Ent ppt seminar

ENT
DISORDERS
Presented by: Mrs.Sapna Kumari
Class:M.Sc (N) 2nd year
A.C.N Baru Sahib 7/15/2017
1

Introduction about human eye
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Introduction :
 The eye allows us to see the shapes, colors and dimensions
of objects by processing the light they reflect or give off. The
eye changes light rays into electrical signals and then sends
the signals to the brain. The brain interprets these electrical
signals as visual images. Six muscles regulate the motion of
the eye. Among the more important parts of the anatomy of
the human eye are the cornea, conjunctiva, iris, lens, retina,
macula and the optic nerve.
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Cont….
Cornea
 The cornea is sometimes referred to as the "window of the eye.
 It provides most of the focusing power when light enters your eye.
Lens
The lens is the clear structure located behind the iris. Its primary
function is to provide fine-tuned focusing for near vision.
Pupil
The pupil is the hole in the center of iris (the colored part of your eye).
The primary function of the pupil is to control the amount of light
entering your eye. 7/15/2017
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Cont…
Iris
The iris provides the color for the eye. The iris’ main role is
to control the size of the pupil through contraction or
expansion.
Vitreous Body
This is the clear, gel-like substance located inside the eye's
cavity. The purpose of the vitreous body is to provide a
spherical shape to the eye.
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Cont…..
Retina
The retina consists of fine nerve tissue that lines the inside
wall of the eye and acts like the film in a camera. Its primary
function is to transmit images to the brain.
Optic Nerve
The optic nerve carries electrical signals from the retina to
the brain.
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Cont…
Sclera:
The sclera is the white part of the eye’s anatomy. The
sclera's purpose is to provide structure, strength and
protection to the eye.
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NEONATAL
CONJUNCTIVITIS

