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Respiratory distress syndrome

Infant respiratory distress syndrome (IRDS), also called neonatal respiratory distress syndrome, (previously called hyaline membrane disease (HMD), is a syndrome in premature infants caused by developmental insufficiency of pulmonary surfactant production and structural immaturity in the lungs.

Respiratory distress syndrome (RDS) occurs in babies born early (premature) whose lungs are not fully developed. The earlier the infant is born, the more likely it is for them to have respiratory distress syndrome RDS and need extra oxygen and help breathing.
RDS is caused by the baby not having enough surfactant in the lungs. Surfactant is a liquid made in the lungs at about 26 weeks of pregnancy. As the fetus grows, the lungs make more surfactant.
Surfactant is a liquid that coats the inside of the lungs. It helps keep them open so that infants can breathe in air once they are born.

Causes of Respiratory Distress Syndrome

Lack or insufficient surfactant
It can also be a consequence of neonatal infection.
It can also result from a genetic problem with the production of surfactant associated proteins.

Risk Factors

Premature birth (before 37 weeks)
A sibling with respiratory distress syndrome
Multiple pregnancy (twins, triplets)
Impaired blood flow to the baby during delivery
Delivery by cesarean
Maternal diabetes
infection
Induction of labor before the baby is full-term
Multiple pregnancy (twins or more)
Cold stress. Baby with trouble of maintaining body temperature
Patent ductus arteriosus
Rapid labor
Prematurity

Pathophysiology

The lungs of infants with respiratory distress syndrome are developmentally deficient in a material called surfactant, which helps prevent collapse of the terminal air-spaces throughout the normal cycle of inhalation and exhalation.

This deficiency of surfactant is related to an inhibition from the insulin that is produced in the newborn especially in diabetic mothers. Deficient surfactant production causes un equal inflation of alveoli on inspiration and collapse of alveoli on end of expiration.

In this case their lungs inflate and therefore exert a great deal of effort to re-expand the alveoli with each breath with increasing exhaustion, they will be able to open the alveoli.

Inability to maintain lung expansion produces a wide spread of atelectasis. Progressive atelectasis with absence of alveolar stability will lead to increased pulmonary vascular resistance where as in normal cases it is supposed to decrease. Consequently there will be hypertension to the lung tissue a (pulmonary hypertension)decrease in effective pulmonary blood flow.

Phases of ARDS (Pathogenesis)

ARDS has three phases—exudative, proliferative, and fibrotic.

1. Exudative Phase

In this phase, alveolar capillary endothelial cells and type I pneumocytes (alveolar epithelial cells) are injured, and tight alveolar barrier is damaged giving away the entry to fluid and macromolecules. The protein rich edema fluid accumulates in the interstitial and alveolar spaces. Pro-inflammatory cytokines are increased in this acute phase, leading to the recruitment of leukocytes (especially neutrophils) into the pulmonary space and alveoli. There is plasma proteins aggregation in air spaces with cellular debris and dysfunctional pulmonary surfactant to form hyaline membrane whorls of which Alveolar edema predominantly leads to lung diminished aeration. Collapse of large sections of dependent lung can contribute to decreased lung compliance. It causes intrapulmonary shunting and hypoxemia develop and the work of breathing increases, leading to dyspnea.

The exudative phase encompasses the first 7 days of illness after exposure to a precipitating ARDS risk factor. Tachypnea and increased work of breathing result frequently in respiratory fatigue and ultimately in respiratory failure.

2. Proliferative Phase

This phase of ARDS usually lasts from day 7 to day 21. Most patients recover rapidly and are liberated from mechanical ventilation during this phase. Despite this improvement, many patients still experience dyspnea, tachypnea, and hypoxemia. Histologically, the first signs of resolution are often evident in this phase, with the initiation of lung repair, the organization of alveolar exudates, and a shift from neutrophil- to lymphocyte- pulmonary infiltrates.

As part of the reparative process, type II pneumocytes proliferate along alveolar basement membranes. These specialized epithelial cells synthesize new pulmonary surfactant and differentiate into type I pneumocytes.

3. Fibrotic Phase

Most patients with ARDS recover lung function within 3–4 weeks, very few progresses into fibrotic phase that may require long-term support on mechanical ventilators and/or supplemental oxygen. There is extensive alveolar-duct and interstitial fibrosis. Marked disruption of acinar architecture leads to emphysema-like changes, with large bullae.

Intimal fibroproliferation in the pulmonary microcirculation causes progressive vascular occlusion and pulmonary hypertension. The physiologic consequences include an increased risk of pneumothorax, reductions in lung compliance, and increased pulmonary dead space.

Signs and Symptoms

Infant respiratory distress syndrome begins shortly after birth
Fast breathing
Fast heart rate
Chest wall retractions (recession)
Expiratory grunting
Nasal flaring
Cyanosis
Ventilatory failure (rising carbon dioxide concentrations in the blood) as condition progresses
Prolonged cessations of breathing (“apnea”).
Reduced urine output

Diagnosis/Investigation

Signs and symptoms
Chest x-ray
Pulse Oximetry
Echocardiography
CT scans
Arterial blood gas (ABG) test to assess the level of oxygen, CO2, and acids in blood

Differential Diagnosis

Acute Anemia
Aspiration Syndromes
Pediatric Gastroesophageal Reflux
Pediatric Hypoglycemia
Pediatric Pneumonia
Pediatric Polycythemia
Pneumomediastinum
Pneumothorax
Transient Tachypnea of the Newborn

Management / Treatment

Delivery and resuscitation: A neonatologist experienced in the resuscitation and care of premature infants should attend the deliveries of fetuses born at less than 28 weeks’ gestation.
Keep the child warm
Oxygen is given with a small amount of continuous positive airway pressure
I.V. fluids (N/S, D5%; (Neonatalyte i.e. D50%= 70mls, D5% = 310 & R/L=120ML) are administered to stabilize the blood sugar, blood salts, and blood pressure.
In severe cases an endotracheal tube is inserted into the trachea and intermittent breaths are given by a mechanical device.
A preparation of surfactant (e.g. survanta or beraksurf), is given through the breathing tube into the lungs.
Administer a glucocorticoid e.g. dexamethasone (0.15mg /kg/dose; max dose 4mg)
Give an antibiotic to prevent secondary bacterial infection
Respiratory monitoring, pulse rate, Bp, temperature, ECG monitoring.
Monitor conscious level
Reassure the mother
NG tube feeding
Vitamin k 0.5-1mgm I.M due to risk of intraventricular hemorrhage.

