CHAPTER 14 Nursing patients with disorders of the ear, nose and throat

Introduction

Some problems of the ear, nose and throat (ENT) are very common; most people at some time in their lives suffer from nosebleeds, sore throats or earache. Many of these problems will be dealt with successfully at home, often with the advice of a pharmacist or general practitioner (GP). Some ENT problems, however, can be life threatening, requiring an immediate visit to an emergency department (ED), surgery and, in some cases, a period of nursing care at home following discharge.

To nurse ENT patients effectively in a home or hospital setting, a basic knowledge of the anatomy and physiology of the relevant structures, along with a thorough understanding of the clinical features of common disorders, is essential. The health visitor, community nurse, school nurse or occupational health nurse is often in a position to detect problems before the medical practitioner or even the patient is aware of them.

This chapter will outline the basic structure and functioning of the ear, nose and throat, describing the most commonly encountered disorders of each, and outlining appropriate medical and nursing interventions. As in every area of nursing care, one of the most important contributions that nurses can make is in the area of communication and education as they provide support and reassurance to the patient and family, and convey information about the causes of the patient’s condition, its treatment and measures to prevent its recurrence.

The ear

Anatomy and physiology of the ear

The ear can be divided into three sections: the external ear, the middle ear and the inner ear. The external and middle ears are primarily involved with the transmission of sound. The inner ear contains the organ of hearing as well as structures concerned with body balance (Figure 14.1).

Figure 14.1 Sagittal section of the ear.

The external ear comprises the cartilaginous pinna and the external auditory canal/meatus (EAM), the inner two thirds of which is composed of bone rather than cartilage. The purpose of the pinna and canal is to capture sound waves and funnel them to the tympanic membrane, which is located at the end of the external canal and divides the external from the middle ear.

The middle ear is ventilated by the eustachian tube, which communicates with the nasopharynx. Three small bones, called the auditory ossicles, pass on sound vibrations received by the tympanic membrane to the inner ear. The first of these, the malleus, is attached to the tympanic membrane and articulates with the incus, which in turn articulates with the stapes. The ‘footplate’ of the stapes lies against the membranous oval window or fenestra of the inner ear.

The inner ear houses the cochlea, which is shaped like a snail shell and is the organ of hearing. The cochlea contains the organ of Corti, which consists of cells with hair-like projections on a membranous layer and connects with the terminal ends of the auditory nerve. The canals of the cochlea and the organ of Corti are bathed in endolymph. Perilymph is the fluid contained within the bony (osseous) cavities of the inner ear, whereas endolymph is the fluid within membranous cavities. As sound waves are transmitted by the ossicles they travel along this fluid and disturb the hair cells. This disturbance changes to impulses, which travel along the auditory nerve to the brain stem and cortex, where they are interpreted as meaningful sound.

The posterior part of the inner ear is formed by three semicircular canals and by the vestibular apparatus. These assist in the perception of body position against gravity and in the maintenance of balance. The vestibular apparatus consists of the utricle and saccule and is sensitive to linear acceleration. The semicircular canals are sensitive to rotatory acceleration. Balance is maintained by the adjustment of muscles, joints, tendons and ligaments in response to information gathered by the vestibular apparatus and the canals as well as that received by the eyes. For further information, see Tortora (2009).

Disorders of the external ear

Otitis externa

The most common causes of otitis externa, inflammation of the external ear, are infection and allergy. Infection may be caused by excess wax trapping water in the EAM or scratching the ear with contaminated fingernails, cotton buds or other sharp objects. Itching is an early symptom of allergy and is more common in dry skin and dermatological conditions. In otitis externa, multiple bacteriological flora are usually present. The condition most commonly occurs in hot, humid climates, where it tends to be recurrent and may be severe. Patients usually present with a sensation of a blocked ear and a history of localised pain and itching and a burning sensation followed by a discharge, which initially may be watery and then becomes thicker. If there is gross oedema of the meatus and a large amount of debris is present, the patient may suffer from conductive deafness (see p. 452).

