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CHAPTER 2 – EARS, NOSE, THROAT AND MOUTH

First Nations and Inuit Health Branch (FNIHB) Clinical Practice Guidelines for Nurses in Primary Care. The content of this chapter was revised August 2011.

Table of Contents

ASSESSMENT OF THE EARS, NOSE, THROAT (ENT) AND MOUTH...... 2–1 History of Present Illness and Review of Systems...... 2–1 Physical Examination...... 2–2 COMMON PROBLEMS OF THE EARS AND NOSE...... 2–3 Anterior Epistaxis...... 2–3 Ceruminosis (Impacted Cerumen)...... 2–4 Labyrinthitis...... 2–5 Menière’s Disease (Endolymphatic Hydrops)...... 2–6 ...... 2–7 Otitis Media, Acute...... 2–9 Otitis Media, Chronic Suppurative...... 2–10 Otitis Media, Serous (Otitis Media with Effusion)...... 2–11 Rhinitis ...... 2–13 Rhinosinusitis, Acute...... 2–15 Rhinosinusitis, Chronic...... 2–16 COMMON PROBLEMS OF THE THROAT...... 2–18 Laryngitis...... 2–18 Pharyngitis (Sore Throat)...... 2–19 COMMON PROBLEMS OF THE MOUTH...... 2–21 Angular Cheilitis...... 2–21 Aphthous Stomatitis...... 2–21 Dental Abscess...... 2–23 Dental Decay...... 2–24 Discoloured (non-vital) Permanent Tooth...... 2–27 Gingivitis...... 2–27 Migratory Glossitis (Geographic Tongue)...... 2–27 Pericoronitis...... 2–27 Periodontitis...... 2–28

Clinical Practice Guidelines for Nurses in Primary Care 2011 Ears, Nose, Throat and Mouth

Toothache...... 2–28 Xerostomia (Dry Mouth)...... 2–29 EMERGENCY PROBLEMS OF THE NOSE, THROAT AND MOUTH...... 2–30 Avulsed Tooth...... 2–30 Fractured Tooth...... 2–30 Mastoiditis...... 2–30 Oral Trauma...... 2–31 Peritonsillar Abscess...... 2–31 Posterior Epistaxis...... 2–32 SOURCES...... 2–33

2011 Clinical Practice Guidelines for Nurses in Primary Care Ears, Nose, Throat and Mouth 2–1

ASSESSMENT OF THE EARS, NOSE, THROAT (ENT) AND MOUTH

HISTORY OF PRESENT ILLNESS Mouth and Throat AND REVIEW OF SYSTEMS –– Dental status –– Oral lesions The following characteristics of each symptom should be elicited and explored: –– Bleeding gums –– Sore throat –– Onset (sudden or gradual) –– Dysphagia (difficulty swallowing) –– Chronology –– Hoarseness or recent voice change –– Current situation (improving or deteriorating) –– Location Neck –– Radiation –– Pain –– Quality –– Swelling –– Timing (frequency, duration) –– Enlarged glands –– Severity –– Precipitating and aggravating factors Other Associated Symptoms –– Relieving factors –– Fever –– Associated symptoms –– Malaise –– Effects on daily activities –– Nausea or vomiting –– Previous diagnosis of similar episodes –– Previous treatments PAST MEDICAL HISTORY (SPECIFIC TO ENT) –– Efficacy of previous treatments –– Frequent ear or throat –– Rhinosinusitis CARDINAL SYMPTOMS –– Trauma to head or ENT area Characteristics of specific symptoms should –– ENT surgery be elicited, as follows. –– Audiometric screening results indicating hearing loss Ears –– Allergies –– Recent changes in hearing –– –– Compliance with and effectiveness of hearing aid –– Prescription or over-the-counter medications used –– Itching regularly –– Earache –– Discharge FAMILY HISTORY (SPECIFIC TO ENT) –– Tinnitus –– Others at home with similar symptoms –– Vertigo –– Seasonal allergies –– Ear trauma, including Q-tip use –– Asthma –– Hearing loss Nose –– Menière’s disease –– Nasal discharge or postnasal drip –– ENT cancer –– Epistaxis –– Obstruction of airflow –– Sinus pain, pressure –– Itching –– Anosmia –– Nasal trauma

Clinical Practice Guidelines for Nurses in Primary Care 2011 2–2 Ears, Nose, Throat and Mouth

PERSONAL AND SOCIAL HISTORY NOSE (SPECIFIC TO ENT) Inspection –– Frequent exposure to water (swimmer’s ear) –– Use of foreign object to clean ear –– External: inflammation, deformity, discharge, bleeding –– Crowded living conditions –– Internal: colour of mucosa, edema, deviated –– Dental hygiene habits septum, polyps, bleeding points –– Exposure to smoke or other respiratory toxins –– Transilluminate sinuses for dulling of light reflex –– Recent air travel –– Nasal vs. mouth breathing –– Occupational exposure to toxins or loud noises Palpation REVIEW OF SYSTEMS –– Sinus (frontal and maxillary) and nasal tenderness Obtain a history about other relevant systems for the presenting concern. This may include Percussion information about the eyes, central nervous system, gastrointestinal system and/or respiratory system. –– Sinus (frontal and maxillary) and nasal tenderness MOUTH AND THROAT PHYSICAL EXAMINATION Inspection GENERAL APPEARANCE –– Lips: colour uniformity (light to dark pink), –– Apparent state of health lesions, symmetry of lips –– Degree of comfort or distress –– Oral mucosa and tongue: breath odour; colour; lesions of buccal mucosa, palate, tongue; –– Colour (flushed or pale) tenderness of floor of mouth –– Nutritional status (obese or emaciated) –– Gums (see the section “Gingivitis” in this –– Match between appearance and stated age chapter): redness, swelling –– Difficulty with gait or balance –– Xerostomia (see the section “Xerostomia” in this chapter) (dry mouth) EARS –– Teeth: caries, fractures Inspection –– Throat: colour, tonsillar symmetry and enlargement, exudates, uvula midline –– Pinna: lesions, abnormal appearance or position –– Canal: discharge, swelling, redness, wax, foreign NECK bodies –– Ear drum: colour, light reflex, landmarks, bulging Inspection or retraction, perforation, scarring, air bubbles, –– Symmetry fluid level –– Swelling –– Assess mobility of ear drum using pneumatic –– Masses otoscope (if available) –– Redness Palpation –– Thyroid enlargement –– Tenderness over tragus or mastoid process –– Active range of motion –– Tenderness on manipulation of the pinna Palpation Estimate hearing with a watch or whisper test; –– Tenderness, enlargement, mobility (passive range perform screening audiometry or tympanography (if of motion), contour and consistency of masses equipment available). Perform Weber and Rinne tests. –– Thyroid: size, consistency, contour, position, tenderness

2011 Clinical Practice Guidelines for Nurses in Primary Care Ears, Nose, Throat and Mouth 2–3

LYMPH NODES OF THE HEAD AND NECK –– Anterior and posterior cervical nodes –– Tonsillar Palpation –– Submaxillary –– Tenderness, enlargement, mobility, contour and –– Submandibular consistency of nodes –– Occipital –– Pre- or post-auricular nodes

COMMON PROBLEMS OF THE EARS AND NOSE

ANTERIOR EPISTAXIS –– History of easy bruising or bleeding elsewhere (for example, melena, heavy menstrual periods) Localized bleeding from the anterior portion of the –– Family history of bleeding disorders nasal septum. (von Willebrand’s disease)

CAUSES PHYSICAL FINDINGS –– Trauma and irritation –– Examine client sitting up and leaning forward –– Drying of nasal mucosa due to lack of humidity so that the blood will flow forward in environment –– Blood pressure normal unless bleeding is severe –– Foreign-body irritation enough to cause loss of volume –– Nasal tumour (rare) –– Heart rate may be elevated because of fear or if bleeding is severe enough to cause loss of volume Predisposing Factors –– Obvious deformity or displacement may be present –– Allergic rhinitis –– Bleeding from anterior portion of septum may –– Deviated nasal septum be present –– of the upper respiratory tract –– Inspect throat for posterior bleeding –– Local vascular lesions –– Sinuses may feel tender –– Nasal polyps –– Septum may be deviated –– use –– use DIFFERENTIAL DIAGNOSIS –– Systemic coagulopathies –– Infection of nasal mucosa –– Drugs (warfarin, NSAIDs) –– Dryness and irritation of nasal mucosa –– Hematological malignancies –– Nasal fracture –– Hypertension –– Foreign body –– Liver failure –– Tumor –– Uremia –– Tuberculosis –– Blood dyscrasias (hemophilia, –– Blood dyscrasias von Willebrand’s disease) DIAGNOSTIC TESTS HISTORY None. –– Exposure to one or more of the predisposing factors MANAGEMENT –– Usually unilateral Goals of Treatment –– Profuse bleeding or blood-streaked nasal discharge –– Determine duration, amount and frequency –– Stop loss of blood of bleeding –– Prevent further episodes –– Use of anticoagulants, ASA products or other medications such as topical nasal steroid sprays

Clinical Practice Guidelines for Nurses in Primary Care 2011 2–4 Ears, Nose, Throat and Mouth

Appropriate Consultation –– Pack the anterior nasal cavity with one-half inch Usually not necessary unless complications arise ribbon gauze soaked in Vaseline layered anterior or serious underlying pathology is a concern. to as far posterior as possible, starting at the nasal floor and going toward the nasal roof. Leave in Nonpharmacologic Interventions place for 2–3 days –– Nasal tampons or Gelfoam, if available, Most bleeding will be stopped by application of are alternatives to ribbon gauze pressure to both sides of the nose, with firm pressure against the nasal septum for 15–20 minutes. Monitoring and Follow-Up Client Education Follow up to remove packing in 2–3 days. –– Recommend increasing room humidity (client should keep a pot of water on the stove at all times, Referral especially in winter) Refer to a physician to rule out other pathologies –– Counsel client about appropriate use of if the problem is recurrent or if the client is older. medications (dosage and side effects; avoidance If there has been trauma (for example, a fist fight), it of overuse) is important to rule out septal hematoma. Management –– Recommend avoidance of known irritants and local of hematoma of the nasal septum is surgical, and trauma (nose-picking, forceful nose-blowing) medevac is necessary. –– Instruct client about first-aid control of recurrent epistaxis (sitting up and leaning forward; applying CERUMINOSIS firm, direct pressure to soft part of nose) (IMPACTED CERUMEN) –– Recommend liberal use of lubricants such as (for example, Vaseline) in the nares Obstruction of the ear canal by cerumen (ear wax). to promote hydration of the nasal mucosa –– Advise client to trim fingernails to avoid trauma CAUSES from nose-picking Cerumen is produced naturally by the ear canal and is normally cleared by the body’s own mechanisms. Pharmacologic Interventions Occasionally, cerumen is produced in excessive If direct pressure alone is insufficient to stop the amounts and partially or totally occludes the ear canal. bleeding, try a topical vasoconstrictor: HISTORY xylometazoline 0.1% drops (Otrivin) –– Ear pain Soak a cotton ball with the . Place the –– Sensation of fullness medicated cotton ball in the anterior portion of the –– Itching nose. Press firmly against the bleeding nasal septum for 10–20 minutes. –– Conductive hearing loss If there is failure to control bleeding with this PHYSICAL FINDINGS measure, nasal packing should be performed. –– Wax blocks canal Anesthesia and vasoconstriction:1 –– Canal may be reddened and swollen –– Soak cotton ball in a mix of 1% with –– Abnormal Weber and Rinne test results epinephrine (1:1000) (evidence of conductive loss) may be present –– Put 1–2 cotton balls into the bleeding nostril. DIFFERENTIAL DIAGNOSIS (If bleeding is not clearly unilateral, put cotton balls into both nostrils.) –– Foreign-body irritation –– Put a dry cotton ball at the external nares to –– Otitis media prevent leakage and dripping –– Otitis externa –– Leave cotton balls in place for 10 minutes COMPLICATIONS –– Hearing loss –– Otitis externa

