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The eyes are complex structures, containing 70% of the sensory receptors of the body.
Each eye is a sphere measuring about 1 in (2.5cm) in diameter, surrounding and
protected by a bony orbit and cushions of fat. The primary functions of the eye are to
encode the patterns of light from the environment through photoreceptors and to carry
the coded information from the eyes to the brain. The brain gives meaning to the coded
information, allowing us to make sense of what we see. Both extraocular and intraocular
structures are considered a part of the eye.
Extraocular Structures
Extraocular or accessory structures of the eye are those portions of the eye outside the
eyeball yet vital to its protection. These structures are the eyebrows, the eyelids, the
eyelashes, the conjuctiva, the lacrimal apparatus, and the extrinsic eye muscles.
The eyebrows are short, coarse hairs located above the eyes over the superior orbital
ridges of the skull. The eye brows shade the eyes and keep perspiration away from
them.
The eyelids are thin, loose folds of skin covering the anterior eye. They protect the eye
from foreign bodies, regulate the entry of light into the eye, and distribute tears by
blinking.
The eyelashes are short hairs that project from the top and bottom borders of the
eyelids. When anything touches the eyelashes, the blinking reflex is initiated to protect
the eyes from foreign objects.
The conjunctiva is a thin, transparent membrane that lines the inner surfaces of the
eyelids and also folds over the anterior surface of the eyeball. The palpebral conjuctiva
lines the upper and lower eyelids, whereas the bulbar conjuctiva loosely covers the
anterior sclera (the white part of the eye ). The conjuctiva is a mucous membrane that
lubricates the eyes.
The lacrimal apparatus is composed of the lacrimal gland, the puncta, the lacrimal sac,
and the nasolacrimal duct. Together, these structures secrete, distribute, and drain tears
to cleanse and moisten the eye’s surface.
The six extrinsic eye muscles control the movement of the eye, allowing it to follow a
moving object. The muscles also help maintain the shape of the eyeball.
INTRAOCULAR STRUCTURES
The intraocular structures transmit visual images and maintain homeostasis of the inner
eye. Those lying in the anterior portion of each eyeball are the sclera and the cornea
(forming the outermost coat of the eye, call the fibrous tunic), the iris, the pupil, and the
anterior cavity.
The white sclera lines the outside of the eyeball. The functions of the sclera are to
protect and give shape to the eyeball.
The sclera gives way to the cornea over the iris and pupil. The cornea is transparent,
avascular and very sensitive to touch. The cornea forms a window that allows light to
enter the eye and is a part of its light-bending apparatus. When the cornea is touched,
the eyelids blink and tears are secreted.
The iris is a disc of muscles tissue surrounding the pupil and lying between the cornea
and the lens. The iris gives the eye its color and regulates light entry by controlling the
size of the pupil.
The pupil is the dark center of the eye through which light enters. The pupil constricts
when bring light enters the eye and when it is used for near vision; it dilates when light
conditions are dim and when eye is used for far vision. In response to intense light, the
pupil constricts rapidly in the papillary light reflex.
The anterior cavity is made up of the anterior chamber (the space between the cornea
and the iris) and the posterior chamber (the space between the iris and the lens). The
anterior cavity is filled with a clear fluid called the aqueous humor. Aqueous humor is
constantly formed and drained to maintain a relatively constant pressure of from 15-20
mm Hg in the eye. The Canal of Schlemm, a network of channels that circle the eye in
the angle at the junction of the sclera and the cornea, is the drainage system for fluid
moving between the anterior and posterior chambers. Aqueous humor provides nutrients
and oxygen to the cornea and lens.
The intraocular structures that lie in the internal chamber of the eye are the posterior
cavity and vitreous humor, the lens, the ciliary body, the uvea, and the retina.
The posterior cavity lies behind the lens. It is filled with a clear gelatinous substance
called the vitreous humor. Vitreous humor supports the posterior surface of the lens,
maintains the position of the retina, and transmits light.
The lens is a biconvex, avascular, transparent structure located directly behind the pupil.
It can change shape to focus and refract light onto the retina.
The uvea, also called the vascular tunic, is the middle coat of the eyeball. This
pigmented layer has three components: the iris, ciliary body, and choroid. The ciliary
body encircles the lens, and along with the iris, regulates the amount of light reaching
the retina by controlling the shape of the lens. Most of the uvea is made up of the
choroids, which is pigmented and vascular. Blood vessels of the choroids nourish the
other layers of the eyeball. Its pigmented areas absorb light, preventing it from scattering
within the eyeball.
The retina is the innermost lining of the eyeball. It has an outer pigmented layer and an
inner neural layer. The outer layer, next to the choroids, serves as the link between
visual stimuli and the brain. The transparent inner layer is made up of millions of light
receptors in structures called rods and cones. Rods allow for vision in dim light as well
as for peripheral vision. Cones allow for vision in bright light and for the perception of
color. The optic disk, a cream-colored round or oval area within the retina is the point at
which the optic nerve enters the eye. The slight depression in the center of the optic disc
is often called the physiologic cup. Located laterally to the optic disc is the macula, which
is a darker area with no visible blood vessels. The macula contains primarily cones. The
fovea centralis is a slight depression in the center of the macula that contains only cones
and is a main receptor of detailed color vision
The optic nerves are cranial nerves formed of the axons of ganglion cells. The two optic
nerves meet at the optic chiasma, which is just anterior to the pituitary gland in the brain.
At the optic chiasma, axons from the medial half of each retina cross to the opposite side
to form pairs of axons from each eye. These pairs continue as the left and right optic
tracts. The crossing of the axons results in each optic tract carrying information from the
lateral half of the retina of the left eye and the medial half of the retina of the right eye,
whereas the right optic tract carries visual information from the lateral half of the retina of
the right eye and the medial half of the retina of the left eye.
The ganglion cell axons in the optic tracts travel to the thalamus and create synapses
with neurons, forming pathways called optic radiation terminate in the visual cortex of the
occipital lobe. Here the nerve impulses that originated in the retina are interpreted.
The visual fields of each eye overlap considerably, and each eye sees a slightly different
view. Because of this overlap and crossing of the axons, information from both eyes
reaches each side of the visual cortex, which then fuses the information into one image.
This fusion of images accounts for the ability to perceive depth; however, depth
perception depends on visual input from two eyes that both focus well.
Refraction
Refraction is the bending of light rays as they pass from one medium to another medium
of different optical density. As light rays pass through the eye, they are refracted at
several points: as they enter the cornea, as they leave the cornea and enter the aqueous
humor, as they enter the lens, and as they leave the lens and enter the vitreous humor.
At the lens, the light is bent so that it converges at a single point on the retina. This
focusing of the image is called accommodation. Because the lens is convex, the image
projected onto the retina (the real image) is upside down and reversed from left to right.
The real image coded as electric signals that are sent to the brain the brain decodes the
image so that the person perceives it as it occurs in space.
The eyes are best adapted to see distant objects. Both eyes fix on the same distant
image and do not require any change in accommodation. For people with emmetropic
(normal) vision, the distance from the viewed object at which the eyes require no
accommodate the lens, constrict the pupils, and converge the eyeballs. Accommodation
is accomplished by contraction of the ciliary muscles. This contraction reduces the
tension on the lens capsule so that it bulges outward to increase the curvature. This
change in shape also achieves a shorter focal length, another requirement for the
focusing of close images on the retina. The closest point on which a person can focus is
called the near point of vision; in young adults with normal vision this is usually 8-10 in.
pupillary constriction helps eliminate most of the divergent light rays and sharpens focus.
Convergence (the medial rotation of the eyeballs so that each is directed toward the
viewed object) allows the focusing of the image on the retinal fovea of each eye.
I. Health History
1. Problems
2. Corrective lenses
1. Lens change
2. Blurred vision
3. Spots, floaters, halos
4. Infections or inflammations of the eyes
5. Eye surgery or injury
6. Styes (hordeolums)
7. High blood pressure
8. Diabetes
9. Eye medications
Equipment Needed
Visual Acuity
In cases of eye pain, injury, or visual loss, always check visual acuity before before
proceeding with the rest of the exem or putting medications in your patients eyes.
1. Allow the patient to use their glasses or contact lens if available. You are
interested in the patient's best corrected vision.
2. Position the patient 20 feet in front of the Snellen eye chart (or hold a
Rosenbaum pocket card at a 14 inch "reading" distance).
3. Have the patient cover one eye at a time with a card.
4. Ask the patient to read progressively smaller letters until they can go no further.
5. Record the smallest line the patient read successfully
6. Repeat with the other eye.
7. Unexpected/unexplained loss of acuity is a sign of serious ocular pathology.
Inspection
Visual Fields
1. Stand two feet in front of the patient and have them look into your eyes.
2. Hold your hands to the side half way between you and the patient.
3. Wiggle the fingers on one hand.
4. Ask the patient to indicate which side they see your fingers move.
5. Repeat two or three times to test both temporal fields.
6. If an abnormality is suspected, test the four quadrants of each eye while asking
the patient to cover the opposite eye with a card.
Extraocular Muscles
Corneal Reflections
Extraocular Movement
Pupillary Reactions
Light
Accommodation
If the pupillary reactions to light are diminished or absent, check the reaction to
accommodation (near reaction): [5] ++
Ophthalmoscopic Exam
5. Look through the ophthalmoscope and shine the light into the patient's eye from
about two feet away. You should see the retina as a "red reflex." Follow the red
color to move within a few inches of the patient's eye.
6. Adjust the diopter dial to bring the retina into focus. Find a blood vessel and
follow it to the optic disk. Use this as a point of reference.
7. Inspect outward from the optic disk in at least four quadrants and note any
abnormalities.
8. Move nasally from the disk to observe the macula.
9. Repeat for the other eye.
Special Tests
Notes
1. Visual acuity is reported as a pair of numbers (20/20) where the first number is
how far the patient is from the chart and the second number is the distance from
which the "normal" eye can read a line of letters. For example, 20/40 means that
at 20 feet the patient can only read letters a "normal" person can read from twice
that distance.
2. You may, instead of wiggling a finger, raise one or two fingers (unialterally or
bilaterally) and have the patient state how many fingers (total, both sides) they
see. To test for neglect, on some trials wiggle your right and left fingers
simultaneously. The patient should see movement in both hands.
3. Additional Testing - Tests marked with (++) may be skipped unless an
abnormality is suspected.
4. PERRLA is a common abbreviation that stands for "Pupils Equal Round Reactive
to Light and Accommodation." The use of this term is so routine that it is often
used incorrectly. If you did not specifically check the accommodation reaction use
the term PERRLA. Pupils with a diminished response to light but a normal
response to accommodation (Argyll-Robertson Pupils) are a sign of
neurosyphilis.
5. Diopters are used to measure the power of a lens. The ophthalmoscope actually
has a series of small lens of different strengths on a wheel (positive diopters are
labeled in green, negative in red). When you focus on the retina you "dial-in" the
correct number of diopters to compensate for both the patient's and your own
vision. For example, if both you and your patient wear glasses with -2 diopter
correction you should expect to set the dial to -2 with your glasses on or -4 with
your glasses off.
e. Inform the client that the dye may cause the skin to appear yellow for
several hours after the test and is eliminated gradually through the
urine.
f. The client may experience nausea, vomiting, sneezing, paresthesia of
the tounge or pain at the injection site.
Postoperative Interventions
a. Encourage rest.
b. Encourage fluid intake to assist in eliminating the dye from the client’s
system.
c. Remind the client that the tallow skin appearance will disappear.
d. Instruct the client that the urine will appear bright green until the dye is
excreted.
e. Instruct the client to avoid direct sunlight for a few hours after the test.
f. Instruct the client that the photophobia will continue until pupil size
returns to normal.
B. COMPUTED TOMOGRAPHY
It is a diagnostic test for the eye wherein there is a beam of x-rays scans the
skull and orbits of the eye. A cross-sectional image is formed by the use of a
computer and a contrast material is not usually administered.
