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Chapter 19 Diseases of the Eyes, Ears, Nose, and Throat National EMS Education Standard Competencies Medicine Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaint. National EMS Education Standard Competencies Diseases of the Eyes, Ears, Nose, and Throat Knowledge of the anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of − Common or major diseases of the eyes, ears, nose, and throat, including nose bleed Introduction • Calls may involve disorders of the eyes, ears, nose, and throat (EENT). − Patients may need to be transported to an emergency department with access to a specialist. Anatomy and Physiology of the Eye • The globe measures about 1 inch in diameter. − Housed within the orbit − Held in place by connective tissue and muscles • Control eye movement Anatomy and Physiology of the Eye • Oculomotor nerve (third cranial nerve) − Cause motion of the eyeballs and upper eyelids • Optic nerve (second cranial nerve) − Provides the sense of vision Anatomy and Physiology of the Eye Anatomy and Physiology of the Eye • Eye structures − Sclera (“white of the eye”) − Cornea − Conjunctiva − Iris − Pupil − Lens − Retina • Converts light impulses to nerve signals Anatomy and Physiology of the Eye • Anterior chamber: between lens and cornea − Filled with aqueous humor • Posterior chamber: between iris and lens − Filled with vitreous humor Anatomy and Physiology of the Eye • Light rays enter the eyes through the pupil. − Focused by the lens − Image is cast on the retina − The optic nerve transmits the image to the brain. − The visual cortex coverts it into a conscious image. Anatomy and Physiology of the Eye • Two types of vision − Central vision • Enables visualization of objects directly in front of you − Peripheral vision • Enables visualization of lateral objects while a person is looking forward Anatomy and Physiology of the Eye • Lacrimal apparatus − Secretes and drains tears from the eye − Tears moisten the conjunctivae. Patient Assessment • Ensure scene safety. • Cover both eyes. • Keep your patient calm. • Consider pain management. • Form a general impression. • Cardiac monitoring is recommended. • Assess airway and breathing. Patient Assessment • Obtain chief complaint and history. − OPQRST − Diabetes is the leading cause of new cases of blindness in adults. • Diabetic retinopathy Patient Assessment • Symptoms that may indicate a serious ocular condition: − Visual loss that does not improve with blinking − Double vision − Severe eye pain − Foreign body sensation • Perform a thorough examination. Patient Assessment • Assess for: − Pain/tenderness − Swelling − Abnormal or loss of movement − Circulatory changes − Deformity − Visual changes − Sensation changes − Airway compromise Patient Assessment • Assess structures: − Orbital rim • Ecchymosis, swelling, lacerations, and tenderness − Eyelids • Ecchymosis, swelling, lacerations, or any abnormalities − Corneas • Foreign bodies Patient Assessment • Assess structures: − Conjunctivae • Redness, pus, inflammation, and foreign bodies − Globes • Redness, pigmentation, and lacerations − Pupils • Size, shape, equality, and reaction to light Patient Assessment • When assessing ocular function, test: − Visual acuity • Ability to see large and small letters − Peripheral vision • Ability to recognize an object entering the visual field − Ocular motility • Ability to move the eyes in all directions Patient Assessment • Obtain a full set of baseline vital signs. • The patient may experience side effects if: − Used more than one eye medication − Used too much medication • Ask how he or she administered the medication. Patient Assessment • Eye drops and lubricants can be applied by: − Gently squeezing the lower eyelid − Applying the medication − Have the patient close the eyes and roll them. − Apply gentle pressure to the corner of the eyes to prevent drainage. Patient Assessment • Irrigation may be necessary. − Use sterile water or isotonic saline solution. − Flush from the inside corner to the outside. • Eye injuries should be seen in the emergency department. Burns of the Eye and Adnexa • Can be caused by: − Chemicals − Heat − Light rays • Thermal burns − Occur when a patient is burned in the face during a fire Burns of the Eye and Adnexa • Retinal injuries caused by extremely bright light: − Generally not painful − May result in permanent