2011 Clinical Practice Guidelines for Nurses in Primary Care Ears, Nose, Throat and Mouth 2–5

DIAGNOSTIC TESTS –– Allergies None. –– Certain medications taken in high doses (for example, furosemide4, ASA, some IV , MANAGEMENT or phenytoin at toxic levels5) –– Benign tumor of the middle ear Goals of Treatment –– Benign positional vertigo, where small stones or –– Remove wax calcified particles break off within the vestibule –– Treat any underlying irritation of the canal and bounce around. The particles trigger nerve impulses that the brain interprets as movement Appropriate Consultation –– Neuronitis Consulting a physician is usually not necessary. –– Vasculitis –– Rarely, more serious causes of vertigo can mimic Nonpharmacologic Interventions labyrinthitis, such as: Sometimes it is helpful to soften the wax with a –– Tumors at the base of the brain few drops of slightly warmed mineral oil or baby –– Strokes or insufficient blood supply to oil before attempting to irrigate the ear. Inject the brainstem or the nerves surrounding lukewarm water upward within ear canal with an ear the labyrinth until wax is cleared (only do this if tympanic membrane is visible and intact). HISTORY –– Vertigo (most prominent symptom) To prevent ceruminosis, anyone who produces large amounts of cerumen can periodically (once or twice –– Dizziness weekly) instill 3 drops of a 1:1 solution of hydrogen –– Nausea and vomiting peroxide and water into each ear to decrease the –– Fluctuating hearing loss likelihood of impaction. One or two drops of baby oil –– Tinnitus once or twice weekly will help to keep wax soft. Only –– Malaise instill a solution if the tympanic membrane is intact. –– Perspiration

Monitoring and Follow-Up PHYSICAL FINDINGS Advise client to return as necessary if symptoms recur. –– Diaphoresis –– Increased salivation LABYRINTHITIS2 –– Nystagmus

Disorder involving inflammation of the vestibular DIFFERENTIAL DIAGNOSIS labyrinth in the inner ear. Most commonly presents as a self-limiting condition following a viral upper –– Menière’s disease respiratory illness (URI). This section also includes –– Chronic bacterial mastoiditis benign positional vertigo. –– Drug-induced damage to the vestibular labyrinth –– Acoustic neuroma 3 CAUSES –– Multiple sclerosis –– Viral infection – influenza, parainfluenza, –– Temporal-lobe epilepsy adenovirus, RSV, coxsackie, CMV, varicella zoster –– Bacterial infections (S. pneumoniae, H. influenzae, COMPLICATIONS M. catarrhalis, P. aeruginosa, P. mirabilis): If –– Permanent hearing loss found in nearby structures such as middle ear, –– Falls potentially leading to injury such infections may cause the following: –– Meningitis (if bacterial cause) –– Fluid to collect in the labyrinth (serous labyrinthitis) DIAGNOSTIC TESTS –– Fluid to directly invade the labyrinth, causing None. pus-producing (suppurative) labyrinthitis –– Trauma or injury to head or ear

Clinical Practice Guidelines for Nurses in Primary Care 2011 2–6 Ears, Nose, Throat and Mouth

MANAGEMENT Referral

Goals of Treatment Refer to a physician if anything other than viral labyrinthitis is suspected, especially if attacks are –– Identify and treat underlying disorder if anything severe or recurrent. A neurology consult may be other than viral labyrinthitis is suspected necessary to identify and treat underlying disorder. –– Supportive treatment of symptoms only

Appropriate Consultation MENIÈRE’S DISEASE (ENDOLYMPHATIC HYDROPS) Consult a physician if the client’s symptoms persist for more than 1 week with therapy or if anything A disorder in which there is inadequate absorption other than a simple viral illness is suspected. of endolymph fluid in the inner ear so it accumulates and distorts the membranous labyrinth resulting in Nonpharmacologic Interventions recurrent attacks of a cluster of symptoms. Advise client to rest in a darkened room with eyes closed during acute attacks (otherwise, activity CAUSES as tolerated). Unknown, but the best theory suggests that it is an inner ear response to an injury (for example, reduced Advise client to drink fluids in sufficient quantity inner ear pressure, allergy, endocrine disease, lipid to maintain hydration status. disorder, vascular disorder, viral infection). If benign paroxysmal positional vertigo is suspected, instruct the patient to do the modified Epley exercise Risk Factors TID until free from vertigo for 24 hours. These –– Caucasian heritage modified Epley instructions are for the left side. Each –– Stress side should be done once with every set of exercises: –– Allergy –– Start sitting in the middle of a bed, with a pillow –– High salt intake behind, so if laying down it will be under your –– Exposure to noise shoulders –– Turn head 45 degrees to left side (looking over HISTORY shoulder) –– Occurs as episodic attacks lasting several hours –– Lie back quickly with shoulders on pillow and with intervening periods of remission head reclined onto the bed. Hold for 30 seconds –– Fluctuating loss of low-frequency hearing –– Turn head only 90 degrees to the right (without –– Tinnitus raising it) and hold for 30 seconds –– Vertigo (spontaneous attacks lasting from –– Turn body and head another 90 degrees to the 20 minutes to several hours) right and hold for 30 seconds –– Sensation of fullness in the ear –– Sit up on right side, with legs hanging down –– Nausea, vomiting over side of bed –– Ataxia; falls may occur Pharmacologic Interventions –– Prostration (inability to stand up because motion increases symptoms) Treat nausea and vomiting: dimenhydrinate (Gravol), 50 mg PO or rectal PHYSICAL FINDINGS q6h prn –– Pallor Monitoring and Follow-Up –– Sweating –– Distress, prostration Follow up in 1 or 2 days to monitor symptom control. Ensure that the client remains hydrated if nausea or –– May be some measure of dehydration if vomiting vomiting is significant. is severe

2011 Clinical Practice Guidelines for Nurses in Primary Care Ears, Nose, Throat and Mouth 2–7

–– Audiometry testing with pure tones may show Pharmacologic Interventions low‑frequency sensorineural nerve loss and For acute attack, control nausea and vomiting: impaired speech distinction –– Tuning fork tests (Weber and Rinne) confirm dimenhydrinate (Gravol), 50 mg PO or rectal suppository q6h prn validity of the audiometry results Monitoring and Follow-Up DIFFERENTIAL DIAGNOSIS Assess hearing at least annually in clients with –– Viral labyrinthitis stable symptoms. –– Benign positional vertigo –– Acoustic neuroma Referral –– Syphilis Refer to a physician if symptoms are not controlled –– Multiple sclerosis or if hearing loss is evident. A neurology consult may –– Vertebrobasilar disease be necessary to identify and treat underlying disorder. COMPLICATIONS OTITIS EXTERNA6 –– Hearing loss –– Injury from falls during attacks Infection or inflammation of the ear canal, which –– Inability to work presents in two forms: –– Failure to diagnose acoustic neuroma –– A benign painful infection of the outer canal –– Malignant (necrotizing) otitis externa is a DIAGNOSTIC TESTS potentially lethal form that usually occurs None. in elderly, immunocompromised or diabetic patients. Involves bacterial spread to the cartilage MANAGEMENT of the external ear with pain and edema. It may be accompanied by a fever and systemic Goals of Treatment manifestations of infection –– Control symptoms CAUSES –– Ascertain underlying cause –– Gram-negative rods: Proteus, Pseudomonas Appropriate Consultation –– Gram-positive cocci (less common): Consult physician for help with diagnosis (not urgent Staphlylococcus, Streptococcus so long as client is stable and symptoms are controlled –– Fungal infection (for example, candidiasis) with treatment). Predisposing Factors Nonpharmacologic Interventions –– Hearing aids –– Narrow ear canal Client Education –– Use of cotton-tipped applicators Counsel client about prevention of attacks: –– Use of ear plugs –– stress-reduction strategies –– Swimming –– avoidance of excessive salt intake –– smoking cessation Risk Factors –– reduction of alcohol intake –– Immunocompromised status, for example: –– avoidance of ototoxic medications such –– Patients with diabetes as acetylsalicylic acid (ASA) –– Patients on immunosuppressant medication Bed rest as necessary until vertigo settles. –– Post-transplant surgery –– Chronic systemic steroid use

Clinical Practice Guidelines for Nurses in Primary Care 2011 2–8 Ears, Nose, Throat and Mouth

HISTORY Appropriate Consultation –– Ear pain (otalgia) Consultation usually not needed, unless complicated –– Pruritus or irritation by cellulitis of the external ear or face, the problem –– Purulent discharge from canal (cheesy white, is recurrent, the therapy failed, systemic symptoms greenish blue or gray) are present (for example, fever), the client is –– Recent exposure to water or mechanical trauma immunocompromised (for example, diabetic) or malignant otitis externa is suspected. –– Reduced hearing or feelings of fullness in ear may be present Nonpharmacologic Interventions –– Unilateral headache may be present Debriding the canal is critical, and the importance PHYSICAL FINDINGS of this step cannot be overemphasized. Clean the outer ear and the canal with normal saline and gently –– Temperature may be elevated debride the area of debris and exudate with a gauze wick. –– Redness and edema of ear canal –– Purulent exudate or debris in canal If there is significant drainage or if there is threat of further narrowing, an ear wick (1 inch [2.5 cm] of –– Tympanic membrane usually normal (may cotton or gauze) threaded gently into the canal and be slightly reddened) left there will help keep the canal open and ensure –– If edema and debris are severe, it may be that medicated drops reach the distal part of the canal. impossible to visualize the tympanic membrane The wick will eventually fall out as edema subsides or –– Manipulation of pinna or pressure on tragus can be removed after 2–3 days. causes pain –– Peri-auricular and anterior cervical nodes may Client Education be enlarged and tender –– Counsel about appropriate use of medications (if possible, have another family member instill DIFFERENTIAL DIAGNOSIS drops and clean the ear) –– Acute otitis media with perforation –– Counsel about proper ear hygiene before instilling –– Skin condition involving the ear medications (for example, eczema) –– Advise client about preventing recurrent irritation –– Mastoiditis (for example, client should not use cotton-tipped –– Furuncle in canal applicators in the ears) –– Foreign-body irritation –– Recommend proper drying of ears after swimming or use of ear plugs while swimming, bathing or COMPLICATIONS showering –– Counsel client about proper hygiene of hearing –– Severe otitis externa with closure of canal aids and ear plugs –– Cellulitis of the external ear and face For recurrent episodes, start the client on prophylactic DIAGNOSTIC TESTS measures: None. Swab for culture and sensitivity is not routinely Burrow’s solution (Buro-Sol otic solution), indicated. 2 or 3 drops after swimming or showers or MANAGEMENT solution of half vinegar and half sterile water, Goals of Treatment 2 or 3 drops after swimming or showers –– Relieve pain Pharmacologic Interventions7 –– Prevent recurrence Manage pain with simple : –– Eradicate infection acetaminophen (Tylenol) 325 mg, 1–2 tabs PO q4-6h prn

2011 Clinical Practice Guidelines for Nurses in Primary Care Ears, Nose, Throat and Mouth 2–9

As otitis externa can be very painful, stronger OTITIS MEDIA, ACUTE8 analgesia may be necessary if acetaminophen does not control pain. Infection of the middle ear. Otitis Externa (Acute Uncomplicated): CAUSES If there is no danger of perforated tympanic –– Viral in 25% of cases membrane, start: –– Bacterial forms due to Streptococcus pneumoniae /polymyxin (Optimyxin) eye/ear solution (primarily), Haemophilus influenzae, Moraxella 4 drops qid for 7 days catarrhalis If the tympanic membrane cannot be visualized Active or passive smoking is a major predisposing or is perforated: factor.

