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Chapter 53
Nose Sinus, and
Throat Disorders
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Learning Objectives
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Describe the nursing assessment of the nose, sinuses,
and throat.
Identify nursing responsibilities for patients undergoing
tests or procedures to diagnose disorders of the nose,
sinuses, or throat.
Describe the nurse’s role when the following common
therapeutic measures are instituted: administration of
topical medications, irrigations, humidification, suctioning,
tracheostomy care, and surgery.
Explain the pathophysiology, signs and symptoms, complications,
and medical or surgical treatment of selected
disorders of the nose, sinuses, and throat.
Assist in developing nursing care plans for patients with
disorders of the nose, sinuses, or throat.
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Anatomy and Physiology of the Nose,
Sinuses, and Throat
• Nose
• External nose
• Internal nose
• Sinuses
• Maxillary, frontal, ethmoid, and sphenoid
• Throat
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Figure 53-1
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Figure 53-2
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Health History
• Chief complaint and history of present illness
• Obtain detailed description of the patient’s
complaints
• Past medical history
• Previous streptococcal infections; sinus infections;
surgery on the nose, sinuses, or throat; known
allergies; and current and recent medications
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Health History
• Review of systems
• Presence of nasal discharge (amount, color),
obstruction, bleeding, sneezing, snoring, throat pain
or soreness, hoarseness, aphonia (loss of voice),
and earache
• An altered sense of smell or facial pain should be
noted
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Physical Examination
• External nose examined for size, shape, color,
and lesions
• If drainage, note amount, color, and
consistency
• Examiner listens for abnormal breath sounds
and notes whether the patient is breathing
through the nose or the mouth
• Patency of the nostrils determined by gently
closing one naris at a time and instructing the
patient to breathe through the other naris
• The sinuses are assessed indirectly
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Physical Examination
• Examiner palpates over the frontal and
maxillary sinuses for tenderness or pain
• Inspect throat at the back of the oral cavity
• Mucous membranes and tonsils inspected for
redness, swelling, drainage, lesions
• Inspection and palpation of the neck may
reveal enlarged lymph nodes
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Age-Related Changes in the Nose,
Sinuses, and Throat
• Nasal obstruction more common because of the
softening of the cartilage of the external nose
• Mucous membrane thinner; produces less mucus
• Epistaxis (nosebleed) more common in older people
• Decline in the sense of smell as people age
• Tissues of larynx are drier and less elastic in older
adult
• Weakened esophageal sphincter allows gastric
contents to flow back into the throat when the patient
lies down
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Diagnostic Tests and Procedures
• Throat culture
• Isolate and identify infective organisms
• Laryngoscopy
• Inspection of the larynx to aid in diagnosis of
abnormalities or to remove foreign bodies
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Figure 53-3
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Therapeutic Measures
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Nose drops
Nasal and throat irrigations
Humidification
Suctioning
Tracheostomy care
Nasal surgery
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Care of the Patient Having
Nasal Surgery
• Assessment
• Pain, pressure, anxiety, and dyspnea
• Monitor vital signs to detect signs of excessive
blood loss
• Number of dressings saturated and the frequency of
changes
• Bleeding from the nasal cavity may flow into throat
and be swallowed although the dressing remains
dry
• Check back of throat for bleeding; be alert for frequent
swallowing
• Inspect vomitus and stool for blood (bright red or “coffee
ground” emesis and red, maroon, or black stools)
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Care of the Patient Having
Nasal Surgery
• Interventions
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Decreased Cardiac Output
Acute Pain
Impaired Gas Exchange
Disturbed Body Image
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Disorders of the Nose, Sinuses,
Throat, and Larynx
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Sinusitis
• Inflammation of the sinuses, most often the maxillary
and frontal sinuses
• Most common organisms are Staphylococcus
