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Family Nurse Practitioner I 471

HEENT
B.

C.

D.

Ear disorders
1.
1.
Otitis media
2.
2.
Otitis externa
3.
3.
Cerumenosis
4.
4.
Cholesteatoma
5.
5.
Foreign body
C.
Nose/sinus disorders
1. 1. Rhinorrhea
2. 2. Allergic rhinitis
3. 3. Polyps
4. 4. Foreign body
5. 5. Epistaxis
6. 6. Sinusitis
Mouth/throat/neck disorders
1.
1.
Dental problems
2.
2.
Pharyngitis
3.
3.
Epiglottitis
4.
4.
Lymphadenitis
5.
5.
Mononucleosis
EARS

Screening recommendations
Not recommended on a routine basis until the age of 65 UNLESS the patient is
exposed to excessive noise (occupation)
Screening basics
May use hand held audioscope
Keep environment quiet
25dB check at 1000, 2000, and 4000 hertz. No response to one is a fail
40dB check at 1000, 2000, and 4000 hertz. No response to one is a fail
Whispered voice and finger rub are not recommended by experts
Test Results
Normal hearing (0-20dB) whisper
Mild loss (20-40 dB) soft voice
Moderate loss (40-60 dB) normal voice
Severe loss (60-80 dB) loud voice
Profound loss (80dB+) shout

Hearing Loss
Conductive dysfunction of external or middle ear (impairment of sound
vibrations to inner ear) due to:
o Obstruction (cerumen)
o Mass loading (acute otitis media)
o Stiffness (of tympanic membrane)
o Discontinuity (perforation of tympanic membrane)
Sensory deterioration of cochlea caused by noise trauma, ototoxicity, and aging
(presbycusis)
Testing for hearing loss
o Weber tuning fork on forehead
Conductive sound is heard in (lateralized to) the impaired ear
Sensorineural sound is heard in the good ear
o Rinne tuning fork on mastoid behind ear, then held out from canal
Conductive (BC = AC or BC > AC)
Sensorineural (AC > BC)
Tinnitus
Abnormal head or ear noises
If persistent, usually there is a sensory hearing loss.
Intermittent periods of high pitched tinnitus is common among normal hearing
adults
Cerumenosis: Excessive secretion of cerumen
Cerumen disimpaction = removing cerumen from the ear canal
o o Indications
To visualize TM to facilitate dx/tx of otitis or other ear disease
For relief of dizziness, pressure sensation, or tinnitus
To enhancing auditory acuity if ear is totally obstructed by
cerumen
A normal change of aging is decreased activity of the cerumen
glands, causing reduced moisture. Dry cerumen is more likely to
become impacted
o o Contraindications/Precautions
If purpose to help visualize the TM for signs of infection, do not
irrigate. Instead, attempt to remove the wax plug with a cerumen
spoon.
Do not irrigate if:
Suspected TM perforation
History of recent middle ear surgery
Tympanostomy tubes in place
History of multiple previous episodes of OM

To avoid accidental TM perforation, gentle pressure and irrigation


should be used slowly.
Irrigating solution should be warm to prevent caloric stimulation.
Irrigating stream should be aimed at the superior wall of the ear
canal instead of at the cerumen plug to avoid compaction of the plug
against the TM
Caution with struggling child: potential for damage to ear canal
or TM with otoscope, cerumen spoon or curette
Use papoose board or immobilization device fashioned
from sheets
Older child may require one person assigned to each limb
and a fifth to control the head
o o Patient Preparation/Education
If possible, use wax softening ear drops for 3-5 days before
procedure (Debrox, Cerumenex)
Advise patient that he may feel pressure, dizziness, or vertigo
during the procedure
Patient should alert NP if pain or discomfort occurs
o o Procedure
Ear syringe or Water Pik on low setting
Irrigating solution should be 1:1 mixture of warm water and
hydrogen peroxide
Basin
Protective drapes
o o After irrigation
Consider having the patient mix 50% rubbing alcohol and 50%
white vinegar and apply drops of it once a day after bathing to the ear
canal for 2-3 days after the procedure to prevent otitis externa
Instruct patient to call or return if following occur: hearing loss,
ear pain or fullness, discharge, tinnitus
Some people, especially the elderly, may require regular ear
hygiene.
Advise patient to use 2 drops of baby or mineral oil once or
twice a week to soften wax so that it expels itself, or to
purchase wax softening ear drops and use as directed on
package.
Remind patient never to put anything in ear canal, especially
commercial cotton tip applicators.