/ (Ciprodex) HISTORY otic solution, 4 drops bid for 7 days –– General malaise and fever Malignant (Necrotizing) Otitis Externa: –– Ear pain (throbbing) Contact physician as treatment requires parenteral –– Sensation of fullness antibiotics with coverage for Pseudomonas species –– Hearing decreased (for example, ciprofloxacin) in addition to hospital –– Tinnitus or roaring in ear, vertigo care. –– Purulent discharge if drum perforated Fungal Otitis Externa (Otomycosis): –– Infection of the upper respiratory tract may Fungal organisms can cause otitis externa, especially be present concurrently or may precede the in immunocompromised patients. In mild to moderate otitis media cases of otitis externa due to fungi, treat with PHYSICAL FINDINGS agents: –– Temperature may be elevated clotrimazole 1% (Canesten), apply bid for 7 days –– Client may be mildly or moderately ill –– Tympanic membrane red, dull, bulging or –– Bony landmarks obscured or absent Locacorten Vioform otic drops, 2 drops bid for –– Possible perforation and purulent discharge 7 days (can be obtained from a retail pharmacy) in canal Monitoring and Follow-Up –– Decreased mobility of tympanic membrane (as noted with pneumatic otoscope if available) Follow up 7 days after course of therapy is complete. –– Bullae seen on tympanic membrane (but only Instruct client to return sooner if pain increases or if in cases of mycoplasma infection) fever develops despite therapy. –– Peri-auricular and anterior cervical nodes enlarged Referral and tender Immediately refer cases of malignant (necrotizing) DIFFERENTIAL DIAGNOSIS otitis externa to a hospital after consultation with a –– Acute otitis externa physician, especially clients with comorbid conditions (such as an immunocompromised status or diabetes). –– Transient middle-ear effusion (not an infection) They require admission to hospital for intravenous –– Mastoiditis (IV) therapy. –– Trauma or foreign-body irritation –– Referred ear pain from dental abscess or temporomandibular joint dysfunction

Clinical Practice Guidelines for Nurses in Primary Care 2011 2–10 Ears, Nose, Throat and Mouth

COMPLICATIONS –– Follow up in 7 days: look for development –– Reduced hearing of serous otitis media –– Serous otitis media –– Assess hearing 1 month after treatment if any symptoms persist –– Mastoiditis –– Chronic otitis media Referral –– Meningitis Not necessary if condition is uncomplicated. –– Epidural abscess –– Cholesteatoma OTITIS MEDIA, DIAGNOSTIC TESTS CHRONIC SUPPURATIVE9 None. Swab for culture and sensitivity if there Nonresolving or recurrent low-grade infection of the is discharge. middle ear associated with perforation of the tympanic membrane. MANAGEMENT It can become a dangerous clinical problem if it Goals of Treatment spreads from being a simple mucosal disease to –– Eradicate infection causing in-growth of stratified epithelium into the middle ear (a cholesteatoma), although such –– Relieve pain conditions are rare. –– Prevent complications CAUSES Appropriate Consultation –– Generally develops as a consequence of recurrent Usually not necessary if condition is uncomplicated. acute otitis media and tympanic membrane rupture Nonpharmacologic Interventions –– Proteus, Pseudomonas or Staphylococcus (usually polymicrobial) Client Education –– Recommend increased rest in the acute febrile HISTORY phase –– Hearing decreased –– Counsel client about appropriate use of –– Continuous foul-smelling discharge from the ear medications (dosage, compliance, follow-up) –– Tinnitus –– Explain disease course and expected outcome –– Usually no pain, occasional dull ache (serous otitis media may persist for several weeks) –– No fever –– Recommend avoidance of flying until symptoms have resolved PHYSICAL FINDINGS

Pharmacologic Interventions7 –– Client appears generally well –– Foul-smelling purulent drainage from ear canal To relieve pain and fever: –– Perforation of tympanic membrane acetaminophen (Tylenol), 325 mg, 1–2 tabs –– Conductive hearing loss PO q4-6h prn Antibiotic therapy: DIFFERENTIAL DIAGNOSIS amoxicillin (Amoxil), 500 mg PO tid for 7 days –– Chronic otitis externa –– Sub-acute otitis media or azithromycin (Zithromax) 500 mg PO on first day COMPLICATIONS then 250 mg PO od for 4 days –– Permanent, severe hearing loss Monitoring and Follow-Up –– Mastoiditis –– Cholesteatoma –– Instruct client to return in 3 days if symptoms do not improve or if symptoms progress despite therapy

2011 Clinical Practice Guidelines for Nurses in Primary Care Ears, Nose, Throat and Mouth 2–11

DIAGNOSTIC TESTS Moderate chronic suppurative otitis media: None. Swab any drainage for culture. If there is significant soft-tissue involvement, systemic antibiotics may be indicated in addition to topical MANAGEMENT therapy with ear drops. Consult a physician for advice about choice of systemic antibiotics. One option is: Goals of Treatment –– Prevent complications ciprofloxacin/dexamethasone (Ciprodex) otic drops, –– Avoid unnecessary use of antibiotics 4 drops bid for 7 days and Appropriate Consultation levofloxacin 500 mg once daily Consult a physician immediately if a cholesteatoma is suspected. Monitoring and Follow-Up Follow up in 7 days. Nonpharmacologic Interventions

Client Education Referral –– Explain disease process and expected course Referral to ear, nose and throat (ENT) specialist –– Counsel client about appropriate use of may be necessary if treatment fails or complications medications (including compliance) develop. Surgical intervention is sometimes required. –– Aural irrigation is an effective therapy prior to In some cases, referral is done by the nurse, but instillation of drops. If possible a solution of 50% usually it is done by a consulting physician. peroxide and 50% sterile water can be used. Thirty to 40 mL of this solution can be irrigated through OTITIS MEDIA, SEROUS the external auditory canal, using a small syringe (OTITIS MEDIA WITH EFFUSION) or bulb-type aspirator. The irrigant solution can be allowed to drain out for 5–10 minutes prior to Presence of non-infective fluid in the middle ear for instilling the ototopical antimicrobial longer than 3 months without symptoms or signs –– Recommend against using Q-tips for cleaning of acute infection. Tympanic membrane is intact. –– Recommend proper drying of ears after swimming, CAUSES bathing or showering; use of ear plugs while swimming –– Dysfunction of eustachian tube –– Counsel client about proper hygiene of hearing –– Nasal obstruction, nasal polyps aids and ear plugs Predisposing Factors To prevent recurrence, recommend that ear canal be cleaned with: –– Viral infection of the upper respiratory tract –– Allergies Burrow’s solution (Buro-Sol otic solution) –– Barotrauma or –– Enlargement of adenoids solution of half vinegar and half sterile water, –– Recent acute otitis media 4–6 drops in the ear after exposure to water HISTORY Pharmacologic Interventions –– Exposure to one of the predisposing factors Mild chronic suppurative otitis media: –– Reduced hearing in affected ear Topical antibiotic ear drop alone is sufficient: –– Sensation of fullness in ear ciprofloxacin/dexamethasone (Ciprodex) otic drops, –– Nose and ears may be itchy 4 drops bid for 7 days –– Pain mild or absent –– Fever absent

Clinical Practice Guidelines for Nurses in Primary Care 2011 2–12 Ears, Nose, Throat and Mouth

PHYSICAL FINDINGS –– If client must fly, recommend the use of topical –– Tympanic membrane intact, dull, retracted or nasal decongestant (for example, xylometazoline hypomobile [Otrivin]) 1 hour prior to flight in addition to appropriate doses of systemic oral decongestants –– Presence of clear fluid, air bubbles or air-fluid level (for example, pseudoephedrine [Sudafed]) behind the tympanic membrane –– Discuss signs and symptoms of purulent otitis –– Bony landmarks usually accentuated because media; advise client to return to clinic if they occur of retraction of the tympanic membrane –– Instruct client to gently try to equalize pressure –– Audiometric screening may show a decrease between middle ear and throat, using a simple in hearing maneuver such as yawning or –– Abnormal Weber and Rinne test results (evidence of conductive loss) may be present Pharmacologic Interventions DIFFERENTIAL DIAGNOSIS Most studies indicate that antihistamines and decongestants are ineffective, but some clients Nasopharyngeal tumour (if problem longstanding). may derive symptomatic relief. COMPLICATIONS Oral decongestant can be obtained from a retail pharmacy: –– Secondary infection (purulent acute otitis media) –– Chronic serous otitis media pseudoephedrine (Sudafed), 30–60 mg PO tid or –– Hearing loss qid for 4–7 days (Maximum dose: 240 mg/day) Note: this frequency is for regular-release DIAGNOSTIC TESTS pseudoephedrine; long-acting preparations must be dosed accordingly. None. Start with the smaller dose and lower frequency. MANAGEMENT Instruct client to increase dose slowly to minimize any side effects (such as restlessness, insomnia, irritability, Goals of Treatment tremor). –– Identify underlying cause Do not prescribe decongestants for elderly clients, for –– Relieve symptoms people with hypertension, heart disease, peripheral –– Prevent hearing loss vascular disease, diabetes, hyperthyroidism, previous acute angle-closure glaucoma, previous urinary Appropriate Consultation retention or prostatic hypertrophy, or for anyone Consult a physician if the client has effusion with taking monoamine oxidase inhibitors or tricyclic significant hearing loss (more than 20 dB), if effusion antidepressants. is bilateral with hearing loss or if effusion persists for Oral antibiotics may be prescribed for those with more than 2–3 months. persistent bilateral effusions causing significant hearing loss. Consultation with a physician is Nonpharmacologic Interventions recommended in these situations. Client Education Monitoring and Follow-Up –– Explain disease process and expected outcomes –– Offer support and reassurance, as symptoms can Monitor the response to therapy in 2–4 weeks. last a long time (2–3 months) In particular, note any improvement in hearing –– Counsel client about appropriate use of or decrease in tinnitus. medications (dosage and compliance) Reassess hearing, preferably with screening –– Recommend against flying until signs and audiometry (if available). symptoms have resolved, if possible Referral Refer to an ENT physician if effusion persists after 3 months.

2011 Clinical Practice Guidelines for Nurses in Primary Care Ears, Nose, Throat and Mouth 2–13

RHINITIS Vasomotor Rhinitis Inflammation of the mucosal lining of the nasal –– Sudden onset of nasal congestion cavity leading to nasal congestion and rhinorrhea –– Perennial symptoms (runny nose). The 3 most common types of rhinitis –– Persistent postnasal drip to consider in the differential diagnosis of rhinitis are: –– Intermittent throat irritation –– Allergic rhinitis: Reactive inflammation of the –– No response to environmental controls and nasal mucosa medications –– Vasomotor rhinitis: Perennial inflammation of the –– Sensation of constantly needing to clear throat nasal mucosa, which represents a hyperreactive –– Changes in acuity of hearing or smell state of the nasal mucosa (nonallergic) –– Snoring at night –– Viral rhinitis (infection of upper respiratory tract): –– Fatigue Viral infection confined to the upper respiratory tract. Usually mild and self-limiting Viral Rhinitis (Infection of Upper Respiratory Tract) CAUSES –– Nonproductive cough or cough that produces clear Allergic Rhinitis sputum –– Low-grade fever –– Sensitivity to inhaled allergens (pollens, grasses, –– Nasal congestion with clear nasal discharge ragweed, dust, molds, animal dander, smoke) –– Sneezing Vasomotor Rhinitis –– Postnasal drip –– Unknown; symptoms do not correlate with –– Scratchy throat exposure to specific allergens –– Mild headache and general malaise –– Atrophic mucosa (in the elderly) –– Pressure in ears –– Attacks may be triggered by abrupt changes PHYSICAL FINDINGS in temperature or barometric pressure, odours, emotional stress or exercise Allergic Rhinitis Viral Rhinitis (Infection of –– Injected conjunctiva may be present Upper Respiratory Tract) –– Eyes may tear –– Numerous viral agents –– Edema of the eyelids and periorbital area may be present HISTORY –– Pale, edematous nasal mucosa is pink, with clear thin secretions Allergic Rhinitis –– Nasal polyps may be present –– Seasonal or perennial symptoms –– Skin around nose may be irritated –– History of familial allergies (for example, ASA) –– “Allergic salute” may be present –– Asthma or eczema may be present –– Sinuses may feel tender if symptoms are severe –– Paroxysmal sneezing –– Mouth breathing –– Itchy nose Vasomotor Rhinitis –– Nasal congestion –– Excessive, continuous, clear, watery nasal discharge –– Vital signs usually normal –– Eyes may be itchy or watery –– Nasal mucosa red and swollen –– Ears may be itchy –– Nasal turbinates enlarged –– General malaise and headache may be present –– Throat may be slightly reddened because of irritation from postnasal drip –– Symptoms worst in the morning and least during the day, worsening again during the night –– Tonsils and adenoids may be enlarged –– Postnasal drip –– Sinuses may feel tender if symptoms are severe –– Breathing through the mouth –– Snoring and dry cough at night may be present

Clinical Practice Guidelines for Nurses in Primary Care 2011 2–14 Ears, Nose, Throat and Mouth

