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Foreign Bodies in The Ear, Nose and Throat

Foreign bodies are objects that are placed in the ear, nose or throat that are not meant to be there and could cause harm without immediate attention.

Common foreign bodies in the ear include, insects e.g. flies cockroaches , ants etc. Seeds, buttons, beads, stones etc. They are commonly found in the ears of children. Children usually insert foreign bodies themselves or their peers may do it.
Adults usually have insects and cotton buds.
Occasionally the foreign bodies may penetrate adjacent parts and lodge in the middle ear & some can be removed by a probe or syringing and after the ear should be checked properly to exclude any damage. Some un co-operative children need general anesthesia.

Clinical features of Foreign bodies in the ear

Pain
Blockage
Hearing loss
Bleeding /discharge in case pt attempted to remove it.
Visible foreign body(FB may be seen in the ear)
Tinnitus (noise in the ear)especially for alive FBs like insects
Vertigo

GENERAL MANAGEMENT

Don’t use forceps to try to grasp the object as it will only push it further in the ear.
If the foreign body has an edge to grab, remove with Hartmann forceps.
Syringe the ear with lukewarm water
If the foreign body cannot be removed by syringing, remove with a foreign body hook.
General anaesthesia may be essential in children.
Insects: Kill by using clean cooking oil or water into the ear, then syringe out with warm water.

For smooth round Foreign bodies.

Syringe the ear with clean Luke warm water
If Foreign body cannot be removed by syringing , remove with a foreign body hook.
General anaesthesia may be essential in children and sensitive adult
Do not use forceps to try to grasp round objects as this will only push them further in the ear.

For other Foreign bodies

If there is an edge to grab, remove with Hartmann(crocodile) forceps.

For insects in the ear

Kill these by inserting clean cooking oil or water into the ear, then syringe out with warm water.
Cockroaches are better removed by a crocodile forceps since they have hooks on their legs that make removal by syringing impossible.

For impacted seeds:

Don’t syringe with water as the seed may swell and block the ear, so refer immediately if you cannot remove with the hook.
Suction may be useful for certain Foreign Bodies
Magnets are sometimes used if the objects are metallic.
Give antibiotics ear drop to prevent infection and pain killers.

WAX IN THE EAR OR IMPACTED CERUMEN

This is accumulation of wax in the external ear that obstructs the external acoustic meatus. Wax is a normal substance produced in the external ear canal and it can accumulate in it . It is made up of epithelial scales mixed with the secretions from special glands in the skin of the outer ear. Wax in the ear is normal & usually comes out naturally from time to time . In most people, the wax escapes as it is formed but in some it remains in the ear canal forming a wax plug and cause a problem by obstructing it and causing deafness.

Causes of impacted cerumen

Excessive and/or thick wax production
Small , tortuous and/ or hairy ear canal
Use of ear pads

Clinical features

Blocked ears
Buzzing sound
Sometimes there is mild pain

Management

Olive oil/vegetable oil or Glycerine or sodium bicarbonate or liquid paraffin ear drops can be applied three times a day for a few days and it will soften the impacted wax . After this wax may fall out by its own.
If it fails, then remove it by ear syringing. The clean water used for ear syringing should be warm i.e. at body temperature and is done when the wax is soft. So as not to stimulate the inner ear and cause dizziness. The ear is then dried gently after the syringing & should be examined to exclude any damage to the tympanic membrane.
N.B Advise the patient not to use any sharp object in the ear in an attempt to remove the wax as this may damage the ear drum. Don’t syringe the ear if there is history of discharge and also if there is pain.

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Common tumors of ear nose and throat (ENT)

Peri-Operative Care (Summary)

Preparation for surgery should begin as soon as the doctor makes a diagnosis and decides that an operation is necessary. From that moment on, the patient and relatives are faced with the decision of accepting this treatment and its consequences or not.

Pre-Operative Care

Admission

Explanation of the surgery: The patient is informed about the nature of the surgery, its purpose, and potential outcomes.
Informed Consent: The patient provides written consent for both admission and the surgical procedure.
Baseline Assessment: Vital signs (temperature, pulse, blood pressure, respiration), lab tests, and imaging studies are performed to establish a baseline for comparison post-surgery.
Counseling and Reassurance: Patients receive emotional support and guidance to address anxieties and concerns.
Addressing Patient Questions: Concerns are discussed, and questions are answered to reduce fear and anxiety.
Spiritual Care: Patients can access spiritual support if desired, with access to religious leaders provided.
Physical Examination: Weight, height, and nutritional status are assessed to ensure overall health.
Site Preparation: The surgical area is marked and prepared, including shaving if necessary.
Removal of Obstacles: Jewelry, dentures, and prosthetics are removed to prevent complications.
IV Line Insertion: An IV line is placed to administer fluids and medications.
Rehydration: IV fluids are given to ensure adequate hydration.
Premedication: Prescribed medications are given to prepare the patient for surgery.
Procedural Preparation: Procedures like nasogastric tube (NGT) placement, catheterization, and bowel irrigation are performed if needed.
Rest and Sleep: Patients are encouraged to rest and sleep to ensure optimal recovery.
Post-Operative Education: Patients are informed about anticipated activities and restrictions after surgery.
NPO (Nil Per Os): Food and drink are withheld according to the doctor’s orders to prepare for surgery.
Post-Operative Bed Preparation: The post-operative bed is prepared with necessary equipment like oxygen and suction apparatus.

Post-Operative Care

Reception from Theater: The patient is received from the operating room with instructions from the surgical team.
Vital Signs Monitoring: Temperature, pulse, blood pressure, respiration, and oxygen saturation are monitored regularly.
Bleeding and Shock Monitoring: Closely observing for signs of bleeding and shock.
Post-Operative Bed Admission: The patient is transferred to a warm, comfortable bed.
IV Fluid and Medication Administration: Fluids and medications are administered via IV.
Fluid Balance Chart: Fluid intake and output are meticulously recorded and monitored.
Post-Operative Medications: Prescribed medications are administered as ordered.
Bowel and Bladder Care: Support for bowel function and urinary elimination is provided.
Rest and Sleep: Patients are encouraged to rest and sleep to promote healing.
Drainage Management: Drains are properly managed and monitored to remove excess fluid.
Pain Management: Pain medication is administered to provide comfort.
Positioning: Patients are repositioned regularly to prevent pressure sores and promote comfort.
Nutrition: Diet is adjusted based on patient tolerance and recovery stage.
Wound Care: Surgical incisions are inspected and cleaned regularly.
Bed Hygiene: The bed is kept clean and dry.
Body and Skin Hygiene: Patients are assisted with hygiene to prevent infections.
Physiotherapy: Breathing exercises and other physical therapy techniques are initiated to improve lung function and mobility.
Psychological Care: Emotional support is provided to address anxiety, fear, and other psychological needs.

Advice on Discharge or Health Education

Explanation of Surgery, Cause, and Prevention: The patient is given a clear understanding of the surgery, the underlying condition, and measures to prevent its recurrence.
Treatment Completion: The importance of finishing the prescribed treatment plan is emphasized.
Hygiene Maintenance: Patients are advised on maintaining good hygiene practices to prevent infections.
Balanced Diet: The benefits of a balanced diet for overall health and recovery are explained.
Rest and Sleep: Adequate rest and sleep are encouraged for optimal healing.
Follow-up Appointment: The importance of attending scheduled follow-up appointments is stressed.
Light Exercise and Activity Restriction: Patients are advised to engage in light exercise but avoid strenuous activities and heavy lifting.

Potential Complications

Hemorrhage: Bleeding, either internal or external, may occur after surgery.
Shock: A life-threatening condition characterized by a sudden drop in blood pressure and oxygen levels.
Pain: Pain is a common post-operative experience, but it should be manageable with medication.
Vomiting: Nausea and vomiting can occur due to anesthesia or changes in diet.
Inability to Walk: Temporary difficulty in walking can result from anesthesia, pain, or muscle weakness.
Paralytic Illness: A rare but serious complication that can affect breathing muscles.
Constipation: Post-operative constipation is common, and measures to promote bowel function are often necessary.
Hiccups: Hiccups can be persistent after surgery and can be uncomfortable.
Burst Abdomen: A rare but serious complication where the surgical wound opens up.
Incisional Hernia: A bulge or protrusion through the surgical incision.
Infections: Infections can develop in the surgical wound or other parts of the body.
Retention of Urine: Difficulty in urinating can occur due to anesthesia or other factors.
Hypostatic Pneumonia: Pneumonia caused by fluid buildup in the lungs due to immobility.

EAR

Outer Ear: The outer ear consists of the pinna (visible part of the ear) and the external auditory canal. The pinna helps collect sound waves and directs them into the ear canal.
Middle Ear: The middle ear is an air-filled space behind the eardrum (tympanic membrane) that contains the three ossicles (tiny bones): the malleus (hammer), the incus (anvil), and the stapes (stirrup). These bones transmit sound vibrations from the eardrum to the inner ear.
Inner Ear: The inner ear comprises the cochlea, vestibule, and semicircular canals. The cochlea is responsible for converting sound vibrations into electrical signals, which are then transmitted to the brain for interpretation. The vestibule and semicircular canals are involved in balance and spatial orientation.

Tumors of the Ear

Tumors are abnormal growths that can occur in any part of the body, including the ear.

They can be benign (non-cancerous) or malignant (cancerous).

Types of Ear Tumors:

1. Benign (Non-Cancerous) Tumors:

Ceruminous Gland Adenomas: These slow-growing tumors arise from the ceruminous glands in the ear canal, responsible for producing earwax. These glands produce cerumen, better known as earwax.

Symptoms:

Hearing Loss: As the adenoma grows, it can block the ear canal, leading to conductive hearing loss.
Feeling of Fullness in the Ear: The tumor can cause a feeling of pressure or fullness in the ear.
Discharge: Some adenomas may produce a clear, watery discharge.
Pain: In rare cases, the adenoma may become painful if it becomes inflamed or infected.

Causes: Unknown, but may be linked to genetic predisposition.

Acoustic Neuroma (Vestibular Schwannoma): This is a benign tumor that arises from the Schwann cells that surround the vestibulocochlear nerve (also called the eighth cranial nerve). This nerve is responsible for hearing and balance. It develops within the inner ear, in the area where the vestibulocochlear nerve exits the brainstem.

Symptoms:

Gradual Hearing Loss: Often the first symptom, typically affecting one ear.
Tinnitus: A persistent ringing, buzzing, or other sound in the ear.
Dizziness and Balance Problems: Can cause vertigo (spinning sensation) or difficulty with coordination and balance.
Facial Numbness or Weakness: In some cases, as the tumor grows, it can compress the facial nerve, causing facial weakness or numbness.

Causes: The exact cause is unknown, but it is not related to exposure to loud noises or any other environmental factors. It may be linked to genetic predisposition in some cases.

Cholesteatoma: This is a non-cancerous, but destructive, growth that develops in the middle ear space, behind the eardrum. It is formed from skin cells that migrate into the middle ear, usually due to chronic ear infections or trauma. The middle ear space, often behind the eardrum.

Symptoms:

Hearing Loss: Often the first symptom, can be conductive (problems with sound transmission) or sensorineural (damage to the inner ear).
Ear Pain: Can be constant or intermittent, sometimes severe.
Ear Discharge: Often foul-smelling, and may contain pus or blood.
Recurrent Ear Infections: Cholesteatomas can contribute to chronic ear infections.
Facial Nerve Paralysis: In rare cases, a large cholesteatoma can compress the facial nerve, causing facial weakness or paralysis.

Causes:

Chronic Otitis Media (Ear Infections): Repeated ear infections can lead to a buildup of pressure in the middle ear, allowing skin cells to migrate behind the eardrum.
Trauma: Injury to the eardrum, such as a blow to the head, can create a pocket where skin cells can grow.

Keloids: Overgrowth of scar tissue following an injury or ear piercing. Keloids are firm, rubbery, and often have a shiny, smooth surface. They can range in color from pink or red to dark brown or black.

Symptoms: Raised, firm, and often itchy scars.
Causes: Overproduction of collagen in response to injury.

2. Malignant (Cancerous) Tumors:

Squamous Cell Carcinoma: This is the most common type of skin cancer that can affect the external ear.

Symptoms: A red, scaly patch, a non-healing sore, a lump, or a change in skin texture.
Causes: Prolonged exposure to sunlight, chronic ear infections, and certain genetic conditions.

Chondrosarcoma: A rare, malignant tumor of cartilage that can occur in the ear.