Foreign Body
Most common between 2 and 4 years of age
Subjective: Child may complain of pain, itching, buzzing (with an insect), a
feeling of fullness in the ear, decreased hearing, discharge from the ear
Objective: Foreign object or insect is visualized on otoscopic exam

Assessment: Foreign body


Plan: Extract the foreign object
o Make only one attempt at removal; if unsuccessful, refer
o Do NOT irrigate if foreign body is a vegetable or a wood object, as it may
expand and make removal more difficult
o Do NOT irrigate if perforation of the TM is suspected
o If an insect is in the ear, it must be killed by filling the ear canal with
mineral oil or alcohol before removal.
o Dislodge ticks by filling the canal with 70% alcohol and then remove
o Method:
If object does not completely occlude the canal, an ear loop,
curette, or forceps can be used.
If object is soft and unwedged, may irrigate with tepid water and a
Water-Pik on low setting.
May try inserting 18-gauge butterfly catheter tubing (needle cut
off) into the canal behind the foreign body, allowing the pulsating
water to help dislodge the object
Best to remove objects using an otoscope with an operating head
for visualization.

Otitis Externa (swimmers ear)


Refers to a spectrum of conditions, ranging from a minor inflammation to an
intensely painful and debilitating disease, which affect both children and adults.
The inflammation of the epithelium of the external ear canal may extend from the
pinna all the way to the TM
In children, the pain of OE can result in irritability, shortened attention span, as
well as disruption of sleep and recreational activities (swimming)
Adults suffering from the discomfort of OE may experience time lost from work,
loss of sleep, and the added financial burden of the cost of medical appointments
and prescription meds.
In its more severe, but rarely occurring form known as malignant or necrotizing
otitis externa, this disease can have debilitating and life-threatening
consequences.
Etiology: the pH of the ear canal is normally acidic, which tends to inhibit the
growth of microorganisms. Alteration in the pH of the ear canal can occur due to
swimming in a pool where the pH is usually alkaline. It is thought that it is this
alteration in pH, not the presence of microorganisms in the pool, that is generally
responsible for creating a climate conducive to the growth of bacteria or fungi.
Causative agents
o Bacteria (most common = Pseudomonas aeruginosa; others = proteus
mirabilis, Staphyloccus aureus, and Streptococcus pyogenes)
o Fungi (more common in DM, transplant patients, AIDS patients, and those
who have been on prolonged courses of antibiotics or steroid drops for
bacterial OE)

o Herpetic viral infections


o Dermatoses (seborrheic dermatitis, atopic dermatitis [eczema])
o Chemical irritants (used in hair dyes and sprays)
o Foreign bodies
Risk Factors
o Chemical irritants
o Anything altering the pH of the ear canal (swimming in pools or bodies of
fresh or salt water)
o Impacted cerumen (may create environment more conducive to microbial
growth)
o Mechanical irritation (from hearing aids)
o Trauma (cotton tip applicators, bobby pins, matchsticks)
o Foreign bodies (including insects)
o Anatomic factors (narrow ear canals, sharp angles in the curve of the
canal, excessive hair)
Differential Diagnosis
o Seborrheic dermatitis
o Atopic dermatitis
o Osteomyelitis of the temporal bone
o Cholesteatoma
o Mastoiditis
o Suppurative otitis media
o Osteoma (from excessive swimming in cold water)
o Exostoses (from excessive swimming in cold water)
o Neoplasm
Management
o Depends upon the causative factors
o Pain management (OTC meds, heating pad, may need stronger med)
o Cleansing of debris from external auditory canal
Gentle irrigation with warmed saline or 2.5% acetic acid solution,
or with gentle suctioning
o Suspected bacterial OE can be treated with antimicrobial drops, which
include polymyxin B, neomycin, and hydrocortisone combination,
ofloxacin, and ciprofloxacin HC otic drops
An ear wick may be inserted in the auditory canal to ensure that
the med is applied to all the affected area
o Severe OE may require hospitalization for systemic antibiotics and
appropriate pain management
o Refer to ENT if:
facial paralysis, erythema, and swelling over the mastoid are
present
granulation tissue is observed in the canal
unresolved fever and lymphadenopathy following initial tx.
Recalcitrant OE