Viral Rhinitis (Infection of Nonpharmacologic Interventions Upper Respiratory Tract) Environmental control is important. Eliminate or –– Temperature may be slightly elevated reduce known allergen(s) in the environment wherever –– Client appears mildly ill possible, or avoid them altogether. –– Clear nasal discharge Client Education –– Skin around nares slightly irritated –– Recommend increasing fluid intake to improve –– Ears may have transient, middle-ear sterile effusion hydration –– Throat may have mild erythema, but otherwise –– Counsel client about appropriate use of is normal medications (dose, frequency, side effects, –– Sinuses may feel tender if symptoms are severe avoidance of overuse) –– Recommend avoidance of caffeine DIFFERENTIAL DIAGNOSIS (ALL TYPES OF RHINITIS) –– Recommend avoidance of known allergens (client should keep living area clear of dust, avoid going –– Acute or chronic sinusitis outside when pollen count is high and use synthetic –– Abuse of nose drops fibres in bedding and clothing) and removal of pets –– Abuse of drugs or solvents (for example, cocaine, (to eliminate animal dander) gas, glue) –– Counsel client about preventing spread of viral –– Foreign body in nares rhinitis to other household members –– Nasal polyps –– Recommend frequent hand-washing, appropriate –– Deviated septum disposal of used facial tissues and covering of –– Hypothyroidism as a cause of the nasal congestion mouth and nose when coughing or sneezing –– Nasal congestion induced by pregnancy or use of Pharmacologic Interventions oral contraceptives Allergic and Vasomotor Rhinitis: COMPLICATIONS Saline nasal drops/salinex nasal spray, prn, to wash (ALL TYPES OF RHINITIS) out mucus and any inhaled allergen. –– Otitis media Oral antihistamines to treat acute symptoms of runny –– Nasal polyps nose, sneezing, itch and conjunctival symptoms (but –– Epistaxis these will not help nasal congestion): –– Enlargement of tonsils and adenoids cetirizine (Reactine), 10 mg PO daily to be taken –– Sinusitis as long as the patient is in contact with the allergen DIAGNOSTIC TESTS Topical nasal steroids are the mainstay of therapy for (ALL TYPES OF RHINITIS) chronic allergic rhinitis and chronic vasomotor rhinitis Consider skin testing for allergies. and for maintenance and prophylactic treatment of these conditions. They can be used alone or in MANAGEMENT combination with the antihistamine and decongestant (ALL TYPES OF RHINITIS) regimen. Consult a physician about the use of inhaled Goals of Treatment nasal steroids/parasympathetic blockers if oral –– Relieve and suppress symptoms antihistamines and decongestants (see “viral rhinitis”) –– Identify the underlying allergen(s) are not effective. For example: –– Prevent complications fluticasone (Flonase/generics), 50 µg/spray, 2 sprays/nostril daily Appropriate Consultation or Consultation with a physician is not usually required. triamcinolone (Nasocort AQ), 55 µg/spray, 2 sprays/ nostril daily

2011 Clinical Practice Guidelines for Nurses in Primary Care Ears, Nose, Throat and Mouth 2–15

Viral Rhinitis: Predisposing Factors Oral antihistamines and decongestants, which can be –– Common cold obtained from a retail pharmacy, can be tried for a –– Allergies maximum 4–7 days, to avoid rebound effect: –– Deviated nasal septum pseudoephedrine (Sudafed), 30–60 mg PO tid or qid –– Smoking for 4–7 days (Maximum dose: 240 mg/day) –– Adenoidal hypertrophy Note: this frequency is for regular-release –– Dental abscess pseudoephedrine; long-acting preparations must –– Nasal polyps be dosed accordingly. –– Trauma Antihistamines have little proven benefit in the –– Foreign body treatment of the common cold, including viral rhinitis. –– Diving or swimming Do not prescribe decongestants for elderly clients, for –– Neoplasms people with hypertension, heart disease, peripheral –– Cystic fibrosis vascular disease, diabetes, hyperthyroidism, previous acute angle-closure glaucoma, previous urinary HISTORY retention or prostatic hypertrophy, or for anyone –– Exposure to one or more of the predisposing taking monoamine oxidase inhibitors or tricyclic factors antidepressants. –– Headache Manage fever: –– Facial pain –– Nasal congestion acetaminophen (Tylenol), 325 mg, 1–2 tabs PO q4-6h prn –– Pressure over involved sinuses increases when bending forward Monitoring and Follow-Up –– Purulent nasal discharge, which may be tinged with Instruct client to return for further assessment if fever blood, can be present develops or if symptoms have not resolved within –– Dental pain, especially of upper incisor and canine teeth 14 days. –– General malaise may be present –– Fever may be present Referral –– Postnasal drainage Refer to a physician if symptoms of rhinitis are not –– Hyposmia/anosmia controlled with initial treatment. Allergy testing, sinus –– Ear pressure/fullness radiography or other medications may be required. PHYSICAL FINDINGS RHINOSINUSITIS, ACUTE10,11 –– Temperature may be mildly elevated –– Client appears mildly to moderately ill Infection of mucosal lining of the paranasal sinuses –– Irritation of skin around nares (symptoms present less than 4 weeks and with less than 3 episodes per year). –– Swollen nasal mucosa may be pale or dull red –– Nasal polyp may be present Maxillary sinuses most commonly affected. –– Dental abscess may be present CAUSES –– Tenderness over involved sinuses –– Poor transillumination of sinuses –– Common: Haemophilus influenzae, Moraxella –– Tenderness over a tooth catarrhalis, Streptococcus pneumonia –– Anterior cervical nodes may be enlarged and tender –– Less common: Chlamydia pneumoniae, Streptococcus pyogenes, viruses, fungi –– Cough may be present

Clinical Practice Guidelines for Nurses in Primary Care 2011 2–16 Ears, Nose, Throat and Mouth

DIFFERENTIAL DIAGNOSIS –– Recommend avoidance of irritants (for example, –– Dental abscess smoke) –– Nasal polyp(s) –– Recommend avoidance of swimming, diving or flying during acute phase –– Tumour –– Presence of foreign bodies Pharmacologic Interventions7 –– Periorbital cellulitis Saline nasal drops/salinex nasal spray, prn may –– Infection of upper respiratory tract be helpful. –– Allergic rhinitis –– Vasomotor rhinitis Nasal decongestant sprays or drops may be used for the first 24–48 hours if congestion is marked. Topical –– Cluster headache decongestants are more effective than oral ones. Client –– Migraine headache should not use antihistamines because these dry and thicken the secretions: COMPLICATIONS xylometazoline (Otrivin), 0.1% nasal drops, –– Contiguous spread of infection to intraorbital 1–3 drops q8-12h prn for a maximum of 4 days or intracranial structures –– Chronic sinusitis It is very important to limit the use of a topical nasal –– Periorbital cellulitis decongestant to a period of 3 or 4 days to prevent development of “rebound” nasal congestion when DIAGNOSTIC TESTS the nasal spray is withdrawn (a complication called rhinitis medicamentosa). None. Manage pain and fever with simple analgesics: MANAGEMENT acetaminophen (Tylenol), 325 mg, 1–2 tabs PO q4h prn Goals of Treatment or –– Make the correct diagnosis –– Identify predisposing factors and treat ibuprofen (Motrin), 200 mg, 1–2 tabs PO q4h prn the conditions Approximately 70% of cases of acute sinusitis will –– Treat the infection as indicated resolve without antibiotic treatment. However, if –– Identify any underlying dental abscess symptoms continue for longer than 10 days or worsen –– Relieve symptoms after 5 days, consider antibiotic therapy. Oral antibiotics: Appropriate Consultation amoxicillin (Amoxil), 500 mg PO tid for 10 days Usually not necessary unless does not resolve with treatment, symptoms progress within 2–3 days or or if allergy to penicillin: complications arise. doxycycline 200 mg po once, then 100 mg po bid for 10 days Nonpharmacologic Interventions Monitoring and Follow-Up Apply moist heat (such as with steam or warm compresses) to sinuses to help relieve pressure Follow up in 3–4 days or sooner if symptoms progress by loosening and liquefying thickened secretions. despite therapy or if symptoms fail to respond to therapy. Saline nose drops also help to do this. 10 Client Education RHINOSINUSITIS, CHRONIC –– Recommend increased rest during acute phase Inflammation of the mucosal lining of the the –– Recommend increasing hydration (6–8 glasses paranasal sinuses lasting 12 weeks or more. of fluid per day) –– Counsel client about appropriate use of CAUSES medications (dose, frequency, side effects) –– Infection (bacterial anaerobes, Staphylococcus aureus, viruses) –– Structural abnormalities

2011 Clinical Practice Guidelines for Nurses in Primary Care Ears, Nose, Throat and Mouth 2–17

HISTORY MANAGEMENT

–– Prolonged nasal congestion (more than 12 weeks) Goals of Treatment –– Nasal discharge, intermittently purulent –– Relieve symptoms –– Postnasal drip may be present –– Identify predisposing or underlying factors –– Early morning hoarseness may be present –– Prevent spread of infection to other structures –– Sinus pain or pressure across the middle of the face –– Headache may be present Appropriate Consultation –– Popping of ears A physician should be consulted for these patients. –– Eye pain Specialist consult may also be necessary if anatomical –– Halitosis abnormalities are suspected or it is not resolving. –– Chronic cough Chronic rhinosinusitis is a complex condition which –– Fatigue often requires a combination of topical or oral –– No fever glucocorticoids, antibiotics and nasal irrigation. –– Decreased sense of smell –– History of underlying risk factors such as allergic Nonpharmacologic Interventions rhinitis, GERD, cystic fibrosis, immunodeficiency, structural abnormalities, eosinophilic nonallergic Client Education rhinitis –– Recommend increasing hydration (6–8 glasses of fluid per day) PHYSICAL FINDINGS –– Recommend inhalation of steam or use of warm –– Client appears well compresses to relieve pressure on sinuses –– Nasal mucous membranes may appear pale –– Counsel client about appropriate use of and “boggy” medications (dosage and side effects) –– Tenderness may be present over sinuses –– Recommend avoidance of irritants (for example, smoke) and allergens DIFFERENTIAL DIAGNOSIS –– Recommend avoidance of diving, swimming –– Allergic rhinitis or flying if symptoms are acute –– Vasomotor rhinitis Pharmacologic Interventions7 –– Nasal polyp Manage current symptoms with oral antibiotics; a –– Infection of upper respiratory tract longer course of therapy than for acute sinusitis is –– Tumour usually needed (that is, 3 weeks). Repeated courses –– Migraine headache of antibiotics are not recommended: –– Cluster headache amoxicillin/clavulanate (Clavulin), 875 mg PO bid –– Dental abscess for 21 days COMPLICATIONS or –– Recurrent acute sinusitis clindamycin (Dalacin C), 300 mg PO qid for 21 days –– Spread of infection to the intraorbital or Monitoring and Follow-Up intracranial structures Follow up in 2 weeks. DIAGNOSTIC TESTS Referral None initially. Consider diagnostic tests such as sinus x-ray or computed tomography (CT) scan of sinuses if Refer to a physician if symptoms do not improve initial therapy fails; discuss these diagnostic tests with after 4 weeks of continuous antibiotic therapy to rule a physician. out underlying pathology (for example, nasal polyps, deviated nasal septum, chronic allergies). Refer to a dentist if underlying dental disease is suspected.