Symptoms: A painless mass, pain, hearing loss, facial nerve paralysis, and bone destruction.
Causes: Unknown, but may be related to radiation exposure or genetic predisposition.

Signs and Symptoms:

Outer Ear: Scaly patches, pearly white lumps, ulcers that bleed, changes in skin texture.
Ear Canal: Lumps, hearing loss, ear pain, numbness, drainage.
Inner Ear: Ear pain, dizziness, hearing loss, tinnitus (ringing in the ear), headache.

Causes of Ear Tumors:

Sun Exposure: Prolonged and unprotected sun exposure significantly increases the risk of skin cancers in the ear.
Genetic Predisposition: Certain genetic conditions can increase the risk of developing various types of ear tumors.
Chronic Ear Infections: Repeated ear infections can potentially contribute to the development of some ear tumors, particularly squamous cell carcinoma.
Age: Some types of ear tumors are more common in older individuals.
Trauma: Ear injuries or trauma can increase the risk of certain types of tumors.
Exposure to Loud Noises: Prolonged exposure to loud noises may increase the risk of certain types of tumors, particularly acoustic neuromas.
Lifestyle Factors: Smoking and alcohol consumption can increase the risk of some ear tumors.

Investigations:

Physical Examination: A thorough examination of the ear by a doctor is essential.
Biopsy: A sample of tissue is taken for microscopic examination to determine the type of tumor.
Imaging Studies: CT scans and MRI scans provide detailed images of the ear and surrounding structures to assess the extent of the tumor.
Audiometry: Hearing tests are used to evaluate hearing loss.
Facial Nerve Testing: Testing is done to assess facial nerve function, which can be affected by some ear tumors.

Treatment:

Surgery: Surgical removal of the tumor is the most common treatment for benign and malignant ear tumors.
Radiation Therapy: Used to shrink or destroy tumors, especially when surgery is not possible or to prevent recurrence.
Chemotherapy: May be used to treat widespread or advanced ear tumors.
Targeted Therapy: Newer therapies that target specific proteins or pathways in tumor cells are being developed and may become more common.

Prevention:

Sun Protection: Protect your ears from prolonged sun exposure by wearing a hat, sunglasses, and sunscreen with a high SPF.
Ear Hygiene: Practice good ear hygiene to prevent infections.
Hearing Protection: Wear earplugs or protective headphones when exposed to loud noises.
Regular Checkups: Schedule regular checkups with a doctor to detect potential ear tumors early.

NOSE

1. External Nose: The external nose includes the nasal bones and cartilages covered by skin.

It helps in filtering, warming, and moistening inhaled air.

2. Nasal Cavity: The nasal cavity is a hollow space behind the external nose that extends from the nostrils to the back of the throat (nasopharynx).

It is lined with mucous membranes and contains the nasal septum (dividing the cavity into left and right sides), nasal turbinates (bony structures that increase the surface area and help with air filtration), and openings to the paranasal sinuses.
At the entrance, Little’s area (also known as Kiesselbach’s plexus) is found on the anterior nasal septum, where epistaxis usually originates because of its vascular delicate structure.

3. Paranasal Sinuses: There are four pairs of paranasal sinuses: frontal, ethmoid, sphenoid, and maxillary sinuses.

These air-filled cavities are connected to the nasal cavity and play a role in producing mucus, providing resonance to the voice, and reducing the weight of the skull bones.

Types of Tumors of the Nose:

Benign Tumors:

1. Nasal Polyps: Benign, soft, teardrop-shaped growths that develop in the nasal lining. These are not true tumors but rather an overgrowth of the tissue lining the nasal cavity.

Causes:

Chronic inflammation due to allergies, sinusitis, aspirin sensitivity/drug sensitivity or immune disorders, cystic fibrosis, recurrent nasal sinus infections and other conditions.

Clinical Presentation:

Nasal obstruction: Difficulty breathing through the nose, feeling like the nose is blocked.
Anosmia/Loss of smell: Reduced or complete inability to smell.
Postnasal drip: Mucus dripping down the back of the throat.
Discharge: There may be nasal discharge which may be yellowish, mucoid or pus.
Facial pain: Aching or pressure in the face, especially around the sinuses.
Frequent headaches: Headaches that may be related to sinus pressure.
Snoring: Loud breathing during sleep, often due to nasal obstruction.
Sleep apnea: Pauses in breathing during sleep, which can be caused by obstruction.
Facial pressure or fullness: A feeling of tightness or pressure in the face.
Recurrent sinus infections: Frequent infections in the sinuses, often associated with inflammation.
There may be signs and symptoms of allergy like Nasal congestion, runny nose/stuffy nose, sneezing, loss of taste or smell.

Diagnosis & Investigations:

Physical examination: Through inspection of the nasal cavity and Grey freshly masses from nasal cavities which look like skinned grapes may be seen.
Nasal endoscopy: A thin, flexible tube with a camera is inserted into the nose to visualize the polyps.
CT scan or MRI: Imaging tests can show the size and location of the polyps and any associated sinus problems.

Management of Nasal Polpys:

Medical:

Treat the cause: Addressing underlying conditions like allergies, sinusitis, or aspirin sensitivity.
Antrum washout or antrostomy: Procedures to clear out the sinuses and improve drainage.
Nasal corticosteroids: Reduce inflammation and shrink polyps. (e.g., betamethasone 50mg instilled twice daily into each nostril for 4 weeks, with the patient lying flat for 3 minutes after instillation).
Antihistamines: Used to manage allergy-related inflammation.
Saline irrigation: Using saline solution to flush out the nasal passages.
Antibiotics: Prescribed for any bacterial infections.

Surgical:

Polypectomy: Removal of the polyps through surgery. This may be necessary if polyps are large, recurrent, or unresponsive to medical treatment.

Procedure:

Local anesthesia: Spray lignocaine 2% into the nose and adrenaline 1:100,000, wait for 5 minutes.
Open nostrils: Use a nasal speculum to open the nostrils under good lighting.
Pass a polypectomy snare: Maneuver the snare to catch the polyp and remove its base.
Repeat process: Repeat the procedure until all polyps are removed.
Bleeding control: Pack the nose if excessive bleeding occurs.

General anesthesia: This may be used for more complex polypectomies or in cases where the patient is unable to tolerate local anesthesia.

Prevention:

Avoiding triggers: Identifying and avoiding allergens and irritants, such as dust mites, pollen, smoke, and strong odors.
Managing underlying conditions: Treating sinusitis, allergies, and other conditions that contribute to inflammation.
Regular nasal hygiene: Using saline sprays, nasal irrigation, and other methods to keep the nasal passages clear.

2. Nasal Angiofibroma: Benign, vascular tumor that originates from the nasal cavity, most commonly in adolescent males. This tumor is made of blood vessels and connective tissue.

Causes: The exact cause is unknown, but hormonal influences are suspected. It may be related to puberty in males.

Clinical Presentation:

Nasal obstruction: Difficulty breathing through the nose.
Epistaxis (nosebleeds): Frequent and often heavy nosebleeds.
Facial swelling: Swelling around the nose and face.
Headache: Pain in the head, often caused by pressure from the tumor.
Snoring: Loud breathing during sleep, often due to nasal obstruction.
Sleep apnea: Pauses in breathing during sleep, which can be caused by obstruction.
Difficulty breathing through the nose: Feeling like you can’t breathe comfortably through your nose.
Repeated nosebleeds: Frequent and sometimes severe nosebleeds.

Diagnosis & Investigations:

Physical examination: Inspect the nasal cavity
Nasal endoscopy: A thin, flexible tube with a camera is inserted into the nose to visualize the tumor.
CT scan or MRI: Imaging tests can show the size and location of the tumor.
Haemogram: Blood tests

Management:

Surgical: Removal of the tumor, often via an endoscopic approach.
Radiation therapy: May be used as an adjunct to surgery or as a primary treatment in cases where surgery is not possible.

3. Nasal Papilloma: Benign, wart-like growth on the nasal lining, often caused by HPV (human papillomavirus). These are usually small but can grow larger.

Causes: HPV infection, specifically types 6 and 11.

Clinical Presentation:

Nasal obstruction: Difficulty breathing through the nose.
Epistaxis: Nosebleeds, which may be frequent or severe.
Nasal discharge: Clear or white mucus coming from the nose.
Smell disturbances: Reduced or complete inability to smell.
Repeated nosebleeds: Frequent and sometimes severe nosebleeds.
Postnasal drip: Mucus dripping down the back of the throat.

Diagnosis & Investigations:

Physical examination: Visual inspection of the nasal cavity.
Nasal endoscopy: A thin, flexible tube with a camera is inserted into the nose to visualize the papilloma.
Biopsy: A small sample of the papilloma is taken for examination under a microscope to confirm the diagnosis.

General Management:

Surgical: Removal of the papilloma, often with electrocautery or laser surgery.
Antiviral medication: May be used for some types of HPV-related papillomas, but generally not as effective as surgery.

General Prevention:

Avoiding exposure to HPV: This means practicing safe sexual practices and avoiding close contact with people who have HPV-related warts.

ADENOIDS AND ADENOIDITIS

Adenoids, also known as pharyngeal tonsils, are lymphatic tissues located in the nasopharynx, the area at the back of the nose. Important in the immune system by trapping and destroying pathogens, particularly bacteria and viruses.

Adenoiditis is the inflammation and enlargement of the adenoids. This condition is common in children under 7 years old and often follows an episode of acute tonsillitis. The most frequent culprit behind adenoiditis is Group A beta-hemolytic streptococcus, the same bacteria often responsible for strep throat.

Symptoms of Adenoiditis:

Nasal Obstruction: The enlarged adenoids block the nasal passages, leading to mouth breathing, difficulty breathing through the nose, and a stuffy feeling.
Difficulty Eating: Pain caused by inflammation can make eating difficult, particularly for children.
Snoring: Adenoid enlargement can obstruct the airway during sleep, resulting in noisy breathing and snoring.
Jaw Deformities: Prolonged mouth breathing due to nasal obstruction can lead to changes in jaw development.
Hearing Loss: The adenoids are located near the openings of the Eustachian tubes, which connect the middle ear to the back of the throat. Inflammation can block these tubes, leading to fluid buildup in the middle ear and hearing loss.
Glue Ear: The accumulation of fluid in the middle ear behind the eardrum, known as glue ear, is a common consequence of adenoiditis.
Recurrent Cough: Adenoiditis can trigger a persistent cough, often accompanied by drainage.
Discharging Cough: Mucus from the inflamed adenoids can drain down the throat, causing a post-nasal drip and a cough with phlegm.
Sleep Apnea: In severe cases of adenoid hypertrophy, the enlarged adenoids can completely block the airway during sleep, leading to episodes of apnea, where breathing temporarily stops.

Diagnosis of Adenoiditis:

History and Physical examination: The diagnosis of adenoiditis relies on a thorough medical history and physical examination. A careful assessment of the patient’s symptoms and examination of the throat can reveal the presence of enlarged adenoids.
Imaging: In some cases, imaging tests may be necessary to confirm the diagnosis and assess the severity of the adenoid enlargement. X-rays of the neck soft tissue, particularly a lateral view, can demonstrate narrowing of the nasopharynx due to enlarged adenoids.

Management of Adenoiditis:

The approach to managing adenoiditis depends on the severity of the symptoms and the patient’s age.

Mild Cases: If symptoms are mild and not significantly impacting daily life, conservative treatment may be sufficient. This includes:

Antihistamines: Chlorphenamine, an antihistamine, can help reduce inflammation and congestion. The dosage is 4 mg orally t.d.s, adjusted according to age, for a period of 7 days.
Topical Nasal Steroids: Nasal sprays containing corticosteroids like betamethasone can effectively reduce inflammation and improve nasal breathing.
Underlying Infection: If an underlying bacterial infection is suspected, antibiotics may be prescribed. Ampicillin, a common antibiotic, is often used at a dosage of 500mg-1g every 6 hours.
Pain Management: Pain relief can be achieved with analgesics like paracetamol (PCT) 500mg-1g three times a day or tramadol 75 mg for severe pain.
Mouth Care: Encouraging good oral hygiene practices, such as regular brushing and flossing, can help prevent secondary infections and promote healing.
Surgery (Adenoidectomy): If conservative treatment fails to alleviate symptoms, or if the adenoids significantly obstruct breathing or cause recurrent ear infections, surgery may be recommended. Adenoidectomy, the surgical removal of the adenoids, is typically performed after the age of one year.
- Note: Adenoids usually shrink as a child grows older, so surgery is considered as a last resort.