Nursing Interventions
C. SLIT LAMP
A slit lamp allows the examination of the anterior ocular structures under
microscopic magnification. The client leans on a chin rest to stabilize the head
while a narrowed beam of light is aimed so that it illuminates only a narrow
segment of the eye.
Nursing Interventions
Advise the client about the brightness of the light and the need to look
forward at a point over the examiner’s ear.
D. CORNEAL STAINING
A topical dye is instilled into the conjunctival sac to outline irregularities of the
corneal surface that are not easily visible. The eye is viewed to a blue filter, and a
bright green color indicatesareas of a non intact corneal epithelium.
Nursing Interventions
The client is instructed to blink after the dye has been applied to
distribute the dye evenly across the cornea.
E. TONOMETRY
Nursing Interventions
The client must instructed to avoid rubbing the eye following the
examination if the eye has been anesthetized because the
potential for scrubbing the cornea exists.
F. FUNDUS PHOTOGRAPHY
Special retinal cameras are use to document fine details of the fundus for
the study and future comparison. One of the most common applications is the
evaluation of insidious optic nerve changes in the clients with glaucoma.
Photographs are compared over time to identify subtle changes in the clients with
glaucoma. Photographs are compared over time to identify subtle changes in
disc shape and color.
G. SPECULAR MIMOGRAPHY
H. EXOPTHALMOMETRY
I. OPTHALMIC RADIOLOGY
MRI has the advantage of not exposing the patient to ionizing radiation.
Also, multidimensional views are possible without repositioning the patient. This
is used to image edema, areas of demyelination, and vascular lesions. However,
the availability of MRI equipment is often lmited and the examination takes
longer. MRI may also cause movement of a metallic foreign body.
K. ULTRASONOGRAPHY
Ultrasonography uses the principle of sonar to study structures not
directly visible high frequency sound waves are transmitted to a probe placed
directly on the eyeball. As the sound waves bounce back off the various tissue
components, they are collected by a receiver that amplifies them on an
oscilloscope screen. Sound waves derived from the most distal structures arrive
last, having travel the farthest. Ultrasonography may be used to evaluate tissue
characteristics of a lesion as well as size and growth over time. It may also be
used to measure axial length (distance from the cornea to the retina) in order to
calculate the power for an intraocular lens implant in cataract surgery.
L. OPTHALMODYNAMOMETRY
M. ELECTRORETINOGRAPHY
An electrical potential exist between the cornea and retina of the eye.
Because the retina is neurologic tissue, the normal retina is exhibit certain
electrical responses when stimulated by light. Electroretinography (ERG)
measures the normal change in electrical potential of the eye caused by a diffuse
flash of light. For this test, electrodes incorporated into a contact lens are placed
directly on the eye. Eye movements disrupt the values of the test, so the client
must be able to fixate on a target while keeping the eyes still. A normal ERG
signifies functional integrity of the retina. Examples of retinal diseases that may
be th evaluated with ERG include retinitis pigmentosa (progressive degeneration
of photoreceptor cells), massive ischemia, disseminated infection, or toxic effects
from drugs or chemicals.
EYE DISORDERS
Degenerative Disorders
A. GLAUCOMA
• Incidence
It is estimated that over 50,000 persons in the US are blind as a result of glaucoma.
The incidence of glaucoma is about 1.5%, and in blacks, between the ages of 45 and 65,
prevalence is at least five times that of the whites in the same age group. In most cases,
blindeness can be prevented if treatment is began early.
Glaucoma is called the “sneak thief of sight” because it strikes without obvious
symptoms. People with glaucoma are usually unaware of it until they have a serious loss
of vision. In fact, about half of those who have glaucoma do not know it. Currently, that
damage cannot be reversed.
While there are usually no warning signs, some symptoms may occur in the later
stages of the disease, such as a loss of peripheral vision, difficulty focusing on close
work, seeing halos around lights, and frequent changes of prescription glasses.
Unfortunately, though, once the vision is lost, it is gone forever.
African Americans are at a higher risk of developing glaucoma than other racial groups.
Others at risk include:
Many terms are used to describe the various types of glaucoma. The terms primary
and secondary refer to whether the etiology is the disease alone or due to another
condition. Acute and chronic refer to the onset and/ duration of the disorder. The terms
open (wide) and closed (narrow) describe the width of the ngle between the cornea and
the iris. Anatomically narrow anterior chamber angles predispose clients to an acute
onset of angle-closure glaucoma.
TYPES OF GLAUCOMA
Primary Open-Angle Glaucoma
Approximately 90% of primary glaucoma cases occur in clients with open angles.
It is a multifunctional disorder that is often genetically determined, bilateral, ininsidious in
onset, and slow to progress. Symptoms appear late when vision is impaired by damage
to the optic nerve. Because there are no early warning symptoms, it is imperative that
regular ophthalmic examinations include tonometry and assessment the optic nerve
head (disc). This type of glaucoma is often referred t as the “THIEF IN THE NIGHT”
because there are no early symptoms alerting the client that vision is being lost. The
most common cause of chronic open angle glaucoma is degenerative change in the
trabecular meshwork, resulting in the decrease outflow of aqueous humor.
Secondary Glaucoma
Increase intraocular pressure may occur as a post operative complication.
Edematous tissue may inhibit the outflow of aqueous through the trabecular meshwork.
Delayed healing of corneal would edges may result in epithelial cell growth into the
anterior chamber.
Glaucoma may occur as a result of trauma. Lens displacement, hemorrhage into
the anterior chamber, laceration, and contusions can dirupt the flow pattern of aqueous
humor.
• Clinical Manifestations
• Diagnostic Assessment
Oral carbonic anhydrase inhibitors, which also reduce the production of aqueous
humor.
• Laser Trabeculocospy
The use of laser to create an opening in the trabecular meshwork is often indicated
before filtration surgery is considered. The laser produces scars in the trabecular
meshwork fibers. The tightened fibers allow increased outflow of aqueous. Intraocular
pressure is reduced through improved outflow in about 80% of cases.
• Filtering Procedures
• ASSESSMENT
Blurred vision
Frontal headaches
Eye pain
Photophobia
Lacrimation
• NURSING INTERVENTIONS
Acute Glaucoma
Administer medications s prescribe to lower intraocular pressure. And prepare
the client for peripheral indectomy, which allows aqueous humor to flow from the
posterior to anterior chamber.
Chronic Glaucoma
Instruct the client on the importance of medications (miotics) to constrict the
pupils, (carbonic anhydrase inhibitors) to decrease production of aqueous humor,
and beta blockers to decrease the production of aqueous humor and intraocular
pressure.
Instruct the client on the need for lifelong medication use and to avoid
anticholinergic medications.
Instruct the client to report eye pain, halos around the eyes, and changes in
vision to the physician.
Teach the client that when maximal medical therapy has failed to halt the
progression of visual field loss and optic nerve damage, surgery will be
recommended.
B. CATARACT
• Definition
A cataract is a cloudy or opaque area (an area you cannot see through) in the
lens of the eye. It is an opacity of the lens that distorts the image projected onto the
retina and that can progress to blindness.
• Alternative Names
Lens opacity
The lens of the eye is normally clear. If the lens becomes cloudy, the condition is
known as a cataract. Rarely, cataracts may be present at or shortly after birth. These are
called congenital cataracts.
Adult cataracts usually develop with advancing age and may run in families.
Cataracts develop more quickly in the presence of some environmental factors, such as
smoking or exposure to other toxic substances. They may develop at any time after an
eye injury. Metabolic diseases such as diabetes also greatly increase the risk for
cataracts. Certain medications, such as cortisone, can also accelerate cataract
formation.
Congenital cataracts may be inherited. The gene for such cataracts is dominant
(autosomal dominant inheritance), which means that the defective gene will cause the
condition even if only one parent passes it along. I families where one parent carries the
gene, there is a 50% chance in every pregnancy that the child will be affected.
Congenital cataracts can also be caused by infections affecting the mother during
pregnancy, such as rubella. They are also associated with metabolic disorders such as
galactosemia. Risk factors include inherited metabolic diseases, a family history of
cataracts, and maternal viral infection during pregnancy.
Adult cataracts are generally associated with aging. They develop slowly and
painlessly, and vision in the affected eye or eyes slowly gets worse.
Vision problems associated with cataracts generally move towards decreased vision,
even in daylight.
Adult cataracts are classified as immature, mature, and hypermature. A lens that
has some remaining clear areas is referred to as an immature cataract. A mature
cataract is completely opaque. A hypermature cataract has a liquefied surface that leaks
through the capsule, and may cause swelling and irritation of other structures in the eye.
Most people develop some clouding of the lens after the age of 60. About 50% of
people aged 65-74, and about 70% of those 75 and older, have cataracts that affect their
vision.
Most people with cataracts have similar changes in both eyes, although one eye
may be worse than the other. Many people with this condition have only slight visual
changes, and are not aware of their cataracts.
Factors that may contribute to cataract development are low serum calcium
levels, diabetes, long-term use of corticosteroids, and various inflammatory and
metabolic disorders. Environmental causes include trauma, radiation exposure, and too
much exposure to ultraviolet light (sunlight).
• Symptoms
• Cloudy, fuzzy, foggy, or filmy vision
• Loss of color intensity
• Frequent changes in eyeglass prescription
• The glare from bright lights causes vision problems at night, especially while
driving
• Sensitivity to glare from lamps or the sun
• Halos around lights
• Double vision in one eye
• Decreased contrast sensitivity (the ability to see shades, or shapes against a
background)
• Signs and tests
• Standard ophthalmic exam, including slit lamp examination
• Ultrasonography of the eye in preparation for cataract surgery
• Glare test
• Contrast sensitivity test
• Potential vision test
• Specular microscopy of the cornea in preparation for cataract surgery
• Treatment
The only treatment for cataract is surgery to remove it. This is done when a person
cannot perform normal activities, even with glasses. For some people, changing glasses,
getting stronger bifocals, or using a magnifying lens is helpful enough. Others choose to
have cataract surgery.
Cataract surgery consists of removing the lens of the eye and replacing it with an
artificial lens. A cataract surgeon will discuss the options with the patient, and together
they will decide which type of removal and lens replacement is best.
• LENS REMOVAL:
There are 2 types of surgery that can be used to remove lenses that have a cataract.
Extracapsular surgery consists of surgically removing the lens, but leaving the
back half of the capsule (the outer covering of the lens) whole. High-frequency sound
waves (phacoemulsification) may be used to soften the lens to help removing it through
a smaller cut. With extracapsular extraction, the lens is lifted out without removing the
lens capsule; the procedure may be performed by phacoemulsification in which the lens
is broken up by ultrasonic vibrations and is extracted.
Intracapsular surgery involves surgically removing the entire lens, including the
capsule. Today this procedure is done very rarely. In this procedure, lens is removed
within capsule through a small incision.
• LENS REPLACEMENT:
People who have cataract surgery are usually fitted with an artificial lens at the same
time. The artificial lens is a synthetic (manufactured) disc called an intraocular lens. It is
usually placed in the lens capsule inside the eye.
Surgery can be done in an outpatient center or hospital. Most people do not need to stay
overnight in a hospital. The patient will need a friend or family member to assist with
travel and home care after outpatient surgery. Follow-up care by the surgeon is
important.
• NURSING INTERVENTIONS
Preoperative Interventions
Postoperative Interventions
2. Exudative
• Management
There is no known means of medical treatment or prevention for age elated macular
degeneration. Further damage from exudative macular degeneration sometimes may be
arrested by the use of argon photocoagulation, even though laser bamage to the retina
in this area results in a blind spot. When the fovea is involved, central vision is lost and
he only helpful measures are low-vision aids.
The client with age-related macular degeneration is threatened with the loss of
central vision. In order to evaluate change in vision, the client is taught to use an Amsler
grid at home. The nurse may be able to assist the client to maximize remaining vision
with low vision aids and community referral to a low vision specialist and low vision
support groups.
C. RETINAL DETACHMENT
Retinal detachment occurs when the layers of the retina separate because of the
accumulation of fluid between them, or when both retinal layers elevate away from the
choroid as a result of a tumor. Partial separation becomes complete if untreated. When
detachment becomes complete, blindness occurs.