damage • Superficial burns of the eye: − May not be painful initially − Symptoms include: • Conjunctivitis • Redness • Swelling • Excessive tear production Burns of the Eye and Adnexa • Assessment and management − Assess for and treat life-threats. − May be difficult if eyes are closed • Open the eye and irrigate with sterile water or sterile saline solution. • Pain may have to be managed before assessment. Burns of the Eye and Adnexa • Assessment and management (cont’d) − Assess positions of gaze. − Cover an eye burned by ultraviolet light with: • Sterile, moist pad • Eye shield − Transport in a supine position. Burns of the Eye and Adnexa • Assessment and management (cont’d) − Chemical burns require immediate irrigation. • Direct as much fluid as possible. • Use a device that will control the flow. • Do not allow contaminated fluid to enter the eye. • Irrigate for at least five minutes. Burns of the Eye and Adnexa Burns of the Eye and Adnexa Burns of the Eye and Adnexa • Assessment and management (cont’d) − Use of the Morgan lens (eye irrigation device) • Administer a topical anesthetic. • Connect the lens to the IV bag, and let it drip. • Slide the Morgan lens under the eyelids. • Run the fluid at the desired rate. Burns of the Eye and Adnexa • Assessment and management (cont’d) − Transport considerations for eye burn patients: • Prevent one eye from draining into the other eye. • Specialized treatment can be found at level-1 trauma centers. Burns of the Eye and Adnexa • Assessment and management (cont’d) − Contact lenses • To remove a hard lens, use a small suction cup. • To remove soft lens, pinch between thumb and index finger and lift off eye. Conjunctivitis • Conjunctiva becomes inflamed and red. − Often starts in one eye and spreads to the other eye − Often caused by bacteria, viruses, allergies, or foreign bodies Courtesy of John T. Halgren, M.D., University of Nebraska Medical Center Conjunctivitis • Assessment and management − Rule out life threats or dangers to the crew. − Perform general assessment of vision. − Viral conjunctivitis resolves on its own − Bacterial conjunctivitis: topical antibiotic − Allergic conjunctivitis: topical antihistamine Corneal Abrasion • Painful • Due to superficial trauma to the cornea • If discomfort does not resolve, patient should be seen in the emergency department. Corneal Abrasion • Assessment and management − Symptoms include: • Pain • Sensitivity to light • Tearing − Lubrication can alleviate some pain. − Taping the eyelid closed can keep the eye from drying out. Corneal Abrasion • Assessment and management (cont’d) − Invert the eyelids to expose the source. − Look for a foreign body in the eye. − A topical anesthetic may relieve symptoms. − If movement of the eye causes discomfort, cover both eyes. Foreign Body • Can cause significant pain • Commonly caused by machines such as: − Grinders − Sanders − Nailers − Weed whackers Foreign Body • Assessment and management − Evaluate the entire eye using a light. − Examine the undersurface of the upper eyelid. • If you spot a foreign object on the surface, attempt to remove it with a moist, cotton-tipped applicator. Foreign Body • Assessment and management (cont’d) − To assist with dislodging: • Irrigate the eye with a sterile saline solution. • Transport the patient to the hospital. Foreign Body • Assessment and management (cont’d) − Do not remove an impaled foreign body. • Stabilize in place. • Cover with a moist, sterile dressing. • Place a protective barrier over the object. • Cover unaffected eye. • Transport promptly. Inflammation of the Eyelid (Chalazion and Hordeolum) − Chalazion: swollen bump or pustule on the external eyelid − Hordeolum (stye): red tender lump in the eyelid or the lid margin © Francoise Sauze/Photo Researchers, Inc. • Oil glands and oil ducts may become blocked, causing: Inflammation of the Eyelid (Chalazion and Hordeolum) • Assessment and management − Often painful − Can progress to become systemic − Thorough assessment of vital signs and history − Treat inflammation with a warm washcloth. − Transport to the emergency department. Glaucoma • Group of conditions that lead to increased intraocular pressure • Usually treated with eye drops to reduce ocular pressures Glaucoma • Assessment and management − Perform a general eye assessment. − Ask patients what medications they have taken. − Treatment in the pre-hospital