Definition:-
Neonatal conjunctivitis is watery or purulent ocular
drainage due to a chemical irritant or a pathogenic
organism.
Or
Conjunctivitis also known as pinkeye is an inflammation
of the conjunctiva.
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Etiology:
The major causes (in decreasing order) are:-
Bacterial infection
Chemical inflammation
Viral infection
Infection is acquired from infected mothers during
passage through the birth canal.
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Cont..
 Chemical conjunctivitis is usually secondary to the
instillation of topical therapy for ocular prophylaxis.
 The major viral cause is herpes simplex virus types 1 and
2 (herpetic kerato conjunctivitis), but this virus causes <
1% of cases.
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Pathophysiology
Microbes/irritants/toxins enter the eye on
contact with infected object/ article
Inflammation of eye
Dilation of blood vessels of eye
Swelling, redness, exudates and
discharge 7/15/2017
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Symptoms of conjunctivitis
(pinkeye)
 Pink or red color in the white part of the eye
 Swelling of the conjunctiva
 Increased tear production
 Feeling like a foreign body is in the eye
 Itching, irritation, and/or burning
 Discharge (pus or mucus)
 Crusting of eyelids or lashes, especially in the morning
 Contact lenses that do not stay in place on the eye and/or feel
uncomfortable
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Depending on the cause, other
symptoms may occur.
Viral Conjunctivitis
 Cold, flu, or other respiratory infection
 Usually begins in one eye and may spread to the other eye within days
 Discharge from the eye is usually watery rather than thick
Bacterial Conjunctivitis
 Usually begins in one eye and sometimes spreads to the other eye
 More commonly associated with discharge of pus, especially a yellow-green
color
 Sometimes occurs with an ear infection 7/15/2017
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Cont…
Allergic Conjunctivitis
Usually occurs in both eyes
Can produce intense itching, tearing, and swelling
in the eyes
May occur with symptoms of allergy, such as an
itchy nose, sneezing, a scratchy throat, or asthma
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Cont..
Conjunctivitis Caused by Irritants
Produce watery eyes and mucus discharge
Neonatal conjunctivitis is a red eye in a newborn
caused by infection, irritation, or a blocked tear
duct. When caused by an infection, neonatal
conjunctivitis can be very serious.
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Symptoms in Newborns
 Mucu-purulent discharge
 Swelling of eyelid
 Irritation in eye
 Sticky eyelid
 Red eye (hyperemia)
 Sandy feeling
 Exudation (flaky and sticky substance on eyelid margins)
 Lesions on eyelids with crusty appearance
 Tearing and itching in eyes
 Photophobia
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Diagnostic evaluation
Mainly based on clinical features.
A culture of the drainage may be obtained to
confirm the diagnosis.
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Medical management
Inclusion (chlamydial) conjunctivitis
Oral antibiotics are usually used to treat inclusion conjunctivitis.
Gonococcal conjunctivitis
Intravenous (IV) antibiotics are usually given to treat gonococcal
conjunctivitis. If untreated, the newborn could develop corneal
ulcerations (open sores in the cornea) and blindness.
Chemical conjunctivitis
This type of conjunctivitis is caused by chemical irritation,
treatment is usually not required. The newborn will usually get
better in 24 to 36 hours. 7/15/2017
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Cont…
Other bacterial and viral conjunctivitis
Antibiotic drops or ointments for the eye are usually
given to treat conjunctivitis caused by bacteria other
than Chlamydia trachomatis and Neisseria gonorrhoeae.
For both bacterial and viral conjunctivitis, a warm
compress to the eye may relieve swelling and irritation.
Be sure to wash hands before and after touching the
infected eyes.
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Precautions:
To relieve the symptoms of pinkeye:-
Protect your eyes from dirt and other irritating
substances.
Avoid the use of makeup.
Remove contact lenses if you wear them.
Non-prescription "artificial tears" a type of eye
drops, may help relieve itching and burning from
the irritating substances causing your pinkeye
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Prevention from Spreading If
child has pinkeye
 Don't touch or rub the infected eye.
 Wash your hands often with soap and warm water, especially
before eating.
 Wash any discharge from your eyes several times a day using a
fresh cotton ball or paper towel. Afterwards, discard the cotton
ball or paper towel and wash your hands with soap and warm
water.
 Wash your bed linens, pillowcases, and towels in hot water
and detergent.
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Cont….
 Avoid wearing eye makeup.
 Don't share eye makeup with anyone.
 Never wear another person's contact lenses.
 Wear eyeglasses instead of contact lenses. Throw away
disposable lenses or be sure to clean extended-wear lenses
and all eyewear cases.
 Avoid sharing common articles such as unwashed towels
and glasses. 7/15/2017
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Cont….
 Wash your hands after applying the eye drops or ointment
to your eye or your child's eye.
 Do not use eye drops that were used for an infected eye in
a non-infected eye.
 If child has bacterial or viral pinkeye, keep child at home
from school or day care until he or she is no longer
contagious. It's usually safe to return to school when
symptoms have been resolved; however, it's important to
continue practicing good hygiene just to be sure.
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Nursing care25
 Clean eyes as above.
 Instruct mother to talk to her health care provider if she has given birth (or
expect to give birth) to a baby in a setting where antibiotic or silver nitrate
drops are not routinely placed in the infant's eyes.
 Persistence of the watery discharge, should arise the suspicion of
blocked nasolacrimal duct. The mother should be instructed to massage
the duct area before instilling eye drops.
 If the blockage is not relieved by the age of five to six months, probing
and dilatation of the duct may have to be done.
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GONOCOCCAL
OPTHALMIA
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Definition
Eye infection Caused by N.
gonorrhea (during birth)
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Clinical manifestation :
 Eye discharge (2nd to 3rd day)
 Edematous conjunctiva
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Treatment:
 2500 units of penicillin/ml drop every ½ an hour
for 3 hours, than every hour for 24 hours, than
every 2 hourly.
 10% sulphacetamide eye drops
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Definition
Conjunctivitis that occurs as a result of
bacterial infection
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CAUSATIVE ORGANISM
 H. influenza
 Staphylococcus
 Corynebacterium diptheriae
 N. gonorrhea
 Streptococcus
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CLINICAL MANIFESTATION
 Mucupurulent discharge
 Yellow/green or white pus
 Photophobia
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DIAGNOSTIC EVALUATION
 Culture and sensitivity
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TREATMENT
 Saline irrigation
 Antibiotic eye drops/ ointments (Bacitracin,
Neomycin, tetracycline)
 Proper eye care and hygiene
 The condition usually improves within 2 to
3 days.
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ALLERGIC
CONJUNCTIVITIS
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Definition
Excessive itching of eyes due to
allergens
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Symptoms
Seasonal onset of symptoms:
 Excessive lacrimation
 Watery or mucoid discharge
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 Conjunctival scraping :-
Reveals eosinophils.
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TREATMENT
 Hydrocortisone 1% opthalmic ointment 3-4 times
per day.
 Anti-histamine eye drops or oral.
 Avoidance of allergens/irritants/toxins.
 Cold compress
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PERIORBITAL
CELLULITIS
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Introduction
 Periorbital cellulitis also called preseptal cellulitis
is a serious but treatable infection of the eyelid
and tissues around the eyeball. It usually affects
only one eye and doesn't travel to the other. It's
most common in children younger than 6 years.
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Definition
 Periorbital cellulitis is a common infection of
the eyelid and periorbital soft tissues that is
characterized by acute eyelid erythema and
edema.
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Epidemiology
 According to the National Center for Disease Statistics, in 1995,
approximately 5000 inpatients in the United States had a
primary discharge diagnosis of deep inflammation of the eyelid,
as specified in the International Classification of Diseases.
 Preseptal cellulitis is primarily a pediatric disease, with
approximately 80% of patients being younger than 10 years and
most patients being younger than 5 years. Patients with
preseptal cellulitis tend to be younger than patients with orbital
cellulitis.
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Etiology
 Upper respiratory tract infection
 Paranasal sinusitis
 The most common organisms
are Staphylococcus aureus, Streptococcus
pneumoniae
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Risk factors
Antecedent events in preseptal cellulitis may include the following
recent eyelid lesions:
 Hordeola
 Chalazia
 Bug bites
 Trauma-related lesions
 Lesions caused by a recent surgical procedure near the eyelids
 Lesions caused by oral procedures
 Dacryocystitis 7/15/2017
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Symptoms
The symptoms of cellulitis of the eyelid may include:
 Redness around your eyelid
 Swelling of your eyelid
 Swelling of the skin around your eye
This condition usually doesn’t cause vision problems
or any pain in the eye.
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 Physical exam
 blood tests
 CT or MRI scan to get clear, detailed images of the
structure of your eye.
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Treatment:
 Oral antibiotics, including amoxicillin
and dicloxacillin
 A warm compress can also be used at home to
help reduce inflammation.
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Complications
 In some cases, the infection may spread to eye
socket or eye itself. This can lead to a serious
condition called orbital cellulitis. Orbital cellulitis
may cause eye pain, vision problems, and even
blindness.
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Retinopathy
of
prematurity
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Introduction
Retinopathy of prematurity occurs when immature blood
vessels in the retina constrict and become necrotic. This
condition which may occur in low birth weight infants or
of short gestation.
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Definition:
ROP is a pathologic process that occurs only in
immature retinal tissue and can progress to
tractional retinal detachment, which can result in
functional or complete blindness.
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Etiology:
 Exposure of the immature retina to high oxygen
concentrations can result in vasoconstriction and
obliteration of the ratinal capillary network, followed by
vasoproliferation .
 Immature infants
 Respiratory distress
 Artificial ventilation
 Apnea 7/15/2017
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Etiology Cont……..
 Bradycardia
 Heart disease
 Multiple blood transfusions
 Infection
 Hypoxia
 Hypercarbia
 Acidosis
 Shock
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Pathophysiology
Prematurity
Incomplete retinal vascularization
Exposure to increase oxygen
Vasoconstriction
Vaso-obliteration and involvation
Peripheral retina ischemia stimulates production of vascular endothelia
growth factor (VEGF)
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Pathophysiology cont…..
Tortuosity of vessels Neovascularization Iris vessel dilation and rubeosis
iridis
Fibrovascular proliferation
Retinal detachment
Blindness
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Clinical manifestation
 Abnormal eye movement
 Crossed eyes
 Severe nearsightedness
 White looking pupils (leukocoria)
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 Dilated funduscopic examination :- Dilated
fundoscopic examination should be performed in
the following patients:-
 All infants born < 30 weeks gestation
 Infants born>30 weeks gestation including those
requiring cardio respiratory support
 Any infant with a birth weight <1500 gm
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Cont……
Timing:-
 For all infants <27 weeks gestation at birth , initial ROP
screening examination should be performed at 31
weeks postmenstrual age
 For all infants >28 weeks gestation at birth ,initial ROP
screening examination should be performed at 4 weeks
chronologic age
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Cont……
 For infants born before 25 weeks gestation consider
earlier screenings at 6 weeks chronologic age.This
may enable earlier detection and treatment
aggressive posterior ROP, which is a sever form of
rapidely progressive ROP.
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Classification of ROP:
 Stage 1: Demarcation line separates avascular from
vascularized retina
 Stage 2: Ridge forms along demarcation line
 Stage 3: Extra retinal fibrovascular proliferation
tissue forms on ridge
 Stage 4: Partial retinal detachment
 Stage 5: Total retinal detachment
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Treatment
 ROP surgery is used to stop the growth of abnormal
blood vessels by focusing treatment on
the peripheral retina to preserve the central. ROP
surgery involves scarring areas on the peripheral
retina to stop the abnormal growth and eliminate
pulling on the retina.
 Surgery focuses treatment on the peripheral retina,
these areas will be scarred and some amount of
peripheral vision may be lost.
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Surgical management :
The most frequently used methods of ROP surgery
are:
 laser surgery: The most common type of ROP
surgery, in which small laser beams are used to scar
the peripheral retina.
 Cryotherapy: Where freezing temperatures are used
to scar the peripheral retina to stop abnormal blood
vessel growth.
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Surgical management
Cont…
Scleral buckling:
 which involves placing a flexible band, usually made of
silicone, around the circumference of the eye.
 The band is placed around the sclera, or the white of
the eye, causing it to push in, or "buckle."
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Surgical management
Cont…..
Vitrectomy:
 A complex surgery that involves replacing the vitreous,
or the clear gel in the center of the eye, with a saline
(salt) solution.
 Removing the vitreous allows for the removal of scar
tissue and eases tugging on the retina, which stops it
from pulling away. Vitrectomy can take several hours.
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Nursing assessment
 Assessment of the infant at risk for retinopathy of
prematurity begins at birth by identifying infants who
may require oxygen therapy .
 Look for risk factors eg: Prematurity, low birth weight
 Assess the infants breathing effort and report any
change
 Be certain the ventilation equipment is properly set to
deliver the correct amount of oxygen 7/15/2017
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Introduction:
Strabismus, also called crossed eyes, is a condition in
which the eyes do not properly align with each other
when looking at an object.
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Definition:
Strabismus is a failure of the two eyes to
maintain proper alignment and work together as
a team.
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Epidemiology:
 Strabismus occurs in 2-3 % of all children.
 Approximately half of these children have a family history for the defect
.
 Transient strabismus is normal in first 4-6 months of life and is
attributed to physiologic hypermetropia.
 In newborn, there may be slight deviation which may disappear by 3-6
month of age. If it does not happen by 6th month, the child may develop
permanent squint.
 5% of infants have congenital squint.
 The paralytic squint is associated with CNS disorders.
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Types:
1. Convergent squint or Esotropia :- Eyes are
crossed
2. Divergent squint or Exotropia:- Eyes diverge
3. Vertical squint or Hypertropia:- Vertically
misaligned
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Other classifications
 Strabismus can be further classified as follows:
 Paretic strabismus is due to paralysis of one or several extraocular
muscles.
 Nonparetic strabismus is not due to paralysis of extraocular
muscles.
 Comitant (or concomitant) strabismus is a deviation that is the
same magnitude regardless of gaze position.
 Noncomitant (or incomitant) strabismus has a magnitude that
varies as the patient shifts his or her gaze up, down, or to the
sides.
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Causes:
 Muscle dysfunction
 Farsightedness
 Problems in the brain
 Trauma
 Infections
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Risk factors:
 Premature birth
 Cerebral palsy
 Family history of condition
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Pathophysiology
Extraocular Muscles control the position of the eyes and
problem with the muscles or the nerves controlling them can
cause paralytic strabismus
Impairment of Cranial Nerve IV causes the associated eye to
deviate down and out
Strabismus
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Symptoms:
 Squinting and frowning when reading
 Non aligned eyes
 Closing one eye to see
 Dizziness
 Headache
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During an eye examination, a test such
as :
 Inspection
 Examination
 Specific tests
 Visual acquity test
 Corneal light reflex test
 Kirmsky test
 Hirschberg’s test
 Cover- uncover test 7/15/2017
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Treatment:
 Early diagnosis and treatment and early referral.
 Correction of refractive errors and associated
conditions like cataract.
 Occlusion therapy
 Orthotropic training
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Strabismus Surgery:
 Glasses prisms, patching or blurring of one eye,
botulinum toxin injections, or a combination of
these treatments.
 Eye muscle surgery to straighten eye
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Pre-operative test for
surgery
 Sensori motor examination:- To assess the
alignment of the eyes to determine which muscles
are contributing to the strabismus and which
muscles need to be altered to improve the
alignment of the eyes.
 Prisms are used to measure the degree of the
strabismus.
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Medications and strabismus
surgery:
Strabismus surgery rarely causes significant
bleeding. Some surgeons may suggest that to stop
taking blood thinners i.e.
 Aspirin, aspirin-containing products
 Ibuprofen
 Nutritional supplements that can affect bleeding for
a week before the surgery
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After surgery:
 Monitoring of patient after surgery.
 Children can return to school after two days.
 Adults should not drive the day of surgery or the day
after and may need up to a week before returning to
work.
 Patient may have double vision that can last hours to
days or a week or more, rarely longer. Exercise caution
with activities like driving if you have double vision.
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After surgery cont….
 Pain is minimal and usually over-the-counter
medicines, such as ibuprofen (Motrin) or
acetaminophen (Tylenol), and cool compresses are
adequate. Adults and older children may need
prescription pain medicine.
 The main restriction after strabismus surgery is not
swimming for two weeks.
 The eye will be red for one to two weeks, rarely
longer, especially if it is a reoperation.
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Potential risks of strabismus
surgery
Risks with any surgery, including:
 Sore eyes
 Redness
 Residual misalignment
 Double vision
 Infection
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Potential risks of strabismus
surgery cont …
Bleeding
Corneal abrasion
Decreased vision
Retinal detachment
Anesthesia-related complications
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DEFINITION
Cataract is an opacification or milky white appearance of the
normally clear transparent crystalline lens that impairs
vision.
INCIDENCE
 1 in 250 newborns
 childhood cataract can be congenital or acquired.
 congenital cataract is from birth and acquired cataract may
be secondary to ocular trauma.