Complications of Adenoiditis:

While adenoiditis is usually a temporary condition, it can lead to complications if left untreated:

Otitis Media (Ear Infection): Blocked Eustachian tubes can result in recurrent ear infections.
Recurrent Infections: Persistent inflammation can increase susceptibility to repeated infections, particularly in the respiratory system.
Quinsy (Peritonsillar Abscess): A rare complication where an abscess forms around the tonsils, requiring drainage.
Mastoiditis: In severe cases, infection can spread to the mastoid bone behind the ear, causing mastoiditis.

Cancerous Tumors:

4. Nasal Carcinoma/Sinus Cancer: Malignant tumor arising from the nasal lining, usually squamous cell carcinoma. This is a serious condition that can spread to other parts of the body if left untreated.

Causes: Exposure to tobacco smoke, industrial chemicals, radiation, and certain viruses (including HPV) are all risk factors.

Clinical Presentation:

Nasal obstruction: Difficulty breathing through the nose.
Epistaxis: Nosebleeds, which may be frequent or severe.
Facial pain: Pain in the face, often related to pressure from the tumor.
Nasal discharge: Mucus coming from the nose, which may be thick, bloody, or foul-smelling.
Loss of smell: Reduced or complete inability to smell.
Facial swelling: Swelling around the nose and face.
Headache: Pain in the head, often caused by pressure from the tumor.
Sinus pain: Pain and pressure in the sinuses.
Facial pressure or fullness: A feeling of tightness or pressure in the face.
Pain in the teeth: Pain in the teeth, especially the upper teeth.
Loss of teeth: Loss of teeth due to tumor growth or pressure.
Weight loss: Unexplained weight loss, which can be a sign of cancer.
Fatigue: Feeling tired and weak.
Neck mass: A lump in the neck, which can be a sign of cancer spreading to the lymph nodes.

General Diagnosis & Investigations:

Physical examination: Visual inspection and examination of the nose, sinuses, and neck.
Nasal endoscopy: A thin, flexible tube with a camera is inserted into the nose to visualize the tumor.
Biopsy: A small sample of the tumor is taken for examination under a microscope to confirm the diagnosis.
CT scan or MRI: Imaging tests can show the size, location, and spread of the tumor.

Management:

Surgery: Removal of the tumor, often with radiation therapy or chemotherapy.
Radiation therapy: May be used as primary treatment or as an adjunct to surgery.
Chemotherapy: May be used to shrink the tumor before surgery or to treat advanced disease.

General Prevention:

Avoiding tobacco use: The most important thing that can reduce the risk of nasal cancer.
Limiting exposure to industrial chemicals: Wear appropriate safety gear when handling chemicals and avoid unnecessary exposure.
Wearing appropriate safety gear: Wear protective gear such as respirators, masks, and gloves when exposed to hazardous materials.
Regular dental check-ups: See your dentist regularly for check-ups and to identify any early signs of oral cancer, which can sometimes be related to nasal cancer.

THROAT:

a. Pharynx: The pharynx is a muscular tube located behind the nasal cavity and mouth.

It is divided into three parts: nasopharynx (behind the nasal cavity), oropharynx (behind the mouth), and laryngopharynx (above the esophagus and larynx). The pharynx serves as a passage for both air and food.

b. Larynx: The larynx, commonly known as the voice box, is situated at the top of the trachea (windpipe).

It houses the vocal cords, which are responsible for voice production. The larynx also helps protect the airway during swallowing by closing the epiglottis.

c. Tonsils and Adenoids: The tonsils (palatine tonsils) are located on each side of the back of the throat, while the adenoids (pharyngeal tonsils) are located in the upper part of the throat, behind the nose.

They are part of the immune system and help fight infection.

Tumors of the Throat:

Benign Tumors:

1. Papilloma: A benign, wart-like growth that occurs on the mucous membrane of the throat, often caused by human papillomavirus (HPV).

Causes: HPV infection, especially types 6 and 11.

Clinical Presentation:

Hoarseness: A change in voice quality, often described as raspy or rough.
Dysphagia/Difficulty swallowing: A feeling of food getting stuck in the throat or discomfort when swallowing.
Sore throat: A painful sensation in the throat that may be constant or intermittent.
Cough: A dry or productive cough that may be persistent.
Change in voice: A noticeable difference in how the voice sounds, such as hoarseness, breathiness, or a loss of vocal range.
Sensation of something in the throat: A feeling of a lump or obstruction in the throat.
Frequent throat clearing: A constant need to clear the throat to relieve a feeling of blockage.
Dyspnea/Difficulty breathing: Shortness of breath, wheezing, or a feeling of being unable to take a full breath.

Diagnosis & Investigations:

Physical examination: Visual assessment of the throat and neck for any visible signs of a papilloma.
Laryngoscopy: A thin, flexible tube with a camera is inserted into the throat to visualize the papilloma.
Biopsy: A small sample of the papilloma is taken for examination under a microscope to confirm the diagnosis and rule out cancer.

Management:

Surgical: Removal of the papilloma using laser surgery, electrocautery, or cryosurgery. These procedures are usually minimally invasive and performed under local anesthesia.
Antiviral medication: May be used for some types of HPV-related papillomas, but it is not always effective.

Prevention:

Avoiding exposure to HPV: This involves practicing safe sexual practices, using condoms, and avoiding close contact with people who have HPV-related warts.

Cancerous Tumors:

2. Laryngeal Cancer: Malignant tumor arising from the larynx (voice box), usually squamous cell carcinoma.

Causes:

Tobacco use (smoking and chewing): The most significant risk factor, both for developing and worsening laryngeal cancer.
Heavy alcohol consumption: Increases the risk of developing laryngeal cancer, particularly when combined with tobacco use.
Exposure to industrial chemicals: Certain chemicals like asbestos, formaldehyde, and nickel can increase the risk.
HPV infection: Some types of HPV can contribute to the development of laryngeal cancer.

Clinical Presentation:

Hoarseness: A persistent change in voice quality, often the first and most noticeable symptom.
Difficulty swallowing: Pain or discomfort when swallowing, sometimes accompanied by a feeling of food getting stuck.
Sore throat: A persistent sore throat, often described as scratchy or burning.
Cough: A chronic or persistent cough that may be dry or produce phlegm.
Neck pain: Pain in the neck, especially when swallowing or moving the head.
Ear pain: Pain in the ear, often on the same side as the tumor.
Difficulty breathing: Shortness of breath, wheezing, or a feeling of being unable to take a full breath.
Fatigue: A feeling of persistent tiredness and weakness.
Change in voice: Noticeable alteration in how the voice sounds, such as hoarseness, breathiness, or a loss of vocal range.
Sensation of something in the throat: A feeling of a lump or obstruction in the throat.
Frequent throat clearing: A constant need to clear the throat to relieve a feeling of blockage.
Pain when swallowing: Discomfort or pain when swallowing food or liquids.
Difficulty breathing: Shortness of breath, wheezing, or a feeling of being unable to take a full breath.
Neck mass: A lump or swelling in the neck, often on one side.
Loss of appetite: A decrease in appetite or a feeling of fullness quickly after eating.
Unexplained weight loss: Significant weight loss without trying to lose weight.
Chronic cough: A persistent cough that lasts for weeks or months.

Diagnosis & Investigations:

Physical examination: Examination of the throat and neck for any visible signs of a tumor.
Laryngoscopy: A thin, flexible tube with a camera is inserted into the throat to visualize the tumor.
Biopsy: A small sample of the tumor is taken for examination under a microscope to confirm the diagnosis and determine the type of cancer.
Imaging studies (CT scan, MRI, PET scan): These scans provide detailed images of the tumor and its location, helping to assess its size and spread. A positron emission tomography (PET) scan is a type of imaging test. It uses a radioactive substance called a tracer to look for disease in the body.

Management:

Surgery: Removal of the tumor, often with radiation therapy or chemotherapy, depending on the stage and location of the cancer.
Radiation therapy: May be used as primary treatment or as an adjunct to surgery to destroy any remaining cancer cells.
Chemotherapy: May be used to shrink the tumor before surgery or to treat advanced disease that has spread to other parts of the body.

Prevention:

Avoiding tobacco use: This is the most important step to reduce the risk of laryngeal cancer.
Limiting alcohol consumption: Moderate alcohol consumption can reduce the risk, but heavy drinking significantly increases it.
Avoiding exposure to industrial chemicals: Wear appropriate protective gear when handling hazardous substances.
Receiving the HPV vaccine: Vaccination can help protect against certain types of HPV that can contribute to laryngeal cancer.

3. Pharyngeal Cancer/Throat cancer: Malignant tumor arising from the pharynx (throat), commonly squamous cell carcinoma.

Causes:

Tobacco use (smoking and chewing): The primary risk factor.
Heavy alcohol consumption: Increases the risk, particularly when combined with tobacco use.
Exposure to industrial chemicals: Certain chemicals can increase the risk.
HPV infection: Some types of HPV can contribute to the development of pharyngeal cancer which can be obtained through oral sex.

Clinical Presentation:

Difficulty swallowing: Pain or discomfort when swallowing, sometimes accompanied by a feeling of food getting stuck.
Sore throat: A persistent sore throat, often described as scratchy or burning.
Ear pain: Pain in the ear, often on the same side as the tumor.
Neck pain: Pain in the neck, especially when swallowing or moving the head.
Hoarseness: A change in voice quality, often described as raspy or rough.
Nasal obstruction: Difficulty breathing through the nose.
Weight loss: Unexplained weight loss without dietary changes.
Fatigue: A feeling of persistent tiredness and weakness.
Sensation of something in the throat: A feeling of a lump or obstruction in the throat.
Frequent throat clearing: A constant need to clear the throat to relieve a feeling of blockage.
Earache: Pain in the ear, often on the same side as the tumor.
Neck mass: A lump or swelling in the neck, often on one side.
Chronic cough: A persistent cough that lasts for weeks or months.

Diagnosis & Investigations:

Physical examination: Examine the throat and neck for any visible signs of a tumor.
Laryngoscopy: A thin, flexible tube with a camera is inserted into the throat to visualize the tumor.
Biopsy: A small sample of the tumor is taken for examination under a microscope to confirm the diagnosis and determine the type of cancer.
Imaging studies (CT scan, MRI, PET scan): These scans provide detailed images of the tumor and its location, helping to assess its size and spread.

Management:

Surgery: Removal of the tumor, often with radiation therapy or chemotherapy, depending on the stage and location of the cancer.
Radiation therapy: May be used as primary treatment or as an adjunct to surgery to destroy any remaining cancer cells.
Chemotherapy: May be used to shrink the tumor before surgery or to treat advanced disease that has spread to other parts of the body.

Prevention:

Avoiding tobacco use: This is the most important step to reduce the risk of pharyngeal cancer.
Limiting alcohol consumption: Moderate alcohol consumption can reduce the risk, but heavy drinking significantly increases it.
Avoiding exposure to industrial chemicals: Wear appropriate protective gear when handling hazardous substances.
Receiving the HPV vaccine: Vaccination can help protect against certain types of HPV that can contribute to pharyngeal cancer.
Avoid Oral sex: Avoid engaging in oral sexual intercourse.

ADENOID HYPERTROPHY

Adenoid hypertrophy is a condition characterized by enlarged adenoids, a collection of lymphatic tissue located at the back of the nasal cavity.

This enlargement can lead to nasal obstruction, impacting breathing, sleep, and overall well-being.

Adenoids and Their Function

The adenoids, also known as the pharyngeal tonsils, are part of the body’s immune system, acting as a first line of defense against infections.
They are usually larger in children, playing a role in protecting them from respiratory infections.
By the age of five, adenoids usually begin to shrink, becoming less prominent in the immune system’s function.

The adenoids are small masses of lymphatic tissue located in the upper airway, between the nose and the back of the throat. Along with the tonsils, the adenoids form part of the lymphatic system, which works to defend the body against microbes, absorb nutrients, maintain proper fluid levels, and eliminate certain waste products. The anatomical position of the adenoids allows them to help fight infection by preventing germs from entering the body through the mouth or nose.