pneumoniae, Haemophilus influenzae, Diplococcus,
and Bacteroides
• Signs and symptoms
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Pain or a feeling of heaviness over the affected area
Purulent drainage from the nose
When maxillary sinuses affected, pain may seem like a toothache
Headache is common, especially in the morning
Fever may be present; white blood cell count may be elevated
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Sinusitis
• Complications
• Chronic sinusitis, meningitis, brain abscess, osteomyelitis, and
orbital cellulitis
• Medical diagnosis and treatment
• Diagnosis
• Sinus radiographs, CT; sinus aspiration or nasal endoscopy
• Treatment
• Antibiotics, decongestants, nasal corticosteroids, analgesics, and
antipyretics
• Twice-daily hot showers, increased fluid intake, humidifier
• Functional endoscopic sinus surgery (FESS); Caldwell-Luc
procedure
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Care of the Patient Having
Sinus Surgery
• After FESS, able to return to work in 4-5 days
• Saline nasal sprays ordered to prevent crusting
and promote healing
• After the Caldwell-Luc procedure, the semiFowler’s position is recommended to prevent
swelling and promote drainage
• Apply cold compresses as ordered during the
first 24 hours
• Provide gentle oral care to avoid injury to the
incision
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Care of the Patient Having
Sinus Surgery
• Nasal packing is usually left in place until the
first postoperative day
• Antral packing is left in place for 36 to 72 hours
• Caution the patient to avoid blowing the nose
or straining, which could cause bleeding and
tissue damage
• Three to 5 days after the Caldwell-Luc
procedure, nasal saline sprays may be ordered
to moisten the nasal mucosa
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Nasal Polyps
• Swollen masses of sinus or nasal mucosa and
connective tissue that extend into the nasal passages
• Exact cause is unknown, but patients often have a
history of allergic rhinitis or infections
• The size of the polyps may be reduced by removing
allergens or treating the allergic response
• Corticosteroids inhaled nasally may be prescribed
• Surgical removal under local anesthesia, however, is
often necessary
• Nasal polyps tend to recur
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Care of the Patient Having
Nasal Polyp Surgery
• Often in an outpatient surgical facility, so
patient teaching before discharge is especially
important
• Advise patient not to take aspirin because it
increases the risk of bleeding and because
some patients are allergic to aspirin
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Allergic Rhinitis
• “Hay fever”: acute (seasonal) or chronic (perennial)
• Follows exposure to a substance (allergen) that causes
an allergic response
• A reaction to the release of chemicals, including histamine,
that cause vasodilation and increased capillary
permeability
• Fluid leaks from capillaries; causes swelling of nasal
mucosa
• Occasionally these changes are triggered by overuse of
decongestant nose drops or sprays
• Acute allergic rhinitis often from exposure to pollens
• The chronic form is more likely due to allergens that
are continuously in the environment
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Allergic Rhinitis
• Signs and symptoms
• Nasal obstruction; sneezing; clear nasal discharge;
frontal headache; and itchy, watery eyes
• Nasal mucosa is often pale, but it can be red or
bluish
• Medical diagnosis
• Made on the basis of a detailed history
• With chronic symptoms, the patient may be
instructed to keep a diary describing all episodes
• This can help identify possible allergens
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Allergic Rhinitis
• Medical treatment
• Desensitizing injections may be advised to
decrease the patient’s reaction to the offending
allergens
• The drugs used to treat allergic rhinitis are primarily
antihistamines and decongestants
• Nursing care
• Patients with allergic rhinitis are usually outpatients
• The nurse who works in a clinic or physician’s office
may need to reinforce teaching about
desensitization and drug therapy
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Acute Viral Coryza
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The common cold
Can be caused by any of some 30 viruses
It is contagious and spread by droplet infection
Signs and symptoms
• Fever, fatigue, nasal discharge, and sore throat
• Complications
• Otitis media, sinusitis, bronchitis, and pneumonia
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Acute Viral Coryza
• Medical treatment
• Antihistamines, decongestants, and antipyretics
• Prevention
• Best accomplished by avoiding people with colds
• Nursing care
• Primarily public education about prevention and