TYPES
Unilateral and bilateral
Partial and complete
Congenital and acquired
ETIOLOGY
 Due to ageing (senile cataract)
 Present since birth ( congenital cataract)
 Due to injury (traumatic cataract )
 Absence of crystalline lens (aphakia)

 CAUSES OF CONGENITAL CATARACT
• Prematurity
• Trauma
• Retrolental fibroplasia
• Glucoma
• Maternal infection
• Chromosomal disorders
• Metabolic disorders

 CAUSES OF ACQUIRED CATARACT
Eye trauma (contusion, penetrating injury etc. )
Drug effects ( tetracycline, chlorpromazine)
Child abuse
Steroid induced
Hypoglycemia
Hypocalcemia
Hypo/hyper vitaminosis ‘D’
Juvenile onset DM
Radiation exposure

Risk factors
Diabetes
High dose radiation
Long term corticosteroids use
Ultraviolet light exposure
Systemic diseases viz. hypothyroidism
Long term use of phenothiazine and
chemotherapy agents

PATHOPHYSIOLOGY
Interference with Lens capsule formation and
development during 4th and 5th week of gestation.
CLINICAL MANIFESTATIONS
oBlurred or distorted vision
oGradually diminishing /impaired vision
oGlare from bright light
oGray opacification of lens
oVisible clouding of lens

INVESTIGATION
Family or prenatal history collection
Physical examination
Local eye inspection/examination
Slit lamp examination
Tonometry
Opthalmoscopy:
Direct
indirect

MANAGEMENT
Surgical removal of cataract/ affected lens and
replacement with artificial intra-ocular lens.
Surgery must be done before 8 weeks to 6
months of age.
Optical iridectomy
Lens fragmentation
 irrigation and aspiration
Cutting and aspiration

BEFORE SURGERY
Patient with one cataract can usually manage
w/o surgery.
If bilateral cataract it is highly recommended.
Only one surgery can be done at a time.
Follow Pre-operative orders.

AFTER SURGERY
Eye shielding with eye patch.
Instillation of antibiotic and steroidal
eye drops.
Routine eye care and aseptic
dressing.
Post –operative care.
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INTRODUCTION
Amblyopia, also called lazy eye, is a disorder
of sight due to the eye and brain not working well
together. Vision loss occurs because nerve
pathways between the brain and the eye aren't
properly stimulated.
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1

Definition
Amblyopia is decreased vision in one or both eyes
due to abnormal development of vision in infancy or
childhood.
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CAUSES OF AMBLYOPIA
 Vision centers do not develop properly
 Refractive error in one or both eyes
 Strabismus or eye misalignment
 Structural anomaly that impairs the visual function
like a droopy eyelid or opacity in the visual axis like
cataract or corneal scar.
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3

TYPES:
Amblyopia has three main types:
 Strabismic: By strabismus (misaligned eyes)
 Refractive: By anisometropia (high degrees
of nearsightedness, farsightedness ,
or astigmatism in one or both eyes)
 Deprivational: By deprivation of vision early in life
by vision-obstructing disorders such as congenital
cataract
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4

Pathophysiology:
 Amblyopia is a developmental problem in the brain,
not any intrinsic, organic neurological problem in the
eyeball
 The part of the brain receiving images from the
affected eye is not stimulated properly and does not
develop to its full visual potential.
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Sign and symptoms:
An eye that wanders inward and outward
Eyes that appear to not work together
Poor depth perception
Squinting or shutting an eye
Head tilting
Abnormal results of vision screening test
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Diagnostic evaluation:
 Amblyopia is diagnosed by identifying low visual
acuity in one or both eyes
 In young children, visual acuity is can be estimated
by observing the reactions of the patient reacts
when one eye is covered, including observing the
patient's ability to follow objects with one eye.
 Retinal birefringence scanning
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Treatment
 Correcting the optical deficit (wearing the necessary
spectacle prescription) and often forcing use of the
amblyopic eye, by patching the good eye, or
instilling topical atropine in the good eye, or both
 Deprivation amblyopia is treated by removing the
opacity as soon as possible followed by patching or
penalizing the good eye to encourage the use of the
amblyopic eye.
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INTRODUCTION
Glaucoma is a disease that damage the
eye’s optic nerve . It usually happen when
fluid builds up in the front part of eye. The
extra fluid increase the pressure in eye,
damaging the optic nerve.

DEFINITION
It is a disorder which is characterized by
optic nerve atrophy, retinal layer
detachment & increase in IOP due to
increase in aqueous humor production.
It is a condition in which pressure within the
eyeball increases, causing gradual loss of
eye sight.

NORMAL EYE PROCESS
Clear liquid called aqueous humor circulates
inside the front portion of the eye.
 To maintain a healthy level of pressure within the
eye, a small amount of aqueous humor is produced
constantly, while an equal amount flows out of the
eye through a microscopic drainage system—the
trabecular meshwork.

ABNORMAL EYE PROCESS
{GLAUCOMA}
In glaucoma, there is obstruction in the out flow
of the aqueous humor which results in increase
intra ocular pressure & damaging the optic
nerve fibers.

TYPES OF GLAUCOMA
Open angle glaucoma
Close angle glaucoma

Open angle glaucoma:
 it’s the most common and also known as the wide angle
glaucoma. The drain structure in eye, trabecular
meshwork looks normal but fluid doesn’t flow out like it
should.
 Intraocular pressure (IOP) builds up, which leads to
damage of the optic nerve.
 Damage to the optic nerve occurs at different eye
pressures among different patients.
 Typically, glaucoma has no symptoms in its early
stages.

Close angle glaucoma :
It’s less common and also known as narrow
angle glaucoma, eye doesn’t drain the
aqueous humor because angle between the
cornea and iris is too narrow.
It may cause sudden buildup of pressure in
eye, and may cause farsightedness and
cataract, clouding of eye lens.

TYPES OF CLOSED ANGLE
GLAUCOMA
 Acute: occur when the fluid pressure inside the eye
rises quickly, the usual symptoms sudden, severe
eye pain, red eye and reduced or blurred vision.
 Sub-acute: it’s intermittent and difficult to diagnose
without gonioscopy and may present with intermittent
headache or with amaurosis fugax.

CONT..
 Chronic: develop after acute angle closure
glaucoma and when the chamber angle closes
gradually and IOP rises slowly as angle function
progressively become compromised.
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CAUSES AND RISK FACTORS
 Degenerative change in the trabecular mesh work
resulting in decrease outflow of aqueous humor.
 History of DM, consuming steroids
 Hypertension, Cardiovascular disease
 Uveitis or severe eye infection (inflammation of filtering
structure)

Cont….
 Encroachment by rapidly growing tumor &
chronic use of topical corticosteroids.
 Eye injury, inflammation, tumor or advanced
cases of cataract or diabetes.
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PATHOPHYSIOLOGY
Due to etiological factors (HTN, injuryetc.)
Variations in the IOP
Hyper production of aqueous humor &obstruction of outflow.
Aqueous fluid accumulates in eye
Increase pressure inhibits blood supplyto optic nerve & retina.
Tissue become ischemic & graduallylose function.