• Assessment
Flashes of lights
Floaters
• Immediate Interventions
Provide bed rest
Surgical Procedures
• Draining fluid from the subretinal space so that the retina can return to the normal
position.
• Diathermy, the use of an electrode needle and heat through the sclera, to
stimulate an inflammatory response.
• Sclera buckling, to hold the choroid and retina together with a splint until scar
tissue forms closing the tear.
• Postoperative Interventions
Prevent nausea and vomiting and monitor for restlessness, which can cause
hemorrhage.
Monitor for sudden sharp eye pain and monitor the physician.
Encourage deep breathing exercise but avoid coughing.
Provide bed rest for 1-2 days and position the client as prescribed.
If gas has been inserted, position the client as prescribed on the abdomen
and turn the head so unaffected eye is down.
Instruct the client to avoid squinting, straining and constipation, lifting heavy
objects and bending from the waist.
Instruct the client to wear dark glasses during the day and an eye patch at
night.
REFRACTIVE DISORDERS
Light is bent (refracted) as it passes through the cornea and lens of the eye.
Refractive errors exist when light rays are not focused appropriately on the retina
of the eye. Three basic abnormalities of refraction occur in the eye: 1) myopia 2)
hyperopia, and 3) astigmatism. Optical correction is important to distinguish
between visual loss caused by disease and visual loss caused by refractive error.
Refractometry is the measurement of refractive error and should not be confused
with refraction, the method used to determine which lens or lenses (if any) will
most benefit the client.
a. Myopia
b. Hyperopia
The hyperopic, or farsighted, eye focuses light rays behind the eye, and
consequently the image that falls on the retina is blurred. Vision may be
brought into focus by placing a convex, or plus, lens in front of the eye.
The lens supplies the magnifying power that the eye is lacking. Hyperopia
may be caused by an eyeball that is shorter than normal or a cornea that
has less curvature than normal. Because children have a greater ability to
accommodate, they are less often affected than adults. Demands for
close work and reading usually bring on manifestations of headache or
eye strain. Correction is based on a person’s age and individual needs
and complaints.
c. Astigmatism
Surgical management
The following are the three main types of refractive surgery and new procedure.
Laser in situ keratomileusis (LASIK) is currently the most commonly used corrective
surgery for nearsightedness in the United States. An extremely thin layer of the cornea is
peeled back for the laser reshaping on the middle layer of the cornea and then put back
in place. There is little postoperative discomfort, rapid recovery of clear vision, and quick
stabilization of refractive change. LASIK is performed in a surgeon’s office or samed-
day surgery center and does not require a hospital stay. It takes about 10-15 minutes per
eye. It has a high success rate and low complication rate for low to moderate
nearsightedness and may also be used to correct more severe nearsightedness.
Excimer laser photorefractive keratectomy (PRK) uses short-wavelenght, high-energy
ultraviolet radiation laser to reshape the corneal surface. In PRK for myopia, the central
cornea is flattened with the excimer laser. The same laser may be used to reshape the
cornea by making the central curvature steeper to correct hyperopia. It may be used to
correct nearsightedness and astigmatism at the same time. PRK is performed on an
outpatient basis in a surgeon’s office or same-day surgery center. The PRK procedure
takes about 30 minutes, most of which is spent teaching the client to hold the eye still.
The actual treatment takes less than a minute. Recovery from PRK is longer and more
painful than recovery from ether radial keratotomy (RK) or LASIK. Vision will be reduced
for several days after surgery.
Radial keratotomy (RK) involves making tiny cuts in the cornea, which flatten it and
reduce nearsightedness. In people who have both astigmatism and nearsightedness, the
surgeon may make additional cutrs to flatten the misshapen part of the cornea that is
causing the astigmatism. RK is an outpatient procedure. It is done under local or topical
anesthesia in a surgeon’s office or same day surgery center.
Corneal ring implants are clear pieces of acrytic that can be surgically implanted into
the cornea. The implants are shaped like crescents or half circles. Two implants are
used for each eye, and the implants are inserted along the sides of the cornea.
Inflammation and infection of eye structures are common. Eye infection is a leading
cause of blindness worldwide.
Clinical manifestations
The most common complaint in dry eye syndrome is a scratchy or foreign body
sensation. Other symptoms include itching, excessive mucus secretions, inability to
produce tears, a burning sensation, redness, pain, and difficulty moving the lids.
Management
Management of dry eye syndrome requires the complete cooperation of the patient with
a regimen that needs to be followed at home for a long period; otherwise, complete relief
of symptoms is unlikely. Instillation of artificial tears during the day and an ointment at
night is the usual regimen to hydrate and lubricate the eye and preserve a moist ocular
surface. Anti-inflammatory medications are also used, and moisture chambers (eg,
moisture chamber spectacles, swim goggles) may provide additional relief.
• Conjunctivitis
Conjunctivitis (inflammation of the conjuctiva) is the most common ocular disease
worldwide. It is characterized by a pink appearance (hence the common term pink eye)
because of subconjuctival blood vessel congestion.
Clinical manifestations
General symptoms include foreign body sensation, scratching or burning sensation,
itching, and photophobia. Conjunctivitis may be unilateral or bilateral, but the infection
usually starts in one eye and then spreads to the other eye by hand contact.
Types of conjunctivitis:
1. Microbial conjunctivitis
Bacterial conjunctivitis can be acute or chronic. The acute type can develop into a
chronic condition. Signs and symptoms can vary from mild to severe. Chronic bacterial
conjunctivitis is usually seen in patients with lacrimal duct obstruction, chronic
dacryocystitis, and chronic blepharitis. The most common causative microorganisms are
streptococcus pneumoniae, haemophilus influenzae, and staphylococcus aureaus. It is
manifested with an acute onset of redness, burning, and discharge.
2. Viral conjunctivitis
Viral conjunctivitis can be acute and chronic. The discharge is watery, and follicles are
prominent. Severe cases include psudomemebranes. The common causative organisms
are adenovirus and herpes simplex virus. Conjunctivitis caused by adenovirus is highly
contagious. The condition isusually preceded by symptoms of upper respiratory
infection. Corneal involvement causes extreme photophobia. Symptoms include extreme
tearing, redness, and foreign body sensation that can involve one or both eyes. There is
lid edema, ptosis, and conjuctiva hyperemia (dilation of the conjuctival blood vessels).
These signs and symptoms vary from mild to sever and may last for 2 weeks.
3. Allergic conjunctivitis
Immunologic or allergic conjunctivitis is a hypersensitivity reaction that occurs as part of
allergic rhinitis (hay fever), or it can be an independent allergic reaction. The patient
usually has a history of an allergy to pollens and other environmental allergens. There is
extreme pruritus, epiphora (excessive secretion of tears), injection, and usually severe
photophobia.
4. Toxic conjunctivitis
Chemical conjunctivitis can be the result of medications; chlorine from swimming pools;
exposure to toxic fumes among industrial workers; or exposure to other irritants such as
smoke, hair sprays, acids, and alkalis.
Management
The management of conjunctivitis depends on the type. Most types of mild and viral
conjuctivits are self-limiting, benign conditions that may not require treatment and
laboratory procedures. For more severe cases, topical antibiotic therapy, eye drops, or
ointments are prescribed. Patients with gonococcal conjunctivitis require urgent antibiotic
therapy. If left untreated, this ocular disease can lead to corneal perforation and
blindness. The systemic complications can include meningitis and generalized
septicemia.
• UVIEITIS
Inflammation of the uveal tract (uveitis) can affect the iris, the ciliary body, or the
choroids. There are two types of uveitis: nongranulomatous and granulomatous.
The more common type of uveitis is the nongranulomatous type, which manifests as an
acute condition with pain, photophobia, and a pattern of conjuctival injection, especially
around the cornea. The pupil is small or irregular, and vision is blurred. There may be
small, fine precipitates on the posterior corneal surface and cells in the aqueous humor.
If the uveitis is severe, a hypopyon (accutmulation of pus in the anterior chamber) may
occur. The condition may be unilateral or bilateral and may be recurrent.
Management
Because photophobia is a common symptom, patients should wear dark glasses
outdoors. Ciliary spasm and synechia are best avoided through mydriasis;
cyclopentolate and atropine are commonly used. Local corticosteroid drops such as
Pred Forte 1% and Flarex 0.1%, instilled four to six times a day are also used to
decrease inflammation. In very severe cases, systemic corticosteroids as well as
intravitreal corticosteroids, may be used.
Ear disease causes significant discomfort and hearing loss. It also creates work
loss and decreased productivity-- this increases as the persons communicative skills
decrease when associated hearing loss increases. In children, developmental delays
and academic failure my result due to manifestation of auditory problem if not properly
treated. Ear Complications such as deafness, meningitis, brain abscesses, and facial
nerve paralysis may also occur. Proper management of ear disease is critical and
immediate attention is necessary.
COMMON DISEASES AND DISORDER OF THE MIDDLE EAR
The basic underlying problem causing most forms of otitis is eustachian tube
dysfunction. Most otitis occurs in patients whose eustachian tube, the tube between the
nose and the middle ear the area behind the eardrum, does not work properly. When air
cannot adequately get through this tube to the middle ear, the negative pressure created
can "suck" fluid out of the lining of the middle ear/mastoid, filling the middle ear and
mastoid air cells with fluid. A mild hearing loss usually accompanies the fluid. The
hearing loss disappears when the fluid is gone as long as there are no other causes for
the hearing loss. Three kinds of otitis can result from eustachian tube dysfunction. They
are serous and secretory otitis, where fluid fills the middle ear and mastoid, acute otitis,
where pus fills the middle ear and mastoid but its presence is of short duration, and
chronic otitis, where pus fills the middle ear and mastoid and it has been present for
months or years. Chronic otitis is associated with infection of the bone itself and
thickening and polyp formation of the mucosal lining of the middle ear and mastoid. The
highest incidence of otitis media occurs in preschool children and decreases gradually
after age 6. The highest incidence occurs poor children, children in day care, and Native
Americans. Additional factors that cause or aggravate otitis include the presence of
enlarged adenoid tissue, lack of proper muscle in the back of the throat (as in those with
a cleft palate), allergy, immune deficiencies, sudden change in atmospheric pressure
(like poor pressurization in an airplane dropping from a high altitude), scarring or tumors
in the nasopharynx, and abnormal cell function of the mucosa of the ear and nose.
Diabetes does not increase the incidence of otitis, but can make it much more difficult to
treat.
• Serous otitis- where fairly clear fluid fills the middle ear and mastoid occurs with
fairly sudden obstruction of the eustachian tube. A sudden descent of an airplane
with poor pressurization or a bad cold are two of the most common causes of
acute serous otitis media. Usually decongestants will clear the fluid or even
bloods that can be sucked from the mucosa into the middle ear with wither of
these processes. If the fluid does not clear within a few weeks, it is considered
chronic serous otitis. Older people with poorly functioning eustachian tubes
commonly have recurrent serous otitis and may require intermittent tube
placement over many years. Hearing loss is present depending on the amount of
fluid in the ear. The hearing loss usually resolves when the fluid is cleared out of
the ear, either medically or surgically.
• Secretory otitis- where somewhat thicker fluid fills the middle ear and mastoid is
common in small children and is often "outgrown" by the time they reach their
teens. It is the most common disease process requiring the placement of PE
tubes. This thicker fluid has components that are actually "secreted" by the
mucous glands of the middle ear. There are actually tissue breakdown enzymes
in this fluid; that, if left untreated, can gradually eat away bone and cause chronic
hearing loss/damage. Luckily, it generally takes quite a while for these enzymes
to cause damage to the ear, so treating secretory otitis in children with
medication for a few weeks or months is safe. Leaving this kind of fluid in an ear
for more than several months, however, places the ear tissues (including the tiny
ear bones) at risk of damage or destruction by these enzymes. Not treating
infections with antibiotics at all places the ear structure at even higher risk of
permanent damage/destruction by the fluid.