Causes of Adenoid Hypertrophy

Adenoid enlargement can be attributed to various factors, including:

Infections: Viral infections, such as Epstein-Barr virus, and bacterial infections, like group A Streptococcus, can trigger inflammation and swelling of the adenoids.
Chronic Inflammation: Repeated acute infections or persistent infections can lead to chronic adenoid inflammation, resulting in hypertrophy.
Allergies and Irritants: Allergens or irritants, when exposed to the adenoid tissue, can trigger an inflammatory response, causing enlargement.
Gastroesophageal Reflux (GERD): Stomach acid refluxing into the esophagus can irritate the adenoid tissue, leading to inflammation and hypertrophy.
Bacterial Infections: Several aerobic bacterial species have been implicated in adenoid hypertrophy, including:

Alpha-, beta-, and gamma-hemolytic Streptococcus species
Hemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
Neisseria gonorrhoeae
Corynebacterium diphtheriae
Chlamydophila pneumoniae
Mycoplasma pneumoniae

Classifying Adenoid Hypertrophy

Adenoid hypertrophy can be classified based on its anatomical relationship with adjacent structures:

Grade 1: No contact between adenoid tissue and vomer, soft palate, or torus tubaris.
Grade 2: Adenoid tissue contacts the torus tubaris.
Grade 3: Adenoid tissue contacts the torus tubaris and vomer.
Grade 4: Adenoid tissue contacts the torus tubaris, vomer, and soft palate in resting position.

Additionally, adenoid hypertrophy can be classified based on its size in relation to surrounding tissues:

Grade 1: Adenoid occupies less than 25% of the choanal area.
Grade 2: Adenoid occupies 25-50% of the choanal area.
Grade 3: Adenoid occupies 50-75% of the choanal area.
Grade 4: Adenoid occupies 75-100% of the choanal area.

Clinical Features of Adenoid Hypertrophy

The symptoms of adenoid hypertrophy can vary depending on the severity of the condition. Common signs include:

Nasal Obstruction: Difficulty breathing through the nose, leading to mouth breathing.
Mouth Breathing: Dry lips and bad breath due to continuous breathing through the mouth.
Nasal Congestion: Feeling like the nose is pinched or stuffed.
Frequent Sinus Symptoms: Recurrent sinus infections, headaches, and facial pain.
Snoring: Loud snoring, especially during sleep.
Sleep Apnea: Restless sleep, frequent awakenings, and potentially obstructive sleep apnea.

Diagnosis of Adenoid Hypertrophy

Physical Examination: Examine the nose and throat for signs of adenoid enlargement.
Lateral Neck X-Ray: An X-ray of the neck can help visualize the size and shape of the adenoids.
Palpation: Gently feeling the adenoids through the roof of the mouth.
Nasal Endoscopy: A thin, flexible tube with a camera is inserted into the nose to visualize the adenoids.
Transnasal Endoscopy: An otolaryngologist (ENT doctor) performs this procedure for a definitive diagnosis.

Management of Adenoid Hypertrophy

Treatment for adenoid hypertrophy depends on the severity of the symptoms:

Minimal Symptoms: No treatment may be needed.

Mild to Moderate Symptoms:

Nasal Sprays: Saline or steroid nasal sprays can help reduce swelling and improve breathing.
Antibiotics: If the condition is caused by a bacterial infection, antibiotics may be prescribed.

Severe Symptoms:

Adenoidectomy: Surgical removal of the adenoids may be recommended if conservative measures are ineffective.

Complications of Adenoid Hypertrophy

If left untreated, adenoid hypertrophy can lead to various complications:

Obstructive Sleep Apnea (OSA): Enlarged adenoids can block the airway during sleep, leading to frequent awakenings, daytime sleepiness, and other health issues.
Chronic Otitis Media: The hypertrophied adenoids can block the Eustachian tube, leading to recurrent ear infections and fluid buildup in the middle ear.
Recurrent Sinus Infections: Obstruction of the nasal passages can lead to frequent sinus infections.
Mouth Breathing and Dental Issues: Continuous mouth breathing can cause dry mouth, bad breath, and dental malocclusions over time.
Speech and Swallowing Problems: Enlarged adenoids can interfere with speech and swallowing, potentially causing nasal speech and difficulty swallowing.
Failure to Thrive: In severe cases, the obstruction can lead to poor weight gain and growth in children.

Post-operative Care for Adenoidectomy

After surgery to remove the adenoids, nurses play a vital role in providing comprehensive care:

Pain Management: Administering pain medication and providing comfort measures.
Hydration and Nutrition: Encouraging fluid intake and offering soft, easy-to-swallow foods.
Monitoring for Complications: Observing for signs of bleeding, infection, and respiratory distress.
Rest and Recovery: Advise on adequate rest and gradual return to normal activities.

Common tumors of ear nose and throat (ENT) Read More »

Partograph

Partograph is a graph or tool used to monitor fetal condition, maternal condition and labour progress during the active 1st stage of labour so as to be able to detect any abnormalities and be able to take action.
It’s only used during 1st stage of labour. It is used for recording salient conditions of the mother and the fetus.

USES OF A PARTOGRAPH

To detect labour that is not progressing normally.
To indicate when augmentation of labour is appropriate.
To recognize CPD when obstruction occurs.
It increases the quality of all observations on the mother and fetus in labour.
It serves as an “early warning system”
It assists on early decision of transfer and augmentation.

Who should not use a partograph?
Women with problems which are identified before labour starts or during labour which needs special attention.
Women not anticipating vaginal delivery (elective C/S).

A partograph has 3 parts i.e. –
fetal part
maternal part
labour progress part

Observations charted on a partograph:

The progress of labour
> Cervical dilatation 4 hourly
> Descent 2 hourly
> Uterine contractions
Fetal condition
> Fetal heart rate ½ hourly
> Membranes and liquor 4 hourly
> Moulding of the fetal skull 4 hourly.
Maternal condition
> Pulse ½ hourly
> Blood Pressure 2 hourly
>Respiration and > temperature 4 hourly
Urine; – volume 2 hourly, acetone, proteins and sugars.
> Drugs
> I.V fluids 2 hourly and Oxytocin regimen

Starting a partograph:

The partograph should be started only when a woman is in active phase of labour.
Contractions must be 1 or more in 10 minutes.
Cervical dilatation should be 4cm or more.

FETAL CONDITION

Fetal heart;
It is taken 1/2 hourly unless there is need to check frequently i.e. if abnormal every 15 minutes and if it remains abnormal over 3 observations, take action. The normal fetal heart rate is 120-160b/m. below 120b/m or above 160b/m indicates fetal distress.
Molding;
This is felt on VE. It is charted according to grades.
State of moulding Record
Absence of moulding. (-)
Bones are separate and sutures felt (0)
Bones are just touching each other (+)
Bone are over lapping but can be Separated (++)
Bones are over lapping but cannot be separated (+++)
Liquor amnii;
This is observed when membranes are raptured artificially or spontaneously.
It has different colour with different meaning and meconium stained liquor has grades.
State of liquor Record
Clear (normal) (C)
Light green in colour (m+) Moderate green, more slippery (m++) Thick green, meconium stained (m+++) Blood stained (B)
Membranes;

State of membranes Record
Membranes intact (I)
Membranes raptured (R)

LABOUR PROGRESS

5. Cervical dilatation,
The dilatation of the cervix is plotted with an “X”. Vaginal examination is done at admission and once in 4 hours. Usually we start recording on a partograph at 4cm.
Alert line starts at 4cm of cervical dilation to a point of expected full dilatation at a rate of 1cm per hour
Action line– parallel and at 4 hours to the right of the alert line.

6. Descent of presenting part.
Descent is assessed by abdominal palpation. It is measured in terms of fifths above the brim.
The width of five fingers is a guide to the expression in the fifth of the head above the brim.
A head that is ballotable above the brim will accommodate the full width of five fingers.
As the head descends, the portion of the head remaining above the brim will be represented by fewer fingers.
It is generally accepted that the head is engaged when the portion of the head above the brim is represented by 2 or less fingers.
Descent is plotted with an “O” on the graph

7. Uterine contractions This is done ½ hourly for every 30 minutes. The duration, frequency and strength of contraction is observed. Observe the contractions within 10 minutes.

-Mild contractions last for less than 20 seconds.
-Moderate contractions last for 20-40 seconds.
-Strong contractions last for 40 seconds and above.
When plotting and shedding contractions use the following symbols.
Dots for mild contractions
Diagonal lines for moderate contractions
Shade for strong contractions

MATERNAL CONDITION

Pulse; this is checked every 30 minutes. The normal pulse is 70-90b/min.
The raised pulse may indicate maternal distress, infection especially if she had rapture of membranes for 8-12 hours and in case of low pulse, it can be due to collapse of the mother.
Blood pressure; it is taken 2 hourly. The normal is 90/60-140/90mmHg. Any raise of 30mmHG systolic and 20mmhg diastolic from what is regarded as normal or if repeated over 3 times and remains high, test urine for albumen to rule out pre-eclampsia.
Temperature; this is taken 4 hourly. The normal range is between 37.2 0 c to 37.5 0 c. Any raise in temperature may be due to infections, dehydration as a sign of maternal distress or if a mother had early rapture of membranes.
Urine; the mother should pass urine atleast every after 2 hours and urine should be tested on admission.
Fluids; she should be encouraged to take atleast 250-300 mls every 30 minutes. Any type of
fluid can be given hot or cold except alcohol. Thefluid should be sweetened in order to give her
strength.

Further mgt in the normal 1st stage of labour- nursing care

Emotional support:

Midwife should rub the mothers backto relieve pain.
Allow the mother to move around or sit in bed if membranes are still intact.
Re-assure the mother and keep her informed about the progress of labour to relieve anxiety.
Allow her to talk to relatives and husband.
Allow her to read or do knitting.

2. Nutrition;
Encourage mother to take light and easily digested food like bread, soup and sweet tea to rehydrate her and provide energy.

3. Elimination;
Taking care of the bladder and bowel. Encourage mother to empty bladder every 2 hours during labour. Every specimen is measured and tested for acetone, albumen, sugars and findings interpreted and recorded.
Pass catheter if mother is unable to pass urine.

4. Personal hygiene;
Allow mother to go for bath in early labour or on admission if condition allows. If membranes rapture, give a clean pad and ask mother to change frequently to prevent infections.
VE should be done only after aseptic technique.

5. Ambulation and position:
In early labour, mother is encouraged to walk around to aid descent of presenting part.
During contractions, ask mother to lean forward supporting herself on a chair or bed to reduce discomfort.
Allow mother to adopt a position of her choice except supine position.
Mother should be confined to bed when membranes rapture in advanced stage of labour.

6. Prevention of infections
Strict aseptic technique should be maintained when doing a VE and vulval swabbing.
When membranes rapture early, vulval toileting should be done 4 hourly to reduce the risk of infections. Put mother on antibiotics to avoid risk of ascending infections in early raptured of membranes.
Frequent sponging is done, bed linen changed when necessary when a mother is confined in bed.
The midwife should pay attention to her own hygiene and be careful to wash her hands before and after attending to the mother.

7. Sleep and rest
Mother is encouraged to rest when there is no contraction (rest in between contractions).

What to report

Abnormality found in urine.
Failure to pass urine.
Rise in temperature, pulse and BP.
Hypertonic uterine contractions.
Rapture of membranes with meconium stained liquor grade 2 and 3.
Failure of presenting part to descend despite good uterine contractions.
Tenderness of abdomen.
Bleeding per vagina.
Fall in BP.
Raise in fetal heart rate.

Complications

Infections
Early rapture of membranes
Cord prolapse
Supine hypotensive syndrome
Fetal distress
Maternal distress
APH
PET and eclampsia
Prolonged labour
Obstructed labour

Partograph Read More »

Cushing’s Syndrome

Cushing’s syndrome results from secretion of excessive cortisol either in response to excess ACTH production by the pituitary tumors and adrenal adenoma or nodular hyperplasia.

Cushing’s syndrome is simply defined as a hormonal disorder associated with excessive production of corticosteroids by the adrenal gland or the pituitary gland and/or prolonged use of corticosteroids.

Causes of Cushing’s Syndrome

Prolonged use of corticosteroid medication.
Hyperplasia of the adrenal gland.
Tumor in the pituitary gland enhancing over production of ACTH.
Tumour in one of the adrenal glands above the kidneys.

Clinical Presentation of Cushing’s syndrome.

Hirsutism
Amenorrhea
Easy bruising and acne
Osteoporosis may cause bone weakening and fracture
Cataracts, glaucoma
Hypertension, heart failure
Truncal obesity, moon face, buffalo hump, sodium retention, hypokalemia, hyperglycemia, negative nitrogen balance, altered calcium metabolism
Decreased inflammatory responses, impaired wound healing, increased susceptibility to
infections
Peptic ulcers, pancreatitis
Thinning of skin, striae, acne
Mood alterations
Depression

Diagnosis

Overnight dexamethasone suppression test frequently used for diagnosis administered at 11pm and cortisol level checked at 8am
Suppression of cortisol to less than 5mg/dL indicates normal functioning
Measurement of plasma ACTH (radioimmunoassay) in conjunction with dexamethasone suppression test helps distinguish pituitary vs. ectopic sites of ACTH.
MRI, CT and CT also help detect tumors of adrenal or pituitary.