CLINICAL MENIFESTATION:
 Hazy or blurred vision due to cornea edema
 The appearance of rainbow colored circles around bright light
(swelling of cornea)
 Severe eye pain, Difficulty in focusing and headache
 Nausea and vomiting
 Sudden sight loss
 Pupil non-reactive, mild-dilated & fixed
 Slowly developing impairment of peripheral vision.

 History collection
 Physical examination
 Ophthalmoscopic examination-show atrophy &
cupping in optic nerve.

Cont..
 Tonometry- elevated IOP usually
greater than 20 mm hg.

Cont….
Ocular examination –to reveal pale
optic disk.

Cont..
Visual field examination- to
determine vision loss.

Cont…
 Gonioscopy- (gonioscope) to study the angle of
anterior chamber of eye between the cornea
and iris. It’s a painless procedure to see the
area where fluid drains out of eye is open or
closed.

TREATMENT/ MANAGEMENT
 MEDICAL MANAGEMENT
 SURGICAL MANAGEMENT
 NURSING MANAGEMENT

MEDICAL MANAGEMENT
 Eye drops: it will reduce the formation of fluid in the eye or increase the
outflow
 Beta adrenergic blockers: To decrease the aqueous humor
production
 Carbonic anhydrase inhibitor: Acetazolamide. Decrease the pressure
in the eye by reducing aqueous humor.
 Cholinergic agents: Pilocarpine. It increases aqueous fluid outflow by
controlling ciliary muscles.
 Hyper osmotic agents: Mannitol (IV)
 Prostaglandin analogs: Relaxes the muscles in the eye to allow better
outflow of fluids. latanoprost, travoprost.

SURGICAL MANAGEMENT
 Laser surgery: it will slightly increase the flow of the fluid
from the eye. It includes:-
 Trabeculoplasty: Eye drops are put in the person's eye
before or after the procedure to decrease the amount of
fluid in the eyes and prevent elevation in eye pressure
immediately after laser treatment. A special microscope (slit
lamp) and lens (goniolens) are used to guide the laser
beam to the canals (trabecular meshwork) where fluid
drains from the eye. The doctor makes small burns in the
trabecular meshwork.

Cont…
 Iridotomy: (incisional or laser) makes a tiny hole in
the iris to let fluid flow more freely

Cont..
 Cyclophotocoagulation: In laser cyclo-
photocoagulation, a laser beam is used to destroy the
ciliary body. For this procedure, medicine to numb the eye
is injected behind the eyeball (retro bulbar anaesthesia)
before the procedure.

Cont…
 A cyclo-destructive: Procedure is a type of
surgery used to destroy the ciliary body, the part of
the eye that produces fluid (aqueous humor).

FILTERING PROCEDURE:
 An anterior sclerotomy or sclerostomy is used to gain
access to the inner layers of the eye in order to create
a drainage channel from the anterior chamber to the
external surface of the eye under the conjunctiva.
Types
 1. Penetrating
 2.Non- penetrating

PENETRATING
 Guarded filtering procedures, also known as
protected, subscleral, or partial thickness filtering
procedures (in which the surgeon sutures a scleral
flap over the sclerostomy site. Trabeculectomy is a
guarded filtering procedure that removes of part of
the trabecular meshwork.

Cont…
 Full thickness procedures include sclerectomy,
posterior lip sclerectomy (in which the surgeon
completely excises the sclera on the area of the
sclerostomy), and sclerostomy (including
conventional sclerostomy and enzymatic
sclerostomy).
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NON-PENETRATING
 Viscocanalostomy Major ocular procedure in which
Schlemm's canal is surgically exposed by making a
large and very deep scleral flap. In this procedure,
Schlemm's canal is cannulated and viscoelastic
substance injected (which dilates Schlemm's canal and
the aqueous collector channels).
 Goniotomy and trabeculotomy are similar simple and
directed techniques of microsurgical dissection with
mechanical disruption of the trabecular meshwork

NURSING MANAGEMENT
 Assess the patient knowledge
 Advice to review the medication with ophthalmologist.
 Report any discharge, irritation, cloudy vision to physician.
 Proper excessive fluid intake.
 Reduce the stress, anxiety.
 Frequently monitor IOP.
 IOP will be increase in lying position.
 Treat DM, HTN.

COMPLICATIONS
 Optic atrophy: in this optic nerve gets affected, which
carries the impulse to the brain.
 Total blindness

Disorders of ear
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Structure of ear
Pinna:
Sound is collected by the pinna (the visible part of the ear)
and directed through the outer ear canal.
The sound makes the eardrum vibrate, which in turn causes
a series of three tiny bones (the hammer, the anvil, and
the stirrup) in the middle ear to vibrate.
The vibration is transferred to the snail-shaped cochlea in
the inner ear; the cochlea is lined with sensitive hairs
which trigger the generation of nerve signals that are sent
to the brain.
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Definition :-
Otitis media (OM) is any
inflammation of the middle ear
with the presence of fluid.
“OTITIS MEDIA”

Acute OM (AOM):- AOM is resulting from infection of fluid in the
middle ear .
OM with effusion (OME):- It is defined as the presence of non-
infectious fluid in the middle ear for more than three months.
Chronic suppurative OM:- Chronic suppurative otitis media is
middle ear inflammation of greater than two weeks that results
in episodes of discharge from the ear.
Adhesive OM:-
AOM is related to childhood anatomy and immune function.
Either bacteria or viruses may be involved.
TYPES OF OM:

A multitude of host, infectious, allergic, and
environmental factors contribute to the
development of OM.
Host factors
Immune system: Immature immune systems of
infants or the impaired immune systems of patients
Etiology:-

Mucins:
Mucins are responsible for gel-like properties of mucus
secretions. The middle ear mucin gene expression is
unique compared with the naso pharynx. Abnormalities
of this gene expression, especially up regulation of
MUC5B in the ear, may have a predominant role in
OME.
Cont..

Anatomic abnormality: Children with
anatomic abnormalities of the palate and
associated musculature, especially the
tensor veli palantini have higher risk for
OM.
Physiologic dysfunction: Abnormalities in
the physiologic function of the ET mucosa,
including ciliary dysfunction and edema ,
increase the risk of bacterial invasion of the
middle ear and the resultant OME.
cont..

Infectious factors:
Bacterial pathogens: The most common bacterial
pathogen in AOM is Streptococcus pneumonia followed by
non type able Haemophilus influenzae and Moraxella
(Branhamella) catarrhalis. These three organisms are
responsible for more than 95% of all AOM cases with a
bacterial etiology.
Cont..

Viral pathogens: The viruses most commonly
associated with AOM are respiratory syncytial
virus (RSV), influenza viruses, parainfluenza
viruses, rhinovirus, and adenovirus. Human
parechovirus 1 (HPeV1) infection is associated
with OM and cough in pediatric patients.
Cont..

Many patients with OM have concomitant allergic respiratory disease
(eg, allergic rhinitis, asthma)
Many patients with OM have positive results to skin testing or radio
allegro sorbent testing (RAST)
Although mast cells are found in the middle ear mucosa, most studies
fail to show significant levels of immunoglobulin E (IgE) or eosinophils
in the MEE of patients with OM
Factors related to allergies:

OM is most common in the winter and early spring, yet most major
allergens (eg, tree and grass pollens) peak in the late spring and early
fall
Most patients with concomitant OM and allergy show no marked
improvement in middle ear disease with aggressive allergy
management, despite marked improvements to nasal and other
allergy-related symptoms
Cont..

Infant feeding methods:
Breastfeeding of this duration reduces the incidence of
OM by 13%. The protective effects of breastfeeding for
the first 3-6 months persist for 4-12 months after
breastfeeding ceases, possibly because delaying onset
of the first OM episode reduces recurrence of OM in
these children.
Environmental factors:

Passive smoke exposure: Many studies have shown a direct relation
between passive smoke exposure and risk of middle ear disease.
Group day care attendance: Day care centres create close contact
among many children, which increases the risks of respiratory
infection, nasopharyngeal colonization with pathogenic microbes,
and OM.
Cont..