• Acute otitis- occurs when pus fills the middle ear. It is usually sudden in onset
and is often associated with sudden obstruction of the eustachian tube at the
same time infections bacteria are present to cause the acute otitis. Without
antibiotic treatment, a true bacterial acute otitis is often associated with sudden
perforation of the eardrum, with profuse drainage from the ear. Often the eardrum
will spontaneously heal over after the infection has resolved, but a perforation
can be left and damage to the middle ear and/or the inner ear can accompany
the infection. The eardrum may be bright red or the creamy color of the fluid can
sometimes be seen through the eardrum. It sometimes looks "soggy." Pain and
fever may accompany an ear infection, but usually disappear rapidly if the
eardrum perforates. Pain and fever are rarely present if there is a whole
(perforation) in the eardrum before the infection starts. The standard treatment of
acute otitis media is oral antibiotics. Ear drops are added if the eardrum
perforates. IV antibiotics are indicated for severe infections, if the mastoid bone is
also infected, or if the facial nerve becomes paralyzed as a "complication" of the
acute infections. Hearing loss is present but usually goes away when the
infection clears.
• Chronic otitis-occurs when chronic infection fills the middle ear space and
mastoid cavity. True chronic otitis media is almost always a form of chronic
mastoiditis, where the bone of the mastoid cavity (the honeycombed bone behind
the ear) is chronically infected along with the tissues of the middle ear space. It is
important to realize that antibiotics alone usually cannot remove infection from
the bone; surgical removal of the infected bone is usually necessary to
accomplish this. Even IV antibiotics do not often eradicate a true bone infection,
especially in the mastoid, which has its connection to the bacteria-filled nose
through the eustachian tube. A cholesteatoma is a common additional finding
along with chronic otitis and mastoiditis. A cholesteatoma is a skin sac that grows
back into the middle ear or mastoid from the eardrum, creating a mass of skin
and debris that keeps getting larger and larger over time, destroying anything in
its path. The ear bones, the inner ear, the facial nerve (the nerve that makes all
the muscles of one side of your face work), and the brain next to the ear can all
be damaged or destroyed by either spreading infection or cholesteatoma. These
diseases must be removed fore the safety of the ear, the head, and the brain.
Infection or cholesteatoma involving the inner ear, facial nerve, or the brain
requires immediate attention by an ear surgeon and often required immediate
surgery.
• Earache
• Headache
• Fever
• Discharge from the ear
• Mild deafness
• Difficulties in sleeping
• Loss of appetite.
In many cases of middle ear infection, the Eustachian tube is blocked and can
cause or at least contributes to a middle ear infection. A Eustachian tube can become
blocked from any combination of the following:
• A contributing factor can be the discharge of the dead bacteria and dead
lymphocytes from the middle ear. The lymphatic system contains the white
blood cells or lymphocytes which are the body's defense against foreign
objects such as bacteria. When the white blood cells kill bacteria, the
lymphatic fluid becomes pus-like due to a build up of dead white blood cells
and dead bacteria. This discharge from the middle ear can irritate the
Eustachian tube causing it to close.
A blocked Eustachian tube is often what causes the pain of a middle ear
infection. Pus builds up in the inner ear cavity with no where to go, putting pressure on
the inner ear and the ear drum. If left without treatment, the pressure can be so great
that it bursts the ear drum. The initial excruciating pain of a burst eardrum is immediately
compensated for by pain reduction from the release of pressure. Whereas, prior to the
burst eardrum, sleep was impossible, the pain relief from the pressure reduction allows
the sufferer to finally sleep. If the middle ear infection is cured on its own, the ruptured
ear drum will also usually heal on its own, although sometimes surgery (tympanoplasty)
is indicated if the rupture is extremely large.
CSOM is the name given to a condition when there is an infection of the middle ear
which fails to heal and is draining all the time.
• Glue Ear
There is a natural flow of fluids from the middle ear (the fluids keep the middle
ear cavity moist) that migrate through the Eustachian tube to the back of the throat. A
blocked Eustachian tube prevents air from reaching the middle ear. When this happens
the middle ear can fill up with the fluid that can becomes thick, like glue over time. This
problem is called glue ear or otitis media with effusion. The buildup of fluid in the middle
ear reduces the movement of the eardrum and ossicles, and hearing is reduced. This
condition is quite prevalent in children. Glue Ear is not a disorder in itself, it is just a
visible symptom of a discharge of bacterial waste from the middle ear.
Note: Glue ear is sometimes confused by anxious parents with the normal
discharge of wax from a child's ear canal. During an infant or child's growth, there may
be periods when ear wax is produced more copiously than normal, causing wax to leak
from the ear.
• If the child has not had a fever then it is a normal wax discharge
• If the child has not complained of earache then it is a normal wax discharge
If the discharge does not have a really smelly odor then it is a normal wax discharge
(there is a slight odor to normal wax, but nothing like that from waste bacteria from the
middle ear)
There are factors that can increase the risk of a child being susceptible to otitis media
and glue ear:
• being a male
• short length of breastfeeding
• attendance at day care centers
• parental smoking
• wet climate
• winter season
• upper respiratory infection
• housing with mold
• allergies
• A thick liquid discharge from the ear that looks like liquid wax and is orange in
color.
• Ear aches
• Headaches
• Fever
• Listlessness
• They may be clumsy. With very small infants (1-3 years old), it might also take
them longer to start to walk, speak or understand language.
• Older children may be able to tell you if they cannot hear very well. Or you may
notice that they say 'pardon' or 'what' a lot or that they turn the television up loud.
Glue ear also makes older children clumsy and dizzy.
1. Many children recover naturally from glue ear once the Eustachian tube opens.
Doctors usually adopt a wait-and-see approach to begin with. Your child will normally
be observed for about three months to see if they need further treatment. If the
eardrum has burst, it should heal over time approximately 3-6 weeks.
Grommets-myringotomy
If your child has had glue ear over a few months and the eardrum has not
burst and antibiotics have not worked, the other option is to have a small
ventilation drain known as a grommet inserted into the ear drum. The
grommet is made of either stainless steel or plastic. This procedure
involves making a small hole in the eardrum and inserting the grommet
through the hole to keep it open. Initially fluid is sucked out of the middle
ear through this hole, then over a few months, the grommet lets air into
the middle ear space and lets fluid in the middle ear drain away. There
are only simple precautions to stop water getting into ear like swimming
on the surface of the water only and not dive and you need to use
earplugs or cotton wool with Vaseline to stop soap water getting into the
ears when showering or washing hair.
It is a surgical treatment for glue ear which aimed to remove the adenoids. The
adenoids are located above the tonsils, at the back of the throat and are thought
to assist the body in its defense against incoming bacteria and viruses by helping
the body to form antibodies. With ear infections, the adenoids often swell, usually
due to an infection in the immediate area, in this case, the middle ear.
• Tubo-Tympanic Otitis Media
• Hearing loss
• Discharge (which may come and go, and will become noticeable
particularly if you get a cold or the ear gets wet)
• Tinnitus.
If the opening is not too large, it may close and heal on its own. Failing
that, an ENT specialist may close it with surgery or by covering it with a special
material to keep the opening closed while it heals.
You can usually help the symptoms by taking simple steps like wearing an
ear plug or keeping the ear dry when you are having a bath or swimming.
However, you may need an operation to repair the hole in the eardrum
(tympanoplasty or myringoplasty).
• Attico-antral
Burst Eardrum
If you have had a middle ear infection that pushed out the eardrum, then
the throbbing pain has been greatly diminished. Wipe off the smelly pus
with a damp cloth, and sit quietly with a warm compress on that side of
the head.
Antibiotics are usually prescribed, sometimes initially by injection, then a
regimen orally three times a day for at least 7 days.
If the perforation is very small and it does not heal after 2-3 weeks, an
ENT may decide not to operate and allow nature to take its course and let
the eardrum heal naturally.
For a larger tear, an outpatient visit to the ENT will allow a small patch
(taken from under the skin behind the ear perhaps) to be attached (not
completely covering the hole) over the hole to help it shrink and
encourage new skin growth.
Another technique an ENT may use to encourage healing is to add a
chemical to the edges of the hole to stimulate growth and then place a
thin paper patch on the eardrum to act as a base for skin growth over the
hole.
There are a variety of surgical techniques, but all basically place tissue
across the perforation allowing healing. The name of this procedure is
called tympanoplasty or myringoplasty. Surgery is typically quite
successful in closing the perforation permanently, and improving hearing.
The mastoid is part of the skull and is made up of spongy bone just behind
the ear. Mastoiditis is an infection of the bony air cells in the mastoid bone. In fact
the middle ear and the inner ear are embedded in the mastoid bone.
Indications of a mastoid infection are reddening and swelling behind the ear. The
cause is usually from an untreated middle ear infection, so otitis media symptoms are
often present. An untreated middle ear infection can slowly spread into the mastoid cells.
When infection becomes trapped in the mastoid it is known as mastoiditis.
Another example showing a child's
Note the mastoid bone
right ear being pushed forward by
swelling behind the ear
the mastoid infection
• Pronounce bulbous swelling that can push the ear forward (acute)
• Large swelling behind the ear
• High fever
• Ear pain
• Sensitive to touch
• Hearing loss
• Paralyzed facial nerves (serious cases)
Antibiotics are the normal treatment for the mild form of mastoiditis. There are a
number of antibiotics available to treat. Because there are few blood vessels permeating
the mastoid area, a normal 10 day protocol of antibiotics may be extended to 14 days to
make sure the medicine penetrates the bony mass. While in acute form mastoidectemy
is inevitably needed.
Diagnostic Procedures for Mastoiditis
A circle is cut out of the bone covering the mastoid and showing the infected
area. The spongy mass that is infected is then cut away and removed. The remaining
cavity is cleaned, coated with antibiotics and if possible the bone cover is place back to
the rest of the skull, and the flap of skin stitched back together. An outer pressure
dressing is then worn for 1-2 days after surgery. If too much mastoid material has been
removed, and it is not possible to reattach the bone covering, it is left off and the skin
flap is stitched back to the surrounding tissue. After healing, there will be depression
behind the ear.
The stay in the hospital is usually 1-3 days. After discharged from the hospital, a
full regimen of antibiotics will be given (10-14 day regimen). The stitches will be removed
after about 2 weeks. Full recovery will take 3-4 weeks with possibly bouts of dizziness
and headaches during this time. Over time the headaches and dizziness should
diminish.
Cholesteatoma
A cholesteatoma occurs if skin from the inner side of the tympanic membrane
sloughs off and mixes with ear wax that penetrates the open hole in the eardrum
to the middle ear chamber and fails to drain through the Eustachian tube. Over
time the accumulation of dead skin and wax causes a cyst-like mass to grow
-cholesteatoma. If left untreated and the mass becomes larger, the mass can put
pressure to nearby parts of the ear causing serious damage such as the eardrum
and ossicles. In serious cases, cholesteatomas have been known to penetrate
into the mastoid area causing infection or into the cranial chamber causing
meningitis-infection of the covering of the brain or the meninges.
Symptoms
The attico-antral form of the condition initially causes a smelly discharge to leak from the
ear. You may also have a hearing loss and sometimes tinnitus. You can get vertigo -
dizziness - if the semicircular canals, which form part of the balance system, are also
affected.
Signs of cholesteatoma
• Extreme pain, especially in the side of the head where the problem is
• Continual vertigo and nausea
• Loss of hearing
• A gradual weakening of the facial muscles causing a droopy look on one side as
if recovering from a stroke
• Headaches similar to migraines
It is important to remove the cholesteatoma and all traces of infection. For this, it is
usually necessary to have a surgical procedure known as mastoidectomy. Once the
middle ear chamber is opened, the mass is removed and the surgeon will check to make
sure the ossicles are not damaged and that the cholesteatoma has not penetrated to
other areas of the cranium.
As with mastoid surgery, an incision is made behind the ear and a flap of skin pulled
back to access the inner ear chamber. The damaged ossicles is removed and matched
against various sized artificial bones to get a close match.