Management

Treatment is dependent on the site of the disease.

If pituitary source, may warrant transphenoidal hypophysectomy(surgery done to remove the pituitary gland)
Radiation of pituitary also appropriate
Adrenalectomy may be needed in case of adrenal hypertrophy
Temporary replacement therapy with hydrocortisone or Florinef
Adrenal enzyme reducers may be indicated if source if ectopic and inoperable. Examples include: ketoconazole, mitotane and metyrapone.
If cause is related to excessive steroid therapy, tapering slowly to a minimum dosage maybe appropriate.

Hypophysectomy

Nursing Care

Assess the level of activity and ability to carry out routine and self care activities.
Observe skin for trauma, infection, breakdown, bruising, and edema.
Note changes in appearance and patients response to these changes, family is good source if information about patients emotional status and changes in appearance.
Assess mental function.
Nursing Diagnosis
Acute pain related to compression fracture of lumber spine as evidenced by back pain.
Self care deficit related to weakness, fatigue as evidenced by starry eyes and inability to answer questions.
Risk For Excess Fluid Volume related to retention of water and sodium caused by an excess of cortisol and mineralocorticoid levels.
Risk For Injury related to decreased bone density or generalized fatigue and weakness or increased capillary fragility or poor wound healing
Risk For Infection related to altered protein metabolism or high serum cortisol level or impaired immune response
Deficient Knowledge related to lack of experience with Cushing’s syndrome evidenced by repeated hospital admissions for complications or repeated questioning or verbalized misconceptions.
Disturbed Body Image related to abnormal fat distribution along with edema resulting in moon face, cervicodorsal fat (buffalo hump), trunk obesity evidenced by compensatory use of concealing clothing.
Disturbed Thought Processes related to chemical changes in the brain from high cortisol evidenced by anxiety or irritability or depression .
Evaluations
Has decreased risk of injury
Has decreased risk of infection
Increases participation in self care activities
Attains or maintains skin integrity
Achieves improved body image
Exhibits improved mental functioning
Experiences no complications
Nursing Interventions
Assess for signs of circulatory overload i.e Cyanosis, Dyspnea. Edema, Distended neck veins, Shortness of breath, Tachypnea. Rationale; Detection of signs of circulatory overload will help in the immediate intervention. Due to excessive glucocorticoid and mineralocorticoid secretion, the client is predisposed to water and sodium retention.
Monitor vital signs, especially Blood pressure and Heart rate. Rationale: Cushing’s disease may result in increased blood pressure resulted from the expanded fluid volume with sodium and water retention. Tachycardia happens as a compensatory response to circulatory overload.
Monitor the client’s sodium and potassium levels Rationale: excessive cortisol causes sodium and water retention, edema, and increased potassium excretion. Mineralocorticoids regulate sodium and potassium secretion, and excess levels cause marked sodium and water retention as well as marked hypokalemia.
Instruct the client to elevate feet when sitting down. Rationale: This position decreases fluid accumulation in the lower extremities.
Encourage the client to have low sodium and high potassium diet. Rationale: Too much sodium in the diet promotes fluid retention and weight gain

Cushing’s Syndrome Read More »

Pheochromocytoma

Pheochromocytoma is a type of that grows from cells called chromaffin cells. These cells produce hormones needed for the body and are found in the adrenal glands.

Pheochromocytomas are benign tumors of the chromaffin tissues arising from the adrenal glands or sympathetic ganglia along the spinal column. They secrete catecholamine like noradrenalin and adrenaline

Clinical Presentation

headaches
heavy sweating
a rapid heartbeat (tachycardia)
high blood pressure
a pale face
feeling of being sick
feeling anxious or panicky
shakiness (tremor)
paroxysmal hypertension
flustering (agitation)
chest discomfort

Diagnosis

Associated with the 5 H’s— hypertension, headache, hyperhidrosis, hypermetabolism and hyperglycemia,
Urinary catecholamine are direct and conclusive tests
Serum epinephrine and norepinephrine levels will be elevated.
Must avoid coffee, tea, bananas, chocolate, vanilla and ASA, nicotine, amphetamines, decongestants before 24h urine testing
Clonidine suppression test— in normal individual, would block catecholamine release
Imaging studies i.e CT Scan and MRI

How the tumour affects the adrenal glands
The adrenal glands make the hormones adrenaline and noradrenaline, which are released into the bloodstream when needed. These hormones control heart rate, blood pressure and metabolism (the chemical processes that keep your organs working).

A phaeochromocytoma can cause the adrenal glands to produce too much of these hormones, which often results in problems such as heart palpitations and high blood pressure.

Management

Treating a phaeochromocytoma

Surgery to remove the phaeochromocytoma is the treatment of choice since most of the surgeries are successful

Alpha blockers (and in some cases beta blockers) for several weeks before the operation. They block the effects of the excess hormones on the body and stabilize your heart rate and blood pressure.

The operation is carried out may include

“keyhole” (laparoscopic) surgery – a number of small cuts (incisions) are made and fine instruments are passed through these to remove the tumour; this is the most common type of surgery for phaeochromocytomas
open surgery – a single larger incision is made in the skin to access and remove the tumour
The incisions will usually be made in your tummy (abdomen).

If phaeochromocytoma is cancerous, chemotherapy or radiotherapy in addition to surgery.

Nursing Care

As given to patients from surgery, and according to the treatment given.

Pheochromocytoma Read More »

Addison’s disease (Adrenal insufficiency)

Addison’s disease

Addison’s disease is a clinical condition characterized by adrenocorticotrophic hormone hyposecretion due to primary disease of the adrenal glands or secondary to pituitary gland disorder.

It’s mostly idiopathic or auto immune but can occur in tuberculosis infection of the gland or obstruction by the adrenal tumor, metastasis / hemorrhage

Pathophysiology

Adrenal glands are incapable of producing sufficient cortisol and other steroids . It is distinguished from acute primary adrenocortical insufficiency caused by Waterhouse-Friderichsen syndrome.
Mineralocorticoid deficiency: Because mineralocorticoids stimulate sodium reabsorption and potassium excretion, deficiency results in increased excretion of sodium and decreased excretion of potassium, chiefly in urine but also in sweat, saliva, and the gastrointestinal tract. A low serum concentration of sodium (hyponatremia) and a high concentration of potassium (hyperkalemia) result.

Glucocorticoid deficiency: Glucocorticoid deficiency contributes to hypotension and causes severe insulin sensitivity and disturbances in carbohydrate, fat, and protein metabolism. In the absence of cortisol, insufficient carbohydrate is formed from protein; hypoglycemia and decreased liver glycogen result. Weakness follows, due in part to deficient neuromuscular function. Resistance to infection, trauma, and other stress is decreased. Myocardial weakness and dehydration reduce cardiac output, and circulatory failure can occur.

Causes of Addison’s Disease(Can be predisposing Factors too)

Autoimmune Reaction: Addison’s Disease can occur when the body’s immune system mistakenly attacks and damages the adrenal glands. This is known as an autoimmune reaction. In this case, the immune system views the adrenal glands as foreign entities and targets them for destruction, leading to a deficiency in adrenal hormones.
Idiopathic Atrophy of the Adrenal Glands: In some cases, the adrenal glands may undergo atrophy, which means they shrink and lose their function without a clear identifiable cause. This condition is referred to as idiopathic adrenal atrophy.
Surgical Removal of Both Adrenal Glands: Addison’s Disease can result from the surgical removal of both adrenal glands. This usually occurs as a last resort when treating conditions such as Cushing’s syndrome or adrenal tumors. After removal, the individual will need hormone replacement therapy.
Adrenal Carcinoma: Adrenal carcinoma is a rare type of cancer that originates in the adrenal glands. In some instances, the cancerous growth can disrupt the normal functioning of the adrenal glands, leading to adrenal insufficiency and Addison’s Disease.
Infections such as TB: Certain infections, particularly tuberculosis (TB), can infiltrate and damage the adrenal glands. TB-induced damage to the adrenal glands can impair their ability to produce hormones, causing Addison’s Disease.
Abnormal/Malfunction of the Pituitary Gland: The pituitary gland plays a crucial role in regulating adrenal function by secreting adrenocorticotropic hormone (ACTH). If the pituitary gland malfunctions and doesn’t produce an adequate amount of ACTH, the adrenal glands won’t receive the necessary signals to produce hormones, leading to Addison’s Disease.
Prolonged Use of Steroid Medication: Long-term use of corticosteroid medications, which are often prescribed for conditions like autoimmune diseases or inflammation, can suppress the production of ACTH by the pituitary gland. This can lead to adrenal gland atrophy and result in Addison’s Disease.

Additional causes include:

Genetic Factors: While most cases of Addison’s Disease are not inherited, there is a rare genetic form known as familial glucocorticoid deficiency (FGD). In FGD, specific genetic mutations can lead to the inadequate production of adrenal hormones.
Hemorrhage into the Adrenal Glands: Severe bleeding into the adrenal glands, often due to injury or other medical conditions, can damage the glands and impair their hormone production.
Amyloidosis: Amyloidosis is a rare condition in which abnormal proteins (amyloids) build up in various organs, including the adrenal glands. This accumulation can disrupt adrenal function and cause Addison’s Disease.

Clinical Presentation of Addison’s Disease:

Due to Cortisol Deficiency:
- Addison’s Disease primarily results in the deficiency of cortisol, which is a crucial hormone for various bodily functions.
- Common symptoms due to cortisol deficiency include:
  - Weakness: Individuals with Addison’s Disease often experience significant weakness, making even simple tasks challenging.
  - Weight Loss: Unexplained weight loss can occur due to a disruption in metabolism.
  - Fatigue: Profound fatigue and tiredness are typical, even after a full night’s sleep.
  - Nausea and Vomiting: Persistent nausea and vomiting may be present.
  - Diarrhea: Chronic diarrhea can develop as a result of gastrointestinal disturbances.
Due to Increased ACTH Production (If the Cause Is in the Adrenal Gland):
- When Addison’s Disease is caused by issues within the adrenal glands, it can lead to increased production of adrenocorticotropic hormone (ACTH).
- Symptoms related to excess ACTH include:
  - Hyperpigmentation of Skin and Mucous Membranes: A distinctive symptom is the darkening of the skin and mucous membranes, which may appear as tan or bronze patches. This is often referred to as hyperpigmentation.
Due to Mineralocorticoid Deficiency:
- Addison’s Disease can also lead to the deficiency of mineralocorticoids, particularly aldosterone, which plays a crucial role in regulating electrolyte balance.
- Symptoms associated with mineralocorticoid deficiency include:
  - Very Low Blood Pressure (Hypotension): The absence of aldosterone can result in extremely low blood pressure, leading to dizziness and fainting.
  - Serum Potassium High, but Sodium and Chloride Are Low: Electrolyte imbalances can manifest as high levels of potassium and low levels of sodium and chloride.
Due to Androgen Deficiency:
- In some cases, Addison’s Disease may also cause androgen deficiency, which can lead to specific symptoms:
  - Sparse Hair in Females: Women with Addison’s Disease may experience hair thinning or loss.
  - General Weakness: Overexertion, exposure to cold, or acute infections can exacerbate the overall weakness and fatigue experienced by individuals with Addison’s Disease.

Diagnosis of Addison’s Disease:

Hormone Levels Testing:
- To diagnose Addison’s Disease, healthcare providers typically start with hormone level testing. The key hormones involved are cortisol and ACTH (Adrenocorticotropic hormone).
- Morning and Evening Cortisol Levels: Blood samples are collected in the morning and evening to measure cortisol levels. In individuals with Addison’s Disease, both morning and evening cortisol levels are usually low.
- Plasma ACTH Level: Simultaneously, the level of ACTH in the blood plasma is measured. The results of this test help differentiate between primary and secondary adrenal insufficiency.
Differentiating Primary and Secondary Adrenal Insufficiency:
- In cases of primary adrenal insufficiency (due to issues with the adrenal glands themselves), ACTH levels are typically elevated (high), while cortisol levels are below normal.
- In secondary adrenal insufficiency (resulting from problems with the pituitary gland), both cortisol and ACTH levels are low.
ACTH Stimulation Test:
- In some cases, an ACTH stimulation test may be performed. In this test, a synthetic form of ACTH is administered, and blood cortisol levels are measured before and after the injection.
- A normal response to exogenous (administered from outside the body) ACTH involves a significant increase in blood cortisol levels.
- Individuals with Addison’s Disease often have a reduced or no increase in cortisol levels in response to ACTH stimulation.
Additional Blood Tests:
- Blood sugar levels and electrolyte values are also examined. Addison’s Disease can lead to imbalances in blood electrolytes, such as sodium and potassium, which can result in symptoms like weakness and low blood pressure.