Low socioeconomic status
Socioeconomic status:

Eustachian tube dysfunction
Recurrent upper respiratory infection
First episode of AOM before 3 months of age
Previous episode of AOM
Family history
Passive smoking
Absence of infant breastfeeding
Immuno compromise
Poor nutrition
Presence of allergies
Risk factors :-

The common cause of all forms
of otitis media is dysfunction of
the Eustachian tube.
Causes:-

This is usually due to inflammation of the mucous membranes in
the nasopharynx, which can be caused by a viral URI, strep throat, or
possibly by allergies.
By reflux or aspiration of unwanted secretions from the nasopharynx
into the normally sterile middle-ear space, the fluid may then become
infected — usually with bacteria. The virus that caused the initial URI
can itself be identified as the pathogen causing the infection
Cont ..

An upper respiratory infection
Proceeds to AOM
Fluids and pathogen travel upward from the nasopharyngeal area
Invading the middle ear space
Fluid behind the eardrum has difficulty draining back out toward the nasopharyngeal area because of the
horizontal positioning of Eustachian tube
Pathogens gain access to the Eustachian tube , where the proliferate and invade the mucosa
Fever and pain occur acutely
Increased pressure behind the tympanic membrane may results in perforation
Drainage in the ear canal
Pathophysiology :-

AOM implies rapid onset of disease associated with one or more of the following
symptoms:
 Otalgia
 Otorrhea
 Headache
 Fever
 Irritability
 Loss of appetite
 Vomiting
 Diarrhea
OME often follows an episode of AOM. Symptoms that may be indicative of OME
include the following:
 Hearing loss
 Tinnitus
 Vertigo
 Otalgia
Signs and symptoms:-

Examination
“Pneumatic otoscopy” remains the standard examination technique for patients with suspected
OM. In addition to a carefully documented examination of the external ear and tympanic membrane
(TM), examining the entire head and neck region of patients with suspected OM is important.
Every examination should include an evaluation and description of the following four TM
characteristics:
Color – A normal TM is a translucent pale gray; an opaque yellow or blue TM is consistent with
middle ear effusion (MEE)
Position – In AOM, the TM is usually bulging; in OME, the TM is typically retracted or in the neutral
position
Diagnostic evaluation:-

Mobility – Impaired mobility is the most consistent finding in patients with OME
Perforation – Single perforations are most common
Adjunctive screening techniques for OM include tympanometry, which
measures changes in acoustic impedance of the TM/middle ear system with
air pressure changes in the external auditory canal, and acoustic
reflectometry, which measures reflected sound from the TM; the louder the
reflected sound, the greater the likelihood of an (middle ear effusion )MEE.
Cont..

Guidelines from American Academy of
Paediatrics:-
According to the guidelines, management of AOM
should include an assessment of pain. Analgesics,
particularly acetaminophen and ibuprofen, should
be used to treat pain whether antibiotic therapy is
or is not prescribed.
Management:-

Recommendations for prescribing antibiotics include the following:-
Antibiotics should be prescribed for bilateral or unilateral AOM in children aged
at least 6 months with severe signs or symptoms (moderate or severe otalgia,
otalgia for 48 hours or longer, or temperature 39°C or higher) and for
nonsevere, bilateral AOM in children aged 6 to 23 months
Amoxicillin is the antibiotic of choice unless the child received it within 30 days,
has concurrent purulent conjunctivitis, or is allergic to penicillin; in these cases,
clinicians should prescribe an antibiotic with additional beta-lactamase
coverage
Cont..

On the basis of joint decision-making with the parents,
unilateral, non severe AOM in children aged 6-23
months or non severe AOM in older children may be
managed either with antibiotics or with close follow-up
and withholding antibiotics unless the child worsens or
does not improve within 48-72 hours of symptom onset
Cont..

In chronic cases with effusions, insertion of tympanostomy
tube into the ear drum reduces recurrence rates in the
6 months after placement but has little effect on long-term
hearing. A common complication of having a
tympanostomy tube is otorrhea, which is a discharge from
the ear.
Tympanostomy tube:-

In severe or untreated cases, the tympanic membrane
may perforate, allowing the pus in the middle-ear space to
drain into the ear canal. An option for severe acute otitis
media in which analgesics are not controlling ear pain is to
perform a tympanocentesis, i.e., needle aspiration through
the tympanic membrane to relieve the ear pain and to
identify the causative organisms.
Membrane rupture:-

Pneumococcal conjugate vaccines when given
during infancy decrease rates of acute otitis media by
6%–7% .
Cessation of smoking in the home should be encouraged
Day care attendance should be avoided or day care
facilities with the fewest attendees should be
recommended.
Breastfeeding for the first year of life is associated with a
reduction in the number and duration of OM infections.
Prevention:-

Intratemporal complications include the following:
Hearing loss (conductive and sensorineural)
TM perforation (acute and chronic)
Chronic suppurative OM (with or without cholesteatoma)
Cholesteatoma
Tympanosclerosis
Mastoiditis
Petrositis
Labyrinthitis
Facial paralysis
Cholesterol granuloma
Infectious eczematoid dermatitis
Complications :-

Intracranial complications include the following :-
Meningitis
Subdural empyema
Brain abscess
Extradural abscess
Lateral sinus thrombosis
Otitic hydrocephalus
Cont..