about drugs prescribed for treatment
• Encourage patients to rest and to drink plenty of
fluids
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Tumors
• Signs and symptoms
• Nasal obstruction
• Bloody discharge from one nasal passage
• Lesions on the external nose typically begin as
small, painless ulcers that do not heal
• Medical diagnosis
• Diagnosed by taking a biopsy of the tumor or
removing the entire tumor for examination
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Tumors
• Medical treatment
• Combination of surgery, radiation therapy, and chemotherapy
• Surgical procedures may be extensive and disfiguring,
depending on the site and extent of the cancer
• Reconstructive surgery or prostheses may be needed
• Nursing care
• Patient may be especially anxious and fearful of disfigurement
or even death
• Be supportive and encourage the patient to ask questions and
express concerns
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Deviated Nasal Septum
• Nose divided into two passages by a cartilaginous wall
called the septum
• In most adults, septum is slightly deviated, meaning it
is off center
• Minor deviations cause no symptoms and require no
treatment
• Major deviations, however, can obstruct the nasal
passages and block sinus drainage
• Headaches, sinusitis, and epistaxis
• Treatment: submucosal resection/nasal septoplasty
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Epistaxis
• Nosebleed; from trauma, clotting disorders,
dryness, inflammation, and hypertension
• First aid
• The patient should sit down and lean forward
• Direct pressure should be applied for 3 to 5 minutes
• Medical treatment
• Nasal balloon catheter
• Nasal packing
• Complications
• Infection, blockage of the eustachian tube, and airway
obstruction
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Figure 16-7
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Figure 53-5
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Epistaxis
• Assessment
• Inspect the nose and back of the throat for obvious
bleeding and observe for frequent swallowing
• Level of consciousness and vital signs to detect
signs of hypovolemia
• Document allergies and major illnesses
• Interventions
• Decreased Cardiac Output
• Anxiety
• Risk for Injury and Infection
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Pharyngitis
• Inflammation of the mucous membranes of the
throat or pharynx
• Usually is caused by a virus but sometimes by
bacteria
• Also can follow exposure to irritating
substances in the environment
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Pharyngitis
• Signs and symptoms
• Dryness, pain, dysphagia (difficulty swallowing), and
fever
• The throat appears red, and the tonsils may be
enlarged
• Compared with viral pharyngitis, bacterial
pharyngitis has abrupt onset; characterized by
abnormal blood cell counts, fever greater than
101° F, and muscle and joint pain
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Pharyngitis
• Complications
• Acute glomerulonephritis and rheumatic fever
• Medical diagnosis
• Throat culture and a complete blood count
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Pharyngitis
• Medical treatment
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Rest, fluids, analgesics, throat gargles or irrigations
Bed rest as long as patient has a fever
If oral intake is low, intravenous fluids
Soft/liquid diet because of painful swallowing
Humidifier to increase moisture in the room air
Antibiotics, usually penicillin or erythromycin, while
awaiting the results of the throat culture
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Pharyngitis
• Prevention
• People with poor resistance should avoid others
with upper respiratory infections
• Good nutrition, adequate rest, avoidance of chilling,
and avoidance of inhaled irritants
• People who have pharyngitis are contagious in the
early stages and should avoid contact with
susceptible people
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Pharyngitis
• Assessment
• Throat pain, dysphagia, muscle and joint pain,
nausea and vomiting, and rash
• Take the patient’s temperature, and inspect the
throat for redness and enlarged tonsils
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Pharyngitis
• Interventions
• Reinforce physician’s directions for drug therapy
• Stress importance of completing prescribed
antibiotics
• 2000-3000 mL fluids daily unless contraindicated
• Advise patients that they are contagious at first and
should not be exposed to people with poor
resistance
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Tonsillitis
• Inflammation of tonsils/other throat lymphatic
tissue
• Common in children but more severe in adults
• Causes
• Usually bacterial, but sometimes caused by a virus
• Causative organisms: streptococci, staphylococci, H.