setting: • Administer tetracaine for pain relief. • Irrigate for the removal of an irritating substance. Hyphema • Bleeding into the anterior chamber of the eye − Obscures vision − Blood clotting is a concern. • Can cause a rise in intraocular pressure Hyphema • Assessment and management − Pain and blurred vision is likely. − Blood may be visible. − If rupture of the globe is suspected, take spinal motion restriction precautions. Hyphema • Assessment and management (cont’d) − If no contraindications, transport upright. • Other medications with antiplatelet effects should be avoided. − An anxiolytic may facilitate transport. Iritis • Inflammation of the iris − Acute causes include: • Trauma • Irritants − Chronic causes include: • Autoimmune diseases • Arthritis • Irritable bowel disease • Crohn disease © Biophoto Associates/Photo Researchers, Inc. Iritis • Assessment and management − Red area surrounding the iris, cloudy vision, or an unusually shaped pupil − Focus on history. • Acute iritis may respond to topical corticosteroids. • Chronic iritis should be referred to a specialist. Papilledema • Swelling or inflammation of the optic nerve • Patients experience: − Headaches − Nausea − Temporary vision loss or narrowing vision fields − A “graying” in the field of vision Papilledema • Can be caused by: − − − − − Abscess Tumor Inner ear infection Lung infection Dental infection • Other causes: − − − − Meningitis Fever Hypertensive crisis Chronic high blood pressure − Guillain-Barré syndrome Papilledema • Assessment and management − Prehospital management consists of: • Treat symptoms. • Transport. • Assess ABCs and life threats. • Administer analgesics or a mild sedative, if needed. Retinal Detachment and Defect • Potential result of blunt eye trauma • Assessment and management: − Generally painless − Produces: • Flashing lights • Specks • “Floaters” − Requires immediate medical attention Cellulitis of the Orbit • Periorbital cellulitis − Presents as a painful, red, swollen eyelid − Risk factors: • Insect bites • Upper respiratory disorders • Trauma • Orbital cellulitis − Medical emergency − Risk factors: • Sinusitis • Tooth infections • Ear infections • Trauma • Sinus infections Cellulitis of the Orbit • Assessment and management − Treatment includes antibiotics. − Prehospital management includes: • Ruling out life threats • Obtaining a thorough history • Transporting to the appropriate care The Ear • The ear is the primary structure for hearing and balance. − Disorders and injuries can leave a person unable to: • Communicate • React • Maintain equilibrium Anatomy and Physiology of the Ear • Divided into three anatomic parts Anatomy and Physiology of the Ear • Sound waves enter the ear. − Travel to the tympanic membrane. − Sound waves set up vibration in the ossicles. − Vibrations transmit to the cochlear duct. − At organ of Corti, vibrations form impulses. − Travel to the brain via the auditory nerve. Patient Assessment • Observe the scene for hazards. • As you approach, assess: − Age and sex of the patient − Environmental conditions − Degree of distress − Presence of hearing aid(s) Patient Assessment • Ensure ABCs and manage life threats. • Take a complete history. • Observe ears for: − − − − Drainage Excess cerumen Inflammation Swelling Patient Assessment • Have patient rate his or her pain. • Ask about: − Changes in hearing − Tinnitus − Dizziness • Inspect for: − − − − Wounds Swelling Drainage Mastoid process • Transport. Foreign Body • Usually seen in pediatric patients • Assessment and management − Determine the nature of the object. − Look for bleeding, redness, or inflammation. − Stabilize impaled objects in place. − Transport in a position of comfort. Impacted Cerumen • Yellowish oily substance found in outer ear • May present as: − “Wet”: a sticky brown color − “Dry”: a grayish flaky substance • Can become impacted Impacted Cerumen • Risk factors include: − Abnormal ear canal shape − Diseases that cause increased cerumen − Improper use of cotton swabs Impacted Cerumen • Assessment and management − Symptoms may include: • Pressure or fullness in the ears • Ringing in the ears • Loss of hearing Impacted Cerumen • Assessment and management (cont’d) − Prehospital treatment includes: • Thorough history • Visual inspection of the ear Labyrinthitis • Feeling of vertigo or loss of balance after an ear infection or upper respiratory infection − Other symptoms may include: • Ringing in the ears • Loss of hearing • Vomiting Labyrinthitis • Assessment and management − Prehospital treatment is directed at: • Reducing nausea and vomiting • Transporting the patient in a position of comfort − Serious disorders will need to be ruled out by a CT scan and an MRI. Meniere Disease • Endolymphatic rupture creates increased pressure in the cochlear duct − Damages organ of Corti and semicircular canal − Patients will likely experience: • Severe vertigo • Tinnitus • Sensorineuronal hearing loss Meniere Disease • Assessment and management − Prehospital care includes an antiemetic. − Physician may treat with diuretics and an antiemetic. Otitis Externa and Media • Infection resulting from bacterial growth in the ear canal − Externa: outer ear − Media: middle ear • More common in children than adults Otitis Externa and Media • Assessment and management − Signs and symptoms may include: • Edema and erythema • Diminished hearing acuity • Inflamed, bulging tympanic membrane − Prehospital treatment: relieving unbearable symptoms Perforated Tympanic Membrane • Ruptured eardrum • Results from: − Foreign bodies in the ear − Pressure-related injuries − Diving-related injuries Perforated Tympanic Membrane • Assessment and management − Signs and symptoms include: • Loss of hearing • Blood drainage from the ear • Pain − Assess and treat other injuries. − Transport for evaluation. The Nose • Susceptible to injury because of prominence − Allergens, particles, and chemicals can cause inflammation, infection, and injury. • Inside of the nose is extremely vascular. − Excellent route for some medicines. The Nose • Smelling disorders include: − Anosmia: total loss of sense of smell − Dysosmia: distorted sense of smell − Hyperosmia: increased sensitivity to smell − Presbyosmia: loss of smell from normal aging Anatomy and Physiology of the Nose • One of two primary entry points for oxygen • Nasal septum: separation between the nostrils • Turbinates: layers of bone within each nasal chamber © Jones & Bartlett Learning Anatomy and Physiology of the Nose • Frontal sinuses are above the nose. • Paranasal sinuses − Cavities within several bones associated with the nose Patient Assessment • Look for environmental clues. • Ensure scene safety. • Assess airway and breathing. • Determine level of distress. Patient Assessment • Insert an airway adjunct as needed. − Do not insert a nasopharyngeal airway or attempt nasotracheal intubation with: • Suspected nasal fractures • CSF or blood leakage from the nose − Inquire about history of nose conditions. Epistaxis • Nosebleed − Anterior • Bleed fairly slowly • Self-limiting and resolve quickly − Posterior • More severe • Often cause blood to drain into the throat, causing nausea and vomiting Epistaxis • Assessment and management: − Place a nontrauma patient in a sitting position, and pinch nostrils together. − Direct the patient not to sniff or blow his or her nose. Foreign Body • Most likely to be seen in pediatric patients • Pressure in the nasal passage can cause: − Tissue necrosis − Inflammation − Swelling Foreign Body • Assessment and management − Determine life threats. − Any persistent, foul-smelling, purulent discharge should lead to suspicion. • Let discharge drain. − Transport the patient in a position of comfort. Rhinitis • A nasal disorder that is most common during childhood and adolescence − Generally caused by allergens Rhinitis • Assessment and treatment − Signs and symptoms may include: • Nasal congestion • Itchy runny nose and eyes • Postnasal drip − Keep the patient in the Fowler position. Sinusitis • Patients experience thick nasal discharge, sinus and facial pressure, headache, and fever. • Infection occurs when an obstruction or growth blocks the paranasal sinus. Sinusitis • Assessment and management − Condition can be chronic, acute, or recurrent − Treatment: reduce inflammation and drain sinuses. − Complications occur when the infection moves into the brain or bone. The Throat • Disorders of the pharynx and larynx may include inflammation, infections, or abnormal growths. The Throat • Esophageal disorders can affect the throat. • Esophageal reflux: valve only partially closes or opens too much − Symptoms include: • Burning sensation in the chest • Indigestion • Change in voice tone Anatomy and Physiology of the Throat • 32 teeth distributed about the