Prevention

Giving the mother glucocorticoids speeds the production of surfactant. Glucocorticoid treatment is recommended for women at risk for preterm delivery prior to 34 weeks of gestation (dose 12-40mg)
Early antenal care
Eat healthy diet rich in vitamins
Avoid smoking and alcohol during pregnancy

Complications

Metabolic disorders (acidosis, low blood sugar)
Patent ductus arteriosus
Low blood pressure
Chronic lung changes
Bleeding in the brain.

CASE SCENARIO

A 1-day-old boy is brought to the intensive care unit from the nursery due to increased work of breathing. The patient was born at 31 weeks to a mother with a history of multiple preterm deliveries, polysubstance abuse and HIV. His temperature is 38°C (100.4°F), pulse is 215/min, respirations are 76/min, blood pressure is 60/41 mmHg, and oxygen saturation is 85% on room air. Physical exam shows tachypnea, nasal flaring, and subcostal retractions. Administration of supplemental oxygen and positive pressure ventilation improve the patient’s oxygen saturation to 95%. Blood glucose is 95 mg/dL. Chest x-ray and laboratory results are shown below:

Laboratory value	Result
Blood Gases, Serum
pH	7.23
PCO2	55 mmHg
PO2	30 mmHg

Which of the following best describes the etiology of this infant’s disease process?

2. Mike, a 55-year-old man, presents with shortness of breath, high fever, and cough. A chest x-ray was ordered and it showed a right lower lobe infiltrate, which is suggestive of pneumonia. He was then started on IV antibiotics but the following day Mike became hypoxic and hypotensive. Because his hypotension didn’t improve despite intubation, IV fluids, and vasopressors, he is diagnosed with septic shock. Next, a repeat x-ray detected newly-developed bilateral alveolar opacities, heart echography ruled out heart failure, and arterial blood gas analysis revealed a PF ratio of 109 milligrams Mercury.

3. Dona, an infant delivered by cesarean section at 36 weeks’ gestational age, with an Apgar score of 9 at birth. A few hours after delivery, she develops tachypnea, chest wall retractions with nasal flaring, and tachycardia. Aside from increased work of breathing, her physical examination findings are normal. A chest x-ray was ordered and it showed diffuse reticulogranular ground glass appearance with air bronchograms.

Detailed Review.

All the above scenerio’s point to respiratory distress syndrome

But first, a bit of physiology.

Normally, when you breathe in, the air reaches the alveoli, which are made up of two types of pneumocytes.

First, type I pneumocytes are thin, and have a large surface area that that facilitate gas exchange.

More important for the exams are the type II pneumocytes, which are smaller, thicker and have the ability to proliferate in response to lung injury.

They are in charge of making a fluid called surfactant which contains various phospholipids. This lets it act like droplets of oil that coats the inside of the alveoli, decreasing surface tension, so if it’s missing, the alveoli will collapse.

These cells also act like stem cells, meaning they can give rise to type I cells and type II pneumocytes.

Ok, so acute respiratory distress syndrome, or ARDS, is characterized by rapid onset of widespread inflammation in the lungs which can lead to respiratory failure.

ARDS is not a primary disease, as it is usually triggered by conditions like sepsis, aspiration, trauma, and pancreatitis.

Now ARDS starts when these conditions cause alveolar damage, and a high yield fact is that the injury triggers the pneumocytes to secrete inflammatory cytokines like TNF-alpha and interleukin 1.

This subsequently leads to neutrophil recruitment, and they will release toxic mediators, like reactive oxygen species and proteases, which will damage the lungs even more.

You’ll need to know that the main site of injury is the alveolar-capillary membrane, which becomes more permeable, causing fluid to move into the alveoli resulting in pulmonary edema. This fluid can impair gas exchange, leading to hypoxemia.

Furthermore, the edema can also wash away the surfactant coating the alveoli to the point where it can’t reduce surface tension anymore, and as a result, the alveoli collapse.

And finally, dead cells and protein-rich fluid start to pile up in the alveolar space and, over time, it forms these waxy hyaline membranes which look like a layer of glassy material.

Individuals with ARDS present with serious symptoms and signs that require urgent investigation. The inflammation process and impaired gas exchange lead to fever, shortness of breath, tachypnea, chest pain, hypotension, hypoxia, and cyanosis. More often than not, ARDS will lead to shock due to hypotension.

The excess fluid in the lungs can cause a crackling sound called rales during auscultation, which is the sound of collapsed alveoli popping open with inspiration.

Keep in mind additional symptoms might provide clues to the underlying cause.

For example, epigastric abdominal pain radiating to the back along with a history of gallstones indicate acute pancreatitis. Diagnosis of ARDS is typically made when the individual presents all of the next four criteria, which you should definitely remember for your exams. First, the symptoms have to be “acute” meaning an onset of one week or less.

Second, and particularly high yield, a chest X-Ray or CT scan shows opacities or “white out” in both lungs, which is due to pulmonary edema.

The third is what’s called the PF ratio. It’s the partial pressure of oxygen in the arterial blood divided by the percent of oxygen in the inspired air, also called the fraction of inspired oxygen.

In ARDS, gas exchange is defective so the PF ratio is below 300 mmHg, and the lower this ratio gets, the more severe the condition.

Fourth, the respiratory distress must not be due to cardiac causes, like heart failure.

Often this is assessed by using an echocardiogram to look for evidence of heart failure, like an ejection fraction below 55% in systolic heart failure, and abnormal relaxation of the myocardium in diastolic heart failure.

Another clue is the pulmonary capillary wedge pressure, which is measured by inserting a catheter into a small pulmonary arterial branch.

In heart failure, this is elevated because more blood remains in the left side of the heart and it prevents pulmonary venous return.

The blood backs up into the pulmonary vessels, and the increase in pressure pushes fluid into the interstitial space of the lungs, resulting in edema.

In ARDS, the pressure is normal since the edema is caused by leaky capillaries instead of increased pressure.

Treatment of ARDS ultimately comes down to treating the condition that triggered it. However, the most important initial step is supportive care, like supplemental oxygen or mechanical ventilation.