Titanium is often used to replace one or more of the bones and is custom fitted
for each patient’s unique bone lengths. Titanium is used as the body will not reject the
metal and after time will actually grow a slime covering over the metal. The ossicles are
very small and this makes the surgery very delicate. Patients are put under local or
general anesthesia in a hospital and the implant procedure usually lasts about two
hours. Because of the small size of the bones and the small workspace of the middle ear
(about a 1" chamber), surgery is performed using a special microscope. For more
serious middle and inner ear operations that are performed under general surgery,
robotic machines are used.
Otosclerosis
Otosclerosis is a spongy bone-like tissue that grows at the place where the
stapes meets the oval window of the cochlea. As this growth grows, it slowly prevents
the ossicles from moving well. Otosclerosis is the most frequent cause of middle ear
hearing loss and affects about 10% of the United States population. It is most commonly
seen in more women than men often during pregnancy, implying a hormonal cause.
Caucasians are more likely to have this disorder than any other race. Only 1% of African
Americans have otosclerosis. It is also rare among Orientals and Native Americans.
Image of otosclerosis occurring between the stapes and the oval window of the cochlea
Causes of Otosclerosis
The causes of otosclerosis are not exactly known. However, the most
generally accepted theory is that it has a genetic basis, combined with hormonal
production abnormalities. The gene that cause the otosclerosis appears to be a
dominant, rather than a recessive gene, but it has a characteristic called
“reduced penetrance” meaning it does not always dominate over a normal gene.
At first, hearing loss occurs in the low frequencies. High frequencies are affected
next, followed by the loss of hearing in the middle frequencies. Otosclerosis
usually begins in one ear, but the other ear often develops it as well. If left
untreated, otosclerosis will cause the hearing to steadily get worse and can lead
to profound deafness. It is rare for otosclerosis to occur after the age of fifty.
Categories of Otosclerosis
• Subclinical Otosclerosis- occurs when the tissue does not interfere with the
ossicles. A person may have this form for many years and not know it.
• Clinical Otosclerosis- This type can be present in the teen years, but not
detected until the young adult years.
• Histologic Otosclerosis- occurs when the tissue is present, but it does not
grow larger. This rare condition may or may not cause a hearing loss. Very
occasionally, otosclerosis can also affect the inner ear. The condition can
affect either one, or more commonly, both ears.
Symptoms of Otosclerosis
• Tinnitus
• Hearing loss, often at lower frequencies
• You may also find that your hearing is better in noisy surroundings.
• People with otosclerosis tend to speak quietly.
In the early stages of otosclerosis, or when the condition is mild, you might not
need any treatment. Hearing aids are very useful initially. However, as the tissue builds
up on the stapes you will gradually lose your hearing. Sodium fluoride tablets have been
shown to help prevent the progression of otosclerosis, but only if the condition has also
affected the inner ear.
About 85% of people find the operation a success and report a good
improvement in hearing. However, there is a very small risk of fluid loss in the years
following surgery -for example, if you have a sudden blow to the head or sudden
pressure change that causes the piston to penetrate the membrane of the oval window.
Fenestration- the idea of the operation is that since the oval window is
obliterated by bony growth, a new window (fenestra) needs to be made, and
usually this window is to be drilled into the lateral semicircular canal level of the
promontory.
Dizziness
The main symptoms of dizziness include a feeling of light headedness. There are
numerous reasons why a person may be experiencing dizziness. It may be related to
anxiety or panic disorders, or mood disorders. Dizziness in the form of light-headedness
may result from a cardiovascular problem such as an irregular heart beat (arrhythmia) or
if your blood pressure drops when you change positions (postural hypotension).
Symptoms of Dizziness
• Light headedness
• Motion sickness or nausea
• Faintness or weakness
Tinnitus
• Vibratory- appears when the underlying etiology originates from outside the
patients like loud noise and head trauma.
• Nonvibratory – appears when the cause is due to disease, drugs or some other
internal process
The body senses its different positions and controls its balance through organs of
equilibrium (balance) that make you feel stable, or normal. These organs of balance are
located in the inner ear and are called the semicircular canals. These canals look like
loops of tubes. Their connections on one side are to the cochlea where they receive
sounds, and to the aural nerves going to the brain.
The semicircular ducts are arranged roughly at right angles with each other so
that they represent all three planes in three-dimensional space. The horizontal duct lies
in a plane pitched up approximately 30 degrees from the horizontal plane of the earth-
erect head. The front canals are located in vertical planes that project forward and
outward by approximately 45 degrees. The rear canals are located in vertical planes that
project backward and outward by approximately 45 degrees.
If you could take the upper portion of each inner ear on each side of the head,
they would be symmetrical the front canal on one side of the head is parallel to the rear
canal on the other.
Vertigo
• Sense of movement
• An illusion of spinning and circling
• Worsened with head movements
• Nausea/vomiting
• Episodes come and go
• Rhythmic Eye Movement (Nystagmus)
Causes of Vertigo
The cause of all vertigo is when the semi-circular canals are not functioning
properly, ether due to infection, inflammation, trauma, hormonal imbalances, blood
disorders, or scarring. However, for vertigo that lasts off and on or continuously for a few
days, the following are some probable causes.
• Low tolerance for vehicular motion such as cars, boats, cruise ships, and
airplanes that cause motion sickness.
• A head cold or some infection of the ear or nasal passages that blocks or swells
the eustachian tube.
• The subsequent inability of the middle ear to equalize air pressure in the middle
ear chamber causes undue pressure on the inner ear, and subsequently the
semicircular canals where balance is registered.
• High blood pressure
• High cholesterol
• Diabetes
• Anemia
• Calcium disorders
• Alcohol or drug abuse
• Brain tumors and Syphilis (rare cause)
Vertigo with hearing loss on one-side, noise in the ear and aural fullness.
Meniere’s Disease is an inner ear disorder that brings spontaneous episodes of vertigo
that can last minutes to hours. Along with the vertigo, there may be some hearing loss in
the affected ear that comes and goes, as well as an increase in tinnitus and a sense of
fullness in the Meniere’s affected ear. Between episodes, you may have a persistent
hearing loss and tinnitus in the affected ear. The vertigo associated with Meniere’s
Disease may happen suddenly, or may build in intensity over several hours and you may
begin to experience nausea or vomiting.
The first is to treat the symptoms of vertigo with anti-vertigo medication. Often an
anti-nausea agent is necessary to combat the sick feeling that comes with
vertigo. During and following a vertigo attack, the affected patient should avoid
movements as they may increase the severity of the symptoms.
There are some changes to diet and lifestyle that may help you manage Menire's
Disease. These include a low-salt diet to help reduce fluid retention as well as taking a
medication that encourages urination. You should also avoid sudden movements as they
may aggravate these symptoms.
• Recurrent Vestibulopathy
Severe vertigo, with or without hearing loss
Patients who suffer multiple episodes of severe vertigo without hearing loss likely
have what is known as recurrent vestibulopathy. These attacks of vertigo come and go,
and last from minutes to hours. This disorder is therefore similar to the later, but without
any hearing loss or noise in the ear. There is no evidence of brain dysfunction with
recurrent vestibulopathy, and it usually goes away over time. Some recurrent
vestibulopathy may turn into Meniere's Disease or benign paroxysmal positional vertigo
(BPPV).
There are some changes to diet and lifestyle that may help you manage this type
of vertigo. These include a low-salt diet to help reduce fluid retention as well as taking a
diuretic.
Vertigo caused by free floating particles in the inner ear organ of balance or
vestibule
Debris in the posterior semicircular canal of the inner ear (BPPV)
The vestibular system located in and around the ear controls our body's sense of
balance. When your head moves, the vestibular system sends information to the organs
inside the ear, and these organs then pass the information on to the brain.
Symptoms of BPVV
Benign paroxysmal positional vertigo (BPPV) results from debris particles that
move freely within fluid in the canals of the inner ear. The debris is not related to getting
anything in the ear canal, it just forms on its own.
A change in your head position, lying down, getting up, turning over in bed, or
tipping your head backwards to look up may cause the debris to shift. This shifted debris
affects the balance receptor in the ear and causes vertigo. The vertigo associated with
BPPV comes on suddenly and usually only lasts for seconds to minutes. There are
usually no hearing symptoms.
A skilled doctor can perform some maneuvers that can move the debris out of the
sensitive part of the ear (posterior canal). Your doctor can also teach you how to do
certain exercises at home, placing your head in various positions at different angles. This
may help move the debris in your ear as well.
The need for surgery is very rare, but in such cases a procedure known as
“posterior canal plugging” can be done. This blocks most of the canal’s function, which
can reduce the symptoms.
Vestibular Neuronitis
Disruption of vestibular input to the brain
The brain and the inner ear communicate information via nerves. The cochlear
nerve carries information about noise and hearing, the vestibular nerve carries
information about balance and body position. Viruses can affect either or both nerves
and the symptoms will vary according to which nerve has been affected.
Viral Labyrinthitis
It is a sudden disruption of the messages to the brain from within the inner ear as
a result of a sudden viral infection. As a result of this virus, you may experience severe
vertigo that usually comes on suddenly and can last from days to weeks, depending on
the length of time the body builds up anti-bodies to the virus. There are no other
symptoms related to the ear.
There are some other things that you can do to help alleviate the symptoms. Bed
rest is recommended for the first 2 to 3 days from the initial onset of your symptoms. If
your vertigo symptoms last more than a few days, staying active may be more helpful.
There are also some exercises that your doctor may suggest once the vertigo has
subsided.
PEDIATRIC DEAFNESS
Normal hearing requires that all parts of the auditory pathway are working
correctly. This pathway includes the external ear, middle ear, inner ear, auditory nerve,
and the connection between the auditory nerve and the brain. The exact location and
nature of the problem in the auditory pathway determines the type and severity of a
person's hearing loss.
Some causes of hearing loss occur before a baby is born. These include genetic
disorders such as Warrensburg syndrome or Crouzon syndrome and infections such as
congenital rubella or congenital syphilis.
Genetic Factors
About half of all cases of hearing loss among children are thought to result from genetic
factors. Sometimes these children have a syndrome of which hearing loss is only one
feature. However, in most children with hearing loss that is due to a genetic cause, the
hearing loss is not part of a syndrome. A variant of the connexin 26 gene is responsible
for much of the hearing loss in this latter group of children.
Postpartum Factors
Problems during or soon after birth can also be risk factors for developing hearing loss.
These include hypoxia, bleeding in the brain, and hyperbilirubinemia. Children who are
born early or at low birth weight are more likely to have problems that may lead to
hearing loss. However, children who are normal birth weight can have hearing loss.
Other Factors
Hearing loss can also occur later in a child's or adult's life. Causes during this time
include infection such as meningitis, chronic middle ear infections, or measles, injuries
such as head injury, or certain drugs such as the antibiotic gentamycin. High noise levels
such as from firecrackers or loud rock concerts can also damage a person's hearing.
About 30 million workers are exposed to dangerous noise levels on their jobs. Another
nine million are at risk of hearing loss as a result of working with certain metals or
solvents. Some causes of hearing loss can be prevented. For example, vaccines can
prevent certain infections, such as H-flu meningitis or measles, which can cause hearing
loss.
This was the first type of hearing aid invented by Harvey Fletcher while working
at Bell Laboratories. These aids consist of a case containing the components of
amplification and an ear mold connected to the case by a cord. The case is about the
size of a pack of playing cards and is worn in the pocket or on a belt. Because of their
large size, body worn aids are capable of large amounts of amplification and were once
used for profound hearing losses.
BTE aids have a small plastic case that fits behind the ear and provides sound to
the ear via air conduction of sound through a small length of tubing, or electrically with a
wire and miniature speaker placed in the ear canal. The delivery of sound to the ear is
usually through an earmold that is custom made, or other pliable fixture that contours to
the individual’s ear. BTEs can be used for mild to profound hearing losses and are
especially useful for children because of their durability and ability to connect to assistive
listening devices such as classroom FM systems.
These devices fit in the outer ear bowl or pinna they are sometimes visible when
standing face to face with someone. ITE hearing aids are custom made to fit each
individual's ear. They can be used in mild to some severe hearing losses. Feedback, a
squealing/whistling caused by sound leaking out of the aid and being amplified again,
may be a problem for severe hearing losses. Some modern circuits are able to provide
feedback regulation or cancellation to assist with this. Traditionally, ITEs have not been
recommended for young children because their fit could not be as easily modified as the
earmold for a BTE, and thus the aid had to be replaced frequently as the child grew.
