Module 3: Upper Respiratory Problems

Question 1

Nasal and Paranasal
Sinus Problems: Deviated Septum

Answer 1

Deflection or shift of the nasal septa
 Trauma—most common cause
 Interferes with airflow and drainage

 Symptoms
* Minor: none, congestion, frequent infections
* Severe: facial pain, nosebleeds, obstruction
 Diagnoses—speculum exam
 Treatment: decongestants, analgesia (pain killers), nasal septoplasty (severe cases)

Nasal Septoplasty - surgical procedure aimed at correcting a deviated nasal septum, which is the partition between the two nasal cavities.

The septum is made of bone and cartilage and ideally sits in the center of the nose, equally dividing the two sides. When it deviates, or bends, to one side, it can cause a blockage in one or both nasal passages. This can lead to problems with breathing through the nose, nasal congestion, frequent nosebleeds, sinus infections, and sometimes snoring or sleep apnea.

Question 2

Nasal Fracture

Answer 2

Trauma—most common cause
 Complications—obstruction, nosebleeds, meningeal
tears with CSF leak, septal hematoma, deformity
 Simple—little displacement
 Complex—damage to adjacent structures; evaluate
for injury of cervical spine, orbital bone, or mandible

Question 3

Nasal Fracture Diagnosis

Answer 3

History + Physical

Manifestations: deformity, nosebleed, pain, crepitus (Crepitus refers to a crackling, popping, or grating sound or sensation that can be felt under the skin or heard in various joints when they move),
swelling, difficulty breathing through nose,
ecchymosis (discoloration of the skin resulting from bleeding underneath, typically caused by bruising. It appears as a purplish or bluish patch that occurs when small blood vessels (capillaries) burst or break under the skin, allowing blood to escape into the surrounding tissue.)

• Periorbital ecchymosis—“raccoon eyes” evaluate for
  basilar skull fracture
• CSF leak—clear or pink persistent drainage; lab
  confirmation more accurate than bedside glucose test

Question 4

Nasal Fracture Nursing Care

Answer 4

Patent Airway
Monitoring: Regularly check for signs of airway obstruction, which can be caused by swelling, bleeding, or the formation of clots in the nasal passages.
Positioning: Encourage the patient to keep their head elevated, even while sleeping, to help reduce swelling and facilitate breathing.

Prevent Complications
Bleeding: Monitor for signs of ongoing or recurrent bleeding. Instruct the patient to avoid blowing their nose, which can exacerbate bleeding.
Edema: Apply ice packs to the nasal area for the first 48 hours post-injury or surgery to reduce swelling. Ice should be applied intermittently (e.g., 20 minutes on, 20 minutes off).

Pain Management: Administer pain relief as prescribed, often acetaminophen is preferred to avoid the increased risk of bleeding associated with NSAIDs. Monitor the patient’s pain level and adjust pain management strategies as needed.

Avoidance of Certain Activities: Advise the patient to avoid activities that could stress the nasal area, including strenuous exercise, bending over, or wearing glasses that rest on the nose until cleared by their healthcare provider.

Environmental Considerations: Recommend the use of a humidifier to keep the nasal passages moist and suggest avoiding hot showers, alcohol, and smoking, which can exacerbate swelling and delay healing.

Infection Prevention: Educate the patient on signs of infection to watch for and ensure they understand the importance of keeping any splints or dressings clean and dry.

Emotional Support
Reassurance: Provide reassurance and support, as facial injuries can be distressing and may impact the patient’s self-esteem and emotional well-being.
Information: Offer clear and concise information about the patient’s condition, treatment plan, and what to expect during the recovery process.

Question 5

Post Realignment Care

Answer 5

Closed Reduction: If the patient undergoes closed reduction (manipulation without an incision), emphasize the importance of not disturbing the nasal area to ensure proper healing.

Open Reduction, Septoplasty, Rhinoplasty: For more invasive procedures, provide wound care instructions, and educate the patient on the signs of complications such as infection or bleeding.