A high yield fact to remember is that it’s vital to maintain positive end-expiratory pressure, which is where the pressure in the lungs is kept slightly above atmospheric pressure, even after exhalation, because this prevents the alveoli from collapsing. It’s also good to have low tidal volumes to prevent over-inflation of the damaged alveoli. Another important thing to watch out for is positive pressure ventilation can cause compression of pulmonary vessels which leads to pulmonary hypertension decreased pulmonary venous return.

This will reduce cardiac output and hypotension might worsen.

Respiratory distress syndrome Read More »

Furunculosis

Furunculosis is the infection of the external ear canal lined by the skin which may be localized or generalized(diffuse).

It occurs in form of a boil. An ear furuncle is a boil that develops in the ear canal. It may be as a result of infection deep in the skin resulting in pus formation in the boil.

CAUSES OF FURUNCULOSIS

Bacteria i.e. streptococcus aureus, pseudomonas pyrogens, Hemolytic streptococci, Viral & Fungal infections

Other predisposing factors include:

Allergy
Foreign bodies
Presence of infected water in the ear
Injury to the ear

CLINICAL FEATURES

Pain and tenderness on pulling the ear that is thrombing in nature
Itching especially if the cause is fungal
Swelling
Pus discharge(thin mucopurulent discharge)
Hearing loss if it occludes the meatus
Inflammation of the neighboring lymph nodes
Difficulty in chewing

Diagnosis/Investigations

History and physical examination
If there is pus discharge, then a pus swab is done for microscopy, culture and sensitivity

NB: If the discharge is whitish or black, it indicates a fungal infection, If the discharge is yellow, it indicates a bacterial infection.

Management of furunculosis

Thorough cleaning of the ear by wicking
Then, apply an antibiotic like chloramphenicol ear drops 0.5% 2 drops 8hrly for 14 days.
If severe, add Caps cloxacillin 250-500mgs QID for 5 days, In children 12.5-25mgs per kg body weight.
Steroids like betamethasone ear drops
Analgesics for pain like PCT Ig tds for 3 days or Ibuprofen
You can also use warm icepacks to relieve pain

If the cause is fungal; Use clotrimazole solution apply O.D for 4-8 Weeks Or Fluconazole 200mg O.D for 10 days.
Proper drying the ear by ear wicking is very important

Complications

Otitis media
Meningitis
Septicemia
Sinus thrombosis

NURSING CARE PLAN OF FURUNCULOSIS MANAGEMENT

Assessment	Diagnosis	Planning (Goals/Expected Outcomes)	Implementation	Rationale	Evaluation
Swelling	Impaired Skin Integrity related to pus buildup as evidenced by tender lumps in the ear canal	Promote skin healing and alleviate discomfort.	– Administer prescribed antibiotics or antifungal medication based on the cause. – Encourage warm compresses to promote drainage. – Provide analgesic medication as prescribed. – Educate the patient on proper ear care and hygiene.	– Medication targets the underlying infection (bacterial or fungal). – Warm compresses aid in promoting drainage and relieving pain. – Analgesic medication helps alleviate pain and discomfort. – Patient education prevents further complications and promotes self-care.	Skin integrity was improved and the patient verbalised comfort.
Hearing loss if occluding the meatus.	Impaired Hearing related to occlusion of the meatus as evidenced by the patient verbalising reduced hearing ability.	Restore and maintain optimal hearing.	– Administer prescribed medications to reduce inflammation. – Encourage the patient to keep the ear dry and avoid inserting foreign objects. – Monitor hearing status and provide support as needed.	– Medication reduces inflammation, aiding in hearing restoration. – Keeping the ear dry prevents further complications. – Regular monitoring ensures early intervention if hearing status worsens.	Patient verbalised having had his hearing restored.
Inflammation of neighboring lymph nodes.	Impaired Lymphatic Drainage related to inflammation of neighboring lymph nodes as evidenced by swollen lymph nodes in the neck area.	Reduce inflammation and promote lymphatic drainage.	– Administer prescribed anti-inflammatory medication. – Encourage gentle massage and warm compresses to the affected lymph nodes. – Educate the patient on the importance of proper ear care to prevent recurrence.	– Anti-inflammatory medication reduces inflammation and promotes drainage. – Massage and warm compresses enhance lymphatic circulation. – Patient education supports preventive measures.	Inflammation was reduced and lymphatic drainage restored.
Difficulty in chewing.	Impaired Nutrition: Less Than Body Requirements related to difficulty in chewing as evidenced by patient verbalising pain on chewing.	Improve nutritional intake.	– Collaborate with the dietitian to plan a soft and nutritious diet. – Provide small, frequent meals that are easy to chew. – Monitor and record food intake.	– Soft and nutritious diet ensures adequate nutrition despite difficulty in chewing. – Small, frequent meals are easier to manage. – Monitoring food intake ensures nutritional needs are met.	Patient verbalised being able to eat soft meals.
Pain and tenderness on pulling the ear, throbbing in nature.	Disturbed Sleep Pattern related to pain and discomfort as evidenced by patient’s inability to get optimal sleep	Improve sleep pattern.	– Administer analgesic medication as prescribed. – Encourage the patient to find a comfortable sleeping position. – Provide a quiet and calm environment for sleep.	– Analgesic medication helps relieve pain and discomfort. – A comfortable sleeping position and a calm environment promote restful sleep.	Sleep pattern was improved.
Presence of furuncles with pus discharge.	Risk for Infection related to compromised skin integrity	Prevent secondary infections.	– Administer prescribed antibiotics or antifungal medication. – Teach the patient about proper wound care and hygiene. – Monitor for signs of infection (increased redness, swelling, or warmth).	– Antibiotics or antifungal medication target the infection. – Patient education on wound care reduces the risk of secondary infections. – Regular monitoring detects early signs of infection.	…..

Pain and tenderness on pulling the ear, throbbing in nature.

Acute Pain related to bacterial infection as evidenced by the patient pulling the ear, and having a 7/10 on a pain scale.

Alleviate pain to 1/10 on the pain scale within 1 hour

– Administer analgesic medication as prescribed.

– Encourage warm compresses to the affected area.

– Provide distractions and diversions to reduce focus on pain.

– Evaluate pain intensity using a pain scale.

– Analgesic medication helps alleviate pain.

– Warm compresses promote comfort and reduce pain.

– Distractions and diversions redirect the patient’s attention from pain.

– Regular pain assessments guide the effectiveness of interventions.