At a first glance, these devices are similar to the BTE aid. There is however one
crucial difference, the receiver of the hearing aid is placed inside the ear canal of the
user and thin electrical wires replaces the acoustic tube of the BTE aid. There are some
advantages with this approach. First, the sound of the hearing aid is arguably smoother
than that of a traditional BTE hearing aid. With a traditional BTE hearing aid, the
amplified signal is emitted by the receiver which is located within the body of the hearing
aid behind the ear. The amplified signal is then directed to the ear canal through an
acoustic tube, which creates a peaky frequency response. With a RITE hearing aid, the
receiver is right in the ear canal and the amplified output of the hearing aid does not
need to be pushed through an acoustic tube to get there, and is therefore free of this
distortion. Secondly, RITE hearing aids can typically be made with a very small part
behind-the-ear and the wire connecting the hearing aid and the receiver is extremely
inconspicuous. For the majority of people this is one of the most cosmetically acceptable
hearing device types.
• In the canal (ITC) and completely in the canal aids (CIC)
ITC aids are smaller, filling only the bottom half of the external ear. You usually
cannot see very much of this hearing aid when you are face to face with someone. MIC
and CIC aids are often not visible unless you look directly into the patient’s ear. These
aids are intended for mild to moderately-severe losses. CICs are usually not
recommended for people with good low frequency hearing, as the occlusion effect is
much more perceivable.
• Open-fit devices
"Open-fit" or "Over-the-Ear" OTE hearing aids are small behind-the-ear type devices.
This type is characterized by a small plastic case behind the ear, and a very fine clear
tube running into the ear canal. Inside the ear canal, a small soft silicone dome or a
molded, highly vented acrylic tip holds the tube in place. This design is intended to
reduce the occlusion effect. Conversely, because of the increased possibility of
feedback, they are limited to moderate high frequency losses.
The BAHA is an auditory prosthetic which can be surgically implanted. The BAHA
uses the skull as a pathway for sound to travel to the inner ear. For people with
conductive losses, the BAHA, bypasses the external auditory canal and middle ear,
stimulating the functioning cochlea. For people with unilateral hearing loss, the BAHA
uses the skull to conduct the sound from the deaf side to the side with the functioning
cochlea. The implant vibrates the skull and inner ear, which stimulate the nerve fibers of
the inner ear, allowing hearing.
• Eyeglass aids
Recently, a new type of eyeglass aid was introduced. These “hearing glasses”
feature directional sensitivity: four microphones on each side of the frame effectively
work as two directional microphones, which are able to discern between sound coming
from the front and sound coming from the sides or back of the user. This allows for
amplification of the sound coming from the front, the direction in which the user is
looking, and active noise control for sounds coming from the sides or back. Only very
recently has the technology required become small enough, in size, to be put in the
frame of the glasses.
Hearing aids are built from analog or digital circuits. Each technology processes sound
differently. Until recently, all hearing aids were analog. Digital hearing aids are the
newest kind of hearing aid and are superior to analog. All hearing aids, whether analog
or digital, are designed to increase the loudness of sounds reaching the ear drum so that
the hearing-impaired person can better understand speech.
When someone talks, you usually want to hear what they are saying, rather than
whatever noise is going on in the background. People who use traditional analog hearing
aids often complain that they find it difficult or impossible to follow conversations in noisy
places. Many digital aids are designed to reduce steady kinds of background noise, such
as crowds in a restaurant or the rumble of traffic or the whirr of a fan. This makes
listening more comfortable. But it does not necessarily help you to pick out a single voice
from everything else that's going on, especially when several people are talking. Some
digital hearing aids also have circuitry to protect whatever hearing is left. If a loud sound
is detected above the 90-100 Db range which can cause damage, dampening circuitry
cut out the sound.
To effectively use any sensory aid, clients must know and understand the
following:
COCHLEAR IMPLANTS
Those who are born deaf prelingual deafness, as well as children and adults
who lost their hearing from either disease or trauma post lingual deafness, can
experience the gift of hearing thanks to cochlear implants.
Once processed, the digital signals go back up to a transmitter (in some models,
the transmitter and the microphone are in the same piece in other models, the
microphone is in a behind-the-ear piece that looks like a conventional hearing aid). The
transmitter, which is held by a magnet on the side of the head behind the ear, sends the
coded signals via radio waves across the skin to the implant. The implant delivers the
signals to electrodes that have been inserted into the cochlea. The electrodes stimulate
the auditory nerve, sending impulses to the brain where they are interpreted as sound.
Initial experiments with deaf participants indicated that if an electrode was placed
on the bony wall of the inner ear and an electric current was passed through the
electrode, the deaf individual could perceive the sensation of sound. From this very
basic observation the concept of placing an active electrode into the inner ear by way of
the round window -the only non-bony entry into the cochlea of the inner ear was born.
Initial implants were thus placed against the outer wall of the inner ear. Soon,
they were introduced into the cochlear chamber itself through the round window. Not
only was this introduction more effective in stimulating the residual nerve endings of the
inner ear, but it also allowed the surgeon to better anchor the implant into the inner ear
without risk of loosing contact with the nerve endings.
Individuals with deafness usually have lost most of their “hair cell” nerve endings
which normally conduct sound from the ear to the brain. Significant residual nerve
endings are needed to be present in the deaf to allow for their direct stimulation by the
neighboring electrodes. The cochlear implant is thought to function by directly
stimulating the surviving nerve population in the cochlea and spiral ganglion.
Both the Nucleus 24 Contour and the Clarion High Focus devices have further
refined this concept with the closer placement of the electrode array to the residual spiral
ganglion cells of the auditory nerve.
The active electrodes in these newest devices allow them to hug the bony inner wall of
the cochlea instead of loosely fitting into the cochlear chamber. This concept may allow
for lower electrical stimulation levels of individual electrodes which would prevent “cross
chatter” between electrodes (jumping of electrical fields from one electrode to another)
and conserve battery life as well.
Long lasting batteries requiring little electric current will allow for a completely
implantable cochlear device in the future. For the present, the implantable portion
includes the electrode array and wire from the electrodes to an implanted portion of the
device which is behind the ear. The remaining hardware of the device includes the
microphone, receiver, speech processor and magnetic link between the outer scalp and
the implanted portion of the device.
The external portion of the unit receives and processes sounds which are then
fed into a specific electrode pair. These, in turn, stimulate the auditory nerve and finally
the auditory center of the brain.
OLFACTION
NOSE
The nose is the organ involved in smell and breathing. It is located in the middle
of the face. The internal part of the nose lies above the roof of the mouth. It processes
the air that you breathe before it enters your lungs. Most of this activity takes place in
and on the turbinates, located on the sides of the nasal passages. In an adult, 18,000 to
20,000 liters of air pass through the nose each day.
The nose is consists of:
Sinuses
The sinuses are cavities, or air-filled pockets inside the face, near the nasal
passages. As in the nasal passages, the sinuses are lined with mucous membranes.
There are four sinuses:
Ethmoid sinus - located around the area of the bridge of the nose. This sinus is
present at birth, and continues to grow until puberty.
Maxillary sinus - located around the area of the cheeks. This sinus is also
present at birth, and continues to grow until puberty.
Frontal sinus - located in the area of the forehead. This sinus does not develop
until around 7 years of age.
Sphenoid sinus - located deep in the face, behind the nose. This sinus does not
fully develop until adolescence.
The nurse uses inspection and palpation to examine the nose and sinuses. The
structures assessed include the external nose, vestibule, nasal mucosa, septum,
turbinates, nasal canals, and sinuses. Function of the first cranial nerve (olfactory) is
usually not tested unless a deficit in the sense of smell is reported or suspected.
NOSE
External Nose
The external nose is inspected and palpated for deviations from normal
alignment, symmetry, color, discharge, nasal flaring, lesions, and tenderness. Normal
findings are listed. The skin color over the nose is the same as that of the facial skin.
Alignment is straight and symmetric without deviation from midline. Discharge from the
nares should be absent and the nares should not flare (spread) with respirations. The
client is able to breath quietly through the nose rather than mouthbreathe. Masses,
lesions, and tenderness are absent. The nurse checks the nasal canals for patency by
asking the client to occlude one nares with a finger and to breathe through the open
nares while closing the mouth. This is repeated for the opposite nares. The client should
be able to breathe without difficulty through both nares. The nurse asks the client to tip
the head back and inspects the outer nares for crusting, bleeding, or dryness, which
should be absent.
Internal Nose
The nurse next inspects the vestibules with use of a penlight while the client’s
head is tipped back. Normal findings include the presence of coarse hairs, a clear
passage without discharge, and a midline septum. Further examination of the internal
nose requires use of a nasal speculum; this is not done unless it is indicated.
If detailed examination of the internal nose is done, the nurse either attaches a
nasal speculum tip to the otoscope head or uses a metal nasal speculum and penlight
for illumination. The client tips the head back, and the nurse gently inserts the speculum
into one nares with care being taken not to scrape the mucosa. One nares is inspected
at a time.
Hold the speculum correctly and inserts the blade gently about ½ inch into the
nostril. Gain additional control of the speculum by resting the index finger of the
dominant hand on the side of the client’s nose. Steady the client’s head with the
nondominant hand. Open the blades gently and vertically, avoiding pressure on the
septum and turbinates. Slowly move the head to inspect all areas of the nasal chamber.
Observe the condition of the mucous membrane (e.g., pallor, redness, swelling).
Normally, the mucosa is moist and dark pink without sign of inflammation, pallor, or blue
color. Presence of discharge is abnormal. The septum is midline without deviation,
masses, perforation, or exudates. The turbinates (only the inferior and part of the middle
turbinates are visible, the superior is not) have the same color as the mucosa and should
be free of exudates, swelling, or inflammation. Look for polyps and other masses.
Observe plugs of mucus for color, consistency, amount, and odor.
Nasopharynx
The nasopharynx is best examined with a mirror with the tongue depressed with
a tongue blade or gauze. Prevent the mirror’s fogging by warming it before putting it into
a mouth. Hold the mirror to one side of the uvula and focus light on it. A small part of the
nasopharynx can be observed with a nasal speculum. Specialists may use a
nasopharyngoscope to examine the nasopharynx.
Paranasal Sinuses
Assess the paranasal sinuses by (1) inspecting and palpating the soft overlying
tissues, (2) observing any nasal secretions (it is possible to determine which sinus is
infected according to where purulent discharge appears), and (3) transillumination of the
maxillary and frontal sinuses.
The nurse palpates and percusses the frontal and maxillary sinuses to assess
for swelling and tenderness, which should be absent. The frontal sinuses are palpated
simultaneously by placing the thumbs above the eyes, just under the bony ridge of the
orbits, and applying gentle pressure. The maxillary sinuses are palpated by use of either
the index and third fingers or thumbs to gently press on each side of the nose just under
the zygomatic bones. Direct percussion is used over the eyebrows for the frontal sinuses
and on either side of the nose below the eyes in line with the pupils for the maxillary
sinuses.
TRANSILLUMINATION
Smell
The senses of taste and smell are closely related. Many conditions affect taste
and smell, such as viral infections, normal aging, head injuries, and local obstruction.
Some medications can affect smell and taste, such as metronidazole (Flagyl), local
anesthetics, clofibrate (Atromid-S), some antibiotics, some antineoplastics, allopurinol,
phenylbutazone, levodopa, codeine, morphine, lithium, and carbamazepine (Tegretol).
A. Flexible Rhinolaryngoscopy
Before undergoing FESS, patients have lab tests, CT scans and other
screenings to confirm the exact nature of the problem. During FESS, our
otolargyngolgists (ear, nose and throat doctors) introduce an endoscope into the interior
of the patient’s nose and sinuses. The slender, fiberoptic device has a tiny light at its
end, enabling the physician to view the problem area. Once the instrument is positioned,
tiny scalpels and other surgical tools are passed through the nostrils alongside the
endoscope to remove polyps and other obstructions. Since there are no external
incisions, the patient rarely experiences any bruising or swelling.