Question 6

Septoplasty

Answer 6

Septoplasty is a surgical procedure aimed at correcting a deviated septum, which is the displacement of the nasal septum, the cartilage and bone dividing the two nostrils. A deviated septum can cause nasal obstruction, leading to difficulties in breathing, recurrent sinus infections, nosebleeds, and snoring.

Septal Hematoma: A potential complication of septoplasty is the development of a septal hematoma, which is a collection of blood within the septum. If not treated promptly, a hematoma can lead to cartilage damage, resulting in a nasal deformity, and can also become infected, leading to further complications.

Question 7

Rhinoplasty

Answer 7

Rhinoplasty, often referred to as a “nose job,” is a surgical procedure that involves the reconstruction or reshaping of the nose. It can be performed for functional reasons, such as improving breathing by correcting structural defects, or for cosmetic reasons, to change the appearance of the nose.

Body Image Considerations: For patients undergoing rhinoplasty for cosmetic reasons, body image is a significant consideration. The decision to alter one’s appearance can have profound psychological impacts, and realistic expectations need to be set.

Digital Photos: Surgeons often use digital photos and imaging software to show patients projected outcomes. This helps in ensuring that the patient’s expectations align with what is surgically achievable.

Outpatient Procedure: Rhinoplasty is usually performed as an outpatient procedure, meaning the patient can go home the same day after surgery.

Question 8

Post Op Care for Septoplasty + Rhinoplasty

Answer 8

Nasal Packing: After both septoplasty and rhinoplasty, nasal packing may be used to support the new structure of the nose, control bleeding, and prevent the formation of excessive scar tissue. Packing is typically removed a few days after surgery.

Nasal Splint: A splint may also be placed on the outside of the nose to protect the nasal bones and cartilage. The splint helps maintain the new shape of the nose as it heals and is usually worn for about a week.

Monitoring for Complications: It’s crucial to monitor for signs of infection, excessive bleeding, or breathing difficulties after the surgery. Any unusual symptoms should be reported to the surgeon immediately.

Recovery: The first few days after the surgery involve rest and limited physical activity to minimize swelling and promote healing. Swelling and bruising around the eyes and nose are common but gradually subside over the weeks following surgery.

Question 9

Nasal Surgery Nursing Management

Answer 9

Nursing management
 Preoperative:
* Avoid Aspirin and NSAIDs 5 days to 2 weeks
* Smoking cessation

 Postoperative:
* Maintain patent airway
* Monitor respiratory status/airway obstruction
* Pain management
* Observe for edema, bleeding, infection

Patient teaching:
 Manage edema, bruising, and pain: Cold compresses
and elevate HOB
 Prevent bleeding and injury: No nose blowing,
swimming, heavy lifting, or strenuous exercise
 May take a year for full cosmetic resul

Question 10

Epistaxis (Nosebleed)

Answer 10

Many causes; often resolve spontaneously
 First aid
* Sitting position, lean forward, with head tilted forward;
direct pressure/squeeze lower part of nose for 5 to 15
minutes

 Medical management
* Pledget (A small, absorbent material, often made from cotton, gauze, or a similar fabric, used to deliver medication directly to a specific area) with anesthetic or vasoconstrictor
* Absorbable packing/sponges; balloon
* Chemical or thermal cauterization; embolization

Question 11

Patient Care for Epistaxis

Answer 11

Monitor respiratory status, LOC, VS, pulse ox,
dyspnea, dysphagia
 Administer analgesia and antibiotics
 Premedicate before removal of packing

 Patient education:
* Humidifier or nasal spray
* Sneeze with mouth open
* Avoid aspirin and NSAIDs
* Avoid vigorous nose blowing, strenuous activity, lifting
or straining for 4 to 6 weeks

Question 12

Allergic Rhinitis

Answer 12

Inflammation of nasal mucosa
 Cause: seasonal (pollen) or perennial (environmental)
allergen
 Frequency of symptoms
* Episodic—sporadic exposure
* Intermittent—less than 4 days/week or less than 4
weeks/year
* Persistent—greater than 4 days/week or greater than 4
weeks/year
 Exposure leads to IgE (Immunoglobulin E (IgE) is a class of antibodies produced by the immune system. It plays a crucial role in the body’s allergic response and is involved in immunity against parasites) and inflammation