o If fungal infection: clean, debride, antifungals agent such as nystatin and


clotrimazole topical solution
Otitis Media:
Definition: an inflammation of the structures within the middle ear
Serous otitis media: transudation of plasma from middle ear blood vessels
leading to chronic effusion
Acute otitis media ( = suppurative or purulent otitis media): an inflammation
secondary to infection, typically of bacterial origin, that may present with or
without effusion; Streptococcus pneumoniae and H. flu most common bacterial
pathogens found in middle ear fluid
Subacute otitis media: effusion lasts between 3 weeks and 3 months
Recurrent otitis media: characterized by the clearance of middle ear effusions
between acute episodes of otic inflammation
Chronic otitis media: occurs when inflammation persists for more than 3
months and is typically related to TM perforation with either intermittent or
persistent otic discharge

Subjective

Objective

Assessment
Plan

Case #1
Unilateral hearing loss
Afebrile
Stuffiness/fullness in ear;
pain rarely
Recent URI or allergy

Case #2
Unilateral hearing loss
Fever
Deep ear pain; otic
discharge
Recent URI
Vertigo, tinnitus, nausea,
vomiting
TM: retracted; may be amber TM: full/bulging;
or yellow-orange in color
injected; pink-gray to red
discharged with perforation
Bony landmarks prominent;
visible air/fluid level behind TM Bony landmarks and
light reflex absent
Nasal/oral mucosa may be
injected or edematous
Serous otitis media
Acute otitis media (AOM)
Topical decongestants
Systemic antibiotics*,
analgesics, antipyretics,
See patient in 4-6 weeks
topical otic analgesics
See patient in 72 hours
if symptoms have not
resolved; otherwise see
patient after
pharmacotherapy is
complete

Antibiotics:
Initial treatment of choice: amoxicillin, 250-500 po tid for 10 days
If symptoms fail to improve within 2 days, or in communities where resistant
organisms are prevalent, or for an immunocompromised patient, beta-lactamaseresistant antibiotics, such as trimethoprim-sulfamethoxazole (1 DS tab bid) or
amoxicillin plus clavulanic acid (250-500 mg tid) or cefaclor (500 mg tid) X 10 days
may be used.
Topical otic analgesics:
Americaine or Auralgan Otic Solutions, 4-5 drops every 1-2 hours
For inflammation:
Cortisporin otic suspension, 4 drops qid for 7-10 days
Cholesteatoma
May result from chronic otitis media and chronic negative ear pressure
An epithelial pocket or cystlike sac filled with keratin debris forms.
The cyst, which is filled with a combination of epithelial cells and cholesterol,
most commonly enlarges to occlude the middle ear.
Enzymes formed within the sac cause erosion of adjacent bones, including the
ossicles, and destroy them.
NOSE/SINUSES
Rhinorrhea: thin, watery discharge from the nose
Rhinitis: an inflammation of the nasal mucosa that is usually accompanied by edema and
a profuse nasal discharge.

Rhinitis (nasal congestion)


Allergic Rhinitis

Atrophic Rhinitis

Rhinitis
medicamentosa

Vasomotor Rhinitis

Viral Rhinitis

Nasal mucosa

Pale, edematous

Crusted with mucous,


blood

Dry, rubbery

Red to blue in color

Erythematous

Rhinorrhea

Watery

Thick postnasal drip

Watery

Watery; watery
postnasal drip

Watery

Speech

Nasal

Normal

Nasal

Nasal

Nasal

Breathing

Forced mouth

Normal

Forced mouth

Forced mouth

Forced mouth

Other

Edematous nasal
turbinates and pharyngeal
tonsils; conjunctivitis,
pruritis in nasal passages,
conjunctiva, and roof of
mouth; sneezing coughing;
sore throat; usually
seasonal paralleling pollen
production

Nasal patency, foul odor in


nose, epistaxis, impaired
olfaction

Increased pulse and


BP

Edematous nasal
turbinates; rapid
onset

Edematous nasal
turbinates and
pharyngeal tonsils;
edematous
erythematous
laryngopharynx;
malaise; headache;
occasional fever,
sneezing, coughing,
sore throat. Symptoms
for < 7-14 days; greenyellow purulent
discharge with
secondary bacterial
infection

Treatment

Avoid exposure to
allergens; Nonsedating
antihistamines; Nasal
decongestant sprays no
longer than 3-4 days,
topical saline spray. May
need steroid nasal spray,
but may require up to 2
weeks of use prior to relief.