D. Sinus X-ray
A sinus x-ray is a type of x-ray used to obtain images of the sinuses. The sinuses
are air-filled cavities lined with mucous membranes located within the bones of the skull.
During a sinus x-ray, x-rays pass through the sinuses and form an image on a
special type of film. The sinuses are usually filled with air, which appears black on x-ray
film. An opaque (whitened) area on an otherwise normal film may indicate the presence
of sinusitis (inflammation of the mucous membranes of the sinuses), hemorrhage, tumor,
or other problems.
As computerized tomography (CT scan) and magnetic resonance imaging (MRI)
technologies are often able to provide improved imaging of the sinuses, the use of these
scans may replace sinus x-rays in certain circumstances.
Other related procedures that may be used to evaluate problems of the sinuses
include x-rays of the skull, CT scan of the brain, and MRI of the brain and spine. Please
see these procedures for more information.
SINUSITIS
Sinusitis is an infection of the sinuses near the nose. These infections usually occur
after a cold or after an allergic inflammation. There are four 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.
Causes of Sinusitis
When the flow of secretions from the sinuses is blocked, bacteria may begin to grow.
This leads to a sinus infection, or sinusitis. The most common bacteria that cause
sinusitis include the following:
• Streptococcus pneumonia
• Haemophilus influenzae
• Moraxella catarrhalis
Symptoms of Sinusitis
The symptoms of sinusitis depend greatly on the age of the child. The following
are the most common symptoms of sinusitis. However, each child may experience
symptoms differently. Symptoms may include:
Younger Children:
• runny nose
o lasts longer than seven to 10 days
o 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
Treatment
Specific treatment for sinusitis will be determined by your child's physician based on:
RHINITIS
Rhinitis is a reaction that occurs in the eyes, nose and throat when airborne
irritants (allergens) trigger the release of histamine. Histamine causes inflammation and
fluid production in the fragile linings of nasal passages, sinuses, and eyelids.
• Allergic Rhinitis
o sneezing
o congestion
o runny nose
o itchy nose, throat, eyes, and ears
o avoiding pets
o oral medications
o inhaled medications
o immunotherapy
o allergy injections
• Nonallergic Rhinitis
o eosinophilic
o rhinitis medicamentosa
o neutrophilic rhinosinusitis
o structural rhinitis
o nasal polyps
o sneezing
o congestion
o runny nose
o itchy nose, throat, eyes, and ears
o oral medications
o inhaled medications
o immunotherapy
o allergy injections
o surgery for some conditions
TONSILO-PHARYNEAL
Tonsils
Tonsils are clusters of lymphatic tissue just under the mucous membranes that line
the nose, mouth, and throat (pharynx). There are three groups of tonsils. The pharyngeal
tonsils are located near the opening of the nasal cavity into the pharynx. When these
tonsils become enlarged they may interfere with breathing and are called adenoids. The
palatine tonsils are the ones that are located near the opening of the oral cavity into the
pharynx. Lingual tonsils are located on the posterior surface of the tongue, which also
places them near the opening of the oral cavity into the pharynx. Lymphocytes and
macrophages in the tonsils provide protection against harmful substances and
pathogens that may enter the body through the nose or mouth.
These lymphoid organs developed from the epithelium of the primitive oronasal
cavity, the mesenchymal stroma and lymphoid cells then infiltrate these areas. Although
the tonsils are present at embryonal stage, they only acquire their typical structure in the
postnatal period. They begin increasing rapidly in size between the first and third year of
life, with peaks in the third and seventh year. They involute slowly at early puberty. In
contrast to other lymphoid aggregates, tonsils do not filter lymph.
The palatine tonsil is supplied by the facial artery, ascending pharyngeal artery,
lingual artery and the maxillary artery. Venous drainage is by the lingual and pharyngeal
veins.
Immunology
Pharynx
The pharynx is a tubular structure extending from the base of the skull to the
esophageal inlet. Superiorly, it opens into the nasal and oral cavities; inferiorly, it opens
into the larynx and the esophagus. It is lined with mucous membrane. The adenoids are
located in the nasopharynx, the palatine tonsils in the pharynx, and the lingual tonsils in
the hypopharynx; all are lymphoid tissue.
The pharynx is subdivided into the nasopharynx, the oropharynx, and the
hypopharynx.
Nasopharynx. The nasopharynx extends from the posterior choanae to the inferior
surface of the soft palate. Malignancies of the nasopharynx can present as nasal
obstruction, epistaxis, tinnitus, headache, diminished hearing, and facial pain.
Oropharynx. The oropharynx extends from the junction of the hard and soft palates and
the circumvallate papillae to the valleculae. It includes the soft palate and uvula, the
base of the tongue, the pharyngoepiglottic and glossoepiglottic folds, the palatine arch
(which includes the tonsils and the tonsillar fossae and pillars), the valleculae, and the
lateral and posterior oropharyngeal walls. Carcinomas of the oro pharynx can present as
pain, sore throat, dysphagia, and referred otalgia.
Hypopharynx. The hypopharynx extends from the superior border of the hyoid bone to
the inferior border of the cricoid cartilage. It includes the pyriform sinuses, the
hypopharyngeal walls, and the postcricoid region (i.e., the area of the
pharyngoesophageal junction). Malignancies of the hypopharynx can present as
odynophagia, dysphagia, hoarseness, referred otalgia, and excessive salivation.
The pharynx is the region of the tonsils, back part of the nose and swallowing area. It is
probably the most examined of all body regions, and reflects many diseases.
Assessment
To inspect the pharynx, the examiner asks the person to open the mouth without
protruding the tongue. A tongue blade is pressed firmly down on the midpoint of the
arched tongue; pressing farther back may cause gagging. The person then says “ah”
while breathing through the mouth to prevent gagging.
The oropharynx, that portion of the pharynx directly posterior to the oral cavity
bounded by the nasopharynx above and laryngopharynx below, is examined with a
tongue blade and a mirror. The anterior and posterior tonsillar pillars, the uvula, tonsils
and posterior pharynx are inspected for color, symmetry, evidence of exudates, edema,
ulceration, and tonsillar enlargement. Redness and swelling of the tonsils, pillars and
uvula with white or yellow exudates on the tonsils may indicate streptococcal infection.
Tonsils may be enlarged without being infected.
Examination of oral cavity should be done properly. Very often, the size of tonsils
may be exaggerated during gagging and pressing hard with the use of a tongue
depressor. The proper way is to gently place the tongue depressor anterior to the
circumvallate papillae or if possible, just by inspection without the use of tongue
depressor. The size and percentage of the obstruction should be recorded using the
scale 0 to +4. 0 means the tonsil is in the fossa; +1 means less than 25% obstruction; +2
is less than 50%; +3 is less than 75% and +4 is more than 75% obstruction.
The pharynx can be seen partially by forceful traction on the tongue, by the
fingers wrapped in a handkerchief. It begins in back of the one-half inch uvula, which
hangs down freely from the posterior rim of the palate.
1. Observe the sides of the pharynx where the tongue appears to originate, and note the
irregular flesh colored tonsils on each side. When removed, a small cavity remains in
their site. Adult tonsils may be atrophied to a pea size or if irritated and infected, be as
large as grapes and flecked with pus.
2. With a flashlight, examine the back of the pharynx while attempting to yawn. An all-
over redness, with noticeable soreness, usually means pharyngitis as in colds, sore
throats, etc.
3. Examine the wall of the pharynx on all sides and the back of the tongue, if possible,
for any one particular sore, ulcer or bleeding point, which may mean cancer.
A. Indirect Laryngoscopy
Indirect laryngoscopy has been used since the 1800s for visualizing the pharynx
and larynx. In this technique, the head light source illuminates the mirror, which in turn
illuminates the laryngopharynx. The patient is seated in the sniffing position and
protrudes the tongue while a warmed laryngeal mirror is introduced firmly against the
soft palate in the midline to elevate the uvula out of the field (gently, so as not to elicit the
gag reflex). The image seen on the mirror can be used to assess vocal cord mobility, as
well as to inspect for a mass or foreign body of the larynx or pharynx. This technique can
be performed rapidly and is inexpensive.
B. Flexible Rhinolaryngoscopy
C. Direct Laryngoscopy
The laryngoscope can also be suspended from a table-mounted Mayo stand (for
hands-free use), and a microscope can be maneuvered into focal distance to allow
magnified visualization of the glottis and subglottis. During a microscopic direct
laryngoscopy, small lesions or topographic abnormalities can be better characterized
and removed if desired. Some examples of lesions that can be diagnosed by direct
laryngoscopy are vocal cord polyps, leukoplakia, intubation granulomas, contact ulcers,
webs, nodules, hematomas, and papillomatosis. Additionally, small malignant lesions of
the vocal cords can be examined and ablated or extirpated by using a CO2 laser under
direct microlaryngoscopic guidance.
D. Angiography
Biopsy Procedures
A. Fine-needle Aspiration
FNA is often used to make an initial tissue diagnosis of a neck mass. The
advantages of this technique include high sensitivity and specificity; however, 5% to 17%
of FNAs are nondiagnostic. Another advantage of FNA is speed: If a cytologist or a
pathologist is available, diagnosis can often be made within minutes of the biopsy.
FNA has several advantages over excisional biopsy. An FNA requires only an
office visit, with minimal loss of time from work for the patient. In contrast, excisional
biopsy is commonly performed in an operating room, so the patient must undergo
preoperative testing. Patients with a significant medical history may require formal
medical clearance. An excisional biopsy exposes the patient to the risks of anesthesia,
postoperative wound infection, and tumor seeding.
B. Ultrasound-Guided FNA
C. CT-Guided FNA
Imaging Procedures
Because many of the deep structures of the head and neck are inaccessible to
either direct evaluation by palpation or indirect evaluation via endoscopy, further
information must be obtained by radiography. Imaging procedures such as CT, MRI,
ultrasound, and positron emission tomography (PET) scanning permit the diagnosis and
analysis of pathologic conditions affecting these deep structures, including the temporal
bone, skull base, paranasal sinuses, soft tissues of the neck, and larynx.
A. Ultrasonography
B. Computed Tomography
A CT scan with intravenous contrast is often the first-line imaging technique used
to evaluate a mass of the neck and to assess for pathologic adenopathy. CT has proved
to be an effective method for primary staging of tumors and lymph nodes. Additionally, it
has been shown to be effective in studying capsular penetration and extranodal
extension. It is clearly superior to MRI in evaluating bone cortex erosion, given that MRI
cannot assess bone cortex status at all. CT scans are also widely used for posttreatment
surveillance in cancer patients.
MRI avoids exposing the patient to radiation and provides the investigator with
superior definition of soft tissue. For example, MRI can differentiate mucous membrane
from tumor, as well as detect neoplastic invasion of bone marrow. In patients with nasal
cavity tumors, MRI can distinguish between neoplastic, inflammatory, and obstructive
processes. MRI is also valuable in assessing the superior extent of metastatic cervical
lymphadenopathy (i.e., intracranial extension). A disadvantage of MRI is its limited ability
to show bone detail; it therefore cannot detect invasion of bone cortex by a neoplasm.
Furthermore, an MRI scan is significantly more expensive than a CT scan.
False negative scans occur when tumor deposits are very small (i.e., 3 to 4 mm
or less in diameter). Thus, micrometastases are not reliably detected using an FDG-PET
image. Furthermore, a false negative scan can occur if the PET scan is performed too
soon after radiation therapy.
The role of PET imaging in head and neck oncology is rapidly expanding.
Currently, the majority of PET imaging used in head and neck oncology is FDG based.
FDG-PET is actively being used to look for unknown primary lesions and second
primaries, to stage disease before therapy, to detect residual or recurrent disease after
surgery or radiation therapy, to assess the response to organ preservation therapy, and
to detect distant metastases. Because false positive and false negative PET scans do
occur, accurate interpretation of PET scans requires a thorough understanding of the
potential confounding factors.