Management
 Identify and avoid triggers
 Reduce inflammation and symptoms
* Corticosteroids; nasal and/or oral
* Antihistamines; decongestants, LTRAs
* Immunotherapy: allergy shots
 Patient education: medications
 Drug alerts

Question 13

Acute Viral Rhinopharyngitis (Upper Respiratory Infection)

Answer 13

Upper Respiratory Infection
 Infection of nose, sinuses or throat
 Over 200 viruses can cause an URI

 Common cold
* Acute viral Rhinopharyngitis
* Nasopharyngitis

 Sinusitis
 Influenza

Viruses
 Contagious: airborne droplets or contact
 Frequent in winter months—close contact
* Also influenced by: fatigue, stress, allergies, and
altered immune status
 Symptoms—2 to 3 days after infection
* Runny nose, watery eyes, nasal congestions, sneezing,
coughing, sore throat, fever, headache, fatigue
 Usual recovery 7 to 10 days

Question 14

Influenza

Answer 14

Highly contagious; increased morbidity and
mortality
 Peak season: December to February
 Classified by serotypes (A, B, C, D)
* A subtypes: H and N antigens (e.g., H1 N1)
 Influenza A—most common and virulent
* Mutated viruses —no immunity
* Pandemics (worldwide spread)
* Epidemics (localized outbreaks)
 Transmission: infected droplets
* 1 day before onset symptoms—5 to 7 days

Question 15

Sinusitis

Answer 15

Inflammation of sinus mucosa results in blockage
and accumulated secretions
 Risk for viral, bacterial, or fungal infection
 Classified
* Acute – 1 to 4 weeks
* Subacute – progresses over 4 – 12 weeks
* Recurrent – 4 or more infections/year; lasts 7 to 10
days without continual symptoms
* Chronic – lasts >12 weeks; persistent infection

Manifestations:
 Acute: pain/tenderness, purulent drainage,
congestion, fever, malaise, headaches, halitosis
 Chronic: facial or dental pain, congestion,
increased drainage
* Affects 50% patients with asthma
 Diagnostic studies: X-ray, CT scan, nasal
endoscopy

Question 16

Nasal Polyps

Answer 16

Nasal polyps—benign growths related to
chronic inflammation
 Large polyps—obstruction, discharge, and
speech distortion
 Treatment: corticosteroids or endoscopic or
laser surgery

Question 17

Foreign Bodies - Nasal Obstruction

Answer 17

inorganic or organic
 Pain, bleeding, difficulty breathing
 Treatment: removal

Question 18

Pharyngeal Problems
Acute Pharyngitis

Answer 18

Acute pharyngitis is an inflammation of the pharyngeal walls, which can include the tonsils, palate, and uvula. It’s a common condition that leads to a sore throat and is caused by a variety of factors:

Viral Infections: The most common cause, accounting for about 90% of cases. Common viruses include the common cold, influenza, mononucleosis, and respiratory syncytial virus (RSV).

Bacterial Infections: Strep throat, caused by the bacterium Streptococcus pyogenes, is the most well-known bacterial cause. It’s less common than viral pharyngitis but requires specific treatment.

Fungal Infections: Oral candidiasis (thrush) can lead to pharyngitis, especially in immunocompromised individuals or those who use inhaled corticosteroids without proper mouth rinsing.

Other Causes: Dry air, smoking, gastroesophageal reflux disease (GERD), allergies, postnasal drip, prolonged intubation with an endotracheal tube (ETT), exposure to irritating chemicals, and, rarely, cancers of the throat can also cause pharyngitis.

Question 19

Clinical Manifestations of Acute Pharyngitis

Answer 19

General Symptoms: Sore throat is the primary symptom, often accompanied by pain when swallowing. The pharynx (back of the throat) may appear red and swollen.