Pain was elevated with a scale reading of 1/10 within 1 hour

EPISTAXIS

This is bleeding from the nostrils/Nasal bleeding which may be arterial venous, or capillary

CAUSES OF EPISTAXIS

LOCAL CAUSES

Foreign bodies in the nostrils
Fracture in the base of the skull
Nose Picking
Trauma like blow to the nose
Tumours or new growth in the nose
Nasal polyps
Rupture of an artery or blood vessel in the nasal cavity

GENERAL CAUSES

They include systemic causes or disorders like;

- Hypertension
- Bleeding disorders(lack of clotting factors)
- Renal failure
- Genetical inheritance (i.e run in families) like in Telangiectasia(dilated small blood vessels)
- Allergic reactions
- Sickle cell trait or diseases
- Infections like Ebola, typhoid Crimean congo, Marburg fever, malaria etc.
- Rupture of distended blood vessel

Clinical Features

Bleeding from the nose
There may be pain in bleeding nostril
Signs and symptoms of shock in case of severe bleeding
Signs of the predisposing cause like Hypertension, Kidney failure, Ebola, malaria and typhoid

Management of Epistaxis

Management depends on the severity, cause and location of bleeding. It can be divided into pharmacological and non-pharmacological management.

Non-pharmacological management/First aid

Re assure the patient to allay anxiety
Put the patient in sit up position if not in shock and instruct him to tilt the head forward to avoid pooling the blood in the posterior pharynx.
Instruct the patient to pitch nostrils(the soft parts the nose) between fingers and the thumb for about 10-15 minutes and breath via the mouth and spit out any blood
Monitor vital observations i.e. TPR & BP to find out the underlying cause, if it is systemic
Apply a cold compress on the fore head using ice pads to facilitate and aid vasoconstriction.

If bleeding persists, pharmacological treatment is required.

If the cause is a foreign body, it is removed if visible using forceps and antibiotics are given.
Pack the nose with a piece of gauze soaked with adrenaline or vitamin K or TEO using forceps to stop bleeding .It is can be left in position for 24-48 hours.
Cauterization with electrical cautery or diathermy machine to seal off the bleeders can be done in theatre
Ligaturing of the bleeding blood vessels can also be done
Pressure can also be inserted on the bleeding area in the nose by inflating a special balloon which is inserted in the nose.
In severe bleeding, the patient is resuscitate with IV Fluids like normal saline or given oral fluids to prevent to prevent shock and dehydration.
Blood transfusion may also be considered depending on the lost blood after doing Hb, grouping and cross-matching.

Other investigations which may be done include;

Blood for CBC to rule out underlying infections
Blood Slide (b/s) Rule out Malaria Parasites
Bleeding and clotting time

Prevention of epistaxis

Early treatment and control of predisposing conditions like Hypertension.
Treatment of hemorrhagic infections like malaria and typhoid fever
Avoid nose picking
Avoid violence that could lead to blows to the nose
Seeking for medical attention and advice in case of re-occurrence.

Complications

Severe hemorrhage leading to anemia ,hemorrhagic shock, septic shock
Sinusitis
Pneumocephalus (presence of air or gas within the cranial cavity)
Septal pressure necrosis
Neurogenic syncope during packing
Epiphora (from blockage of lacrimal duct)
Hypoxia from impaired nosal air movement)
Infections may result if sterility is not maintained especially in nasal packing.

Furunculosis Read More »

Tonsillitis

Tonsilliitis is inflammation of the tonsils, two oval-shaped pads of tissue located at the back of the throat (one tonsil on each side). Tonsillitis is contagious especially before signs and symptoms show up. Tonsils act as filters, trapping germs that could otherwise enter the air way and cause infection in our body. They also make antibodies. Tonsillitis may be acute or chronic.

Tonsils

They consist of a mass of lymphoid tissue, situated on each side of the oropharynx.
They function as a defense mechanism.
They help prevent the body from infection.

CAUSES OF TONSILLITIS

Tonsillitis may be caused by viruses as in common cold(most common cause of tonsillitis causing viral tonsillitis), It is commonly caused by viruses causing viral tonsillitis. The viruses that causes the common cold are often the source of tonsillitis but other viruses cause it. These include; Rhino viruses, Epstein-Bar virus, Hepatitis A,HIV etc.

Since the Epstein Bar virus can cause both Mononucleosis & tonsillitis; some people with mono will develop tonsillitis as a secondary bacterial infection.

The other cause of tonsillitis is a bacteria. Normally the bacteria is called streptococcus( strep throat) but other bacteria’s can cause it, Tonsillitis is common in children between 5 and 8 years
The tonsils (made of lymphatic tissues) are frequently affected with acute infections.

TYPES OF TONSILLITIS

Acute tonsilitis
Chronic tonsilitis

ACUTE TONSILLITIS(Recurring): This is sudden generalized inflammation of tonsils. It is usually accompanied by inflammation of fornices and pharynx . It is common in children than adults, normally caused by group A Beta streptococcus and some times viruses.

CHRONIC TONSILLITIS: Is defined as persistent progressive inflammation of the tonsils . If acute attack re-occurs 5-6 times a year , it indicates that some one has failed to develop immunity &it is considered to be chronic

CLINICAL FEATURES OF TONSILLITIS

Sudden onset
Sore throat
Fever and shivering
Snoring due to obstruction
Headache and vomiting
Difficult in swallowing which may be painful
Enlarged tonsils with exudates
Enlarged lymph nodes
Excessive secretion of saliva
Halitosis
Neck stiffness, loss of weight especially in chronic
Sometimes coughing and stuffy nose in viral tonsillitis

DIAGNOSIS AND INVESTIGATIONS

History taking
Do a physical examination of the throat by palpating to feel for enlarged lymph nodes.
Pus swab from the back of the throat for C/S (Throat swab)
Blood for complete blood count(CBC) to check whether the cause is bacterial or viral for appropriate treatment.