influenzae, and pneumococci
• The infection is contagious; spread by food or
airborne routes
• Most cases run their course in 7 to 10 days
• May have repeated infections that respond to
treatment or may have a chronic infection
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Tonsillitis
• Signs and symptoms
• Sore throat, difficulty swallowing, fever, chills,
muscle aches, and headache
• If swollen tissue blocks eustachian tubes, ear pain
• Offensive breath odor often with chronic infection
• The tonsils typically are enlarged and red
• Purulent drainage/yellowish or white patches on
tonsils
• Lymph nodes in the neck may be tender and
enlarged
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Tonsillitis
• Medical diagnosis
• Complete blood count, throat culture and sensitivity,
and a test for infectious mononucleosis
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Tonsillitis
• Medical treatment
• Antibiotic therapy for 7 to 10 days
• Analgesics and anesthetic lozenges for pain and
antipyretics for fever
• Warm saline gargles or irrigations to decrease
swelling and remove drainage
• Rest and adequate fluids promote recovery and
decrease the risk of complications
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Tonsillitis
• Complications
• Peritonsillar abscess
• Surgical treatment
• Tonsillectomy and adenoidectomy
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Care of the Patient Having a
Tonsillectomy
• Assessment
• Frequently monitor responsiveness/vital signs
• Inspect drainage from the mouth or vomited fluid for
blood
• Excessive swallowing may indicate bleeding
• Monitor respiratory effort and skin color to evaluate
oxygenation
• Evaluate pain and dysphagia
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Care of the Patient Having a
Tonsillectomy
• Interventions
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Decreased Cardiac Output
Ineffective Airway Clearance
Acute Pain
Ineffective Therapeutic Regimen Management
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Obstructive Sleep Apnea
• Airway obstruction during sleep
• The tongue and soft palate fall backward partially or
completely blocking the airway, causing apnea and
hypopnea (abnormally slow, shallow breathing)
• Blood oxygen level falls; carbon dioxide level rises
• Stimulate ventilation; cause the patient to arouse
• Patient startles, snorts, and gasps causing the tongue
and soft palate to move forward so the airway is open
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Figure 53-6
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Obstructive Sleep Apnea
• Symptoms related to disrupted sleep pattern
• Patient often irritable and sleepy during the day
• Sleeping partner may report loud snoring or
episodes of apnea
• Symptoms can affect many aspects of life
• Concentration and memory may be impaired
• Hypertension and cardiac dysrhythmias
• Diagnosis confirmed by polysomnography
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Obstructive Sleep Apnea
• Conservative treatment: weight loss if obese,
avoidance of sedatives and alcohol for 3-4 hours
before bedtime
• Oral appliance that shifts mandible and tongue forward
may be effective
• Serious symptoms are treated with nasal continuous
positive airway pressure (CPAP)
• Surgical procedures: uvulopalatopharyngoplasty
(UPPP or UP3), genioglossal advancement and hyoid
myotomy (GAHM), and laser-assisted
uvulopalatoplasty (LAUP)
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Figure 53-7
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Laryngitis
• Inflammation of the larynx
• Causes: upper respiratory infections, voice
strain, smoking, alcohol ingestion, and
inhalation of irritating fumes
• Signs and symptoms
• Hoarseness, cough, and scratchy or painful throat
• Aphonia: absence of sound production; “losing” his
or her voice
• Medical diagnosis
• Patient’s history and symptoms
• Throat culture
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Laryngitis
• Medical treatment
• Voice rest is advised, meaning that the patient
should not talk
• Removal of the irritant
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Laryngitis
• Assessment
• Document severity, how long it has persisted, and
factors that to aggravate or precipitate it
• Information about the patient’s occupation and
hobbies may provide clues to the cause of the
laryngitis
• Take the patient’s temperature and describe
respiratory status to detect possible infection
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Laryngitis
• Interventions
• Pad and pencil or Magic Slate for communication
• Sign over the bed noting that patient should not
speak
• Notice on the intercom at the nurse’s station that the
patient cannot (or should not) speak
• Discourage smoking
• An environment with a constant temperature
• Teach patients that irritants can lead to laryngitis
• Recognize irritants in the home and workplace and
know how to protect themselves from harm
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Laryngeal Nodules
• Benign masses of fibrous tissue result primarily
from voice overuse but can follow infections
• Singers and public speakers prone to
development of nodules
• The only symptom is hoarseness
• Nodules are surgically removed under local or
general anesthesia
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Laryngeal Polyps
• Swollen mass of mucous membrane attached
to vocal cord
• Can cause continuous or intermittent
hoarseness, depending on its location and
attachment
• In heavy smokers, masses may develop on
both cords
• A procedure called stripping of the vocal cords
is necessary to treat this condition
• Unless patient continues smoking, condition
usually does not return
• Voice rest prescribed if polyps removed
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Cancer of the Larynx
• Factors: exposure to smoke or other noxious
fumes, alcohol consumption, vocal strain, and
chronic laryngitis
• Malignant tumors can develop throughout the
larynx: above the glottis, on the vocal cords, or
below the vocal cords
• Most malignancies are squamous cell
carcinomas
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Cancer of the Larynx
• Signs and symptoms
• Early symptoms include persistent hoarseness or
sore throat and ear pain
• Later signs and symptoms are hemoptysis and
difficulty swallowing or breathing
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Cancer of the Larynx
• Prevention
• Stop smoking and drinking alcohol
• The public also should be educated to recognize the
signs and symptoms of laryngeal cancer and seek
prompt medical attention
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Cancer of the Larynx
• Medical diagnosis
• Confirmed by study of a tissue sample obtained
during a laryngoscopy
• Radiographs, CT scans, and MRI to define the
extent of the cancer
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Cancer of the Larynx
• Medical treatment
• Surgery, radiotherapy, chemotherapy, or a
combination
• Surgery: from simple removal of the tumor to
extensive procedures, such as laryngectomy and
modified or radical neck dissection
• A laryngectomy can be total or partial
• Voice preserved with hemilaryngectomy or
supraglottic laryngectomy; total laryngectomy
causes permanent loss of the natural voice
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Figure 53-8
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Care of the Patient Having a
Total Laryngectomy
• If patient will lose the ability to speak,
information about other means of
communication should be available
• Listen compassionately and accept the
patient’s expressions of anger or despair
• A total laryngectomy will require that the patient
breathe through the trachea
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Care of the Patient Having a
Total Laryngectomy
• Complications
• Salivary fistula, carotid artery blowout, tracheal
stenosis
• Assessment
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Patient’s level of consciousness
Ask about pain and observe for signs of discomfort
Measure vital signs at frequent intervals
Continuous electrocardiogram monitoring and pulse
oximetry to assess oxygenation and circulation
• Fluid intake and output, wound drainage
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Care of the Patient Having a
Total Laryngectomy
• Interventions
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Ineffective Airway Clearance
Anxiety
Decreased Cardiac Output
Acute Pain
Risk for Injury
Imbalanced Nutrition: Less Than Body
Requirements
Impaired Verbal Communication
Ineffective Coping
Risk for Infection
Ineffective Therapeutic Regimen Management
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Figure 53-10
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Care of the Patient Having a
Supraglottic Laryngectomy
• Care like that for total laryngectomy except the
tracheostomy is temporary, the voice is not lost, and
swallowing is more problematic
• Enteral feedings may be needed for a long time, so
begin to instruct the patient in self-feeding
• Be alert for signs and symptoms of this complication:
increased pulse and respiratory rates, dyspnea, cough,
crackles and rhonchi, fever, wheezing, and frothy, pink
sputum
• Keep a suction machine readily available
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Care of the Patient Having a
Partial Laryngectomy
• Temporary tracheostomy for 2 to 5 days
• IV fluids and enteral feedings are ordered at
first
• Patients have considerable difficulty
swallowing when oral nourishment is resumed
• To prevent aspiration, seat the patient upright,
with the head flexed slightly forward
• Semisolids easier to manage than thin liquids
• Suction machine should be on hand
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