maxillary and mandibular arches − Each side of the arch form 4 quadrants • One central incisor • One lateral incisor • One canine • Two premolars • Three molars Anatomy and Physiology of the Throat • The top portion of the tooth is the crown. − The pulp cavity fills the center of the tooth. − Dentin forms the principal mass of the tooth. • Alveoli are the bony sockets for the teeth. − Alveolar ridges: ridges between the teeth that are covered by gums Anatomy and Physiology of the Throat The Mouth • Digestion begins with mastication. • Tongue: the primary organ of taste − Attached at mandible and hyoid bone − Covered by a mucous membrane The Mouth • Nerves: − Hypoglossal • Provides motor function to the tongue − Glossopharyngeal • Provides taste sensation − Trigeminal • Provides motor innervation to the muscles of mastication − Facial • Supplies motor activity of facial expression • Provides taste sensation • Provides cutaneous sensations to the tongue and palate The Neck • Anterior part of the neck include: − Thyroid and cricoid cartilage − Trachea − Muscles and nerves − Major blood vessels The Neck • Other structures: − Vagus nerves − Thoracic duct − Esophagus − Thyroid and parathyroid glands − Lower cranial nerves − Brachial plexus − Soft tissue and fascia − Various muscles Patient Assessment • Swallowing abnormalities require a position to allow drainage. • Assessments should consider epiglottitis if: − Sore throat − Drooling − Head that is hung forward Dentalgia and Dental Abscess • Dentalgia: toothache • Dental abscess − Occurs when a bacteria growth spreads into the gums, facial tissue, bones, and/or neck © Dr. P. Marazzi/Photo Researchers, Inc. Dentalgia and Dental Abscess • Assessment and management − Infection may become systemic. − An abscess in the throat, neck, or under the tongue can affect the ability to breathe. − Prehospital treatment is aimed at relieving symptoms. Diseases of Oral Soft Tissue • Can be the root cause to other health problems • Include: − Cold sores − Canker sores − Thrush − Leukoplakia − Gingivitis − Bad breath Diseases of Oral Soft Tissue • Assessment and management − Rule out urticaria and allergic reactions. Oral Candidiasis (Thrush) • Candida albicans accumulates on the lining of the mouth. • Patient will have creamy white lesions. − May be painful and may bleed © Biophoto Associates/Photo Researchers, Inc. Oral Candidiasis (Thrush) • Assessment and management − Most likely to be found in: • Babies • Patients with compromised immune systems • Patients who wear dentures • Patients who use inhaled corticosteroids Oral Candidiasis (Thrush) • Assessment and management (cont’d) − Additional symptoms may include: • Cracking and redness at the corners of the mouth • A “cottony” feeling in the mouth • Sensation of food stuck in the throat Oral Candidiasis (Thrush) • Assessment and management (cont’d) − Patients at increased risk: • HIV/AIDS • Cancer • Diabetes • Vaginal yeast infections − Treat higher priorities. − Make the patient comfortable. Ludwig Angina • Cellulitis caused by bacteria from an infected tooth root or mouth injury • Physical exam may show redness and swelling of the neck or under the chin. Ludwig Angina • Assessment and management − Symptoms may include: • Difficulty breathing • Neck pain and swelling • Altered speech sounds Ludwig Angina • Assessment and management (cont’d) − Prehospital treatment requires aggressive management of the airway in severe cases. − Contact medical control physician early on. − Attend to basic ABCs. Foreign Body in the Throat • Assessment and management − Keep the patient calm. − Transport in a position where if the object becomes dislodged, gravity will allow it to fall out. Epiglottitis • Inflammation of the epiglottis − Blocks the trachea and obstructs the airway − Often a result of the H. influenzae type b virus Epiglottitis • Assessment and management − Symptoms may include: • Fever • Painful swallowing • Stridor − Signs may include: • Sick and anxious • “Tripod” position or sniffing position • Pallor or cyanosis Epiglottitis • Assessment and management (cont’d) − Transport to an appropriate hospital. • Minimize scene time. • Do not agitate the patient. • Do not attempt to look in the mouth. • Alert receiving personnel. Laryngitis • Swelling and inflammation of the larynx • Causes may include: − Pneumonia − Irritants and chemicals − Bronchitis − Allergies