Management can be Medical or Surgical

AIMS

To limit the spread/prevent spread
To relieve signs and symptoms like pain and fever
To treat the cause
To prevent complications

Admit the patient in medical isolation ward and emphasize Isolation and barrier-nurse the patient to limit the spread.
Re-assure the patient and relatives
Observations both vital (TPR & BP) Plus specific are taken and recorded i.e enlargement of tonsils.
Relieve high fever/temperatures by tepid sponging
Drugs: Administer Antibiotics especially Penicillin(Pen-V 500mgs 6hrly for 10 days) but if the cause is viral then they are not needed
Give analgesics to relieve pain or fever like Tablets Aspirin
Throat gaggling with normal saline
Encourage plenty of oral fluids(atleast 4-5 litres in 24hrs) and oral hygiene (mouth goggling)
Do daily nursing care like for any other patient.
If the patient is a child, support the neck while swallowing.
Give a highly nourishing soft and light diet gradually.
Hygiene-mouth care should be done frequently
Special observations
1. Observe for facial oedema in the morning which may be suggestive of nephritis
2. Observe for painful joints suggestive of rheumatic fever
3. Observe and monitor fluid in take and output for diminished urine output and albumin
4. Continue to observe for other complications

SURGICAL MANAGEMENT (only for chronic tonsilitis)

The management of chronic tonsillitis is the surgical removal of the tonsils i.e. ‘Tonsillectomy’. However in simple enlargement removal is not indicated. Normally tonsils in children are large but decrease in size with age.

The pre-operative mgt is like for any other condition.

TONSILLECTOMY

Tonsillectomy is a surgical removal of the enlarged tonsils. It is only indicated in severe and chronic tonsillitis and where the disease has chronically interfered with schooling(chronic re-occurrence and where there is fear of complications from the disease.

The operation is carried under general anesthesia and the tonsil is dissected from the underlying pharyngeal tissue.

Pre-operatively; The patient is prepared like any other patient for general operation but more emphasis put on oral care and pre-operative antibiotics like I.V Ceftriaxone

POST-OPERATIVE CARE

After handing over the patient to theatre staff, a post operative bed is made with all its accessories.

Post-operatively the patient is received & nursed on the lateral position with the head down in order to prevent the patient from in haling blood, tonsil fragments hence avoiding aspiration OR (recovery position) with the head down so as not to inhale blood or tonsil fragments. He/she is maintained in such position until alert.
Post operative observations are carried out i.e. TPR & BP
Observe the skin colour and observe for bleeding mostly detected on frequent swallowing and the patient will need to be returned to theatre for ligation of the bleeding points.
Encourage the patient to spit the secretions
Give antibiotics for prophylaxis/treat infections e.g iv ceftriaxone, in acute then penicillin v orally 6hrly.
The next day, the patient is encouraged to drink and eat soft foods.
Oral care-better using warm saline water(throat goggling) . When he improve , he is discharged on advice.

Complications of tonsilitis

Rheumatic fever
Nephritis
Asthma
Peri-tonsillar abscess(quinsy)
Peri-tonsillar cellulitis
Otitis media

Complications following tonsillectomy

Hemorrhage is the most common
Secondary bacterial infections.

Tonsillitis Read More »

Peritonsillar

PERITONSILLAR ABSCESS

Peritonsillar Abscess (Quincy) is defined as an abscess between the tonsil capsule and the lateral wall of the pharynx.

Peritonsillar abscess (Quincy) is a bacterial streptococcal infection that usually begins as a complication of untreated tonsillitis(often mild).

It generally involves a pus-filled pocket that forms near one of your tonsils. It is a collection of pus around the tonsils. It usually begins as a complication of untreated streptococcal throat or tonsillitis infection

If left untreated, the infection can spread deep into the neck and chest. Rarely in adults.

CAUSES OF PERITOSILLAR ABSCESS

Peritonsillar abscesses usually occur as a complication of tonsillitis. If the infection breaks out of a tonsil and spreads to the surrounding area, an abscess can form. Peritonsillar abscesses are becoming less common due to the use of antibiotics in the treatment of strep throat and tonsillitis.

Peritonsillar abscesses are caused by bacteria and these include,

Streptococcus pyogenes (the same that causes strep throat & tonsillitis
Fuso bacteria necrophorum (causes mastoiditis, sinusitis &meningitis
Staphylococcus
Haemophilus
Mononucleosis (commonly referred to as mono) can also cause peritonsillar abscesses, as well as tooth and gum infections. In much rarer cases, it’s possible for peritonsillar abscesses to occur without an infection. This is generally due to inflammation of the Weber glands. These glands are under the tongue and produce saliva.

CLINICAL PRESENTATION

Inability to open the mouth, salvation and dribbling
Severe throat pain
Dysphagia
Bad mouth odor (Halitosis)
Ptylism (excessive salvation)
Thickened muffled(un clear) speech
Ear pain -Fever, headache, malaise, rigors
Enlarged cervical lymph nodes
Tonsil and soft palate are reddish & edematous
Swelling pushing the uvula to opposite side (May be pointing(bulging collection of pus)
Otalgia (earache)
Enlarged cervical lymph nodes
Difficult in swallowing
Impaired speech
Swelling of the neck and face
Difficulty swallowing saliva (drooling)
Swelling of the face or neck

Investigations

Physical Examination: A thorough physical examination of the throat, neck, and oral cavity is essential to assess the presence of an abscess. The doctor will examine the tonsils, check for swelling, redness, and the presence of pus or fluctuance (a soft, fluid-filled area).
Throat Swab: A swab may be taken from the throat to identify the causative organism. This helps guide appropriate antibiotic therapy.
Complete Blood Count (CBC): A CBC test is performed to assess the white blood cell count. In cases of infection, the white blood cell count is often elevated, indicating an inflammatory response.
Ultrasound: An ultrasound may be performed to assess the size and location of the abscess. It can help differentiate between a peritonsillar abscess and other possible causes of throat pain.
CT Scan: In some cases, a computed tomography (CT) scan of the neck may be ordered. It provides detailed imaging of the area and helps determine the extent and location of the abscess.
Blood Cultures: Blood cultures may be obtained to identify the causative organism and guide appropriate antibiotic therapy, especially in severe or complicated cases.

Management Of Peritonsillar

Aims:

To drain the abscess
Promote healing by relieving symptoms & treating the cause
Prevent complications

Admission

The patient is admitted in surgical ward& on complete bed rest
Baseline vital observations are taken and recorded
In severe cases, where the patient’s airway is affected, oxygen therapy is provided.
Pain is managed with analgesics like diclofenac 75 mgs or tramadol 50mgs start.
General and systemic examination is done, to rule out other health problems.
After this, an iv line is secured and intravenous fluids are administered eg dextrose alternate with normal saline are administered to maintain the body fluids
Antibiotics like penicillin may be given to control the spread of infection before the operation

PRE-OPERATIVE CARE.

Explain to the patient what is going to happen
Gaining an informed consent from the patient is very essential.
Pass an NGT to help in feeding after surgery.
Oral care is performed to minimise infection after surgery.