Definition:
 A severe case of acute otitis externa. Note the narrowing of the
ear channel, the large amounts of exudate, and swelling of
the outer ear.
Or
 Otitis externa, also known as swimmer's ear is
an inflammation of the ear canal. It often presents with ear pain,
swelling of the ear canal, and occasionally decreased hearing.
Typically there is pain with movement of the outer ear. A high
fever is typically not present except in severe cases.
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Epidemiology
 Otitis externa affects 1-3% of people a year with
more than 95% of cases being acute
 About 10% of people are affected at some point in
their life.
 It occurs most commonly among children between
the ages of seven and twelve and among the
elderly
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Types of otitis externa
 Acute Otitis externa:- Meaning less than six weeks
and typically due to a bacterial infection.
 Chronic Otitis externa:- More than three months
in duration and often due
to allergies or autoimmune disorders.
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Other classifications
 Acute diffuse OE – This is the most common form of OE, typically
seen in swimmers; it is characterized by rapid onset (generally
within 48 hours) and symptoms of EAC inflammation (eg, otalgia,
itching, or fullness, with or without hearing loss or jaw pain) as well
as tenderness of the tragus or pinna or diffuse ear edema or
erythema or both, with or without otorrhea, regional lymphadenitis,
tympanic membrane erythema, or cellulitis of the pinna
 Acute localized OE – This condition, also known as furunculosis, is
associated with infection of a hair follicle
 Chronic OE – This is the same as acute diffuse OE but is of longer
duration (>6 weeks)
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Cont..
 Eczematous (eczematoid) OE – This encompasses various
dermatologic conditions (eg, atopic dermatitis, psoriasis, systemic
lupus erythematosus, and eczema) that may infect the EAC and
cause OE
 Necrotizing (malignant) OE – This is an infection that extends into
the deeper tissues adjacent to the EAC; it primarily occurs in adult
patients who are immune compromised (eg, as a result of diabetes
mellitus or AIDS) and is rarely described in children; it may result in
cases of cellulitis and osteomyelitis (see Cellulitis, Osteomyelitis, and
Chronic Osteomyelitis Imaging)
 Otomycosis - Infection of the ear canal secondary to fungus species
such as Candida or Aspergillus
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Risk factors
In acute cases:
 Absence of cerumen
 High humidity
 Swimming
 Increased temperature
 Minor trauma from cleaning using hearing aids or ear plugs
 Diabetes
Other skin problems like:-
 Psoriasis or dermatitis 7/15/2017
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Causes
 Swimming in polluted water
 Constriction of the ear canal from bone growth (Surfer's
ear) can trap debris leading to infection.
 Saturation divers have reported Otitis externa during
occupational exposure.
 Use of objects such as cotton swabs or other small
objects to clear the ear canal is enough to cause
breaks in the skin, and allow the condition to develop.
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Cont…
 Infections:-
The majority of cases are due to:
 Pseudomonas aeruginosa
 Staphylococcus aureus
 Candida albicans and Aspergillus
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The two factors that are
required for external otitis to
develop are
 The presence of germs that can infect the skin and
 Impairments in the integrity of the skin of the ear
canal that allow an infection to occur.
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Pathophysiology
OE is a superficial infection of the skin
Obstruction , resulting in water retention Absence of cerumen
Trauma
Alteration of the pH of the ear canal
Trauma allows invasion of bacteria into the damaged skin. This often
occurs after attempts at cleaning the ear with a cotton swab, paper clip,
or any other utensil that can fit into the ear
Infection is established, an inflammatory response occurs with skin
edema. Exudate and pus often appear in the ear as well. If severe, the
infection may spread and cause a cellulitis of the face or neck.
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Clinical manifestations
 Otalgia - Ranges from mild to severe, typically progressing over 1-2
days
 Hearing loss
 Ear fullness or pressure
 Erythema, edema, and narrowing of the EAC
 Tinnitus
 Fever (occasionally)
 Itching (especially in fungal OE or chronic OE)
 Severe deep pain - Immunocompromised patients may have
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Cont…
 Discharge - Initially, clear; quickly becomes purulent and foul-
smelling
 Cellulitis of the face or neck or lymphadenopathy of the ipsilateral
neck (occasionally)
 Bilateral symptoms (rare)
 History of exposure to or activities in water (frequently) (eg,
swimming, surfing, kayaking)
 History of preceding ear trauma (usually) (eg, forceful ear cleaning,
use of cotton swabs, or water in the ear canal)
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Diagnostic Evaluations:
 Patient’s history and physical examination and
Inspection of ear canal
 Culture of ear secretions
 Laboratory testing
 Imaging studies:-
 High-resolution computed tomography (CT) - Preferred;
better depicts bony erosion
 Radionucleotide bone scanning
 Gallium scanning
 Magnetic resonance imaging (MRI)
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Prevention:
 Avoid inserting anything into the ear canal
 Most normal ear canals have a self-cleaning and self-
drying mechanism, the latter by simple evaporation.
 Avoid swimming in polluted water.
 Avoid washing hair or swimming if very mild symptoms
of acute external otitis begin.
 Use of earplugs when swimming and shampooing hair
may help prevent external otitis, there are important
details in the use of plugs.
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Medical management
 Initial management:-
 Pain management
 Removal of debris from the EAC
 Administration of topical medications to control edema and infection
 Avoidance of contributing factors
 Pharmacotherapy:-
 Topical medications (eg, acetic acid in aluminum acetate, hydrocortisone
and acetic acid otic solution, alcohol vinegar otic mix)
 Analgesic agents (eg, acetaminophen, acetaminophen and codeine)
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Cont..
 Antibiotics :-
(eg, hydrocortisone/neomycin/polymyxin B, otic
ofloxacin, otic ciprofloxacin, otic finafloxacin,
gentamicin 0.3%/prednisolone 1% ophthalmic,
dexamethasone/tobramycin, otic ciprofloxacin and
dexamethasone, otic ciprofloxacin and hydrocortisone
suspension)
 Oral antibiotics (eg, ciprofloxacin)
 Antifungal agents (eg, otic clotrimazole 1% solution,
nystatin powder)
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Surgery :
Surgical debridement of the ear canal - Usually
reserved for necrotizing OE or for complications
of OE (eg, external canal stenosis)
Incision and drainage of an abscess
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Complications
 Chronic otitis externa
 Spread of infection to other areas of the body
 Necrotizing external otitis
 Otitis externa haemorhagica
 Cellulitis (infection of the skin)
 Chondritis (ear cartilage infection)
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Patient Education:
 Education regarding ways of keeping the ear dry is helpful.
 Preventive use of acidifying drops is encouraged in patients with
recurrent OE.
 Avoidance of the use of cotton-tipped swabs to remove ear
cerumen should be discussed with patients. Improper use of cotton-
tipped applicator sticks simply packs cerumen into the canal and
can cause trauma to the tympanic membrane.
 Patients should be made aware that when OE does strike, it can
usually be resolved in a short time, with few if any complications.
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Definition:
Hearing loss also known as hearing
impairment is a partial or total inability to hear
,it may occur in one ear or both ears.
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Types of hearing loss:
 Sensorineural hearing loss:- Sensorineural hearing
loss is caused by a loss of function within the inner ear or
with the connection to the brain. It can be present at birth
(congenital) or acquired, due to genetic causes, or less
commonly due to loud noise exposure, trauma, infection or
damage from medications that can be harmful to the ears.
 Conductive hearing loss:- Conductive hearing loss is
caused by a problem in the outer or middle ear in which
the sound waves are not sent to the inner ear correctly.
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Causes of conductive
hearing loss
 Ear infections (otitis media) or fluid behind
the ear drums
 Perforation of the ear drum
 Excessive wax
 Foreign bodies in the ear canal
 Tumors (rare)
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Signs and symptoms of
hearing loss
 Child doesn’t startle at loud noises
 Child turns up the volume of the tv or radio excessively high
 Lack of response when name is called
 Difficulties articulating words
 Delayed speech/language
 Difficulties in school
 Repeated earaches, ear pain or head noises
 Difficulty understanding what people are saying, or consistently
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Diagnosing hearing loss
 Newborn hearing screening measures child's physical response to
quiet sounds. The most common newborn hearing tests are the
otoacoustic emissions (OAE) test and the auditory brain stem
response (ABR) test
 Behavioral hearing assessments determine the softest sounds that
a child can hear, also referred to as their hearing
thresholds. Sounds are presented via air conduction (soundfield,
headphones or insert earphones) and bone conduction by placing a
device that sends vibrations to the skull).
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Three main types of
behavioral hearing tests
 Behavioral observation audiometry, often used for infants,
involves watching behaviors such as sucking, eye widening
and startles in response to sound.
 Visual reinforcement audiometry, often used for children 5
months to 2 years old, involves having the child sit on the
caregiver's lap while the clinician teaches the child to respond
to sounds with a head turn. The child is reinforced with a light-
up animated puppet or video.
 Conditioned play audiometry, often used with children 2 ½
years of age and older, uses games to teach a child to respond
to sound.
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Cont…
 Tympanometry assesses how well the eardrum is functioning.
 Acoustic reflexes are tests that check the function of a small
reflexive muscle in the middle ear space called the stapedial reflex
 Auditory Brainstem Response (ABR) testing is usually done while a
child is sleeping. Electrodes are placed on the forehead and near
each ear. Different sounds are played through earphones and the
child's brainwaves are recorded in response to the sounds played.
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Treatment and management
of hearing loss
 Hearing aids
 Surgery to correct a structural deformity
 Cochlear implants can be an appropriate option for children who are not
candidates for other surgical options or hearing aids.
 Bone conduction aids, also known as Bone Anchored Hearing Aids
(BAHA), or osseointegrated hearing aids, combine a sound processor with
a small titanium fixture implanted behind the ear.
 Speech therapy from our certified speech-language pathologists ensures
that your child will receive habilitation services from a professional who
specializes in language impairments due to hearing loss.
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1

DISORDERS OF NOSE
AND THROAT
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2

definition
Tonsillitis is inflammation of the tonsils,
two oval-shaped pads of tissue at the back
of the throat — one tonsil on each side.
205 7/15/2017

causes
Tonsillitis is most often caused by common viruses
mainly adenovirus, rhinovirus, influenza, coronavirus,
Epstein-Barr virus, herpes simplex virus &
cytomegalovirus.
The most common bacterium causing tonsillitis is
Streptococcus pyogenes (group A streptococcus
206 7/15/2017

Clinical manifestation
Red, swollen tonsils
White or yellow coating or patches on the tonsils
Sore throat
Difficult or painful swallowing
Fever
Enlarged, tender glands (lymph nodes) in the neck
A muffled or throaty voice
Bad breath
Stiff neck
Headache
207 7/15/2017

diagnosis
PHYSICAL EXAM THAT WILL INCLUDE:
look throat & his or her ears and nose, which
may also be sites of infection
Gently feeling (palpating) neck to check for
swollen glands (lymph nodes)
Listening to his or her breathing with a
stethoscope208 7/15/2017

Contd….
THROAT SWAB
 COMPLETE BLOOD CELL COUNT (CBC)
209 7/15/2017

management
AT-HOME CARE STRATEGIES TO USE DURING THE RECOVERY TIME INCLUDE THE
FOLLOWING:
 Encourage child to get plenty of sleep and to rest his or her voice. Provide adequate fluids.
 Give plenty of water to keep the throat moist and prevent dehydration.
 Provide comforting foods and beverage. Warm liquids caffeine-free tea or warm water with
honey
 Prepare a saltwater gargle.
 Avoid irritants. Keep your home free from cigarette smoke and cleaning products that can
irritate the throat.
 Treat pain and fever.
210 7/15/2017

CONTD…..
ANTIBIOTICS:
If tonsillitis is caused by a bacterial infection, Penicillin
taken by mouth for 10 days is the most common
antibiotic treatment prescribed for tonsillitis caused by
group A streptococcus.
211 7/15/2017

contd….
SURGERY:
 Surgery to remove tonsils (tonsillectomy) may be used to treat frequently
recurring tonsillitis, chronic tonsillitis or bacterial tonsillitis that doesn't
respond to antibiotic treatment.
212 7/15/2017