Clinical Practice Guidelines for Nurses in Primary Care 2011 2–18 Ears, Nose, Throat and Mouth

COMMON PROBLEMS OF THE THROAT

LARYNGITIS DIAGNOSTIC TESTS Laryngitis is an inflammation of the voice box None. (larynx) due to overuse, irritation or infection. MANAGEMENT CAUSES Goals of Treatment –– Viral infection (common cold) –– Relieve symptoms –– Bacterial infection (Streptococcus) –– Identify and remove contributing factors –– Chronic mouth breathing (for example, smoking) –– Overuse of voice –– Chronic sinusitis Appropriate Consultation –– Excessive smoking (or exposure to second-hand Consult a physician immediately if client has stridor smoke) and shortness of breath. –– Aspiration of caustic chemical –– Gastroesophageal reflux Nonpharmacologic Interventions –– Changes due to aging (for example, muscle –– Voice rest is the mainstay of treatment (including, atrophy, bowing of cords) throat clearing)12 –– Alcohol abuse –– Removal of contributing factors (for example, –– Long-term exposure to dust or other irritants smoking and alcohol) is also important –– Increase humidity of room air HISTORY –– Increase fluid intake if febrile –– Presence of risk factors (see “Causes”) –– Increase rest until any fever settles –– Concurrent infection of the upper respiratory tract may be present Client Education –– Hoarseness or loss of voice, abnormal-sounding voice –– Explain disease course and expected outcomes –– Throat pain, tickle or rawness –– Counsel client about appropriate use of medications (dosage and side effects) –– Aphonia (no sound is emanated from vocal folds) –– Stress importance of follow-up if not resolved –– Dysphonia (a general alteration in voice quality) in 1 week –– Cough –– Fever Pharmacologic Interventions –– Malaise Usually none. PHYSICAL FINDINGS Monitoring and Follow-Up –– Temperature may be elevated Follow up in 7 days if not resolved, (sooner –– Client appears mildly ill if symptoms worsen). –– Throat may be mildly to moderately injected –– No exudate Referral –– Lymph nodes may be enlarged Refer to a physician if symptoms persist for longer than 2 weeks. DIFFERENTIAL DIAGNOSIS –– Cancer of the throat or larynx (if condition prolonged or recurrent) –– Polyps of vocal cords –– Gastroesophageal reflux disease (GERD)

2011 Clinical Practice Guidelines for Nurses in Primary Care Ears, Nose, Throat and Mouth 2–19

PHARYNGITIS (SORE THROAT) Noninfectious Inflammation or infection of mucous membranes –– Slow, progressive onset of sore throat of pharynx (may also affect the palatine tonsils). –– Mild malaise –– Cough CAUSES –– Persistent, recurrent –– Pain on swallowing Infectious –– Viruses (for example, rhinovirus, adenovirus, PHYSICAL FINDINGS parainfluenza, coxsackievirus, Epstein-Barr virus, herpes virus) Bacterial –– Bacteria (for example, group A ß-hemolytic –– Temperature elevated Streptococcus [most common]), Chlamydia, –– Pulse elevated Corynebacterium diphtheriae, Haemophilus –– Client appears acutely ill influenzae, Neisseria gonorrhoeae –– Posterior pharynx red and swollen –– Fungi (for example, Candida); rare except in –– Tonsils enlarged, may be asymmetric immunocompromised people (for example, –– Purulent exudate may be present those with HIV or AIDS) –– Tonsillar and anterior cervical nodes enlarged Noninfectious and tender –– Rash (scarlatiniform in group A streptococcal –– Allergic rhinitis infection) –– Sinusitis with postnasal drip –– Mouth breathing Viral –– Trauma –– Temperature may be elevated –– Gastroesophageal reflux disease –– Posterior pharynx red and swollen –– Risk factors: contact with a person with group A –– Purulent exudate may be present streptococcal infection, crowded living quarters, –– Tonsillar and cervical nodes may be enlarged immunosuppression (for example, HIV/AIDS), and tender fatigue, smoking, excess consumption of alcohol, oral sex, diabetes mellitus or use of steroids (oral –– Petechiae on palate (in mononucleosis) or inhaled) –– Vesicles (in herpes)

HISTORY Noninfectious –– Posterior pharynx red and swollen Bacterial –– Tonsillar and anterior cervical nodes may –– Abrupt onset of sore throat be enlarged and tender –– Pain on swallowing –– Exudate may be present –– Absence of cough It is often impossible to distinguish clinically between –– Fever or chills bacterial and viral pharyngitis. See the clinical tool –– Malaise “The Sore Throat Score” to help decide whether a –– Skin rash may be present patient has a group A streptococcal throat infection –– Headache and needs antibiotics. –– Anorexia THE SORE THROAT SCORE Viral In adults, 85–90% of sore throats are caused by viral –– Slow, progressive onset of sore throat infections.13 In an effort to assess the probability of –– Mild malaise diagnosing Group A streptococcal pharyngitis in a patient presenting with a sore throat, a number of –– Cough tools have been developed. In a primary care setting, –– Nasal congestion the Sore Throat Score provides an evidenced-based clinical decision rule for all age groups.14,15

Clinical Practice Guidelines for Nurses in Primary Care 2011 2–20 Ears, Nose, Throat and Mouth

Step 1 COMPLICATIONS Determine the client’s total sore throat score by –– Rheumatic fever (group A Streptococcus only) assigning points using the following criteria. –– Glomerulonephritis (group A Streptococcus only) –– Peritonsillar abscess Criteria Points History of fever or measured 1 DIAGNOSTIC TESTS temperature > 38°C –– Rapid Strep test if available (see “The Score Throat Absence of cough 1 Score” for indications to swab) Tender anterior cervical adenopathy 1 –– Swab the throat for culture and sensitivity when Tonsillar swelling or exudate 1 indicated (see “ The Score Throat Score”) Patient’s age 1 Age < 15 years 1 MANAGEMENT Age 15–44 0 Goals of Treatment Age ≥ 45 -1 –– Eradicate infection Step 2 –– Prevent complications –– Prevent spread of group A Streptococcus Choose the appropriate management according to the to contacts total score. Appropriate Consultation Total Score Management -1 to 0 No culture or antibiotics Consult a physician if the client has significant dysphagia or dyspnea (signaling obstruction of 1 to 3 If Rapid Strep test is available: the upper airways) or if there is concern about • If result is negative: culture throat an underlying pathology such as HIV. and await results • If result is positive: treat with Nonpharmacologic Interventions antibiotics –– Bed rest during febrile phase If no Rapid Strep test is available: perform culture; no antibiotics unless –– Adequate oral intake of fluids (6–8 glasses culture returns positive of fluid per day) 4 to 5 Culture and consider empiric antibiotic –– Avoidance of irritants (for example, smoke) therapy on clinical grounds until culture –– Gargling with warm saline qid result available Pharmacologic Interventions16 The score is invalid: For pain and fever: –– in any community in which an outbreak or epidemic of group A streptococcal pharyngitis is occurring acetaminophen (Tylenol), 325 mg, 1–2 tabs PO q4h prn and should not be applied in this type of situation, or –– in populations where rheumatic fever remains ibuprofen (Motrin), 200 mg, 1–2 tabs q4h prn a problem, –– in clients with a history of rheumatic Treat with antibiotics if streptococcal disease is fever or valvular heart disease or who are suspected according to “The Sore Throat Score” immunosuppressed (see “The Score Throat Score”) and/or it has been confirmed by culture or Rapid Strep testing: DIFFERENTIAL DIAGNOSIS penicillin V potassium (Penicillin V), 300 mg –– Distinguish bacterial from viral infection PO tid or 600 mg PO bid for 10 days –– Infectious mononucleosis For clients with penicillin allergy: –– Sexually transmitted infection (for chronic erythromycin 250 mg PO qid or 500 mg PO bid pharyngitis, investigate sexual practices) for 10 days –– Vincent’s angina (necrotic tonsillar ulcers) Do not use ampicillin or amoxicillin, because these –– Distinguish reactive inflammation from an drugs may cause a generalized red “drug rash” if underlying disorder (see “Cause”) infectious mononucleosis is present.

2011 Clinical Practice Guidelines for Nurses in Primary Care Ears, Nose, Throat and Mouth 2–21

Monitoring and Follow-Up Referral Instruct client to return to clinic for reassessment Referral may be necessary if condition is recurrent if symptoms do not improve in 48–72 hours. or persistent or an undiagnosed underlying pathology is suspected.

COMMON PROBLEMS OF THE MOUTH

ANGULAR CHEILITIS17 Predisposing Factors Cracks or lines at the corners of the mouth. –– Immunocompromised status –– Autoimmune disease (for example, Crohn’s CAUSES disease)

–– Bacteria: Staphylococcus aureus Contributing Factors –– Fungus: Candida –– Allergies (coffee, chocolate, potatoes, cheese, Predisposing Factors figs, nuts, citrus fruits and gluten) –– Stress –– Increased moisture at corners of mouth –– Exposure to sunlight –– Sagging face and loss of teeth (particularly back –– Generalized physical debility teeth) in older adults –– Trauma –– Fungal infection –– Nutritional deficiencies (Vitamin B12, folate, iron) PHYSICAL EXAMINATION –– Hormones –– Erythema, maceration at corners of mouth –– Medications (antihypertensives, antineoplastics, gold salts, nonsteroidal anti-inflammatories) –– White coating HISTORY DIAGNOSTIC TESTS –– Onset and duration of symptoms –– Swab for culture –– Previous history of the same and treatment –– KOH test for candidiasis –– Fever MANAGEMENT –– Burning or tingling before ulceration The key to treating angular cheilitis is to identify –– Pain and treat the cause. –– Drooling –– Difficulty swallowing APHTHOUS STOMATITIS18,19 –– Decreased nutritional intake –– Associated respiratory or gastrointestinal Ulcers and inflammation of the tissues of the mouth, symptoms including the lips, buccal mucosa, tongue, gingiva –– Associated skin rash and posterior pharyngeal wall that are recurrent –– Nutritional deficiencies, stressors, allergies, recent and painful. After mucosal breakdown, lesions mouth trauma, infections, risk factors for STIs become secondarily infected by mouth flora. It is –– Medications less prevalent in men and chronic smokers.20 It is the most common cause of oral ulcers, occurring in up –– Weight loss (if severe ulcers) to 30% of otherwise healthy individuals. –– Systemic diseases –– Recent dental treatment CAUSES –– Smoking or alcohol use –– Herpes simplex virus –– Coxsackievirus –– Oral candida

Clinical Practice Guidelines for Nurses in Primary Care 2011 2–22 Ears, Nose, Throat and Mouth

PHYSICAL FINDINGS of lesions. Also note colour(s), borders (distinct or –– Temperature may be increased in infectious types diffuse), texture (firm or fluctuant), discharge and size of lesions. –– Check weight, record as baseline –– Hydration status Look for the following features: –– Assess for lymphadenopathy –– Erythema (herpangina) –– Assess for lesions on body –– Vesicles (early stages of all infectious types) –– Auscultate chest –– Ulcers: check distribution (confluent ulcers may –– Complete physical if systemic disease is suspected appear as large, irregular white areas) Examine outside of lips first. Next, gently retract the –– Submandibular lymph nodes (most prominent lips with a tongue depressor to examine the anterior in herpes) buccal mucosa and gingiva. Then gently depress See Table 1, “Features of Common Forms the tongue. Note location, number and distribution of Stomatitis”.

Table 1 – Features of Common Forms of Stomatitis Disease Cause Type of Lesions Site Diameter Other Features Herpangina or Coxsackievirus, Vesicles and Anterior pillars, 1–3 mm Dysphagia, vesicles on hand-foot-and- echovirus, ulcers with posterior palate, palms of hands and soles mouth disease enterovirus 71 erythema pharynx and of feet and in mouth buccal mucosa Herpes stomatitis Herpes Vesicles and Gingiva, > 5 mm Drooling, coalescence simplex virus shallow ulcers buccal mucosa, of lesions (round or oval), tongue, lips Duration about 10 days which may be confluent Aphthous Unknown Ulcers with Buccal mucosa, Minor Pain, no fever stomatitis exudate lateral tongue < 10 mm Usually only one (minor or major) Major or two lesions > 10 mm

DIFFERENTIAL DIAGNOSIS –– Mucus retention cyst (a normal-coloured, fluid- –– Immunologic: gingival hyperplasia filled cyst on the inner portion of the lip). It will resolve normally by itself –– Systemic lupus erythematosus –– Adverse drug reaction –– Erythema multiforme –– Oral cancer (suspect if lesions present more than COMPLICATIONS 3–6 weeks and are unresponsive to treatment) –– Dehydration –– Oral candidiasis –– Secondary infection (for example, gangrenous –– Lichen planus stomatitis) –– Leukoplakia (chronic irritation) –– Ludwig’s angina –– Hand-foot-and-mouth disease –– Herpes simplex virus DIAGNOSTIC TESTS –– Herpangina –– Usually none –– Primary HIV/AIDS infection –– Vitamin B12, folate and iron if nutritional –– Syphilis deficiencies are suspected –– Vincent’s stomatitis –– CBC to rule out anemias –– Trauma –– Tzank smear (for herpetic stomatitis) –– Pemphigus –– Biopsy (for oral cancer) –– Denture stomatitis (red palate under denture)

2011 Clinical Practice Guidelines for Nurses in Primary Care Ears, Nose, Throat and Mouth 2–23

MANAGEMENT Herpetic lesions on the lips There are as yet no specific treatments for any of If the lesions are herpetic, consult a physician these conditions. Herpes stomatitis usually lasts who may suggest oral antiviral therapy depending 10 days. Herpangina lasts for only a few days and has on severity/recurrence. Topical antivirals such as few complications. Aphthous stomatitis requires no acyclovir (for example, Zovirax) are sometimes used treatment. but must be started before lesions appear.22