IN OPERATING THEATRE;

- Incision and drainage of the abscess is done.
- Tonsillectomy is performed (simultaneous tonsillectomy with open abscess drainage and oral packing to control bleeding.

ON WARD

- Suction for oral secretions to prevent aspiration.
- Fluid resuscitation as necessary i.e I.V N/S
- Anti-pyretics and analgesics are prescribed and administered
- Bleeding is prevented by gentle handling of the patient avoiding coughing, laughing, and opening the mouth widely.
- Soft food and drinks can be tried later.
- Oral hygiene is maintained until full recovery.
- Antibiotics are administered as prescribed to prevent infection.
  - Nsaids like ibuprofen are administered to control inflammation and fever.
  - IV benzyl penicillin 2 mu 6 hly for 48hrs then switch to Amoxil 500mgs tds for 7days or
  - Alternative iv ceftriaxone 1 g od for 7 days
  Children 50mg/kg iv
  - Plus Iv metronidazole 500mg 8hrly .if unable to take oral fluids, set up an IV drip of Normal saline
  - Daily routine Nursing care is provided till the patient is fit for discharge.
  Advice:
  - Early treatment for streptococcal throat.
  - Oral hygiene.

NURSING CARE PLAN.

Assessment	Diagnosis	Planning (Goals/Expected Outcomes)	Implementation	Rationale	Evaluation
Inability to open the mouth, salvation and dribbling, severe throat pain, dysphagia, bad mouth odor (Halitosis), Ptylism (excessive salvation), thickened muffled(un clear) speech.	Impaired Oral Mucous Membrane related to peritonsillar abscess evidenced by difficulty swallowing, thickened speech, excessive salvation, and bad mouth odor.	Maintain oral hygiene and alleviate discomfort.	– Administer prescribed antibiotics and analgesics. – Encourage regular oral care, including gentle rinsing with saline solution. – Provide pain management interventions (e.g., cold compresses).	– Antibiotics target the bacterial infection. – Regular oral care prevents secondary infections and promotes comfort. – Pain management interventions reduce discomfort.	Maintained oral hygiene, reduced discomfort.
Fever, headache, malaise, rigors, enlarged cervical lymph nodes.	Hyperthermia related to systemic infection evidenced by fever, malaise, headache, and rigors.	Reduce fever and promote comfort.	– Administer antipyretic medication as prescribed. – Encourage adequate fluid intake. – Provide cooling measures (e.g., tepid sponging).	– Antipyretic medication helps lower fever. – Adequate fluid intake prevents dehydration. – Cooling measures aid in reducing body temperature.	Fever reduced, improved comfort.
Swelling pushing the uvula to the opposite side, otalgia, and difficulty in swallowing.	Impaired Swallowing related to swelling and pain evidenced by difficulty swallowing and drooling.	Improve swallowing function and reduce pain.	– Encourage small, frequent meals and fluids. – Administer analgesic medication as prescribed. – Monitor and record intake and output.	– Small, frequent meals are easier to swallow. – Analgesic medication helps relieve pain. – Monitoring intake and output prevents dehydration.	Improved swallowing function, reduced pain.
Swelling of the neck and face.	Disturbed Body Image related to visible swelling evidenced by patient distress.	Support patient’s body image and self-esteem.	– Provide emotional support and encourage expression of feelings. – Educate the patient about the temporary nature of the swelling. – Collaborate with the healthcare team to explore potential interventions to reduce visible swelling.	– Emotional support and education reduce anxiety and distress.<br>- Understanding the temporary nature of the swelling helps manage patient expectations. – Exploring interventions shows commitment to addressing patient concerns.	Enhanced body image and self-esteem.

Peritonsillar Read More »

Otitis Media

Otitis media is an acute or chronic inflammation of the middle ear . It commonly occurs in children.

Acute Otitis media: implies rapid onset of disease associated with 1 or more of the following symptoms:

Otalgia
Fever
Otorrhea
Recent onset of anorexia
Irritability
Vomiting
Diarrhea

These symptoms are accompanied by abnormal otoscopic findings of the tympanic membrane, which may include: opacity, bulging, erythema, middle ear effusion.

Chronic otitis media:
Chronic otitis media is a chronic inflammation of the middle ear that persists at least 6 weeks and is associated with otorrhea through a perforated tympanic membrane, an indwelling tympanostomy tube.

Cause

Streptococcus pneumoniae
Hemophilus influenzae
Moraxella Catarrhalis
Group A beta-hemolytic streptococcus
Respiratory viruses
Enlarged tonsils or adenoids (small lumps of tissue at the back of the throat, above the tonsils) may block the Eustachian tube.

The earache usually subsides within 8 hours of initiation of appropriate antibiotic therapy.

Predisposing factors

In children, developmental alterations
of the Eustachian tube (short, wide, & straight)
An immature immune system
Frequent infections of the upper respiratory mucosa all play major roles in acute otitis media development.
Furthermore, the usual lying-down position of infants favors the pooling of fluids, such as formula.

Signs

Earache
Fever
Red and bulging tympanic membrane, ± presence of fluid in the middle ear, ± ear discharge, ear itch.
In younger children, irritability, restlessness, crying and sometimes pulling at the ear may be the only
symptoms.
Tenderness behind the ear
Pus discharge for less than 14 days
Tinnitus
Bulging of the eardrum
Hearing loss
Lying down, chewing, and sucking can also cause painful pressure changes in the middle ear, so a child may eat less than normal or have trouble sleeping.
On examination, tympanic membrane is red and mastoid process is tender
There is redness of the eardrum
A high temperature (fever) of 38°C (100.4°F) or higher
Patient feels very ill/being sick – lack of energy
Slight deafness
Babies with ear infections will be hot and irritable. As babies are unable to communicate the source of their discomfort, it can be difficult to tell what is wrong with them.

Pathophysiology

The ear is responsible for hearing and balance and is made up of three parts — the outer ear, middle ear, and inner ear. Hearing begins when sound waves that travel through the air reach the outer ear, or pinna, which is the part of the ear that’s visible. The sound waves then travel from the pinna through the ear canal to the middle ear, which includes the eardrum (a thin layer of tissue) and three tiny bones called ossicles. When the eardrum vibrates, the ossicles amplify these vibrations and carry them to the inner ear.

The inner ear translates the vibrations into electric signals and sends them to the auditory nerve, which connects to the brain. When these nerve impulses reach the brain, they’re interpreted as sound.