Nursing management
Assess the throat carefully during each physical examination.
Observe for tonsils that are usually large
Provide general supportive care
Encourage full course of the treatment
If surgery is indicated ,the parents are help to prepare their
child for short time surgical procedure
Avoid aspirin and ibuprofen for two weeks before surgery
because these medications increase the bleeding213 7/15/2017

Cont…
Discharge planning and home care teaching :-
Have the child drink adequate cool fluids or chew gum, as
this reduce the spasms in the muscles surrounding the
throat.
Apply ice collar around the child’s neck
Have the child gargle with a solution of ½ teaspoon each
of baking soda and salt in a glass of water
Have the child rinse the mouth well with viscous lidocaine
and then swallow the solution
214 7/15/2017

Definition
 It is defined as bleeding from nose occurs
frequently in the children.
216 7/15/2017

Causes
A. Local :
1.Idiopathic < 90%
2. Nasal picking specially in children
3. Trauma
4. Foreign body
5. After nasal surgery
6. Inflamatory e.g chronic sinusitis
7. Fever
8. Dry weather
9. Hot weather
10. Cold weather
11. Benign and malignant tumours of the nose , paranasal
sinuses and nasopharynx
217 7/15/2017

Cont..
B. General :
1. Hypertension
2.Raised venous pressure in cardiac or pulmonary
diseases e. g miteral stenosis
3. Renal failure
4. Chronic liver diseases e g liver cirrhosis or liver
failure
218 7/15/2017

Cont..
5. Diseases of blood and blood vessels :
- Leukaemia
- Haemophelia
- Christmas disease (lack of Vit K )
- Purpura
- Sickle cell anemia
- Vit C diffeciency
- Von Willebrand’s disease
- Familiar haemorrhegic telangectasia (Osler – Rendu disease )
219 7/15/2017

Sign and symptoms
 Bleeding from nose
220 7/15/2017

Therapeutic management
 A. Immediate :
 Pressure on the nostril compresses the vessels in
Little’s area
 Packing of the nose :
-Anterior nasal packing with gauze impregnated in
vaselin or tetracycline ointment
- Posterior nasal packing by gauze or Foley’s
catheter
221 7/15/2017

Cont…
B. Curative and preventive :
Done when immediate treatment fails or repeated bleeding occurs
1. Cauterization of the bleeding point either with galvanocautery or silver
niterate (chemical cautery )
2. Examination under general anesthesia to identify the site of bleeding
3 . Arterial ligation done on rare occasions when packing and cautery fails
- External carotid artery
- Ligation or clipping of the maxillary artery
-Ethmoidal artery
4. Embolization.222 7/15/2017

Nursing management
 Prevention:-
 Humidify the child’s room especially in winter
 Discourage the child from picking or rubbing the nose or inserting
foreign objects into the nose
 Instruct child to blow the nose gently and release sneeze through
mouth
 Apply thin layer of petroleum jelly twice a day to the septum to
relieve dryness and irritation
223 7/15/2017

 Home management:-
 Keep the child calm
 Sit the child upright with head tilted slightly forward so blood does not run
down the throat
 Press a roll of cotton under the lip to compress the labial artery
 Apply steady pressure to both nostrils just below the nasal bone with the
thumb and forefinger for 10-15 minutes
 Apply an ice pack to the bridge of the nose and back of the neck
 Call health care provider if bleeding does not stop
224 7/15/2017

Introduction:-
Sinuses: The sinuses are cavities, or air-
filled pockets, near the nasal passage.
Like the nasal passage, the sinuses are
lined with mucous membranes.
There are four different types of
sinuses:
Ethmoid sinus
Maxillary sinus
Frontal sinus
Sphenoid sinus
7/15/2017
22
6

Definition
Sinusitis is an infection of the sinuses near
the nose. These infections usually occur after
a cold or after an allergic inflammation.
7/15/2017
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7

Types of sinusitis
 Acute. Symptoms of this type of infection last less than four weeks
and get better with the appropriate treatment.
 Subacute. This type of infection does not get better with treatment
initially, and symptoms last four to eight weeks.
 Chronic. This type of infection happens with repeated acute
infections or with previous infections that were inadequately
treated. These symptoms last eight weeks or longer.
 Recurrent. Three or more episodes of acute sinusitis a year.
7/15/2017
22
8

Causes of sinusitis
 Upper respiratory infection (URI)
 Allergies
 Abnormalities in the structure of the nose
 Enlarged adenoids
 Diving and swimming
 Infections from a tooth
 Trauma to the nose
 Foreign objects stuck in the nose
 Cleft palate
 Gastroesophageal reflux disease (GERD)
 Secondhand smoke
7/15/2017
22
9

Most common bacteria that
cause sinusitis:
 Streptococcus pneumonia
 Haemophilus influenzae
 Moraxella catarrhalis
7/15/2017
23
0

Symptoms of sinusitis:
Younger children
Runny nose
Lasts longer than seven to 10 days
Discharge is usually thick green or yellow,
but can be clear
Nighttime cough
Occasional daytime cough
Swelling around the eyes
Usually no headaches younger than 5 years of
age
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1

Symptoms: Older children
and adults
 Runny nose or cold symptoms lasting longer than
seven to 10 days
 Drip in the throat from the nose
 Headaches
 Facial discomfort
 Bad breath
 Cough
 Fever
 Sore throat
 Swelling around the eye, often worse in the morning
7/15/2017
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2

Sinus X-rays
Computed tomography (also called CT or CAT
scan)
Cultures from the sinuses
7/15/2017
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3

Medical management
 Specific treatment for sinusitis will be determined
based on:
 Child's age, overall health, and medical history
 Extent of the infection
 Child's tolerance for specific medications,
procedures, or therapies
 Expectations for the course of the infection
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4

Cont…
Treatment of sinusitis may include the following:
 Antibiotics, as determined by your child's physician (antibiotics
are usually given for at least 14 days)
 Acetaminophen (for pain or discomfort)
 A decongestant (for instance, pseudoephedrine [Sudafed] and/or
mucus thinner such as guaifenesin [Robitussin])
 Cool humidifier in your child's room
 Nasal spray to reduce inflammation
 Medications to treat GERD
 Surgery to remove the adenoids
 Endoscopic sinus surgery
7/15/2017
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5

Complications
Abscess
Bone infection (osteomyelitis)
Meningitis
Skin infection around the eye (orbital cellulitis)
7/15/2017
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6

Prevention:
 The best way to prevent sinusitis is to avoid colds and flu
or treat problems quickly.
 Eat plenty of fruits and vegetables, which are rich in
antioxidants and other chemicals that could boost your
immune system and help your body resist infection.
 Get an influenza vaccine each year.
 Reduce stress.
 Wash your hands often, particularly after shaking hands
with others.
7/15/2017
23
7

Cont…
Other tips for preventing sinusitis:-
 Avoid smoke and pollutants.
 Drink plenty of fluids to increase moisture in your body.
 Take decongestants during an upper respiratory infection.
 Treat allergies quickly and appropriately.
 Use a humidifier to increase moisture in your nose and
sinuses.
7/15/2017
23
8

NASOPHARYNGITIS
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9

Introduction:
 Nasopharyngitis is a contagious, viral infectious
disease of the upper respiratory system, primarily.
It is the most common infectious disease in
humans.
7/15/2017
24
0

Definition:
 Nasopharyngitis also known as common cold
also known simply as a cold, is a viral infectious
disease of the upper respiratory tract that
primarily affects the nose.
7/15/2017
24
1

Causes:
 Viral cause:
 Rhinovirus(30-80%)
 Human coronavirus(15%)
 Influenza virus (10-15%)
 Adenovirus(5%)
Transmission:
 Transmitted via airborne droplets (aerosols)
 Direct contact with infected nasal secretions
 Hand-to-hand and hand-to-surface-to-hand contact seems of more
importance than transmission via aerosols
 Little immunity and frequently poor hygiene
7/15/2017
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2

Cont..
Weather:
Prolonged exposure to cold weather such as
rain or winter conditions
Other:
Insufficient sleep and malnutrition
7/15/2017
24
3

Pathophysiology
7/15/2017
24
4 Immune response to rhinovirus
Release of inflammatory mediators
Produce the symptoms
Contracted by direct contact and airborne droplets
Replicates in the nose and throat before frequently spreading to the lower respiratory
tract.
Respiratory syncytial virus does cause epithelium damage
Human parainfluenza virus typically results in inflammation of the nose, throat, and bronchi

Sign and symptoms
 Sore throat
 Runny nose
 Nasal congestion
 Sneezing
 Sometimes accompanied by 'pink eye'
 Muscle aches
 Fatigue
 Malaise
 Headaches
 Muscle weakness
 Uncontrollable shivering
7/15/2017
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5