E. PET/CT
After a histologic diagnosis has been made and correlated with the imaging
information, the patient and physician can have a comprehensive discussion of the
pathology, the stage of the disease, and the selection of therapy.
NOSE DISORDERS
EPISTAXIS
PATHOPHYSIOLOGY
The most common cause of epistaxis is trauma to the nasal mucosa from
damage by a foreign object, picking crusts from the nasal septum, or dryness of the
nasal mucosa. Nosebleeds are fairly common in patients with coagulation defects such
as hemophilia, leukemia and purpura. Infection, tumors and some drugs and toxins may
cause nosebleeds; in many instances however, the cause is simply not identified or is
considered idiopathic.
There may be some relationship between the menstruation and epistaxis. It may
be that in some women with premenstrual syndrome the nasal mucosa becomes
congested at the time of menstruation, setting the stage for epistaxis.
The incidence of epistaxis is no higher in hypertensive patients than in
normotensive patients. However, hypertensive patients may bleed more profusely, partly
because of the direct effect of the increased pressure and also because the small nasal
arteries and arterioles of hypertensive patients tend to have much of their muscular walls
replaced by fibrous tissue and are incapable of contracting adequately to attain
hemostasis.
Children experience frequent nosebleeds from the anteroinferior part of the
septum known as the Little’s area or Kiesselbach’s plexus. The etiology is not clear, but
the area is richly vascular and children have hyperemic and congested upper respiratory
tracts. Children also pick up and rub their noses in the area where the mucosa is
stretched over the cartilage and bone.
Intractable nose picking is another cause of anterior nosebleeds. Some patients
cannot stop picking their noses, either because of a nervous habit or because crusts are
present from an earlier ulceration or perforation. Constant nose picking can cause septal
ulceration or even a perforation which leads to epistaxis.
A hereditary disease that is an unusual cause of epistaxis is Rendu-Osler-Weber
disease of hemorrhagic hereditary telangiectasia. This disease is gene dominant and
may be passed from either parent to a child of either sex. Epistaxis is usually the initial
symptom, but telangiectasis is commonly found in other mucous membranes or
anywhere on the external surface of the body. Bleeding usually occurs from the nose
and gastrointestinal tract because mucosa in those areas is very fragile, whereas other
areas have protective layers of squamous epithelium.
Most nosebleeds in the anterior part of the nose originate from Kiesselbach’s
plexus, the highly vascular network in the anterior septum. It is also anatomically closer
to the rapid inspiratory air flow, which may dry the normal mucus flow especially in cold,
dry weather. Because the vessels are fairly small and easily accessible, these
nosebleeds are the easiest to treat. If the bleeding is from the posterior part of the nose,
the exact source of bleeding is more difficult to locate because it is sometimes
impossible to see and bleeding is more profuse. Usually just one source on one side of
the nose bleeds, although bleeding frequently originates from both sides in patients with
blood dyscrasias.
Anterior nasal packing may be all that is required. Antibacterial ointment such as
Bacitracin or Neosporin is applied to half inch gauze and gently, but firmly inserted
into the anterior nasal cavities to apply pressure to the bleeding vessels
Nasal packing should be in place for a minimum of 48 to 72 hours.
For posterior plugs:
Figure 4. Posterior nasal packing. A. After adequate anesthesia has been obtained,
a catheter is passed through the affected nostril and through the nasopharynx, and
drawn out the mouth with the aid of ring forceps. B. A gauze pack is secured to the
end of the catheter using umbilical tape or suture material, with long tails left to
protrude from the mouth. C. The gauze pack is guided through the mouth and
around the soft palate using a combination of careful traction on the catheter and
pushing with a gloved finger. This is the most uncomfortable (and most dangerous)
part of the procedure; it should be completed smoothly and with the aid of a bite
block (not shown) to protect the physician's finger. D. The gauze pack should come
to rest in the posterior nasal cavity. It is secured in position by maintaining tension on
the catheter with a padded clamp or firm gauze roll placed anterior to the nostril. The
ties protruding from the mouth, which will be used to remove the pack, are taped to
the patient's cheek.
A small, red rubber catheter is passed through the nose into the oropharynx and
mouth. A small gauze pack is tied to the catheter, and it is withdrawn; this moves the
pack into proper placement in the nasophrarynx and posterior nose to apply
pressure.
The nasal cavity is packed with half-inch gauze and the strings from the posterior
pack are tied around a rolled gauze for maintaining its position. The ties from the oral
cavity are taped to the client’s face in order to prevent loosening or dislodgement of
the plug.
General comfort measures such as humidification, the use of drip pad to collect
bloody drainage and mucus, and providing lubrication to the nares.
Nurse must monitor for bleeding, and the proper placement of the posterior plug. If
the plug is visible in the oral cavity, notify the physician for readjustment of the
packing.
Posterior nasal packs should be in place for 5 days.
Prophylactic antibiotics are administered to prevent toxic shock syndrome and
sinusitis.
Medications:
• Fibrinolytics VITAMIN K (Aquamephyton) 10mg po or IM; useful in some cases of
epistaxis, but packing remains therapy of choice
• Anti-infective agents PENICILLIN 1.5 million U, IV q6h recommended for
prophylaxis because packing obstructs drainage of paranasal sinuses and may
precipitate a sinus infection.
1. Assess for:
Nasal Bleeding
Bright red blood comes from the nares; patient may also swallow
or expectorate blood; history of trauma, nose picking or other unknown
cause.
2. Examination of patient’s body for bruises or petechiae that may indicate
underlying hematologic disorder.
3. Nursing Diagnoses:
• Risk for fluid volume deficit r/t nasal bleeding
• Fear r/t loss of blood
• Risk for aspiration r/t inability to clear secretions; gagging
• Altered cerebral and cardiopulmonary tissue perfusion r/t large-
volume blood loss
4. Interventions for:
ANTERIOR BLEEDING
Assess the location of bleeding
Pinch the nose firmly and hold for at least 10 minutes. It is best if you
pinch the patient’s nose instead of asking the patient to do so. This way,
you can ensure steady and firm pinching.
If bleeding continues beyond the pinching 10 min. period, prepare the
client for additional treatment.
With the patient in a high Fowler’s position, slightly hyper flex the head
and suction the clots in the nasal passage.
Observe the canal for continued bleeding. If present, apply
vasoconstriction agent such as 10% cocaine solution.
If bleeding continues, the nose may need to be cauterized with silver
nitrate or anterior nasal packing inserted.
POSTERIOR BLEEDING
The bleeding usually originates from the sphenopalatine artery, anterior
ethmoid artery or the nasopalatine artery.
Assess that the bleeding is posterior.
Place the patient in a high Fowler position.
As ordered, anesthetize the posterior nasal passage with 10% cocaine
solution
Pack the bleeding site with packing materials such epistaxis catheter,
Foley catheter tip and or tampon.
Monitor vital signs and estimate blood loss. If necessary, provide fluid
volume replacement
Instruct patient to (1) tilt head forward if bleeding occurs (2) not to blow
nose and (3) to apply steady pressure for at least 5 min. if bleeding
recurs.
NASAL FRACTURES
A nasal fracture is a traumatic injury to the nasal bones. Most common causes
are accidents, sports injuries, and assaults. In children, falls are the most common cause
of nasal fractures. They occur more commonly in men, however when nasal fractures
are diagnosed, it is essential to rule out fractures of the associated facial bones such
zygomatic or mandibular fractures because facial injuries or trauma may also damage
\these bones.
Even a nasal fractures that appear simple usually have associated damage to
the mucosal lining of the nose. If the patient suffered a facial trauma that causes
epistaxis, damage to the bone-cartilage structures of the nose is more likely.
PATHOPHYSIOLOGY
A nasal fracture occasionally occurs in the birth canal during delivery. These are
usually “greenstick” fractures, and the baby’s nose inclines slightly to one side. The nose
can be grasped at the tip and pulled toward the midline to realign it.
Nasal fractures can be classified as unilateral, bilateral or complex. Unilateral
fracture – may produce little no displacement and may appear on an xray examination
as a simple crack.
Bilateral fractures – which are the most common, may be caused by a
swinging punch or blow that pushes both nasal bones to one side or by a frontal blow
that depresses the nasal bones and gives a flattened look to the nose. The entire nose
may be deviated and the nose may have a C or S deformity.
Complex fractures – are usually caused by a powerful frontal blow. Such blows
may shatter the nasal pyramid and frequently the frontal bones as well, causing a
marked depression of the nasal and frontal bones.
The usual findings are epistaxis, a noticeable facial deformity and a history of trauma.
Edema occurs quickly at the injury site and depending on the severity may include a
periorbital swelling. Ecchymosis is common, the nose is exquisitely tender, and nasal
obstruction occurs. Complex fractures of the nose and face may result in diplopia and
subscleral hemorrhage.
Polyps are benign grapelike cluster of mucous membrane and connective tissue
growths that appear as soft, pale gray, non tender masses and gradually form from
recurrent, localized swelling of the sinuses or nasal mucosa. Polyps are seen in about
90% of patients with chronic maxillary sinusitis. Polyps may become quite large. They
are usually bilateral, occur in multiples and may cause actual distention and enlargement
of bony structures of the nose. Even after surgical removal, some nasal polyps recur.
Although rare in children, polyps are occasionally found in children with cystic fibrosis
and allergies and in those with Peutz-Jeghers syndrome. The symptoms of this
syndrome include pigmented spots on the skin, especially around the mouth and
polyposis of the gastrointestinal tract. Many patients with polyps have anosmia or
hyponosmia.
PATHOPHYSIOLOGY
The etiology of nasal polyps is not clear. They are often suspended in the nasal
cavity by stalks of varying lengths. The polyps and stalks usually originate in the
paranasal sinuses, particularly the ethmoid sinuses and pass into the middle meatus of
the nose through the ostia connecting them to the nasal cavities. They are often called
pseudotumors. Their pathogenesis is thought to be the result of focal mucosal edema
that causes a polypoid swelling. Because of the polyp’s weight, the swelling tend to
enlarge and eventually becomes suspended on a stalk.
Polyps are usually found in the middle meatus near the openings of the sinuses
and in the roof of the nose. They are never found on the septum or in the lower meatus;
the reason for this is not known. Nasal polyps are often found in patients with allergy,
cystic fibrosis, asthma, disorders of ciliary motility, chronic rhinitis and chronic sinusitis.
The exact relationship is unknown but may be related to an inflammatory response
causing hypertrophy of the mucosa, edema, and thinning of mucous membranes.
An interesting phenomenon that occurs in some patients with asthma and nasal
polyps is intolerance to aspirin, indomethacin and coal tar dyes. The intolerance is
severe, and can cause respiratory arrest if these substances are ingested. This is
thought to be related to the inhibitory action of these substances on prostaglandin
synthesis.
Medications:
• Corticosteroids. Prednisone high dose for 5 days.
• Methyprednisolone – decreasing doses may be used for severe nasal
obstruction to decrease size of polyps.
• Steroids not recommended for long term use; steroid sprays may be used for
long term control of the size of polyps and to prevent recurrence by reducing the
inflammatory response.
• Antihistamines
• Decongestants
• Anti infective agents
Nursing Assessment:
INEFFECTIVE AIRWAY CLEARANCE r/t swelling of the nasal mucosa and nasal
obstruction
PATHOPHYSIOLOGY
For deviation:
Submucous resection (SMR) – may be performed to reposition septum and
relieve nasal obstruction
Rhinoplasty – may be done to correct nasal structure deformity
Septoplasty – to replace septum in midline, may be done to relieve nasal
obstruction and to enhance external appearance of nose.
For perforation:
Surgical closure – possible but not always successful; a Silastic “button”
prosthesis may be inserted to close perforation.
MEDICATIONS: Analgesics
Antihistamines
Decongestants
Antiinfective agents
General Management:
Nursing Assessment:
Irregularities or deformity of external nose; obstruction to nasal breathing; feeling of
facial fullness; headaches; epistaxis; crusting of nasal mucosa; whistle sound when
breathing (perforation); or sinusitis