Goals of Treatment Oral Candidiasis –– Relieve symptoms Antifungal: –– Prevent complications oral 500,000 units (5 mL) swish and swallow qid Appropriate Consultation If large (> 1 cm), persistent and painful lesions The disease is self-limiting, so consultation is usually interfere with nutrition where there is no possibility of unnecessary, unless there are complications. infection, consult a physician who may suggest a brief course of prednisone: 60 mg PO tapered by 5 mg/day Nonpharmacologic Interventions over two weeks.23 Maintenance of hydration is important. Increase oral intake of fluids (that is, maintenance requirements Monitoring and Follow-Up + fluid deficits caused by fever). –– If lesions are severe, follow up in 2–3 days –– For lesions of unknown origin, follow up in 7 days Client Education –– Have client return if lesions persist after 3 weeks –– Counsel clients about the expected duration of this despite treatment, if they are unable to eat or if they illness and the signs and symptoms of dehydration are losing weight –– Recommend dietary adjustments: bland, non-acidic fluids (such as milk and water); popsicles, ice Referral cream and similar food items; avoid citrus foods such as orange juice Refer to a physician, for lesions that are not resolving after 3 weeks. –– Recommend local (1:1 and water), especially after eating –– Warm saline rinse 4 times daily for traumatic DENTAL ABSCESS or viral ulcers Infection of the soft tissue surrounding tooth or gums –– To prevent spread of infection, recommend due to infection of a tooth or the structures supporting avoidance of direct contact with infected the tooth. individuals (for example, kissing, sharing glasses and utensils, hand contact) CAUSES –– Educate clients that the herpes virus can spread –– Progressive dental decay causing pulpitis from even when sores are not present gram-positive anaerobes and Bacteroides Pharmacologic Interventions7 –– Foreign body impaction around the tooth –– Predisposing factors: deep caries, poor dental Antipyretic and for fever and pain: hygiene, dental trauma acetaminophen (Tylenol), 325–650 mg PO or PR q4-6h prn HISTORY A topical containing benzocaine (for –– Localized tooth pain example, Anbesol) can be obtained from a retail –– Constant, deep, throbbing pain pharmacy. –– Pain worsens with mastication or exposure Do not treat this condition with antibiotics, as to extreme temperatures they are not indicated and are not helpful. –– Tooth may be mobile –– Gingival or facial swelling (or both) may be present

Clinical Practice Guidelines for Nurses in Primary Care 2011 2–24 Ears, Nose, Throat and Mouth

PHYSICAL FINDINGS For clients with penicillin allergy: –– Fever may or may not be present clindamycin (Dalacin C), 150–300 mg PO qid –– Facial swelling may be present for 7 days –– Carious tooth For spreading infections involving facial swelling: –– Gingival edema and erythema amoxicillin/clavulanate (Clavulin), 875 mg –– Tooth may be loose (of amoxicillin) PO bid for 10 days –– Localized tenderness over affected area of jaw For clients with penicillin allergy: –– Anterior cervical nodes enlarged and tender –– Localized tooth pain clindamycin (Dalacin C), 300 mg PO qid for 7 days Simple analgesics for mild to moderate dental pain: DIFFERENTIAL DIAGNOSIS ibuprofen (Motrin), 200 mg, 1–2 tabs PO q4h prn –– Disease of the salivary gland (for example, mumps) to a maximum of ibuprofen 800 mg PO tid. Ensure –– Sinusitis patient is aware this is the maximum daily dose. –– Cellulitis or if unable to take ibuprofen: COMPLICATIONS acetaminophen (Tylenol), 325 mg 1–2 tabs PO q4-6h prn –– Cellulitis –– Recurrent abscess formation If the patient cannot take ibuprofen and is experiencing severe pain contact a physician for DIAGNOSTIC TESTS a codeine-containing product: None. acetaminophen with codeine (Tylenol #3), 1–2 tabs PO q4-6h prn MANAGEMENT Monitoring and Follow-Up Goals of Treatment Follow up in 48–72 hours. If unresolved, consult –– Relieve symptoms with a physician who may suggest changes to –– Prevent spread of infection the antimicrobial therapy such as the addition of metronidazole. Appropriate Consultation Referral Consult a physician if a large fluctuant abscess is present, if client is acutely ill, if the infection has Refer to a dentist for definitive therapy. spread to the soft tissues of the neck or if there is no response to initial treatment in 48–72 hours. DENTAL DECAY24

Nonpharmacologic Interventions Dental decay is a multifactorial disease. In general, bacterial colonies (dental plaque) convert Warm saline oral rinses qid. the sugar in fermentable carbohydrates into an Client Education acid that demineralizes the dental enamel. When –– Counsel client about appropriate use of demineralization is not occurring, protective factors medications (dosage and side effects) such as from the saliva or fluoride exposures result in remineralization of the enamel. Decay occurs when –– Recommend dietary modifications ( or the balance tilts toward demineralization exceeding soft diet) remineralization over an extended period of time. –– Recommend improvements to dental hygiene In the early stages of decay, the enamel takes on a dull white appearance; however the decay can Pharmacologic Interventions7 still be halted or reversed at this stage. It is usually Oral antibiotics (only if lymph node involvement): asymptomatic. If demineralization is allowed to amoxicillin 500 mg PO tid for 10 days continue, eventually the enamel breaks down and cavitation occurs, at which time the process becomes less reversible.

2011 Clinical Practice Guidelines for Nurses in Primary Care Ears, Nose, Throat and Mouth 2–25

As decay progresses into the dentine, the tooth HISTORY becomes more sensitive to sweet and cold. When it For explanation of the progression of dental decay, approaches the pulp of the tooth, the pulp becomes its pathology, signs and symptoms see Table 2, hyperaemic (engorged), reacting more strongly to “Pathology, signs and Symptoms of Dental decay”. temperature change and other stimuli. Once bacteria have entered the pulp the process of a dental abscess –– Sensitivity of tooth/teeth to sweets, cold or hot begins. With destruction of the pulp, pressure builds food and liquids and pressure at the apex (root end) and the tooth throbs constantly, –– History of dental caries, abscess(es) becoming worse with hot temperatures and pressure. –– Pain, particularly when eating –– Dental care routine CAUSES –– Recent dental treatments –– Bacteria, carbohydrate sugar and saliva in combination

Table 2 – Pathology, Signs and Symptoms of Dental Decay (along its course of progression) Tooth or Soft Pathology / Discomfort – Presenting Tissue Condition Reversibility Explanation Symptoms Asymptomatic None Normal – slight sensitivity to hot and (Normal – no decay) cold Asymptomatic Minor decay or trauma Remaining hard tooth Normal (as above) (Normal – minor decay Reversible structure insulates pulp tissue. No long-lasting pain or trauma) Mild pulpal involvement Hypaemia of pulpal Cold contracts hard Increased sensitivity to cold - cavity tissue tissue, putting pressure and sweet. - deep filling Reversible on hyperaemic tissue; Occasional sharp pain to insult, but - trauma sweet causes osmotic ion short lasting. - recent dental treatment movement. Severe pulpal Necrosis of pulp tissue Heat expands gas produced Increased sensitivity to heat. involvement Irreversible by necrotic tissue. Sensitivity to percussion (tapping, - deep decay biting). - deep filling Spontaneous pain, throbbing, - recent severe trauma moderate duration. Involvement of soft Chronic inflammatory Soft tissue supporting tooth is Very sensitive to percussion. tissue surrounding tip response outside of stretched, swelling confined Tooth is extruded. of root tooth by bone. Mobility of tooth. Irreversible Long-lasting pain. Expansion of apical “Gum boil” or facial Chronic suppuration – body Pain decreases but an obvious sign pathology beyond swelling (depends on cannot get to source of is present: gum boil or facial swelling. nearest bony cortex length of root) problem. Oral soft tissue may look normal. Irreversible If there is a draining fistula, Pain originates from stretched soft there is no intrabony pressure, tissue of face. so no pain. Trismus of musculature (lockjaw) may limit opening of the mouth.

PHYSICAL EXAMINATION –– Draining lesion To assist with staging the progression of dental decay –– Oral soft tissue colour, swelling see Table 2, “Pathology, signs and Symptoms of –– Sensitivity of affected teeth to percussion (tapping) Dental decay”. Assess for: –– Mobility of tooth –– General appearance –– Pits or caries in teeth –– Pain –– Facial swelling or gum boil –– Temperature (client should not be febrile, unless –– Ability to open mouth an abscess is present)

Clinical Practice Guidelines for Nurses in Primary Care 2011 2–26 Ears, Nose, Throat and Mouth

DIFFERENTIAL DIAGNOSIS Severe pulpal involvement: –– Dental abscess –– Antibiotic (lower dose) (for example, Penicillin VK [Pen V] 300 mg qid) COMPLICATIONS –– Analgesic as required –– Dental abscess Involvement of soft tissue surrounding tip of root: –– Chronic discomfort in the mouth –– Exposure of the bone in the socket after a lower Oral antibiotics and analgesia. Antibiotics as follows: back tooth has been removed (dry socket) penicillin V potassium (Penicillin V) 300–600 mg –– Fractured tooth PO qid for 7 days Metronidazole should be added to penicillin if MANAGEMENT infection spreads or systemic symptoms present: Appropriate Consultation metronidazole (Flagyl), 500 mg po bid for 7 days A physician should be consulted if: For clients with penicillin allergy or in areas of –– the client has facial swelling significant penicillin resistance: –– the client is immunocompromised (for example, clindamycin (Dalacin C), 150–300 mg PO qid for has diabetes mellitus) 7 days –– the client has pain not relieved by treatment Expansion of apical pathology beyond nearest bony –– the condition is not resolving after one course cortex: of treatment –– the client is febrile –– None if draining intraorally –– the client has difficulty opening mouth –– With facial swelling, oral/IV antibiotic, and analgesics if required. Consult the physician if Nonpharmacologic Interventions intravenous antibiotics are deemed necessary. Otherwise, oral antibiotics as used for involvement Encourage regular dental hygiene. of soft tissue surrounding tip of root can be used Mild pulpal involvement: Monitoring and Follow-up Allow time for healing if there has been recent dental treatment. –– Clients with facial swelling should be seen daily until it resolves Pharmacologic Interventions –– Instruct client to return for reassessment immediately if lesion develops, if pain increases Refer to Table 2, “Pathology, signs and Symptoms or if fever develops of Dental decay” for presenting symptoms. Mild pulpal involvement: Referral –– Antibiotics not necessary If a client presents with severe facial swelling or has difficulty opening their mouth, referral to a physician Simple analgesics for mild to moderate dental pain: may be warranted. This decision should be made in ibuprofen (Motrin), 200 mg, 1–2 tabs PO q4h prn consultation with a physician. or Referral to a dentist is warranted in the following acetaminophen (Tylenol), 325 mg 1–2 tabs situations for treatment: PO q4-6h prn –– Asymptomatic with minor decay or trauma For moderately severe dental pain, codeine may for dental restorations be required: –– Mild pulpal involvement for temporary filling if cavity present acetaminophen with codeine (Tylenol #3), 1–2 tabs PO q4-6h prn –– Severe pulpal involvement for removal of necrotic tissue in tooth by extraction or root canal treatment (temporary or permanent filling will not work and may increase pain)

2011 Clinical Practice Guidelines for Nurses in Primary Care Ears, Nose, Throat and Mouth 2–27

–– Involvement of soft tissue surrounding tip of root PERICORONITIS for drainage of area by extraction or root canal treatment Pericoronitis is infection and inflammation of the gingival tissues around a partially erupted tooth. It is –– When an expansion of apical pathology beyond most common around a mandibular wisdom tooth. nearest bony cortex requires an extraction of tooth, possibly with curettage. If intraoral gum boil only, CAUSES immediate treatment is often not necessary –– Bacterial (often spirochete) infection DISCOLOURED (NON-VITAL) HISTORY PERMANENT TOOTH –– Newly erupting tooth See the section “Discoloured (non-vital) Permanent –– Smoking is often a factor Tooth” in the chapter “Ears, Nose, Throat and Mouth” in the pediatric clinical practice guidelines for PHYSICAL FINDINGS detailed information on the clinical presentation and –– Redness and swelling of soft tissues surrounding treatment of a discoloured permanent tooth. Treatment a partially erupted tooth is the same for children and adults. –– The opposing tooth may be occluding on the swollen tissues around the affected tooth GINGIVITIS –– Possible swelling of the submandibular lymph nodes Gingivitis is inflammation of the unattached gingival tissue around a tooth. –– There might be limited opening of the mandible

HISTORY AND PHYSICAL FINDINGS COMPLICATIONS The tissues are red in colour, slightly swollen, –– More generalized infection and bleed with slight manipulation (such as MANAGEMENT toothbrushing). Goals of Treatment MANAGEMENT –– Prevent broader infection of the area Nonpharmacologic Interventions –– Reduce discomfort Gingivitis is reversible with thorough brushing and Appropriate Consultation flossing. The client should be advised that the tissues will bleed upon brushing for the first few days, but Consultation with a physician is not normally with thorough self-care, this bleeding will stop and warranted, unless complications arise. the tissues will return to health in a few days. Nonpharmacologic Interventions MIGRATORY GLOSSITIS –– Warm saline rinses, four times daily until (GEOGRAPHIC TONGUE) condition resolves –– Avoid spicy foods Tongue demonstrates several smooth, red areas –– Avoid smoking outlined by elevated gray margins of epithelial tissue. Migratory glossitis is not a pathological condition and Client Education no treatment is indicated. –– Condition will usually resolve itself –– Stress meticulous oral hygiene of other teeth CAUSES Unknown. Pharmacologic Interventions Pericoronal infection (pericoronitis) does not require MANAGEMENT antibiotics, unless there is lymph node involvement and facial swelling, or restricted opening. Nonpharmacologic Interventions Reassure client.