Laryngitis • Assessment and management − Symptoms include: • Fever • Hoarseness • Swollen lymph nodes or glands − Have the patient follow up with a physician. Tracheitis • A bacterial infection of the trachea caused by Staphylococcus aureus − Frequently occurs in children following URI − Trachea is easily blocked by swelling − Can be life-threatening Tracheitis • Assessment and management − Symptoms: • “Croup-like” cough • Difficulty breathing • High fever − Signs: • Tripod positioning • Intercostal retractions Tracheitis • Assessment and management (cont’d) − Minimize stress to the patient. − Administer 100% oxygen. − Use pulse oximetry. − Monitor vital signs. − Be prepared for difficult intubation. − Transport promptly. Tonsillitis • Swelling and inflammation of the tonsils • Usually caused by viral infections − Can also be caused by bacteria © Biophoto Associates/Photo Researchers, Inc. Tonsillitis • Assessment and management − Symptoms: • Swollen tonsils • Sore throat • Difficulty swallowing − Signs: • White or yellow coating or patches • Fever • Sore throat Pharyngitis • Inflammation of the pharynx • Often due to a rapid onset of sore throat − Without discomfort or pain with swallowing © BSIP/Photo Researchers, Inc. Pharyngitis • Assessment and management − Symptoms may include: • Discomfort or pain on swallowing • Pharyngeal erythema • Purulent patchy yellow, gray, or white exudate • Ulcers on the soft palate Peritonsillar Abscess • Collection of infected material around the tonsils • Complication of tonsillitis © Dr. P. Marazzi/Photo Researchers, Inc. Peritonsillar Abscess • Assessment and management − Symptoms may include: • Facial swelling • Inability to swallow • Tender glands of jaw and throat Peritonsillar Abscess • Assessment and management (cont’d) − Treatment involves antibiotics and draining the abscess. − Transport patient to the hospital. Temporomandibular Joint Disorders • Causes include: − Arthritis damage to the joint’s cartilage − Jaw injury − Jaw muscle fatigue from grinding or clenching of the teeth Temporomandibular Joint Disorders • Assessment and management − Symptoms may include: • Jaw pain • Difficulty chewing • Locking of the joint Summary • Paramedics may encounter emergencies related to disorders of the eye, ear, nose, or throat (EENT) or may discover these disorders while assessing an unrelated emergency. • Assess the eye for pain, tenderness, swelling, abnormal or loss of movement, sensation changes, circulatory changes, deformity, and visual changes. Summary • Early transport to an appropriate facility can improve outcomes. • Provide emotional care to patients with eye conditions. • Flush burns to the eye. Never use chemical antidotes when treating burn injuries to the eye. Summary • Specific conditions of the eye include conjunctivitis, corneal abrasion, foreign body, inflammation, glaucoma, hyphema, iritis, papilledema, retinal detachment and defect, and cellulitis of the orbit. • The ear is the primary structure for hearing and balance. Summary • Adequate assessment of the external ear canal and middle ear cannot be performed in the field. • Specific conditions of the ear include foreign body, impacted cerumen, labyrinthitis, Meniere disease, otitis, and perforated tympanic membrane. Summary • The nose is a vascular structure and contains nasal mucosa that is a short route to the brain. • Never insert a nasopharyngeal airway or attempt nasotracheal intubation in any patient with suspected nasal fractures or in patients with CSF or blood leakage from the nose. Summary • Specific problems related to the nose include epistaxis, foreign body, rhinitis, and sinusitis. • Disorders of the throat may represent acute inflammation and infections, chronic inflammation, or abnormal growths. Summary • When assessing a patient with a throat complaint, note whether the patient is able to swallow. • Specific disorders include dentalgia, dental abscess, Ludwig angina, foreign body, epiglottitis, laryngitis, tracheitis, oral candidiasis, peritonsillar abscess, pharyngitis/tonsillitis, and temporomandibular joint disorders. Credits • Chapter opener: © Biophoto Associates/Photo Researchers, Inc. • Backgrounds: Green—Jones & Bartlett Learning; Purple—Courtesy of Rhonda Beck; Red—© Margo Harrison/ShutterStock, Inc.; Orange—© Keith Brofsky/Photodisc/Getty Images. • Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.