Nursing management and health promotion: otitis externa

The first priority of the nursing staff is to clean the EAM so that an examination can be carried out and any prescribed treatment administered effectively. This procedure is called aural toilet and should only be carried out by an appropriately qualified ENT nurse. Cotton wool can be tightly applied to an instrument specifically designed for aural toilet (Figure 14.2). This looks similar to a cotton bud, however the area of cotton is designed to be narrower to ensure the ear canal is not occluded once the cotton-tipped instrument is inserted into the canal. Care must be taken not to damage the skin. Gentle pulling of the pinna will straighten the canal and allow easier access (as demonstrated in Figure 14.3). A good light source should be used or an operating microscope. Gentle irrigation with water can clean the EAM but large amounts of discharge and debris are best removed by an appropriately qualified nurse or doctor using microsuction via a fine-bore tube under an operating microscope in the outpatient department.

Figure 14.2 Aural toilet using cotton wool.

Figure 14.3 Straightening the ear canal.

It may be necessary to administer an oral analgesic before the external auditory canal can be properly examined, as often any movement of the pinna is painful, see Box 14.1.

Box 14.1 Reflection

History of a patient with otitis externa

At the end of August Mr Smith had just returned from a short break in Cornwall. He had been swimming in the sea in the warm weather. His right ear felt blocked as if he had some water left in it, so he tried to dry his ear with a cotton bud. The ear continued to feel blocked and also became very itchy. On the Monday night Mr Smith woke up in the early hours of the morning with severe earache and a ringing noise on the same side of his head. He was finding it painful to talk as jaw movement hurt his ear and paracetemol had not relieved the discomfort. There was a small amount of dried liquid on the outside of the ear and it was uncomfortable to touch the ear itself. He was worried that there was something dreadfully wrong as he had never had any problems with his ear before.

Mr Smith attended the minor injuries department and the triage nurse examined his ear. The nurse said that there was debris present and the ear canal was mildly swollen. She explained it would be necessary to clean the ear canal to optimise the chance of clearing the infection. The nurse gently irrigated Mr Smith’s ear with water to remove the debris. Mr Smith found this quite relieving and the ear felt better once the nurse dried the canal with a cotton-tipped carrier. He was diagnosed with otitis externa and the nurse prescribed an ear spray with combined steroid and antibiotic. The nurse advised Mr Smith to be careful not to allow water enter the ear and to stop using the cotton buds. The nurse warned that he was to follow this advice forever or the ear infection might re-occur. The pain in the ear subsided very quickly and within 3 days Mr Smith’s ear was better; however, he continued to use the drops for the full week of the prescription.

Since the vast majority of patients are seen in the community or outpatient department, the nurse’s involvement will range from the total management of ear conditions in a nurse-led clinic to demonstrating how to administer topical preparations effectively. The nurse should also teach the patient to keep the ear dry from water entry and not to insert implements into the ear and stress the importance of frequent, thorough cleansing of any appliances, including hearing aids, that are put in the ear.

Cerumen excess

Cerumen is the normal waxy secretion of special glands in the external auditory canal. Along with shed skin scales and hair, the cerumen normally migrates naturally out of the EAM but can be hindered by coarse hair, narrow canals or by the person impacting the material by attempting to clean the ears with cotton wool buds or other instruments. Nurses should provide patients with health education information regarding the normal cleansing mechanism and avoiding the use of cotton buds and other foreign bodies (Reynolds 2004). The patient usually presents with a blocked feeling in the ear. Tinnitus may develop, causing the patient distress (see p. 458), and disturbance of balance may result from pressure of the hard material on the tympanic membrane.

Medical management

If there is an excessive amount of wax, or the patient needs to have a hearing test or hearing aid review, the doctor, community nurse or outpatient nurse will need to clear the EAM. The wax can be removed manually with instruments, by irrigation with water using an electronic irrigator or by microscope and suction. If the wax is too hard and compacted for this to be carried out, water can be inserted into the EAM for 15 minutes to soften the wax (Roland et al 2008). To improve patient comfort, written information can be given at the time of booking recommending they use olive oil for a few days before the procedure. An advice sheet regarding ear care and how to insert ear drops is available on the website.