Complications of Addison’s Disease:

Renal Failure:
- One of the potential complications of Addison’s Disease is renal failure, which refers to the loss of kidney function.
- Addison’s Disease can disrupt the balance of electrolytes in the body, particularly causing increased levels of potassium. This imbalance can have a detrimental effect on the kidneys.
- High levels of potassium can lead to abnormal heart rhythms (arrhythmias) and, in severe cases, impair kidney function.
Adrenal Hemorrhage:
- Adrenal hemorrhage, though rare, is another complication that can occur in individuals with Addison’s Disease.
- It involves bleeding into the adrenal glands, typically due to an adrenal crisis or severe stress. This can lead to sudden and severe abdominal or back pain.
- Adrenal hemorrhage requires immediate medical attention, as it can be life-threatening.
Addisonian Crisis:
- An Addisonian crisis, also known as an adrenal crisis, is a severe and potentially life-threatening complication of Addison’s Disease.
- It occurs when the adrenal glands fail to produce enough cortisol to meet the body’s needs, often triggered by stress, illness, trauma, or abrupt cessation of corticosteroid medications.
- Symptoms of an Addisonian crisis can include extreme weakness, confusion, low blood pressure, rapid heart rate, and even loss of consciousness.
- Prompt emergency medical treatment is essential to stabilize the patient, typically through intravenous administration of cortisol and fluids.
Depression:
- Chronic illnesses like Addison’s Disease can lead to emotional and psychological challenges, including depression.
- Coping with the demands of managing a chronic condition, along with the physical symptoms and potential complications, can take a toll on a person’s mental health.
- It’s essential for individuals with Addison’s Disease to receive comprehensive care that includes addressing emotional well-being and providing support for mental health issues such as depression.

Medical Management

Restore blood circulation IV fluids NS and Dextrose.
Small dose of fludrocortisones 0.05 – 0.1mg/day is given to maintain BP and electrolytes
Hormone replacement with cortisone daily in divided doses i.e prednisolone 20mg in the morning and 10mg in the evening
Vasopressor amines may be required if hypertension persists.
Antibiotic therapy if infection has precipitated the adrenal crisis
Lifelong replacement of corticosteroids and mineralocorticoids.
ORS for salt replacement.
May need additional salt intake
Treat underlying cause ie TB

Nursing Care

Monitor for BP,P, as patient moves from lying, sitting, and standing position to asses for inadequate fluid volume.
Assess skin color and turgor
Assess history of weight changes, muscle weakness, and fatigue.
Ask patient and family about onset of illness or increased stress that may have precipitated the crisis

Nursing diagnosis

Electrolyte imbalance related to low sodium level as evidenced by craving for salt, vomiting and diarrhea.
Ineffective tissue perfusion related to hyperpigmentation of skin as evidenced by skin tanning.
Risk for fluid volume deficit related to vomiting and diarrhea.

Addison’s disease (Adrenal insufficiency) Read More »

Dwarfism (Panhypopituitarism)

Dwarfism is a condition of short stature. It is defined by the advocacy group Little People of America (LPA) as an adult height of 4 feet 10 inches or under, as a result of a medical or genetic condition. Although other groups may extend the criteria for certain forms of dwarfism to 5 feet, the average height of an adult with dwarfism is 4 feet.

Types Of Dwarfism

There are two main types of dwarfism — disproportionate and proportionate.

Disproportionate dwarfism

Disproportionate dwarfism is characterized by an average-size torso and shorter arms and legs or a shortened trunk with longer limbs. The most common types of dwarfism, known as skeletal dysplasia’s, are genetic. Skeletal dysplasia’s are conditions of abnormal bone growth that cause disproportionate dwarfism.
Skeletal dysplasia’s include:

1. Achondroplasia: The most common cause of dwarfism which causes disproportionately short stature. This is the most common form of dwarfism, occurs in about one out of 26,000 to 40,000 babies and is evident at birth. People with achondroplasia have a relatively long trunk and shortened upper parts of their arms and legs.

- This disorder usually results in the following:
- An average-size trunk
- Short arms and legs, with particularly short upper arms and upper legs
- Short fingers, often with a wide separation between the middle and ring fingers
- Limited mobility at the elbows
- An adult height around 4 feet (122 cm)
- a large head with a prominent forehead and a flattened bridge of the nose
- protruding jaw
- crowded and misaligned teeth
- forward curvature of the lower spine
- Progressive development of bowed legs

2. Spondyloepiphyseal dysplasia Congenita (SEDC): Another rare cause of disproportionate dwarfism that affects approximately one in 95,000 babies. It refers to a group of conditions characterized by a shortened trunk, which may not become apparent until a child is between ages 5 and 10.

A very short trunk
A short neck
Shortened arms and legs
Average-size hands and feet
Slightly flattened cheekbones
Hip deformities that result in thighbones turning inward
Instability of the neck bones.
Progressive hunching curvature of the upper spine.
Progressive development of swayed lower back
Vision and hearing problems.
Arthritis and problems with joint movement.
Adult height ranging from 3 feet (91 cm) to just over 4 feet (122 cm).
club feet (A foot that’s twisted or out of shape).
Opening in the roof of the mouth (cleft palate).
severe osteoarthritis in the hips
weak hands and feet.
barrel-chested appearance (Broad, rounded chest)

3. Diastrophic dysplasia: A rare form of dwarfism, diastrophic dysplasia occurs in about one in 100,000 births. People who have it tend to have shortened forearms and calves (calf muscles-this is known as mesomelic shortening).

Achondroplasia

Spondyoepipheseal

Diastrophic

Proportionate dwarfism

Proportionate dwarfism, the body parts are in proportion but shortened. It usually results from medical conditions present at birth or appearing in early childhood that limit overall growth and development. So the head, trunk and limbs are all small, but they’re proportionate to each other. Because these disorders affect overall growth, many of them result in poor development of one or more body systems. Growth hormone deficiency is a relatively common cause of proportionate dwarfism. It occurs when the pituitary gland fails to produce an adequate supply of growth hormone, which is essential for normal childhood growth.

Signs include:

Height below the third percentile on standard pediatric growth charts
Growth rate slower than expected for age
Delayed or no sexual development during the teen years.

Causes of Dwarfism

Most dwarfism-related conditions are genetic disorders, but the causes of some disorders are unknown. Most occurrences of dwarfism result from a random genetic mutation in either the father’s sperm or the mother’s Ovum rather than from either parent’s complete genetic makeup.
Dwarfism can be caused by any of more than 200 conditions. Causes of proportionate dwarfism include metabolic and hormonal disorders such as growth hormone deficiency.
The most common types of dwarfism, known as skeletal dysplasias, are genetic. Skeletal dysplasias are conditions of abnormal bone growth that cause disproportionate dwarfism.
Other causes include;

Deficiency of growth hormone
Malnutrition
Inherited defect i.e. turners syndrome(Turner syndrome, a condition that affects only girls and women, results when a sex chromosome (the X chromosome) is missing or partially missing. A female inherits an X chromosome from each parent. A girl with Turner syndrome has only one fully functioning copy of the female sex chromosome rather than two)
Renal disorders
Congenital heart disease
Chronic infection in childhood

Diagnosis of Dwarfism

Some forms of dwarfism are evident at birth or during infancy and can be diagnosed through X-rays and a physical exam.
A diagnosis of achondroplasia, diastrophic dysplasia, or spondyloepiphyseal dysplasia can be confirmed through genetic testing. In some cases, prenatal testing is done if there is concern for specific conditions.
Sometimes dwarfism doesn’t become evident until later in a child’s life, when dwarfism signs lead parents to seek a diagnosis. Here are signs and symptoms to look for in children that indicate a potential for dwarfism:
- Late development of certain motor skills, such as sitting up or walking.
- Breathing problems
- Curvature of the spine
- bowed legs
- Joint stiffness and arthritis
- Lower back pain or numbness in the legs
- Crowding of teeth.

Measurements. A regular part of a well-baby medical exam is the measurement of height, weight and head circumference. At each visit, they will be plotted on a chart to show the child’s current percentile ranking for each one. This is important for identifying abnormal growth, such as delayed growth or a disproportionately large head. If any trends in these charts are a concern, the health worker may make more-frequent measurements.
Appearance. A child’s appearance may also help to make a diagnosis. Many distinct facial and skeletal features are associated with each of several dwarfism disorders.
Imaging technology. Imaging studies, such as X-rays, may be ordered because certain abnormalities of the skull and skeleton can indicate which disorder a child may have. Various imaging devices may also reveal delayed maturation of bones, as is the case in growth hormone deficiency.
A magnetic resonance imaging (MRI) scan may reveal abnormalities of the pituitary gland or hypothalamus, both of which play a role in hormone function.
Genetic tests. Genetic tests are available for many of the known causal genes of dwarfism-related disorders, but these tests often aren’t necessary to make an accurate diagnosis. If the pediatrician believes the daughter may have Turner syndrome, then a special lab test may be done that assesses the X chromosomes extracted from blood cells.
Family history. The pediatrician may take a history of stature in siblings, parents, grandparents or other relatives to help determine whether the average range of height in the family includes short stature.
Hormone tests. Tests that assess levels of growth hormone or other hormones that are critical for childhood growth and development may be ordered.

Medical Management

Early diagnosis and treatment can help prevent or lessen some of the problems associated with dwarfism.
Most dwarfism treatments don’t increase stature but may correct or relieve problems caused by complications.
People with dwarfism related to growth hormone deficiency can be treated with growth hormone.

Surgical Management

Surgical procedures that may correct problems in people with disproportionate dwarfism include:
Correcting the direction in which bones are growing
Stabilizing and correcting the shape of the spine
Increasing the size of the opening in bones of the spine (vertebrae) to alleviate pressure on the spinal cord
Placing a shunt to remove excess fluid around the brain (hydrocephalus), if it occurs to drain excess fluid and relieve pressure on the brain.
Limb lengthening
Some people with dwarfism choose to undergo surgery called extended limb lengthening. This procedure is controversial for many people with dwarfism because, as with all surgeries, there are risks.
Because of the emotional and physical stress of multiple procedures, waiting until the person with dwarfism is old enough to participate in the decision to have the surgery is recommended.
Ongoing health care
Regular checkups and ongoing care by a doctor familiar with dwarfism can improve quality of life.
Because of the range of symptoms and complications, treatments are tailored to address problems as they occur, such as assessment and treatment for ear infections, spinal stenosis or sleep apnea.
Adults with dwarfism should continue to be monitored and treated for problems that occur throughout life.
In many cases, people with dwarfism have orthopaedic or medical complications. Treatment of those can include:
- A tracheotomy to improve breathing through small airways.
- Corrective surgeries for deformities such as cleft palate, club foot, or bowed legs
- Surgery to remove tonsils or adenoids to improve breathing problems related to large tonsils, small facial structures, and/or a small chest.
- Surgery to widen the spinal canal to relieve spinal cord compression.
Other treatments may include:
Physical therapy to strengthen muscles and increase joint range of motion.
Back braces to improve curvature of the spine
Placement of draining tubes in the middle ear to help prevent hearing loss due to repeated ear infections.
Orthodontic treatment to relieve crowding of teeth caused by a small jaw.
Nutritional guidance and exercise to help prevent obesity, which can aggravate skeletal problems.
Life style and home remedies
Talk with the pediatrician or a specialist about home care. Issues particularly critical for children with disproportionate dwarfism include:
Car seats. Use an infant car seat with firm back and neck supports. Continue using a car seat in the rear-facing direction to the highest weight and height possible (and beyond the recommended age limit).
Infant carriers and play equipment. Avoid infant devices such as swings, umbrella strollers, carrying slings, jumper seats and backpack carriers that don’t support the neck or that curve the back into a C shape.
Adequate support. Support the child’s head and neck when he or she is seated.
Complications. Monitor the child for signs of complications, such as ear infection or sleep apnea.
Posture. Promote good posture by providing a pillow for the lower back and a footstool when the child is sitting.
Healthy diet. Begin healthy eating habits early to avoid later problems with weight gain.
Healthy activities. Encourage participation in appropriate recreational activities, such as swimming or bicycling, but avoid sports that involve collision or impact, such as football, diving or gymnastics.
Coping and support. If a child has dwarfism, a number of steps to help him or her cope with challenges and function independently:
Seek help. Organizations provides social support, information about disorders, advocacy opportunities and resources. Many people with dwarfism stay actively involved in this organization throughout their lives.
Modify the home. Make changes in the home, such as putting specially designed extensions on light switches, installing lower handrails in stairways and replacing doorknobs with levers.
Provide personal adaptive tools. Everyday activities and self-care can be a problem with limited arm reach and problems with dexterity. An occupational therapist also may be able to recommend appropriate tools for home and school use.
Talk to educators. Talk to school personnel about what dwarfism is, how it affects the child, what needs the child may have in the classroom and how the school can help meet those needs.
Talk about teasing. Encourage the child to talk to you about his or her feelings, and practice responses to insensitive questions and teasing.
If the child tells you that bullying occurs in school, seek help from the child’s teacher, principal or the school guidance counselor and ask for a copy of the school’s policy on bullying.