Viral Pharyngitis: Can include symptoms like cough, runny nose, hoarseness, and conjunctivitis, reflecting a more generalized upper respiratory infection.

Bacterial Pharyngitis (Classic Strep Throat):
Fever greater than 38°C (100.4°F).
Enlargement of the cervical lymph nodes.
Presence of pharyngeal exudate (white or yellow patches on the tonsils or pharynx).
Absence of cough is more suggestive of a bacterial cause.
**Typically treat with penicillin or amoxicillin

Fungal Pharyngitis: Characterized by white patches or plaques on the oral or pharyngeal mucosa, often with underlying redness.
*Antifungal medications, either topical (nystatin swish and swallow) or systemic (fluconazole), depending on severity and patient factors

Question 20

Peritonsillar Abscess

Answer 20

Complication of tonsillitis
 Most often caused by group A β-hemolytic
streptococci
 Pain, swelling, possible blockage of throat
 High fever, chills, leukocytosis, difficulty swallowing,
muffled voice
 IV antibiotics, needle aspiration, drainage of abscess
 May need emergency tonsillectomy

Question 21

Laryngeal and Tracheal
Problems: Laryngeal Polyps

Answer 21

Benign growth on vocal cords from vocal abuse or
irritation
 Most common: hoarseness
 Large: dysphagia, dyspnea, stridor
 Treatment: vocal rest and hydration
 Surgical removal if large or risk of cancer

Question 22

Acute Laryngitis

Answer 22

Inflammation of larynx (voice box)
 Causes: virus, upper respiratory tract infection,
overuse of voice, smoke or chemical
exposure/inhalation
 Classic manifestations:
* Tingling or burning back of throat; need to clear throat,
hoarseness, loss of voice
* Other: fever, cough, full feeling in throat

Question 23

Airway Obstruction

Answer 23

Medical emergency!
 Partial or complete
 Manifestations: choking, stridor, use of accessory
muscles, suprasternal and intercostal retractions,
nasal flaring, wheezing, restlessness, tachycardia,
cyanosis, change in LOC
 Immediate assessment and treatment—brain damage
or death in 3 to 5 minutes

Question 24

Interventions to Establish Patient Airway

Answer 24

Heimlich Maneuver
Indication: Used in cases of choking due to a foreign body obstructing the upper airway.
Procedure: A sudden, upward abdominal thrust just above the navel and below the ribcage is applied to force the foreign object out of the airway.

Cricothyroidotomy (also known as Cricothyrotomy)
Indication: Emergency procedure used when there is a blockage in the upper airway that cannot be quickly relieved and it’s not possible to secure the airway using endotracheal intubation.
Procedure: Involves making an incision through the skin and cricothyroid membrane to insert a tube directly into the trachea, bypassing upper airway obstructions.

Endotracheal (ET) Intubation
Indication: Used for significant airway obstruction, respiratory failure, or when protecting the airway during anesthesia.
Procedure: A flexible tube is inserted through the mouth or nose, past the vocal cords, and into the trachea to maintain an open airway and enable mechanical ventilation if necessary.

Tracheostomy
Indication: Performed when long-term airway support is needed or when ET intubation is not possible due to facial or upper airway injuries or abnormalities.
Procedure: A surgical opening is created directly in the front of the neck into the trachea, and a tracheostomy tube is inserted to maintain a patent airway.

Question 25

Management of Recurring Symptoms of Airway Obstruction

Answer 25

For patients experiencing partial airway obstruction or recurrent symptoms suggesting an underlying problem, further diagnostic tests may be necessary to identify the cause and guide treatment:

Chest X-ray: Helps in visualizing the lungs and airways, identifying obstructions, infections, or other lung conditions.

Laryngoscopy: A procedure where a scope is used to view the back of the throat, voice box (larynx), and vocal cords, useful in detecting obstructions or abnormalities in these areas.

Bronchoscopy: Involves inserting a bronchoscope through the nose or mouth and down into the airways to directly visualize the inside of the airways and lungs. It can also be used to remove foreign bodies or perform biopsies.

Question 26

Head and Neck Cancer

Answer 26

Structures includes: nasal cavity, paranasal sinuses,
nasopharynx, oropharynx, larynx, oral cavity, and/or
salivary glands
 Squamous cells in mucosal surfaces
 Etiology: smoking (85%)
 Age: most over age 50
 Risk factors: HPV, excess alcohol, exposure to: sun,
asbestos, industrial carcinogens, marijuana, radiation to
head and neck, and poor oral hygiene

Question 27

Head and Neck Cancer Manifestations

Answer 27

Manifestations—vary with location
 Lump in throat or sore throat (pharyngeal), white or
red patches, change in voice, hoarseness greater
than 2 weeks (laryngeal)
 Other: ear pain, ringing in ears, swelling or lump in
neck, constant cough, cough up blood, swelling in jaw
 Late signs: unintentional weight loss; difficulty with
chewing, swallowing, moving tongue or jaw, or
breathing; airway obstruction (partial or full)

Question 28

Head and Neck Cancer Diagnostic Studies

Answer 28

Diagnostic studies
 Physical assessment: ears, nose, throat, mouth, and
neck
* Check for: thickening of oral mucosa, lymph nodes,
leukoplakia (white patches or plaques that cannot be rubbed off and cannot be characterized as any other disease. These patches are the result of an overgrowth of cells in the mucous membrane), or erythroplakia (red, velvety patches on the mucous membranes that cannot be attributed to any other condition. These lesions are less common than leukoplakia but are considered more serious due to a higher risk of malignancy)
 Pharyngoscopy and laryngoscopy for inspection and
biopsies
 CT scan, MRI, PET scan

Question 29

Head and Neck Cancer Staging

Answer 29

TNM Staging System
T (Tumor):
Describes the size and extent of the primary tumor. The categories range from T1 to T4, with higher numbers indicating larger tumors or greater extent of disease.
N (Nodes):
Indicates whether the cancer has spread to nearby lymph nodes and, if so, the number and location of affected nodes. This part of the staging ranges from N0 (no lymph node involvement) to N3 (more extensive lymph node involvement).
M (Metastasis):
Describes whether the cancer has spread (metastasized) to other parts of the body. M0 means there is no metastasis, while M1 indicates distant metastasis.

Question 30

Interprofessional Care of Head and Neck Cancer: Surgery

Answer 30

Surgery:
Often the first-line and possibly the only treatment needed, especially for early-stage tumors.
The goal is to remove the tumor completely while preserving as much function as possible.
Reconstructive surgery may be necessary to restore appearance and function, particularly for more extensive tumors.

Question 31

Head + Neck Cancer: Radiation Therapy

Answer 31

Radiation Therapy:
May be used alone or in combination with surgery and/or chemotherapy.
Can be external beam radiation or brachytherapy (internal radiation).

External beam or internal implants
* Early head and neck cancer; preserves voice
* Brachytherapy
 Concentrated, localized method places radioactive
source near or in tumor
 Limits exposure of surrounding tissues
 Radioactive seeds, placed in needles, emit continuous
radiation

Question 32

Head + Neck Cancer: Chemotherapy

Answer 32

Chemotherapy:
Often used in combination with radiation therapy (chemoradiation) for advanced stages of cancer or for tumors that are not amenable to surgery.
Can also be used as palliative treatment to relieve symptoms in advanced cancers.

Question 33

Head and Neck Cancer: Therapies

Answer 33

Nutrition therapy:
* Concerns with swallowing after surgery, side effects of
chemotherapy and/or radiation, oral mucositis;
* Gastrostomy tube and enteral feedings; assess
tolerance, weight, and risk of aspiration

Physical therapy
* Strengthen, support, and move upper extremities,
head, and neck to avoid limited ROM; continue after
discharge

 Speech therapy
* Preoperative: effect of therapy on voice and potential
adaptations or restoration; support groups
* Postoperative restoration: electrolarynx,
transesophageal puncture (TEP), esophageal speech

Question 34

Electrolarynx

Answer 34

In cases of head and neck cancer, especially those involving the larynx or voice box, patients may undergo treatments like laryngectomy (removal of the larynx) that can result in the loss of natural voice. Various speech rehabilitation methods are available to help these patients regain their ability to communicate verbally. Among these, the electrolarynx, tracheoesophageal puncture (TEP), and esophageal speech are notable

Electrolarynx
Description: The electrolarynx is a hand-held, battery-powered device that creates speech by generating sound waves. The device is typically held against the neck or cheek, and the vibrations produce a mechanical sound that can be modulated into speech by the movement of the mouth and tongue.
Sound Quality: The resulting speech has a mechanical or robotic quality but can be understood relatively easily with practice.
Ease of Use: It is generally easy to learn and can be used immediately after surgery, making it a popular initial choice for voice rehabilitation.

Question 35

Tracheoesophageal Puncture (TEP)

Answer 35

Tracheoesophageal Puncture (TEP)
Procedure: TEP involves creating a small fistula between the trachea and the esophagus. A voice prosthesis is placed in this fistula to allow air from the lungs to enter the esophagus and produce sound when the stoma (the opening in the neck from a laryngectomy) is covered, typically by the patient’s finger.
Speech Quality: TEP allows for more natural-sounding speech compared to an electrolarynx, as the sound is produced by the vibration of the patient’s own tissues.
Learning and Use: While TEP can provide the best speech quality among voice rehabilitation options, it requires surgical intervention to create the fistula and insert the prosthesis, and patients must learn to use and maintain the device properly.

Question 36

Esophageal Speech

Answer 36

Esophageal Speech
Technique: Esophageal speech involves “swallowing” air into the esophagus and then expelling it to create sound. The upper esophageal sphincter vibrates and functions as a pseudo-vocal cord.
Challenges: This method can be difficult to learn and master. It requires significant practice and not all patients can achieve functional esophageal speech.
Voice Quality: The voice quality is typically lower in volume and less clear than natural speech or speech produced with a TEP.

Question 37

Radiation Therapy

Answer 37

While effective in targeting and destroying cancer cells, radiation therapy can also cause several side effects due to its impact on healthy cells in the treatment area.

Dry Mouth (Xerostomia)
Cause: Radiation can damage the salivary glands, reducing saliva production.
Management:
Stay hydrated by drinking plenty of water.
Use saliva substitutes or mouth moisturizers.
Chew sugar-free gum or suck on sugar-free hard candies to stimulate saliva production.
Practice good oral hygiene to prevent dental problems.
Avoid caffeine and alcohol, which can worsen dry mouth.

Oral Mucositis
Cause: Radiation can cause inflammation and ulceration of the mucous membranes in the mouth.
Management:
Maintain excellent oral hygiene using a soft-bristle toothbrush and gentle rinsing with a saltwater or baking soda solution.
Avoid spicy, acidic, hard, or hot foods that can irritate the mouth.
Consult a healthcare provider for pain relief options, which may include topical anesthetics or pain medication.
Use prescribed oral gels or mouthwashes that form a protective coating to reduce pain and facilitate healing.

Skin Care
Cause: Radiation can irritate and damage the skin in the treated area, leading to redness, itching, peeling, or blistering.
Management:
Gently clean the treated area with lukewarm water and mild soap as advised by your healthcare team.
Avoid applying any creams, lotions, perfumes, or deodorants to the treated area without your healthcare provider’s approval.
Protect the skin from sun exposure by wearing loose, soft clothing over the area and using sunscreen as directed by your healthcare provider.
Avoid hot or cold packs on the treated area unless recommended by your healthcare provider.

Fatigue
Cause: Radiation therapy can be physically and emotionally taxing, leading to fatigue.
Management:
Prioritize rest and ensure adequate sleep.
Balance activity with rest periods; light exercise like walking can help combat fatigue.
Eat a balanced diet to maintain energy levels.
Seek support from friends, family, or support groups to help manage the emotional aspects of cancer treatment.