Topical bacitracin
ointment intranasally 2-3
X/day until crusting and
foul odor gone.
Expectorants, saline
sprays. Postmenopausal
women may be helped by
systemic estrogens.

Immediately stop all


topical decongestant
use; problem resolves
in 2-3 weeks. Oral
antihistaminedecongestant med,
short courses of nasal
or systemic steroids
(prednisone 40 mg
tapered over 8-10
days)

Treat symptoms.
Vaporizer, topical
saline nasal sprays,
Astelin spray
(antihistamine),
systemic
decongestants, May
need intranasal
steroid med.

Treat symptoms.
Acetaminophen for
fever and H/A.
Decongestants for
rhinorrhea. Cough
med.

Sinusitis:

An inflammation of the mucous membranes of one or more of the paranasal


sinuses: frontal, sphenoid, anterior ethmoid, and maxillary, with the latter two sinuses
most often affected
Classifications:
Acute abrupt onset of infection
Subacute purulent nasal discharge persists despite therapy
Chronic occurs with episodes of prolonged inflammation
Chronic sinusitis is classified by the U.S. Public Health Service as the most
common chronic disease.
Signs/symptoms of acute sinusitis
Gradual onset, recurrent or chronic dull, constant pain over the affected
sinuses (because of expanding purulent inflammation)
Pain increases and becomes characteristically throbbing
Pain is exacerbated by coughing and sudden head movements
Frontal sinus pain may worsen with recumbency; maxillary sinus pain may
worsen when erect; and ethmoidal sinusitis is associated with retro-orbital pain
Nasal congestion, mucopurulent rhinorrhea, cough sore throat malaise, and
fatigue.
Acute sinusitis is strongly predicted by maxillary toothache, a poor response
to nasal decongestants, and a colored nasal discharged.
Headache is worse in the morning or when bending forward.
Physical exam: purulent nasal secretions, total opacification of affected
sinuses on transillumination, and highly erythematous nasal mucosa
With subacute or chronic sinusitis, the patient complains of a persistent cough
or coldlike symptoms lasting from several weeks to several months.
Treatment: Antibiotic and symptomatic therapy is recommended for all forms of
sinusitis to prevent disease progression and complications.
For acute sinusitis treat 10-14 days (up to 21 days)
For subacute and chronic sinusitis, treat up to 3-4 weeks
Decongestant sprays or oral forms, topical steroids

Nasal Polyps
If also has asthma, avoid ASA (triad of problems)
Nasal steroid sprays
Foreign body in nose
May note unilateral purulent (at times malodorous) rhinorrhea
Common offenders include peas, marbles, beads, buttons
Treatment
Position head forward to prevent aspiration

Suction nose, vigorous nose blowing (older), insert 8 Fr foley past object then
inflate balloon and remove
If too deep or failed attempts to remove, refer to ENT
<![if !supportEmpty

Deteksi Gangguan Pendengaran Sejak Bayi


Selasa, 1 November, 2005 oleh: Siswono

Deteksi Gangguan Pendengaran Sejak Bayi


Gizi.net - Deteksi gangguan pendengaran dan ketulian sebaiknya dilakukan sejak
bayi. Deteksi bisa dilakukan orangtua secara sederhana, misalnya dengan
memperdengarkan sumber bunyi ke bayi dan mengamati ada atau tidak respons
bayi terhadap suara.
Hal tersebut diutarakan dr Jenny Bashiruddin SpTHT, Jumat (28/10) di Jakarta.
Menurut dia, tidak semua kasus gangguan pendengaran sejak bayi diketahui.
Pasalnya, tidak semua orangtua memeriksakan gangguan pendengaran yang dialami
bayi.
Data dari Pusat Kesehatan Telinga dan Gangguan Komunikasi Departemen THT-FKUI,
misalnya, pada tahun 1999-2003 tercatat 2.579 kasus tuli berat pada kedua telinga.
Sebagian besar (45,29 persen) ketulian itu diketahui pada saat berusia 1 sampai 3
tahun. Sekitar 24,42 persen diketahui pertama sekali pada usia 5 tahun atau lebih.
Hanya 6,13 persen yang terdeteksi sebelum berusia 1 tahun.
Dijelaskan, ada dua tipe gangguan pendengaran bayi sejak lahir. Pertama, gangguan
pendengaran yang disebabkan kerusakan bagian dalam telinga atau rumah siput
(koklea).
Kerusakan ini tidak bisa kembali normal sehingga si penderita harus memakai alat
bantu dengar sepanjang hidupnya. Kedua, gangguan pendengaran konduksi, yaitu
gangguan yang terjadi pada telinga bagian luar dan tengah. Untuk gangguan tipe ini,
ujarnya, bisa dilakukan operasi untuk memulihkan pendengaran.
Dengan kemajuan teknologi, kata Jenny, saat ini upaya mengatasi gangguan pada
koklea dilakukan dengan implan koklea.
Metode ini sudah bisa dilakukan di Indonesia, namun hanya di rumah sakit tertentu.
Selain itu, biayanya pun mencapai ratusan juta rupiah sehingga tidak semua orang
yang mengalami gangguan pendengaran bisa melaksanakan implan koklea.
Risiko Tinggi
Jenny menjelaskan, ada beberapa indikasi yang perlu diketahui orangtua untuk
mendeteksi gangguan pendengaran pada bayinya. Misalnya, bayi tetap tidur lelap,
sekalipun di sekitarnya ada suara atau bunyi yang keras. Demikian juga kalau bayi
berusia enam bulan belum bisa mengoceh dan tidak memberi respons bila ada bunyi.

"Di Indonesia deteksi gangguan pada bayi baru lahir belum menjadi program,
sehingga tidak semua kasus tercatat. Di rumah sakit, deteksi gangguan pendengaran
dilakukan dengan pemeriksaan emisi otoakustik, yang kemudian dilanjutkan dengan
pemeriksaan automated brainstem evoked response audiometry," ujarnya.
Disebutkan, deteksi terhadap gangguan pendengaran dan ketulian sudah harus
dimulai sebelum bayi ke luar dari rumah sakit atau saat berusia dua hari. Sedangkan
bayi yang lahir di tempat lain, sebaiknya dideteksi paling lambat saat berusia 1
bulan. Diagnosis terhadap ketulian hendaknya sudah dipastikan sebelum bayi berusia
3 bulan dan pemasangan alat bantu dengar sudah dimulai sejak usia 6 bulan.
Lebih jauh dikatakan, ada beberapa hal yang membuat seorang bayi berisiko tinggi
mengalami gangguan pendengaran dan ketulian. Seperti, bayi dengan berat badan
lahir kurang dari 1.500 gram, ibu hamil yang memakai obat bersifat toksik, seperti
obat tuberkulosis dan antibiotik, serta ibu hamil yang mendapatkan kemoterapi.
Selain obat, hal lain yang membuat bayi berisiko tinggi mengalami gangguan
pendengaran adalah ada riwayat meningitis karena bakteri, bayi kuning (kolestasis),
dan bayi yang memakai ventilator lebih dari lima hari.
" Bila bayi mengalami tiga dari hal-hal tersebut maka kemungkinan mengalami
ketulian lima puluh sampai enam puluh kali dibanding bayi yang tidak berisiko.
Bahkan dari hasil penelitian, bayi yang dirawat di neonatal intensive care unit
(NICU), sepuluh kali lipat berisiko mengalami ketulian dibanding yang tidak dirawat
di NICU," ucap Jenny.
Ditambahkannya, 0,1 persen penduduk Indonesia mengalami ketulian sejak lahir.
Sedangkan di negara maju 1 sampai 3 kasus tuli per seribu kelahiran hidup. Menurut
Organisasi Kesehatan Dunia (WHO), ada 2,1 persen atau sekitar 120 juta dari
penduduk dunia mengalami gangguan pendengaran. Dari jumlah itu sebanyak 25
juta orang berada di Asia Tenggara. (N-4)
Sumber: http://www.suarapembaruan.com