Complications of Dwarfism

Complications of dwarfism-related disorders can vary greatly, but some complications are common to a number of conditions.

Disproportionate dwarfism

The characteristic features of the skull, spine and limbs shared by most forms of disproportionate dwarfism result in some common problems.
Delays in motor skills development, such as sitting up, crawling and walking.
Frequent ear infections and risk of hearing loss.
Bowing of the legs.
Difficulty breathing during sleep (sleep apnea).
Pressure on the spinal cord at the base of the skull.
Excess fluid around the brain (hydrocephalus).
Crowded teeth
Progressive severe hunching or swaying of the back with back pain or problems breathing
Narrowing of the channel in the lower spine (spinal stenosis), resulting in pressure on the spinal cord and subsequent pain or numbness in the legs
Arthritis
Weight gain that can further complicate problems with joints and the spine and place pressure on nerves

Proportionate dwarfism

With proportionate dwarfism, problems in growth and development often result in complications with poorly developed organs. For example, heart problems often present in Turner syndrome can have a significant effect on health.
An absence of sexual maturation associated with growth hormone deficiency
Turner syndrome affects both physical development and social functioning.
Pregnancy
Women with disproportionate dwarfism may develop respiratory problems during pregnancy. A C-section (cesarean delivery) is almost always necessary because the size and shape of the pelvis doesn’t allow for successful vaginal delivery.
Public perceptions
Most people with dwarfism prefer not to be labeled by a condition. However, some people may refer to themselves as dwarfs or little people.
People of average height may have misconceptions about people with dwarfism. And the portrayal of people with dwarfism in modern movies often includes stereotypes.
Misconceptions can impact a person’s self-esteem and limit opportunities for success in school or employment.
Children with dwarfism are particularly vulnerable to teasing and ridicule from classmates. Because dwarfism is relatively uncommon, children may feel isolated from their peers.

Dwarfism (Panhypopituitarism) Read More »

Acromegaly & Gingatism (Hyperpituitarism)

Acromegaly and gigantism can also be referred to as hyperpituitarism and the most common cause is prolonged hypersecretion of growth hormone (GH), usually by a hormone-secreting pituitary tumour. The conditions are only occasionally due to excess growth hormone releasing hormone (GHRH) secreted by the hypothalamus. As the tumour increases in size, compression of nearby structures may lead to: hyposecretion of other pituitary hormones of both the anterior and posterior lobes damage to the optic nerves, causing visual disturbances.

The effects of excess GH include:
> excessive growth of bones
> enlargement of internal organs
> formation of excess connective tissue
> enlargement of the heart and raised blood pressure
> reduced glucose tolerance and a predisposition to diabetes mellitus.

Growth hormone stimulates skeletal and soft tissue growth. Growth hormone (GH) excess therefore produces gigantism in children and acromegaly in adults.

Gigantism occur before fusion of the diaphysis and an individual increases in height
reaching 7-8 feet.
Acromegaly occur after fusion of the diaphysis with the epiphysis and there is enlargement of the acral parts
Both are caused due to a pituitary tumor in almost all cases

Clinical presentation growth hormone hypersecretion.

Changes in appearance (physical)
Visual field defects or headaches
Diabetes
Hypertension
Dermatological problem ie coarsening of the face, broad thick nose, prominent eye brows and spade like hands
Elongation and widening of the mandible
Sleep apneas
Sweating
Headaches
Soft tissue swelling i.e lips, tongue, heal pad…
NB: other signs of Acromegaly
Tiredness
Weight gain
Amenorrhea
Breathlessness
Pain / tingling in hands
Deep voice
Goiter
Muscular weakness
Joint pains
Hypopituitarism also can occur

Diagnosis
> It is confirmed by finding high basal levels of growth hormone
> CT-scan to rule out pituitary adenoma

Medical Management

Drugs

Bromocriptine
Cabergoline

These could be used together with injection octreotide that slow down the production of growth hormones

Radiation therapy : This suppress the growing tumour

Surgical intervention : This involves surgical removal of the tumour

Nursing Management of Acromegaly

PREOPERATIVE. At the time of diagnosis, the patient requires education and emotional support. Focus education on the cause of the disease, the prescribed medical regimen, and preparation for surgery. Encourage the patient to interact with family and significant others. Reassure the patient that treatment reverses some of the physical deformities. If you note disabling behavior, refer the patient to psychiatric resources.

Prepare the patient and family for surgery. Explain the preoperative diagnostic tests and examinations. For a patient who is undergoing a transsphenoidal hypophysectomy or a transfrontal craniotomy, explain the postoperative need for nasal packing and a mustache dressing.

POSTOPERATIVE. Elevate the patient’s head to facilitate breathing and fluid drainage. Do not encourage the patient to cough, as this interferes with the healing of the operative site. Provide frequent mouth care, and keep the skin dry. To promote maximum joint mobility, perform or assist with range-of-motion exercises. Encourage the patient to ambulate within 1 to 2 days of the surgery. To assure healing of the incision site, explain the need to avoid activities that increase intracranial pressure, such as toothbrushing, coughing, sneezing, nose blowing, and bending.

Discharge and Home Healthcare Guidelines Referrals

Refer patients with advanced acromegaly who experience arthritic changes and require assist devices for ambulation and activities of daily living to a physical therapist.

ACTIVITY RESTRICTIONS. Instruct the patient to avoid activities that increase intracranial pressure for up to 2 months after surgery. Toothbrushing can be resumed in 2 weeks. Instruct the patient to report increased nasal drainage. Incisional numbness and altered olfaction may occur for 4 months after surgery.

MEDICATIONS. If octreotide is prescribed, the patient will need to be able to demonstrate how to administer a subcutaneous or intramuscular injection.

FOLLOW-UP. Patients need to be monitored for development of cardiac disease, diabetes mellitus, and gallstones and a recurrence of symptoms. Advise the patient to wear a medical identification bracelet.

Complications

Sterility in females and importance in males
Poor learning ability
Lack of sexual development
Poor concentration
Irritability
Heart disease
Diabetes mellitus
Gallstone
Enlargement of internal organs like heart, liver
Cancer
Polyp formation

Acromegaly & Gingatism (Hyperpituitarism) Read More »

Endocrine System

REVIEW OF ANATOMY AND PHYSIOLOGY OF ENDOCRINE SYSTEM

Endocrine system is a system of ductless glands, which secrete hormones that are pored in the blood stream to be transported to the target cells.
The endocrine system is composed of the following

Pituitary gland
Parathyroid gland
Thyroid gland
Adrenal gland
Pancreas
Tests and ovaries

Hormones secreted by these glands act on the specific target tissue away from their site of secretion. Some hormones are protein in nature while others are not.

They act by interacting with specific cell membrane receptors to stimulate the intra cellular Adenylyl cyclase system (membrane-bound enzyme that catalyzes the conversion of Adenosine triphosphate (ATP)-organic compound that provides energy to drive many processes in living cells, such as muscle contraction, nerve impulse to Cyclic adenosine monophosphate (cAMP) – messenger used for intracellular signal induction, which in turn forms ATP to stimulate protein synthesis.

Hormones regulate their own production through a feedback (negative feedback mechanism) system where the increase in concentration of the hormone suppresses its own production.

Pituitary gland

The pituitary gland secretes hormones like; (Anterior lobe)

Adrenocorticotrophic hormone (ACTH)
Somatotrophic hormone (STH)/(GH)
Thyroid stimulating hormone (TSH)
Follicle stimulating hormone (FSH)
Luteinizing hormone (LH)’
Melanocyte stimulating hormone (MSH)

The Posterior lobe secretes

Anti diuretic hormone (ADH),
Vasopressin
Oxytocin.

Secretion of the anterior lobe is under the control of Hypothalamus which secretes regulatory hormones.

Growth hormone stimulates muscular and skeletal growth either by regulating synthesis of somatomedins by the liver or by directly stimulating incorporation of amino acids into proteins.
Hypoglycemia is a potent stimulant of growth hormone release; obesity blunts its release.
Excess secretion of growth hormone after epiphyseal fusion produces acromegaly where as before epiphyseal fusion causes gigantism

Image showing hormones produced by the anterior lobe.

Overview of the Endocrine System

The endocrine system consists of glands widely separated from each other with no physical connections . Endocrine glands are groups of secretory cells surrounded by an extensive network of capillaries that facilitates diffusion of hormones (chemical messengers) from the secretory cells into the bloodstream. They are commonly referred to as ductless glands because hormones diffuse directly into the bloodstream. Hormones are then carried in the bloodstream to target tissues and organs that may be quite distant, where they influence cellular growth and metabolism.

Homeostasis of the internal environment is maintained partly by the autonomic nervous system and partly by the endocrine system. The autonomic nervous system is concerned with rapid changes, while endocrine control is mainly involved in slower and more precise adjustments.
Although the hypothalamus is classified as a part of the brain rather than an endocrine gland, it controls the pituitary gland and has an indirect effect on many others.

The ovaries and the testes secrete hormones associated with the reproductive system after puberty. The placenta that develops to nourish the developing fetus during pregnancy also has an endocrine function. In addition there are also other hormones that do not travel to remote target organs but act locally.

Overview of hormones

When a hormone arrives at its target cell, it binds to a specific receptor, where it acts as a switch influencing chemical or metabolic reactions inside the cell.

The level of a hormone in the blood is variable and self-regulating within its normal range. A hormone is released in response to a specific stimulus and usually its action reverses or negates the stimulus through a negative feedback mechanism. This may be controlled either indirectly through the release of hormones by the hypothalamus and the anterior pituitary gland, e.g. steroid and
thyroid hormones, or directly by blood levels of the stimulus, e.g. insulin and glucagon.

The effect of a positive feedback mechanism is amplification of the stimulus and increasing release of the hormone until a particular process is complete and the stimulus ceases, e.g. release of oxytocin during labour

Endocrine System Read More »

Normal First Stage Of Labour

PHYSIOLOGY OF FIRST STAGE OF LABOUR:

UTERINE ACTION

Fundal dominance;
Each uterine contraction starts from the fundus near the cornua and spreads across and down wards.
The contraction lasts longer in the in the fundus where it is most intense but the peak is reached simultaneously over the whole uterus and the contractions fade from all parts together.
This permits the cervix to dilate and the strongly contracting fundus to expel the fetus.

Polarity
This is a neuromuscular harmony that prevails between the two poles of the uterus throughout
labour.
During a contraction, these two poles act harmoneously. The upper uterine segment contracts strongly and retracts to expel fetus and the lower pole contracts slightly and dilates to allow expulsion of the fetus. If polarity is disorganized, labour progress is inhibited.

Contraction and retraction
During labour, a contraction does not pass off entirely but muscle fibres retain some of the shortening contractions instead of becoming completely relaxed. This is termed as retraction. This is a unique property of the uterine muscles and because of this,
the upper uterine segment becomes shorter and thicker and diminishes its cavity assisting in expulsion of the fetus.

Formation of the upper and lower uterine segment
By the end of pregnancy, the body of the uterus has divided into two segments;
> The upper segment is mainly for contraction and is muscular and thicker while the lower uterine segment is for distension and dilatation and is thinner.
> The lower segment develops from the isthmus and is about 8-10cm in length.