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Nursing management and health promotion: cerumen excess

Individuals with cerumen excess are usually seen in the doctor’s surgery or, more rarely, in the outpatient department, for removal of the impacted wax. Ear syringing with a metal syringe is now obsolete and impacted wax is removed by instrumentation, ear irrigation with water, or microsuction.

The doctor or nurse who performs the irrigation should first take a full history to ensure there are no contraindications to irrigation with water. In order to protect against the transmission of infection, gloves and disposable aprons should be worn and a disposable cape/apron placed over the patient’s shoulders to keep them dry. The nurse should obtain valid consent and should be seated at the same level as the patient. The contraindications to irrigation with water and full guidelines for the procedure are available on the website.

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Patients should also be advised that, following effective wax removal, they should prevent water entry to the EAM for approximately 4–5 days and may be hypersensitive to even quite normal sounds for a short time.

Small objects may become lodged in the ear by some mishap or, as frequently occurs among children, by accident during play (Reynolds 2004). Such objects may lie undetected for years unless they have damaged the tympanic membrane. Sometimes gentle irrigation with water or microsuction will remove the foreign body, but if it has become impacted it may be necessary for the patient to be admitted to hospital as a day case and for the object to be removed under general anaesthetic. Only objects that will not expand when in contact with water should be irrigated. Hydroscopic matter such as peas and lentils will absorb the water and become enlarged and often impacted in the canal; as a result removal from the EAM will be through microsuction and/or instrumentation.

Deafness and hearing loss

Although total deafness is comparatively rare, many people suffer hearing loss to varying degrees. Deafness can affect both adults and children. There are 840 babies born each year in the UK with significant deafness. Many children who are deaf continue to be so for all of their lives, but some can be helped to maximise auditory function. This section will concentrate on hearing problems among adults. There are estimated to be 9 million deaf and hard of hearing adults in the UK. This figure is rising as the number of those over 60 increases, with 698 000 of this age group being severely or profoundly deaf (RNID 2008a). A high proportion of severely or profoundly deaf people have other disabilities as well. Among those under 60, 45% have additional disabilities, which are more likely to be physical disabilities. Among severely or profoundly deaf people over 60 years of age, 77% have some additional disability. For 45%, this means significant dexterity or sight difficulties, or both.

Presbycusis

the most common type of sensorineural deafness, develops as a consequence of ageing and is becoming increasingly prevalent in Western society. In the UK, 71.1% of people over 70 and 41.7% of people over the age of 50 years will have some kind of hearing loss (RNID 2008a). Audiometry initially shows loss of ability to hear high tones, but there is gradual deterioration of lower tone hearing as well. Degeneration of the nervous tissue leads to loss of intelligibility in the sounds that are heard. Hearing loss in this disorder is symmetrical, i.e. it affects both ears. A hearing aid may be of slight advantage, but distortion and poor discrimination may cancel out any benefit from amplification. When communicating with these patients, it is important to speak a little slower and more distinctly and to try to eliminate any background noise. Because the high tones are affected first, the individual may have trouble hearing consonants, as these are usually of higher tone than vowels. Durga et al (2007) has found that taking a daily folic acid supplement (800 μg) may be helpful in slowing down the progression of presbycusis.

Medication

It has been recognised for some time that salicylates and quinine can cause deafness, but this can be reversed by discontinuing these medications. Other drugs, such as antibiotics of the aminoglycoside group, some diuretics, such as intravenous furosemide, and cytotoxic agents of the nitrogen mustard group, are ototoxic and can cause irreparable damage.