Clinical Practice Guidelines for Nurses in Primary Care 2011 2–28 Ears, Nose, Throat and Mouth

If needed, oral antibiotics: PHYSICAL FINDINGS amoxicillin 250–500 mg po tid for 7 days –– There may not be easily detectible signs of periodontitis (calculus might be subgingival; Metronidazole should be added to penicillin if bone loss not evident) infection spreads or systemic symptoms present: –– Heavy calculus accumulations metronidazole (Flagyl), 500 mg po bid x 7 days –– Usually no discomfort – patient might complain For clients with penicillin allergy or in areas of of “itchy” or “uncomfortable” feeling in gums significant penicillin resistance: –– Mouth odour clindamycin (Dalacin C), 150–300 mg PO qid for –– In advanced stages, teeth may be mobile 7 days COMPLICATIONS Simple analgesics for mild to moderate dental pain: –– Progression of periodontal disease will lead ibuprofen (Motrin), 200 mg, 1–2 tabs PO q4h prn to tooth loss or –– There is growing evidence of links between acetaminophen (Tylenol), 325 mg, 1–2 tabs periodontal disease and other medical conditions PO q4-6h prn such as cardiovascular disease, respiratory diseases For moderately severe dental pain, codeine may be and diabetes required: MANAGEMENT acetaminophen with codeine (Tylenol #3), 1–2 tabs –– Thorough, regular oral hygiene PO q4-6h prn –– Regular professional care by dentists, dental Referral hygienists and/or dental therapists Refer to a dentist for follow-up. Goals of Treatment –– Prevent or slow down the loss of supporting tissues PERIODONTITIS –– Reduce the inflammation

Periodontitis is inflammation of the periodontal tissues Nonpharmacologic Interventions around the teeth, and subsequent loss of supporting structures (periodontal ligament and alveolar bone). –– Thorough brushing and flossing on a regular basis In the adult a common form of periodontitis will –– Avoid smoking manifest with a slow progression of tissue destruction which may result in a loose tooth or the loss of teeth. Client Education –– Need for thorough and regular oral hygiene CAUSES –– Need for regular professional care (with frequency based on individual needs) –– Inflammation of the gingiva (gingivitis) –– Build-up of calculus (tartar) Referral Periodontitis is influenced by general health issues Refer to a dental professional for follow-up. such as diabetes, and local irritants such as smoking.

HISTORY TOOTHACHE –– Medical conditions such as diabetes See “Toothache” in “Ears, Nose, Throat and Mouth”, –– Smoking is often a factor in the pediatric clinical practice guidelines for detailed –– Rate of build-up of calculus information on the clinical presentation and treatment of a toothache. Treatment is the same for children and adults.

2011 Clinical Practice Guidelines for Nurses in Primary Care Ears, Nose, Throat and Mouth 2–29

XEROSTOMIA (DRY MOUTH)25,26 MANAGEMENT

Everyone’s mouth is dry now and then, but for many Goals of Treatment adults, dry mouth (xerostomia) is a chronic condition –– Prevent dental decay, fungal infections that leaves the mouth dry, sore and sticky. Some patients have difficulties eating, swallowing, talking –– Improve comfort or wearing dentures (due to loss of suction). They may Nonpharmacologic Interventions be vulnerable to sores and yeast infections, and their teeth are more prone to decay. –– Increase fluid intake, particularly water or carbonated water CAUSES –– Avoid acidic fluids – pop, energy drinks –– Side effect of medications such as tricyclic –– Avoid drinks with caffeine – coffee, tea, antidepressants, benztropine and other some sodas anticholinergics, benzodiazepines, isotretinoin –– Encourage use of a humidifier –– Medical conditions – diabetes, Sjogren’s syndrome, –– Sugar free gum – sweetened with xylitol Parkinson’s disease –– Xylitol sweetened candies –– Therapeutic radiation or chemotherapy –– Avoid spicy foods –– Alcohol –– Avoid smoking and alcohol –– Head injury Client Education HISTORY –– Discuss causes of dry mouth –– Medications –– Stress fluid intake –– Other medical conditions such as diabetes, –– Stress oral hygiene Parkinson’s disease –– Share interventions above to help decrease –– Smoking and alcohol use xerostomia

PHYSICAL FINDINGS Referral –– Oral mucosa and tongue very dry –– Refer to a physician for review of medications –– Loose dentures –– Refer to a dentist for monitoring caries and oral health –– Candidiasis –– Alteration in speech

DIFFERENTIAL DIAGNOSIS –– Chronic xerostomia –– Short-term reaction to temporary medications

COMPLICATIONS –– Increased dental decay –– Sores –– Fungal infections –– Nutritional deficiencies (difficulty eating certain foods)

Clinical Practice Guidelines for Nurses in Primary Care 2011 2–30 Ears, Nose, Throat and Mouth

EMERGENCY PROBLEMS OF THE NOSE, THROAT AND MOUTH

AVULSED TOOTH –– Pinna may be displaced anteriorly if edema severe –– Manipulation of pinna and otoscopic exam of the See the section “Avulsed Tooth” in the chapter “Ears, ear causes acute pain Nose, Throat and Mouth,” in the pediatric clinical –– Purulent drainage if tympanic membrane ruptured practice guidelines for detailed information on the clinical presentation and treatment of an avulsed –– Posterior auricular warmth tooth. Treatment is the same for children and adults. –– Tenderness over mastoid process –– Anterior cervical and peri-auricular nodes enlarged and tender FRACTURED TOOTH See the section “Fractured Tooth” in the chapter DIFFERENTIAL DIAGNOSIS “Ears, Nose, Throat and Mouth,” in the pediatric –– Severe otitis externa clinical practice guidelines for detailed information on –– Posterior auricular cellulitis the clinical presentation and treatment of a fractured –– Benign or malignant neoplasm tooth. Treatment is the same for children and adults. –– Infection of deep neck space (Ludwig’s angina)

MASTOIDITIS COMPLICATIONS Suppurative (bacterial) inflammation/infection of –– Residual hearing loss mastoid antrum and air cells. Can be acute or chronic. –– Meningitis –– Intracranial abscess CAUSES –– Subperiosteal abscess –– Acute mastoiditis is a rare complication of acute otitis media DIAGNOSTIC TESTS –– Chronic mastoiditis is more commonly associated Swab for culture and sensitivity if ear is draining. with cholesteatoma (cyst of the middle ear) or chronic suppurative otitis media (tympanic MANAGEMENT perforation with chronic drainage) Goals of Treatment –– Most common organisms: Haemophilus influenzae, group A Streptococcus, Streptococcus pneumoniae –– Relieve pain and swelling –– Prevent spread of infection Risk Factors –– Recurrent otitis Appropriate Consultation –– Cholesteatoma Consult a physician concerning intravenous (IV) –– Immunocompromised status antibiotic therapy.

HISTORY Adjuvant Therapy –– Ear pain Start IV therapy with normal saline. Adjust rate –– Nonresolving otitis media according to state of hydration. –– Spiking fever Pharmacologic Interventions –– Tinnitus –– Otorrhea if ear drum is perforated Consult a physician for prescription of IV antibiotics. Polymicrobial coverage is necessary (for example, PHYSICAL FINDINGS cefuroxime [Zinacef]). Analgesics for pain and fever: –– Temperature moderately to severely elevated acetaminophen (Tylenol) , 325 or 500 mg, 1–2 tabs PO q4-6h –– Client appears moderately ill –– Hearing loss –– Posterior auricular swelling and erythema

2011 Clinical Practice Guidelines for Nurses in Primary Care Ears, Nose, Throat and Mouth 2–31

Referral PHYSICAL FINDINGS Medevac to hospital as soon as possible; client will –– Fever need an urgent ENT consultation. Client may need –– Heart rate increased several days of IV drug therapy and possibly surgery. –– Client may appear acutely ill or distressed –– Diaphoretic; flushed if feverish ORAL TRAUMA –– Affected tonsil grossly swollen medially and reddened With trauma, a tooth may fracture, become displaced or become non-vital (and abscess) or oral mucosa may –– Tonsil may displace uvula and soft palate to be damaged or ulcerated. the opposite side of pharynx –– Swelling and redness of the soft palate MANAGEMENT –– Trismus (difficulty opening mouth) –– Increased salivation Nonpharmacologic Interventions –– Dysphonia with (“hot potato” voice) –– Warm saline rinse 4 times daily for traumatic ulcers –– Unilateral referred ear pain –– Tonsillar/cervical lymph nodes enlarged and Referral very tender Any problems resulting from trauma should be –– Fluctuance may be felt on affected side of palate referred to a dentist for monitoring and/or treatment. DIFFERENTIAL DIAGNOSIS PERITONSILLAR ABSCESS –– Epiglottitis –– Gonococcal pharyngitis Cellulitis of the space behind the tonsillar extending onto the soft palate, leading to an abscess. COMPLICATIONS It is most common in 15–30 year olds. It is considered moderate to severe if the patient has any of the –– Obstruction of the airways following symptoms: appears acutely ill, drooling, –– Sepsis difficulty swallowing, difficulty breathing and/or inability to open mouth. Otherwise it is considered DIAGNOSTIC TESTS mild to moderate. Swab any exudate for culture and sensitivity.

CAUSES MANAGEMENT OF MILD-TO-MODERATE Bacterial infection, usually related to group A PERITONSILLAR ABSCESS Streptococcus (GAS) (50%), S. pyogenes, S. aureus, Treat on an outpatient basis. H. influenza. Goals of Treatment HISTORY –– Relieve symptoms –– Recent episode of pharyngitis –– Prevent complications –– Gradually increasing unilateral ear and throat pain –– Fever Nonpharmacologic Interventions –– Malaise Client Education –– Dysphagia (difficulty swallowing) –– Advise client to return immediately if pain –– Dysphonia becomes worse or if drooling, difficulty –– Drooling swallowing, difficulty breathing or inability to –– Trismus (difficulty opening mouth) open mouth develops –– Recommend increased fluid intake –– Recommend increased rest until fever settles –– Recommend frequent gargling with warm saline for 48 hours

Clinical Practice Guidelines for Nurses in Primary Care 2011 2–32 Ears, Nose, Throat and Mouth

Pharmacologic Interventions Monitoring and Follow-Up Antibiotics: Monitor client to ensure adequate airway is maintained. penicillin V potassium (Penicillin V), 300 mg PO qid Referral or 600 mg bid for 10 days Medevac to hospital; client requires IV antibiotics For clients with penicillin allergy: and aspiration or surgical incision to drain abscess. clindamycin (Dalacin C), 300 mg PO tid for 10 days Analgesics for pain and fever: POSTERIOR EPISTAXIS acetaminophen (Tylenol), 325 mg, 1–2 tabs PO Source of bleeding appears to be from the posterior q4h prn portion of the nose. or ibuprofen (Motrin), 200 mg, 1–2 tabs PO q4h prn CAUSES –– Idiopathic (cause unknown) Monitoring and Follow-Up –– Hypertension Follow up in 24 hours. If no improvement, consult –– Vascular abnormalities (hereditary hemorrhagic with a physician. Needle aspiration, performed by telangiectasia) a physician, may be required. –– Trauma: deviation or perforation of the septum –– Infection (for example, chronic sinusitis) MANAGEMENT OF MODERATE-TO- –– Neoplasm (rare) SEVERE PERITONSILLAR ABSCESS Client appears acutely ill and has difficulty HISTORY swallowing. –– Sudden onset of brisk, bright bleeding from nose –– May be unilateral or bilateral Goals of Treatment –– Blood running down back of throat –– Relieve symptoms –– May be a history of hematemesis if client has –– Prevent complications swallowed a large quantity of blood –– History of easy bruising, bleeding elsewhere (for Appropriate Consultation example, melena, heavy menses), family history Consult a physician if the abscess is significant in size of bleeding tendencies, use of anticoagulants, use and the client appears acutely ill; immediate referral of acetylsalicylic acid (ASA) products to hospital and examination by an ear, nose and throat (ENT) specialist are in order. PHYSICAL FINDINGS –– Heart rate elevated Adjuvant Therapy –– Blood pressure may be reduced if loss of blood Start IV therapy with normal saline; adjust rate is significant according to age and state of hydration. –– Client appears anxious Nonpharmacologic Interventions –– Client may be pale, sweaty if loss of blood is significant –– Bed rest –– Bright red bleeding from nares (unilateral –– Give sips of cold liquids only or bilateral) –– Give nothing by mouth if drooling –– Bleeding site not visible –– Blood observed in pharynx Pharmacologic Interventions DIFFERENTIAL DIAGNOSIS Consult with a physician concerning choices for IV antibiotic treatment. Clindamycin (Dalacin) IV is –– Upper gastrointestinal bleed often the drug of choice. In addition, one or two doses –– Post-tonsillectomy bleed of dexamethasone IV can be used in conjunction with –– Perforation of the septum IV antibiotics.