Retraction ring

This is a ridge formed between the upper and lower uterine segment.
The physiological retraction ring gradually rises when the upper uterine segment contracts and retracts and lower uterine segment thins out to accommodate the descending fetus.
This ring is not usually visible and when cervix is fully dilated and fetus can leave the uterus, it rises no further.
An exaggerated phenomenon of retraction ring in obstructed labour it becomes visible above the
symphysis pubis. This is termed as a bundle’s ring

2. CERVICAL ACTION

Cervical effacement
This is inclusion of the cervical canal. The muscle fibres surrounding the internal os are drawn upwards by the retracted upper uterine segment and the cervix merges into the lower uterine segment.

Cervical dilatation
This is the process of enlargement of the os from a tightly closed aperture to an opening large enough to permit passage of the fetal head.
It is measured in cm. a full dilatation at term equates to 10cm.
Pressure applied by the bag of fore waters and a well flexed fetal head closely applied to the cervix favors efficient dilatation.

Show
This is blood stained mucus which is seen before or at the onset of labour. The mucus is a thick mucoid substance which forms the cervical plug (opeculum) during pregnancy. Blood comes from raptured capillaries when the chorion has become detouched from the dilating cervix.

3. MECHANICAL FACTORS

Formation of fore waters

As the lower uterine segment stretches, the chorion becomes detouched from it and the increased intra uterine pressure causes this loosened part of the sac of fluid to bulge down wards into the dilating internal os. A well flexed head fits snugly into the cervix and cuts off the fluid in front of the head from that surrounding the body. The water in front is known as fore waters and that
behind is called hind waters.
General fluid pressure
When the membranes are intact, the pressure of the uterine contractions is exerted on the fluid and since the fluid is not compressible, the pressure is applied on the uterus and over the fetal
body. This is termed as general fluid pressure.
When membranes rapture and quantity of fluid escapes, the fetal head, placenta and umbilical cord will be compressed between the uterine wall and body of fetus during contraction resulting in reduced oxygen supply to the fetus.

Rapture of membranes
The optimum physiological moment for membranes to rapture is at the end of 1st stage of labour when the cervix becomes fully dilated and no longer supports the bag of fore water.
The uterine contractions are also applying increasing expulsive force at this time. Membranes may also rapture days before labour begins or during 1st stage of labour especially in a badly
fitting presenting part.
Occasionally, membranes do not rapture even in 2 nd stage and appear at the vulva as a bulging sac covering the fetal head as it is born. This is known as caul(CAL DE SAC)

Fetal axis pressure

During the contraction, the uterus rises forward and the force of fundal contraction is transmitted to the upper pole of the fetus down the long axis of the fetus and is applied to the cervix by the presenting part. This becomes more significant after rapture of membranes and during 2 nd stage of labour.

Descent of the presenting part.

It refers to the downward and outward movement of this part through the pelvis.
The normal well flexed head twists and turns flexes and extends to maneuver through the pelvis.
There are 3 planes or obstacles involved in the process of descent:
– Pelvic inlet/ brim.
When the presenting part is at the level of the ischial spines, a pelvic brim mark, it indicates the largest part of the head has come through the brim. The head is thus engaged.
The presenting part is now at station 0.
– Pelvic cavity.
When the presenting part has descended to the perineum, the largest part has passed the ischial
spines. The head is now at station +2.
– Pelvic outlet.
Delivery of the head brings it past the 3 rd obstacle ( pelvic outlet), which is under the pubic arch, between the ischial tuberosities and over the coccyx.
NB: station is the relationship of the lowermost part of the presenting part to an imaginary line
drawn between the ischial spines and the woman’s pelvis.

MANAGEMENT OF FIRST STAGE OF LABOUR

Aims

To monitor labour progress.
To prevent maternal exhaustion.
To prevent infections.
To give comfort to the mother and maintain patient’s moral.
To relieve pain.
To prevent complications.

Admission of a mother in labour
Welcome the mother and her relatives to allay fear and anxiety, create rapport.
Obtain full history and review the antenatal card while the mother is sitting or lying on
the couch.
The histories taken include;-
-Demographic data
-Date and time of admission
-When contractions started
-Frequency and strength of contractions
-If membranes raptured
Obtain consent from the mother and sign. Make sure mother is given sufficient
information before she decides to give consent.
Vital observations;- pulse ½ hourly if >100b/m indicates pain, anxiety, infections,
ketosis, hemorrhage etc.
– Blood pressure 2 hourly
– Temperature 4 hourly
-Respiration 4 hourly (16-20r/m)
Investigations e.g.- Urinalysis to rule out acetones, glucose and proteins.- Blood for Hb estimation, grouping and cross matching can be obtained depending on mother’s condition.
General examination The midwife examines a mother from head to toe paying more attention to general appearance (health or ill), size, any deformity, signs of anaemia, jaundice, oedema, dehydration, infections, Vericose veins and enlarged glands and veins in the neck. Examine the breasts and notice their suitability for breast feeding.
Abdominal examination: The mother’s bladder should be empty. It’s done following 3 steps.

-Inspection:-for size, shape, scars, signs of pregnancy etc
-Palpation: – Noting tenderness, height of fundus, presentation, lie, position, descent,
contractions, frequency, length and strength.
-Auscultation: – Noting rate, regularity and volume.

Vaginal examination.

This is a sterile procedure carried out on a woman through the vagina to rule out obstetrical or
gynecological abnormalities.

Indications of VE during pregnancy

> To confirm pregnancy
> To exclude abnormalities e.g. fibroids
> For pelvic assessment
> To determine the state of the cervix
> To confirm the type of abortion
> To rule out abnormal discharges
> During labour

During First stage

> To determine cervical dilation

> To exclude cord prolapse when membranes rapture
> To confirm full dilation when mother is bearing down.
> Before induction of labour to determine state of the cervix
> In prolonged labour to rule out obstructed labour.
> To make a positive identification of the presentation.
> To determine if the presenting part is engaged.

–During Second stage
> To confirm full dilation of the cervix
> When there is no descent to determine the delay e.g. face to pubis
> After delivery of the 1st twin to determine the presentation of the 2nd twin.

-During Third stage
> In delayed 3rd stage of labour to know whether the placenta is in the birth canal where it can be
removed quickly.
> To exclude lacerations and expel clots from the birth canal.
> In emergency i.e. manual removal of placenta.
> During puerperium
To find out whether the perineum has healed after 6 weeks.
> To find out whether the reproductive organs have regained their muscle tone and position.
> To obtain a specimen for examination.
> In abnormal vaginal discharge to confirm the type of infection.

Contraindications of VE

In APH and elective caesarian section

Complications of VE
-Infections
-Early rapture of membranes.
-Trauma or lacerations to the birth canal

Requirements
Tray containing;
> Galipot for swabs with antiseptic
> 2 receivers
> Sterile gloves
> Vaginal speculum
> Sterile bowl for lotion.
> Perineal pad/ clean pads
> Sheet and mackintosh.
> Clean gloves.
> Lubricant
At the bed side
> Screen
> Hand washing equipment
> Bed pan

PROCEDURE OF VAGINAL EXAMINATION

Welcome and explain procedure to the mother.
Empty bladder and screen the bed.
Assemble a VE tray.
Ask mother to relax during examination.
Woman’s arms should be down by her sides or across her abdomen to relax her abdominal
muscles.
Assist her into dorsal position and drape her.
Put on clean gloves
Place mackintosh and draw sheet under the buttocks
Remove gloves and wash hands thoroughly and put on sterile gloves.
Observe the external genitalia. Before the midwife cleans the vulva, should observe the
following;-
– Hygiene
– Labia for signs of varicosities.
– Oedema
– Vulval warts
– Sores
– If the perineum has old scars for tears, episiotomy, female circumcision.
– Any discharge from the vaginal opening i.e. blood, raptured membranes, smell of liquor
and colour.
– If liquor smells, it indicates infections. If green or meconium stained, indicates fetal
distress.
Vulva is swabbed using the left hand, swab from the front towards the rectum.
The 2 fingers of the right hand are dipped in the antiseptic cream for lubrication and gently inserted down wards and backwards into the vagina while the labia majora are held apart by the fingers of the left hand.
The fingers are directed along the anterior vaginal wall and should not be withdrawn until the
required information has been obtained. NB: The clitoris should not be touched because it causes discomfort.

Findings:

Condition of the vagina;

The vagina should feel warm and moist. A hot and dry vagina is a sign of obstructed labour and should not be found in modern obstetric care.
If a mother has a high temperature, the vagina will feel correspondingly hot but not dry.
Previous scar from Perineal wound, cystocele or rectocele.

The cervix;
The normal should feel thin and elastic and well applied to the presenting part.
A spongy feeling may show undiagnosed placenta previa.
The midwife should sweep the examining fingers from side to side to locate the os. It is usually felt in the center but sometimes in early labour, it is very posterior.
The length of the cervical canal assessed through a tightly closed cervix shows that labour has not yet started.
In a PG, the cervix can be completely taken up(effaced) but still closed and in this manner, it will be closely applied to the presenting part and it can be confused with a fully dilated cervix. If poorly applied to the presenting part, then it means there is an ill-fitting presenting part.
Assess cervix for; effacement, dilatation, consistency.

Membranes;
When membranes are intact, they can be felt through the dilating os; they feel tenser on contraction. When the fore waters are shallow, it is not easy to feel membranes.
If the presenting part does not fit well in or at the cervix, some of the fluid from the hind waters escapes into the fore waters causing the membranes to bulge or protrude through the cervix and are liable to rapture early.

Level or station of presenting part;
The presenting part is that part of the fetus that lies over the internal os during labour.
In order to assess the descent of the fetus in labour, the level of presenting part is assessed or estimated in relation to maternal ischial spines.

Position;
On feeling the features of the presenting part, the position of the fetus can be detected. The vertex is the normal presentation and the midwife must be familiar with it. Commonly the first feature to be felt even in early labour is the sagittal suture. The sagittal suture should be followed with a finger until a fontanel is reached.
If the head is well flexed, the posterior fontanel will be felt. This can be judged by feeling the amount of overlapping of the skull bones and can give additional information on position.
The parietal bones override the occipital bone to reduce the distance of the presenting diameter.

Pelvic capacity (pelvic assessment);
Although the pelvis was assessed during ANC period, the midwife should take opportunity to assure herself of its adequacy as she completes vaginal examination.
At completion of examination, withdraw fingers from the vagina and note any blood or amniotic fluid, cleans up the mother and removes gloves.
Record all findings of what was observed on admission on a partograph and observation chart.

Normal First Stage Of Labour Read More »

Clinical features of Foreign bodies in the ear

GENERAL MANAGEMENT

WAX IN THE EAR OR IMPACTED CERUMEN

Causes of impacted cerumen

Clinical features

Management

Peri-Operative Care (Summary)

Pre-Operative Care

Post-Operative Care

Tumors of the Ear

Types of Tumors of the Nose:

Tumors of the Throat:

ADENOID HYPERTROPHY

Causes of Adenoid Hypertrophy

Classifying Adenoid Hypertrophy

Clinical Features of Adenoid Hypertrophy

Diagnosis of Adenoid Hypertrophy

Management of Adenoid Hypertrophy

USES OF A PARTOGRAPH

Starting a partograph:

FETAL CONDITION

LABOUR PROGRESS

MATERNAL CONDITION

Further mgt in the normal 1st stage of labour- nursing care

What to report

Complications

Causes of Cushing’s Syndrome

Clinical Presentation of Cushing’s syndrome.

Diagnosis

Management

Nursing Care

Clinical Presentation

Diagnosis

Management

Treating a phaeochromocytoma

Addison’s disease

Pathophysiology

Causes of Addison’s Disease(Can be predisposing Factors too)

Clinical Presentation of Addison’s Disease:

Diagnosis of Addison’s Disease:

Complications of Addison’s Disease:

Medical Management

Nursing Care

Types Of Dwarfism

Disproportionate dwarfism

Proportionate dwarfism

Causes of Dwarfism

Diagnosis of Dwarfism

Medical Management

Surgical Management

Complications of Dwarfism

Clinical presentation growth hormone hypersecretion.

Medical Management

Nursing Management of Acromegaly

Discharge and Home Healthcare Guidelines Referrals

Complications

REVIEW OF ANATOMY AND PHYSIOLOGY OF ENDOCRINE SYSTEM

Pituitary gland

Overview of the Endocrine System

Overview of hormones

PHYSIOLOGY OF FIRST STAGE OF LABOUR:

UTERINE ACTION

2. CERVICAL ACTION

3. MECHANICAL FACTORS

Descent of the presenting part.

MANAGEMENT OF FIRST STAGE OF LABOUR

Vaginal examination.

Indications of VE during pregnancy

Contraindications of VE

PROCEDURE OF VAGINAL EXAMINATION

Findings: