusitis results as a secondary infection from either viral syndrome or allergic rhinitis. As a result of the persistence of clear mucus production and obstruction, the ethmoid and maxillary sinuses may become infected. Sinus inflammation and mucus production are normal components of any viral syndrome and should not be confused with acute sinusitis. If the patient's symptoms persist past seven to ten days, then the nurse practitioner would consider acute sinusitis.

The most common pathogen is Streptococcus pneumoniae. In addition, Haemophilus influenzae and Moraxella catarrhalis may also be causative. Signs and symptoms would include sore throat and low- grade fever, with toothache in some patients. Sinus pain and pressure are also seen.

Once the diagnosis of acute sinusitis is made, non-pharmacological and pharmacological therapy provides resolution. Non-pharmacological therapy includes humidification, warm compresses, adequate hydration, smoking cessation (if applicable), and nonnarcotic analgesia. Antihistamines have not been shown to be effective in the treatment of sinusitis. Intranasal decongestants can be used to decrease edema. Intranasal decongestants should not be used longer than 72 hours (3 days) to prevent rebound congestion. Penicillins, cephalosporins, and macrolides all appear to have adequate effect in the treatment of acute sinusitis. However, randomized controlled trials in antimicrobial therapy are lacking.

Additional workup such as CT scan of the sinuses is only warranted if the patient has recurrent sinus infections or chronic sinusitis. A referral to an ENT specialist may also be warranted to assess for obstruction.

Pediatric patients may also present with acute purulent rhinitis. This typically results from stagnation of clear mucus in the nasal passageway. There is controversy as to whether this requires oral antibiotic therapy and should be treated on a case-by-case basis. It would be prudent to check for a foreign body in the nares in these patients.

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Thyroid Disorders

Thyroiditis

The inflammation of the thyroid gland is referred to as thyroiditis and is typically caused by a virus. This is a painful subacute inflammation that should be self-limiting. It consists of a hyperthyroid episode, followed by a rebound hypothyroidism, and then returns to a euthyroid state. Postpartum thyroiditis develops in the first six months after childbirth but is not associated with a painful thyroid. Females are more likely to experience thyroiditis than males.

Signs and Symptoms

The patient typically presents with complaints of pain in the neck or throat. The pain may radiate to the ear. Associated symptoms may include malaise, fever, myalgias, or dysphagia. The symptoms tend to be abrupt.

Evaluation

The thyroid is enlarged and tender to palpation. There should not be specific nodules but rather a diffuse enlargement. Note any displacement of the trachea or airway involvement.

The thyroid panel may be abnormal or normal, depending upon the state of the thyroiditis at time of presentation. The ESR is often elevated due to inflammation.

Treatment

Thyroiditis is typically self-limiting and requires monitoring to ensure that a euthyroid state is achieved. There may be some flux of metabolic symptoms, but overall, a return to baseline is expected. You should educate the patient as to the expectations and anticipated outcomes. Include the symptoms of hyperthyroidism and hypothyroidism in your educational material or discussion.

Other thyroid disorders will be discussed in the endocrinology section of this course.

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Hoarseness

Hoarseness may be self-limiting, as associated with viral syndromes and overuse; however, other sources for the symptoms should be considered, such as malignancies or gastroesophageal reflux disease (GERD), and further evaluation provided.

Signs and Symptoms

Note a change in voice in the patient. You may do this by performing the following tasks:

 Ask the patient how his or her voice has changed.

 Does it seem lower, higher, softer, louder, rougher, deeper, etc.?

 When did this change occur?

 Was the change gradual or abrupt?

 Do the symptoms wax and wane or persist?

 Does anything make the symptoms better or worse?

 Have they taken any medications, including over-the-counter medicines?

 Are there any associated symptoms such as reflux, postnasal drip, or pharyngitis?

 Note any use, current or previous, of tobacco and alcohol products.

 Note quantity, type, and usage patterns.

 When did the patient use tobacco or alcohol last?

 Has there been trauma to the neck or chest in the past?

 Any previous surgeries?

Evaluation

Perform a full examination of the head, ENT, as well as lungs, chest, and cranial nerve assessment. Note any localized or regional lymphadenopathy. Consider a chest x-ray, especially if there is a history of tobacco abuse. Assess the abdomen for epigastric pain or hepatosplenomegaly. The presence of epigastric tenderness can be suggestive of reflux disease that is exacerbating the hoarseness.

Refer to an otolaryngologist for evaluation with a laryngoscope to look for erythema, edema, excoriation, polyps, or masses. If a gastrointestinal illness or malignancy is suspected refer for endoscopy.

Treatment

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Treatment is based upon the final findings and diagnosis. Voice rest may be all that is necessary to relieve the symptoms. Postnasal drip may be treated with antihistamines, saline irrigation, or prescription medications. GERD may require a H2 blocker or proton pump inhibitor to decrease acid production in the stomach.

Laryngeal cancer or tumors may require chemotherapy, surgery, and/or radiation treatments. Refer for additional workup of this patient.