2011 Clinical Practice Guidelines for Nurses in Primary Care Ears, Nose, Throat and Mouth 2–33

COMPLICATIONS 1. Place a 12–16 French catheter with a 30-cc balloon –– Hypotension or shock (hypovolemic) into the nose along the floor of the nasopharynx, until the tip is visible in the posterior pharynx. –– Anemia, if bleeds are intermittent and frequent 2. Slowly inflate the balloon with 15 mL of sterile DIAGNOSTIC TESTS water, pull it anteriorly until it firmly sets against None. the posterior choanae. 3. Maintain catheter traction and stretch slightly. MANAGEMENT 4. Insert an anterior nasal pack next (½ x 72 inch Goals of Treatment [1.25 x 180 cm] ribbon gauze impregnated with –– Stop bleeding petroleum jelly). –– Maintain circulating blood volume 5. Place an umbilical cord clamp across the nostril against the anterior pack so that the elasticity of the Appropriate Consultation catheter compresses the balloon against the anterior Consult a physician if initial management fails pack. to control bleeding, client is not stable or there is 6. Protect facial skin from clamp by padding with significant potential of underlying pathology. 2 x 2 inch (5 x 5 cm) gauze.

Adjuvant Therapy 7. Drape rest of catheter over ear on same side and tape in place. –– Resuscitate patient as required –– Start IV therapy with normal saline or Ringer’s Bilateral packing is sometimes required to achieve lactate solution; adjust IV rate according to pulse, adequate compression. The bleeding should stop blood pressure and rate of bleeding after the nasal packs are in place.

Nonpharmacologic Interventions Monitoring and Follow-Up –– Keep client at rest, sitting in most comfortable Monitor vital signs and loss of blood closely. Remove position for patient packs and balloons in 24–36 hours. There is a –– Apply pressure to the nose possibility that bleeding may continue or restart. –– Insert a posterior nasal pack; use a posterior nasal Referral pack balloon system if available; alternatively use a Foley catheter Medevac to hospital if bleeding does not stop, if hypovolemia is evident (hypotension, tachycardia) Procedure for Foley catheter system: or if significant underlying pathology is suspected.

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Greenberg DE, Muraca M (Editors). Canadian Reviews2007, Issue 3. Art. No.: CD006394. DOI: clinical practice guidelines. Toronto, ON: Elsevier 10.1002/14651858.CD006394.pub2. Available at: Canada; 2008. http://www2.cochrane.org/reviews/en/ab006394.html Karch AM. Lippincott’s 2002 nursing drug guide. Jefferson T, Del Mar C, Dooley L, et al. Physical Philadelphia, PA: Lippincott; 2002. interventions to interrupt or reduce the spread of respiratory viruses. Cochrane Database of Systematic Repchinsky C (Editor-in-chief). CPS Compendium Reviews 2010, Issue 1. Art. No.: CD006207. DOI: of pharmaceuticals and specialties: the Canadian 10.1002/14651858.CD006207.pub3. Available at: reference for health professionals. Ottawa, ON: http://www2.cochrane.org/reviews/en/ab006207.html Canadian Pharmacists Association; 2007. Reveiz L, Cardona Zorrilla AF, Ospina EG. Tierney LM Jr, McPhee SJ, Papadakis MA. Current Antibiotics for acute laryngitis in adults. Cochrane Medical Diagnosis and Treatment. 40th ed. New York: Database of Systematic Reviews 2007, Issue 2. Art. Lange Medical Books - McGraw-Hill; 2001. No.: CD004783. DOI: 10.1002/14651858.CD004783. Tintinalli J, et al. Emergency medicine. 5th ed. pub3. Available at: http://www2.cochrane.org/reviews/ McGraw-Hill; 2000. en/ab004783.html

INTERNET GUIDELINES Sheikh A, Hurwitz B, Shehata Y. House dust mite avoidance measures for perennial allergic rhinitis. Ahovuo-Saloranta A, Borisenko OV, Kovanen N, et Cochrane Database of Systematic Reviews 2007, Issue al. Antibiotics for acute maxillary sinusitis. Cochrane 1. Art. No.: CD001563. DOI: 10.1002/14651858. Database of Systematic Reviews 2008, Issue 2. Art. CD001563.pub2. Available at: http://www2.cochrane. No.: CD000243. DOI: 10.1002/14651858.CD000243. org/reviews/en/ab001563.html pub2. Available at: http://www2.cochrane.org/reviews/ en/ab000243.html Thirlwall AS, Kundu S. Diuretics for Ménière’s disease or syndrome. Cochrane Database of Arroll B, Kenealy T. Antibiotics for the common Systematic Reviews 2006, Issue 3. Art. No.: cold and acute purulent rhinitis. Cochrane Database CD003599. DOI: 10.1002/14651858.CD003599.pub2. of Systematic Reviews 2005, Issue 3. Art. No.: Available at: http://www2.cochrane.org/reviews/en/ CD000247. DOI: 10.1002/14651858.CD000247.pub2. ab003599.html Available at: http://www2.cochrane.org/reviews/en/ ab000247.html END NOTES Burton MJ, Doree CJ. Ear drops for the removal 1 Goralnick E, Kulkarni R. (2009, May 17). Nasal of ear wax. Cochrane Database of Systematic pack, anterior epistaxis: Treatment & medication. Reviews2003, Issue 3. Art. No.: CD004326. DOI: eMedicine. Available at: http://emedicine.medscape. 10.1002/14651858.CD004326 Available at: http:// com/article/80526-trea www2.cochrane.org/reviews/en/ab004326.html 2 Barton J. (2010, May). Benign paroxysmal positional vertigo. UpToDate Online 18.2. Available by Del Mar C, Glasziou PP, Spinks A. Antibiotics subscription: www.utdol.com for sore throat. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD000023. DOI: 3 eMedicineHealth. (2009). Labyrinthitis causes. eMedicine. Available at: http://www.emedicinehealth. 10.1002/14651858.CD000023.pub3 Available at: com/labyrinthitis/page2_em.htm http://onlinelibrary.wiley.com/o/cochrane/clsysrev/ articles/CD000023/frame.html 4 Ogbru O. (2009). Medications: furosemide. eMedicine. Available at: http://www.emedicinehealth. De Sutter AIM, Lemiengre M, Campbell H. com/script/main/art.asp?articlekey=772 Antihistamines for the common cold.Cochrane 5 eMedicineHealth. (1997). Medications: phenytoin. Database of Systematic Reviews2003, Issue 3. eMedicine. Available at: http://www.emedicinehealth. Art. No.: CD001267. DOI: 10.1002/14651858. com/script/main/art.asp?articlekey=740 CD001267. Available at: http://www.ncbi.nlm.nih. 6 Anti-Infective Review panel. Anti-infective gov/pubmed/12917904 guidelines for community-acquired infections. Harvey R, Hannan SA, Badia L, Scadding G. Nasal Toronto, ON: MUMS Guideline Clearinghouse; saline irrigations for the symptoms of chronic 2010. p.15-16. rhinosinusitis.Cochrane Database of Systematic

2011 Clinical Practice Guidelines for Nurses in Primary Care Ears, Nose, Throat and Mouth 2–35

7 Blondel-Hill E, Fryters S. Bugs and drugs 2006. 21 Casiglia JM, Mirowski GW, Nebesio CL. Aphthous Edmonton, AB: Capital Health; 2006. Available at: stomatitis. Emedecine. Available at: http://emedicine. http://www.bugsanddrugs.ca/bugs_drugs_website/ medscape.com/article/1075570-overview web-content/COMBINED_BandD2006_certified.pdf 22 Goldstein BG, Goldstein AO. Oral lesions. 8 Anti-Infective Review panel. Anti-infective (2009, May). UpToDate Online Available by guidelines for community-acquired infections. subscription: www.utdol.com. Toronto, ON: MUMS Guideline Clearinghouse; 23 Wolff K, Allen Johnson R. Fitzpatrick’s color atlas 2010. p.17. and synopsis of clinical dermatology. 6th ed. Toronto: 9 Anti-Infective Review panel. Anti-infective McGraw-Hill; 2009. p. 1034. guidelines for community-acquired infections. 24 American Medical Association. Dental disorders. Toronto, ON: MUMS Guideline Clearinghouse; MD Guidelines; n.d. Available at: http://www. 2010. p. 21. mdguidelines.com/dental-disorders 10 Fryters SR, Blondell-Hill EM. Sinusitis. In Gray J. 25 Bartels CL. (2009). Xerostomia information Therapeutic choices. 5th ed. Ottawa, ON: Canadian for dentists. Available at: http://www. Pharmacist’s Association; 2007. p. 1206-1221. oralcancerfoundation.org/dental/xerostomia.htm 11 Anti-Infective Review panel. Anti-infective 26 National Institute for Dental and Craniofacial guidelines for community-acquired infections. Research. (2010). Dry mouth. Available at: http:// Toronto, ON: MUMS Guideline Clearinghouse; www.nidcr.nih.gov/OralHealth/Topics/DryMouth/ 2010. p. 23. DryMouth.htm 12 Anti-Infective Review panel. Anti-infective guidelines for community-acquired infections. Toronto, ON: MUMS Guideline Clearinghouse; 2010. p. 12. 13 Worrall G, Hutchinson J, Sherman G, Griffiths J. Diagnosing streptococcal sore throat in adults. Canadian Family Physician 2007:53:666. 14 Ebell MH. Point-of-care guide; Strep throat. Am Fam Physician 2003;68(5):937-38. Available at: www.aafp.org/afp/20030901/poc.html 15 Anti-Infective Review panel. Anti-infective guidelines for community-acquired infections. Toronto, ON: MUMS Guideline Clearinghouse; 2010. p. 8. 16 Anti-Infective Review panel. Anti-infective guidelines for community-acquired infections. Toronto, ON: MUMS Guideline Clearinghouse; 2010. p. 9. 17 Wolff K, Allen Johnson R. Fitzpatrick’s color atlas and synopsis of clinical dermatology. 6th ed. Toronto: McGraw-Hill; 2009. p.1028. 18 Uphold C, Graham M. Clinical guidelines in family practice. 4th ed. Gainesville, Florida: Barmarrae; 2003. p. 382-84. 19 Wolff K, Allen Johnson R. Fitzpatrick’s color atlas and synopsis of clinical dermatology. 6th ed. Toronto: McGraw-Hill; 2009. p. 1034-35. 20 Axell T, Henricsson V. Association between recurrent apthous ulcers and tobacco habits. Scandinavian Journal of Dental Research 1985;93(3):239‑42. Available at: http://www.ncbi.nlm.nih.gov/ pubmed/3860909?dopt=Abstract

Clinical Practice Guidelines for Nurses in Primary Care 2011