Trauma

Noise-induced hearing loss is well documented and has become recognised as an industrial disease. Socioacusis, the term used to describe the hearing loss caused by sources of noise outside work (loud music, traffic), can be as great a risk as loud noise in the workplace (RNID 2008b). A single exposure to a loud noise such as an explosion or gunshot can cause permanent deafness, or the injury may be temporary. Tinnitus usually accompanies this injury and often takes longer to resolve than any deafness (see p. 458). Exposure to loud noise over a period of time leads to destruction of the hair cells in the organ of Corti. The Noise at Work Regulations (HMSO 1989) laid down strict standards of noise control and protection for employers in the UK, who are liable to be prosecuted if they do not comply (see Useful websites for more information). Occupational health nurses have a role to play in monitoring noise levels and encouraging auditory health through education. On audiometry, early changes in hearing caused by exposure to noise are seen as a dip that gradually deepens and involves adjacent frequencies.

Head injuries

or other trauma resulting in deafness usually involve fractures or penetrating injuries of the temporal bone. Occasionally, concussion (see Ch. 9) can cause deafness due to haemorrhage into the middle ear or cochlea. These injuries are often accompanied by severe vertigo, nausea and vomiting.

Infection

leading to deafness is usually viral in origin. The causative viruses are those associated with mumps, measles, meningitis, chickenpox and rubella.

Ménière’s disease

See page 458.

Nursing management and health promotion: deafness and hearing loss

In the case of conductive deafness, the nurse’s role may be to prepare the patient for surgery and facilitate postoperative recovery. Some of the surgical procedures that may benefit patients are myringoplasty (repair of the tympanic membrane), ossiculoplasty (repair to the ossicular chain in the middle ear) and stapedectomy (a prosthetic stapes is inserted to replace the damaged bone). A patient for whom surgery is not feasible may be fitted with a hearing aid and educated in its use by members of the audiology department, including the hearing therapist. In this case the nurse, as a member of the multiprofessional team, should also explain how to obtain the greatest benefit from the aid (see guide to looking after hearing aids on the website).

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Most patients in this situation also benefit from learning how to lip-read. Lip-reading sessions are usually available as a day or evening class at audiology departments or a local college. It can take many months to become proficient at lip-reading, so the earlier the patient starts the better. Slow progress, combined with deteriorating hearing, can be very demotivating.

Communicating effectively with a hearing-impaired patient is a very important nursing priority (Box 14.2). In the assessment, the nurse should obtain and record information about the patient’s preferred method of communicating, e.g. lip-reading, finger-spelling or sign language. A study by the RNID (2008a) suggested that deaf adults who used sign language were dissatisfied with and disadvantaged in their communication with health care staff, including nurses. According to Ratna (1994), the problems deaf clients bring to counselling include isolation, frustration, discrimination and physical and sexual abuse.

Box 14.2 Information

Talking with someone who has a hearing deficit

• Do not speak until you have the person’s attention and they can see your full face.

• Never turn your back on the person when you are speaking or cover your mouth.

• Ask the person if they can lip-read.

• Do not exaggerate your lip movements.

• Direct your voice to one ear if it has better hearing than the other.

• Speak slowly, enunciate clearly and do not shout.

• Remember that vowels are heard more easily than consonants.

• Check that the person has understood what you have said.

• If the person has difficulty in understanding, try rephrasing the sentence.

• Do not laugh at misinterpretations.

• Have patience. Give the person time to adjust their hearing aid if necessary.

• Encourage the person to participate in group conversations when the occasion arises.

• If verbal communication is impossible, explore alternative means, e.g. sign language.

It is now recognised that deafness can have a profound psychological impact and that hearing-impaired individuals may require support to help resolve problems. Many deaf people would prefer to have counselling from a counsellor who is deaf, and attempts should be made to find such a professional if preferred (via the British Association for Counselling and Psychotherapy [BACP] if necessary, see Useful websites). Older adults and their carers have complained of symptoms such as depression, anxiety, decreased social activity and emotional turmoil (Berry et al 2004).

Community nurses can provide tremendous help and support for patients and their relatives when sensorineural deafness is a problem. They should be able to assist their patients to obtain many of the aids available, including a hearing dog for the deaf, which can help to overcome communication difficulties in everyday life. There are many associations, both voluntary and professional, which can provide support and help. The nurse working in the community should be a resource person for patients and guide them to the support that is available (see Useful websites and Box 14.3).

Box 14.3 Evidence-based practice

Are we being heard?

• The RNID decided to commission this report because of the frequency with which it received examples of poor communication experienced by deaf and hard of hearing people when attempting to use the NHS. The study took place within the context of the Disability Discrimination Act (1995), which came into force in 2004 and places a legal obligation on the NHS to meet the needs of disabled people. The NHS in England, Wales and Scotland has acknowledged defects in services which affect disabled people, including difficulties in communication with staff and in finding their way around premises. There are thought to be approximately 9 million deaf and hard of hearing people in the UK. As one in every seven people in the UK has some level of hearing loss, and it is known that the average GP will have up to four patients with hearing loss in their surgery daily, it is important that health care professionals in all care settings are aware of the particular needs for effective communication of those who have reduced hearing.

• The RNID and the UK Council on Deafness conducted this research in collaboration with 21 UK-based deaf and hard of hearing groups and charities; a total of 866 participants completed the survey.

• The main findings reported by deaf and hard of hearing people when using GP services were that 35% had experienced difficulty communicating with their GP or practice nurse and 15% avoided going to see their GP because of communication problems. Making and keeping appointments was another problematic area, with 28% reporting that they found their hearing loss made it difficult for them to make an appointment: of 24% who stated they had missed an appointment, 19% had missed more than five. Of those who did see their GP or nurse, 35% reported being unclear about their condition because of communication problems. Of those who used British Sign Language (BSL), 33% were either unsure about medication instructions or had taken inaccurate doses.

• The situation in NHS hospitals is equally disturbing, as 42% of the deaf and hard of hearing who had visited a hospital for non-emergency treatment found it difficult to communicate with staff. BSL users experienced even more difficulties, with 77% of this group reporting communication problems for emergency and non-emergency overnight stays and 70% of those admitted to emergency departments were not provided with a BSL/English interpreter to facilitate effective communication.

• Overall, the picture is one of poor communication, resulting in people having inadequate access to health care and insufficient information about their health condition and treatment, thus limiting their ability to make informed choices, and being placed in higher risk situations than their hearing counterparts. It is also unacceptable that family, including young children, and friends have to act as interpreters and on occasion convey critical health information. The financial cost to the NHS of missed appointments is put at approximately £20 million a year. The financial and non-financial costs to the patient, family and friends will never be known.

• The report notes that NHS staff do wish to deliver a better and more equitable service to the deaf and hard of hearing but that often the necessary resources and infrastructure are not available. Solutions recommended include increasing the number of BSL/English interpreters, using video phones, providing improved written information, installing loop systems to allow better use of hearing aids in noisy environments, providing visual displays in appointment areas and clear lighting, and providing deaf awareness education, including communication skills, for all health care staff, whether working in hospital or community settings. Deaf awareness seminars should be provided for appropriate hospital departments and GP surgery staff, so that these areas have at least one formally trained ‘front line’ staff member.

RNID 2004 A simple cure. A national report into deaf and hard of hearing people’s experiences of the National Health Service. RNID, London. (See also Useful websites.)

Hearing aids

About 2 million people in the UK have hearing aids, but only 1.4 million use them regularly. There are at least another 4 million people who do not have hearing aids but experience significant hearing difficulties in everyday life. They would be likely to benefit from hearing aids. All electronic hearing aids have a microphone, which picks up the sound; the sound is processed electronically either by analogue or digital circuits to make it more audible. This is then delivered to the receiver, converted back to sound and reaches the ear via an ear mould. For further information on hearing aids see the website.

See website for further content

Disorders of the middle ear

Secretory otitis media (glue ear)

Glue ear is the most common cause of hearing impairment and the most common reason for elective surgery in children. Approximately 80% of children will suffer from glue ear before they are 4 years old (Scottish Intercollegiate Guidelines Network [SIGN] 2003). This disorder is known as glue ear because it is characterised by a thick, tenacious fluid that collects in the middle ear. Normally, the mucosal secretions of the middle ear drain down the eustachian tube into the nasopharynx (see Figure 14.1). It is not certain whether the abnormal accumulation of this fluid is caused by the viscosity of the fluid, congestion of the eustachian tubes or obstruction caused by enlarged adenoids or a tumour.

Common presenting symptoms

Pain is rarely associated with this condition. The adult patient usually comes to the medical practitioner complaining of hearing loss. A child might never complain, and their condition might be discovered only upon investigation into poor performance at school or during routine screening of hearing at school.

Medical management

Examination

of the tympanic membrane by auriscope usually confirms the diagnosis, as in this disorder the membrane has a characteristic dull grey or orange appearance. It will also lose its normal translucence and become retracted.

Conservative treatment

is to prescribe a decongestant, or antihistamines, to reduce oedema of the nasal mucosa. Mucolytics, which liquefy the mucus, have been shown to have no effect on the condition (SIGN 2003).

Surgical intervention

involves performing a myringotomy (incising the tympanic membrane) and suctioning of the glue. If a grommet is not inserted, the delicate tympanic membrane heals within a few days. The fluid may, of course, accumulate again. The insertion of a grommet (Figure 14.4) is sometimes considered appropriate, although some specialists think this can lead to scar formation in later years which will impair hearing. If a grommet is inserted, it usually is extruded from the tympanic membrane at 9–12 months; patients sometimes find it on their pillow when they waken one morning. A grommet allows aeration of the middle ear, thus restoring middle ear air pressure. There is usually a marked improvement in hearing after this procedure which is maintained in about 75% of patients.

Figure 14.4 Grommet and grommet in situ.

Nursing management and health promotion: secretory otitis media (glue ear)

Only care specific to ENT patients is outlined in this chapter. The reader is referred to Chapter 26 for details of routine peri-operative care.

Pre-operative care

Most of this surgery is carried out on a day case basis, and the nurse must ensure that the patient and family are adequately informed about what the surgical procedure will entail. This may involve the use of diagrams and it may be helpful to show them a grommet if one is to be inserted. When communicating with the patient pre-operatively, the nurse should make allowances for hearing loss (see Box 14.2).

Postoperative care

The anaesthetic for this operation is very light. Measures to prevent the spread of infection, e.g. washing the hands before and after touching the affected ear, how to change and dispose of cotton wool plugs in the external auditory canal, and specific instructions about whether and when it is safe to allow water to enter the ear must be discussed with the patient. When a grommet is in place, most surgeons allow swimming, as long as the patient does not dive or swim underwater. Usually, a cotton wool plug moistened with petroleum jelly is inserted in the external canal when the hair is being washed or when taking a shower. The nurse must ensure that the patient and family understand this advice and are given information booklets or advice sheets. Patients should be told to see their GP if they experience any pain or if there is a bloodstained discharge from the ear. Most of these precautions apply to all patients who have undergone aural surgery. The patient may be asked to see their GP for regular checks of the position of the grommet rather than requiring them to attend the outpatient department.

Otosclerosis

Otosclerosis is a condition in which the ossicles in the middle ear, along with the temporal bone (see Figure 14.1), begin to soften. This spongy bone gradually becomes a dense sclerotic mass; the ossicles may become fixed and less effective in passing on auditory vibrations. The individual with this condition will complain of increasing hearing loss. While this loss is conductive in origin, if the damage extends to the cochlea, sensorineural loss of hearing will also occur. Mild tinnitus (see p. 458) may also be experienced, in which case some people find that they can actually hear better in a noisy environment where their tinnitus is masked.

This disorder commonly begins in adolescence and its cause is as yet unknown. Heredity, vitamin deficiency and otitis media have all been cited as significant factors.