 History collection and physical examination
 The distinction between viral upper respiratory tract
infections is loosely based on the location of
symptoms with the common cold affecting primarily
the nose, pharyngitis the throat, and bronchitis the
lungs.
7/15/2017
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6

Treatment:
There is no cure for the common cold. For relief, try
 Getting plenty of rest
 Drinking fluids
 Gargling with warm salt water
 Using cough drops or throat sprays
 Taking over-the-counter pain or cold medicines
However, do not give aspirin to children. And do not
give cough medicine to children under four.
7/15/2017
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7

PROGNOSIS
 The common cold is generally mild and self-limiting
with most symptoms generally improving in a week.
Half of cases go away in 10 days and 90% in 15 days.
Severe complications, if they occur, are usually in the
very old, the very young, or those who are immuno
suppressed. Secondary bacterial infections may occur
resulting in sinusitis, pharyngitis, or an ear infection. It
is estimated that sinusitis occurs in 8% and ear
infection in 30% of cases
7/15/2017
24
8

Definition:
 Pharyngitis is inflammation of the back of
the throat, known as the pharynx. It typically
results in a sore throat and fever.
7/15/2017
25
0

Epidemiology
 Acute pharyngitis is the most common cause of
a sore throat and, together with cough, it is diagnosed
in more than 1.9 million people a year in the United
States.
7/15/2017
25
1

Classification
 Acute pharyngitis : Acute pharyngitis may
be catarrhal , purulent or ulcerative, depending on the
causative agent and the immune capacity of the
affected individual.
 Chronic pharyngitis : Chronic pharyngitis may be
catarrhal, hypertrophic or atrophic.
7/15/2017
25
2

Causes
 The majority of cases are due to an infectious organism acquired from
close contact with an infected individual.
Other causes:-
Viral cause:
 Adenovirus
 Orthomyxoviridae which cause influenza
 Infectious mononucleosis caused by Epstein-Barr virus
 HSV
 Measles
 Common cold: Rhinovirus, coronavirus, respiratory syncytial
virus, parainfluenza virus can cause infection of the throat, ear, and lungs
causing standard cold-like symptoms and often pain.
7/15/2017
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3

Cont….
Bacterial cause:
 A number of different bacteria can infect the human throat.
The most common is Group A streptococcus
 Others include : Streptococcus pneumoniae, Haemophilus
influenzae, Bordetella pertussis, Bacillus anthracis etc.
Fungal:-
 Some cases of pharyngitis are caused by fungal infection
such as Candida albicans causing oral thrush
7/15/2017
25
4

Non-infectious
 Pharyngitis may also be caused by mechanical, chemical or
thermal irritation, for example cold air or acid reflux. Some
medications may produce pharyngitis such
as pramipexole and antipsychotics.
7/15/2017
25
5

Diagnostic approach:
 MODIFIED CENTOR SCORE:
7/15/2017
25
6
Points Probability of Strep Management
1 or less <10% No antibiotic or culture
needed
2 11–17% Antibiotic based on culture
or RAPD
3 28–35%
4 or 5 52% Empiric antibiotics

Cont…
 The modified Centor criteria may be used to determine the
management of people with pharyngitis. Based on 5 clinical
criteria, it indicates the probability of a streptococcal infection.
One point is given for each of the criteria:
 Absence of a cough
 Swollen and tender cervical lymph nodes
 Temperature >38.0 °C (100.4 °F)
 Tonsillar exudate or swelling
 Age less than 15
7/15/2017
25
7

Cont…
The McIsaac criteria adds to the Centor:
 Age less than 15: add one point
 Age greater than 45: subtract one point
Throat swab to rule out bacterial cause
7/15/2017
25
8

Management:-
 The majority of time treatment is symptomatic. Specific treatments
are effective for bacterial, fungal, and herpes simplex infections.
 Medications:-
 Pain medication such as NSAIDs and acetaminophen
(paracetamol) can help reduce the pain associated with a sore
throat. Aspirin may be used in adults but is not recommended in
children due to the risk of Reye syndrome.
 Steroids (such as dexamethasone) may be useful for severe
pharyngitis. Their general use however is poorly supported.
 Viscous lidocaine relieves pain by numbing the mucus membranes.
7/15/2017
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9

Cont…
 Antibiotics are useful if a bacterial infection is the cause
of the sore throat. For viral infections, antibiotics have
no effect. In the United States they are used in 25% of
people before a bacterial infection has been detected.
 Oral analgesic solutions, the active ingredient usually
being phenol, but also less
commonly benzocaine, cetylpyridinium chloride
and/or menthol. Chloraseptic and Cēpacol are two
examples of brands of these kinds of analgesics.
7/15/2017
26
0

Alternative:
 Gargling salt water is often suggested but evidence
looking at its usefulness is lacking. Alternative
medicines are promoted and used for the treatment
of sore throats.
7/15/2017
26
1

Introduction
 Drooling also known
as salivation, driveling, dribbling, slobbering, or, in a
medical context, sialorrhea is the flow of saliva outside
the mouth. It’s often a result of weak or underdeveloped
muscles around your mouth or having too much saliva. The
glands that make your saliva are called the salivary glands.
You have six of these glands, located on the bottom of your
mouth, in your cheeks, and near your front teeth.
7/15/2017
26
3

Definition:
 Drooling is defined as saliva flowing outside of
your mouth unintentionally
7/15/2017
26
4

Risk factors of drooling
 Drooling can be a symptom of a medical condition,
developmental delay, or a result of taking certain
medications. Anything that leads to excessive saliva
production, difficulty swallowing, or problems with
muscle control may lead to drooling.
 Age
 Diet
 Neurological disorders
7/15/2017
26
5

Causes
 Stroke and other neurological pathologies
 Intellectual disability
 Adenoid
 Cerebral palsy
 Amyotrophic lateral sclerosis
 Tumors of the upper aerodigestive tract
 Parkinson's disease
 Rabies
 Mercury poisoning
7/15/2017
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6

Cont…
 Drooling associated with fever or trouble swallowing may be a sign
of an infectious disease including:
 Retropharyngeal abscess
 Peritonsillar abscess
 Tonsilitis
 Mononucleosis
 Strep throat
 Exercise, especially cardiovascular activities, can cause a severe amount
of saliva build up in the mouth, making it difficult to breathe.
 A sudden onset of drooling may indicate poisoning (especially
by pesticides or mercury) or reaction to snake or insect venom
7/15/2017
26
7

Cont…
 Drooling is also common in children with neurological disorders
or undiagnosed developmental delay. The reason for excessive
drooling seems to be related to:
 Lack of awareness of the build-up of saliva in the mouth,
 Infrequent swallowing,
 Inefficient swallowing,
 Impossibility of swallowing by obstructive diseases
(tumors, stenosis),
 Impossibility of swallowing by neurodegenerative diseases
(amyotrophic lateral sclerosis).
7/15/2017
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8

Treatment of excessive drooling
is related to these causes
 Increased awareness of the mouth and its functions,
 Increased frequency of swallowing,
 Increased swallowing skill,
 Diminishing of saliva production by the local use of
botulinum toxin A,
 Surgical interventions (salivary duct relocalization,
resection of salivary glands) in severe cases.
7/15/2017
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9

A comprehensive treatment plan
depends from the etiology and
incorporates several stages of
care
 Correction of reversible causes
 Behavior modification:- Speech and occupational therapists
 Appliance/Dental Device
A special device placed in the mouth helps with lip closure during
swallowing. An oral prosthetic device such as a chin cup or dental
appliances may help with lip closure as well as tongue position and
swallowing.
7/15/2017
27
0

Medical treatment
 Atropine sulfate tablets are used in some circumstances to reduce
salivation.
 Anticholinergic drugs which can be also a benefit because they
decrease the activity of the Acetylcholine Muscarinic Receptors
and can result in decreased salivation.
 Scopolamine, which comes as a patch and is placed on your skin
to deliver the medication slowly throughout the day. Each patch
lasts for 72 hours.
 Glycopyrrolate, which is given as an injection or in the form of a pill.
Robinul decreases your saliva production but can cause dry mouth
as a result. 7/15/2017
27
1

Surgical procedures
 Reroutes the salivary ducts to the back of the
mouth to prevent drooling outside of the mouth.
Another procedure removes your salivary glands
completely.
7/15/2017
27
2

Basvanthapa BT; Text book of Medical surgical
Nursing; 2nd edition ; Jaypee publishers; Pp: 1229-
1231.
Cpnp,msn,kyle.Terri; Essentials of Pediatric
Nursing;1st edition ;Jaypee publishers;Pp:536-41
www.otitis media.wikipidea.com
Bibliography:-

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