The Eustachian Tube

- To function properly, the middle ear must be at the same pressure as the outside world. This is taken care of by the eustachian tube, a small passage that connects the middle ear to the back of the throat behind the nose.
- By letting air reach the middle ear, the eustachian tube equalizes the air pressure in the middle ear to the outside air pressure. (When your ears “pop” while yawning or swallowing, the eustachian tubes are adjusting the air pressure in your middle ears.) The eustachian tube also allows for drainage of mucus and other debris from the middle ear into the throat.
- Sometimes, the eustachian tube may malfunction. For example, when someone has a cold or an allergy affecting the nasal passages, the eustachian tube may become blocked by congestion in its lining or by mucus within the tube. This blockage will allow fluid to build up within the normally air-filled middle ear.
Otitis media is the result of dysfunction of the Eustachian tube.
The Eustachian tube, which connects the middle ear to the naso-pharynx, is normally closed, narrow and, directed downward,
preventing organisms from the pharyngeal cavity from entering the middle ear.
It opens to allow drainage of secretions produced by middle ear mucosa and to equalize air pressure between the middle ear
and outside environment.
Impaired drainage causes the pathological condition due to retention of secretion in the middle ear.

Diagnosis/Investigations

History taking
Pus swab for microscopy, culture and sensitivity.

Physical examination of the ear using Otoscope

To examine the ear, an otoscope is used, a small instrument similar to a flashlight. This device has a magnifying glass and a light source at the end. It is used to study the inside of the ear.

Other test or investigations which can be done include:

Tympanometry: Tympanometry measures how the ear drum reacts to changes in air pressure. A healthy ear drum should move easily if there is a change in air pressure. During a tympanometry test, a probe placed into ear changes the air pressure at regular intervals while transmitting a sound into the ear. The probe measures how sound reflects back from the ear, and how changes in air pressure affect these measurements. If less sound is reflected back when the air pressure is high, it usually indicates an infection.
A computer tomography (CT) scan may be used if it is thought the infection may have spread out of the middle ear . A CT scan takes a series of X-rays and uses a computer to assemble the scans into a more detailed image of the skull.
Tympanocentesis involves draining fluid out of the middle ear using a small needle. The fluid can then be tested for bacteria or viruses that could be responsible for the infection.

Management

Amoxycillin is 1st line antibiotic.
In patients who are penicillin-allergic, trimethoprim-sulphasoxazole is the drug of choice.
Second line antibiotics include
amoxycillin/clavulanate, ampicillin/salbactam or a cephalosporin
Children under the age of 2 yrs are at higher risk of developing recurrent episodes, chronic otitis media and serious septic complications.
Give Antibiotics like caps Amoxicillin 500mgs QID for 5 days (in adults), children 15mgs per kg body weight
Or tabs Erythromycin 500mg QID for 5 days (Adults) if the patient is allergic to penicillin’s
Give analgesics like Paracetamol 1g tds for 3 days to control pain OR Tabs ibuprofen 400mgs tds for 3 days.
Topics antibiotics like Gentamycin ear drops can be applied 2 drops tds for 5 days after ear wicking
Review after 5 days, If eardrum still red repeat the above treatment

Surgical Management

Grommets: For children with recurrent, severe middle ear infections, tiny tubes may be inserted through the eardrum to help drain fluid. These tubes are called grommets or tympanostomy tubes.
Myringotomy: A myringotomy is a surgical procedure where the surgeon makes a tiny cut into the eardrum. This can help relieve pressure on the middle ear and allows the surgeon to drain away excess fluid inside the middle ear. In some cases a myringotomy may then be followed with a grommet insertion.
Tympanotomy :is a surgical procedure during which a surgical opening is made in the ear drum or tympanic membrane in order to promote drainage of infected fluid from the middle ear. & surgical tubes are implanted into the eardrum to promote ongoing drainage. It is done when there is scaring or little damage to tympanic membrane, in cases of deafness, or hearing.
Myringoplasty Is a surgical procedure done to repair a hole in the eardrum. The hole is repaired by placing a graft made of either a small piece of tissue from elsewhere on the body, or a gel-like material.
Tympanoplasty-Repair of damaged ossicles by replacing it with apiece of bone or prosthesis.

Grommet

Grommet already inserted

Nursing care

Apply hot water bag over the ear with the child lying on the affected side may reduce the discomfort (applied during the attack of pain).
Put ice bag over the affected ear may also be beneficial to reduce edema (between pain attacks).
For drained ear; the external canal may be frequently cleaned using sterile cotton swabs (dry or soaked in hydrogen peroxide).
Excoriation of the outer ear should be prevented by frequent cleansing and application of zinc oxide to the
area of oxidate.
Give special attention to the tympanostomy tube i.e., avoid water entering the middle ear and introducing bacteria.
Educate family about care of child, and; keep them aware with the potential complications of acute
otitis media e.g., conductive hearing loss.
Provide emotional support to the child and his family.
Rest the patient in bed i.e complete bed rest
Encourage or give plenty of oral fluids
In case of any discharge, dry the ear by ear wicking i.e make a wick using cotton swab and clean the pus from the ear.

Complications

Meningitis
Mastoid abscess
Acute mastoiditis
Facial nerve damage leading to facial palsy
Infection in adjacent areas e.g. tonsils, noise.
Brain abscess
Labyrinthitis ( extension of the infection to the internal ear)
Sinus thrombosis
Septicemia

Prevention

Health education, e.g. advising patients on recognizing the discharge of otitis media
Early diagnosis and treatment of acute otitis media and upper respiratory tract infections
Treat infections in adjacent areas e.g tonsillitis

Otitis Media Read More »

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.

Foreign Bodies in The Ear, Nose and Throat Read More »

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

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.

Hypersecretion of ACTH. (disease)

Hypersecretion of ACTH by the anterior pituitary-causes increased release of both cortisol and androgenic hormones

Hypersecretion of Cortisol. (syndrome)

… too much cortisol secreted by the adrenal cortex organ itself.

Causes of Cushing’s Syndrome

Cushing’s syndrome arises from excessive cortisol production, which can be caused by;

Pituitary Adenoma (Cushing’s Disease): This is the most common cause, involving a non-cancerous tumor in the pituitary gland. The tumor produces excessive amounts of adrenocorticotropic hormone (ACTH), which in turn stimulates the adrenal glands to produce excess cortisol.
Adrenal Adenoma (Primary Adrenal Hyperplasia): A non-cancerous tumor within the adrenal glands themselves. The tumor directly produces excess cortisol, bypassing the regulation of ACTH.
Adrenal Carcinoma: A cancerous tumor in the adrenal gland. The cancerous cells uncontrollably produce large amounts of cortisol.
Iatrogenic Cushing’s Syndrome: This type is caused by long-term use of corticosteroid medications. Corticosteroids, such as prednisone, are synthetic versions of cortisol, and long-term use can lead to similar symptoms as Cushing’s syndrome.

Classifications of Cushing’s Syndrome:

Cushing’s syndrome can be classified based on the underlying cause of excess cortisol production:

1. ACTH-Dependent Cushing’s Syndrome:

Cause: Excess cortisol production is driven by high levels of ACTH. This can occur due to:

Pituitary Adenoma (Cushing’s Disease): Most common cause, with a tumor in the pituitary gland producing ACTH.
Ectopic ACTH Syndrome: A tumor outside the pituitary gland produces ACTH, such as in the lungs, pancreas, or thymus.

2. ACTH-Independent Cushing’s Syndrome:

Cause: Excess cortisol production is not driven by ACTH, but rather by the adrenal glands themselves. This can occur due to:

Adrenal Adenoma (Primary Adrenal Hyperplasia): A benign tumor in the adrenal gland directly producing cortisol.
Adrenal Carcinoma: A malignant tumor in the adrenal gland producing excessive cortisol.
Iatrogenic Cushing’s Syndrome: Long-term use of corticosteroid medications.

Signs and Symptoms of Cushing’s Syndrome:

Cushing’s syndrome is a condition caused by prolonged exposure to high levels of cortisol, a hormone produced by the adrenal glands. This can be due to an adrenal tumor, pituitary tumor, or external medications.

Weight Gain: Cortisol promotes fat deposition, especially in the face, abdomen, and upper back. Increased cortisol levels lead to increased fat storage in these areas.
Moon Face: A round, puffy face due to fat deposition. Cortisol stimulates fat accumulation in the face, resulting in a characteristic rounded appearance.
Buffalo Hump: Fat deposition in the upper back between the shoulders, creating a hump. Similar to moon face, cortisol leads to fat accumulation in this specific area.
Thinning Skin: The skin becomes thinner and more fragile due to protein breakdown. Cortisol promotes protein breakdown, leading to thinner skin, making it more prone to tearing and bruising.
Easy Bruising: Bruising occurs more easily due to the thinning of the skin and increased fragility of blood vessels. Thin skin and increased fragility of blood vessels make it easier for the capillaries to leak, causing bruising.
Striae (Stretch Marks): Stretch marks appear on the abdomen, thighs, and breasts due to rapid skin stretching and thinning. Cortisol weakens the collagen fibers in the skin, making it more prone to tearing, leading to striae.
Purple Striae (Purple Stretch Marks): Stretch marks appear purple or red due to increased blood vessel fragility and rupture. Similar to regular striae, but the increased vascular fragility leads to discoloration.
Acne: Cortisol stimulates oil production in the skin, leading to acne. Increased oil production clogs pores, promoting bacterial growth and causing acne.
Hirsutism (Excessive Hair Growth): Excessive hair growth on the face, chest, and back, particularly in women. Cortisol can change the way the body processes androgens, leading to increased hair growth in areas typically affected by androgens.
Muscle Weakness and Fatigue: Muscle breakdown and weakness due to protein catabolism. Cortisol promotes protein breakdown, weakening muscles and contributing to fatigue.
High Blood Pressure: Cortisol increases blood pressure by constricting blood vessels and increasing sodium retention. Increased cortisol levels directly affect blood pressure regulation, causing vasoconstriction and increased sodium retention.
High Blood Sugar: Cortisol inhibits insulin’s action, leading to high blood sugar levels. Cortisol’s interference with insulin function leads to impaired glucose uptake and utilization, resulting in high blood sugar.
Mood Changes and Depression: Cortisol can affect mood and lead to depression. Chronic exposure to high cortisol levels can disrupt neurotransmitters involved in mood regulation, leading to mood swings and depression.
Increased Thirst and Frequent Urination: Increased thirst and urination due to increased fluid loss and sodium excretion. Cortisol’s influence on fluid balance leads to increased sodium excretion and water loss, causing thirst and frequent urination.
Osteoporosis: Increased bone loss and decreased bone density due to protein breakdown and calcium excretion. Cortisol’s effect on protein and calcium metabolism weakens bones, increasing the risk of fractures.
Menstrual Irregularities: Irregular periods or amenorrhea (absence of periods) in women. High cortisol levels can interfere with the hormone regulation of the menstrual cycle.
Impotence: Erectile dysfunction in men due to hormonal imbalances and reduced testosterone levels. Cortisol’s influence on hormone balance can lead to reduced testosterone levels, contributing to impotence.
Delayed Wound Healing: Wounds heal more slowly due to impaired immune function and tissue repair. Cortisol’s immunosuppressive effect inhibits the body’s natural healing response, delaying wound healing.

Diagnosis and Investigations of Cushing’s Syndrome

1. Clinical Evaluation:

History and Physical Examination: Detailed medical history focusing on symptoms like weight gain, fatigue, muscle weakness, skin changes, and hypertension. Physical examination to assess for signs of Cushing’s, such as moon face, buffalo hump, purple striae, and high blood pressure.

2. Laboratory Tests:

24-Hour Urine Free Cortisol: Measures the total amount of cortisol excreted in urine over 24 hours. A high level is suggestive of Cushing’s syndrome.
Overnight Dexamethasone Suppression Test: A low dose of dexamethasone (a synthetic corticosteroid) is given at bedtime. Ideally, this should suppress cortisol production in a healthy individual. In Cushing’s, cortisol levels remain high, indicating the problem is not responsive to feedback suppression.
ACTH Levels: Measured to distinguish between ACTH-dependent and ACTH-independent Cushing’s.
Cortisol Levels: Blood tests can measure serum cortisol levels, particularly in the morning when they should be high.

3. Imaging Studies:

MRI of the Pituitary Gland: To visualize the pituitary gland and detect any tumors (for Cushing’s disease).
CT or MRI of the Adrenal Glands: To detect tumors in the adrenal glands (for primary adrenal hyperplasia or carcinoma).

Management of Cushing’s Syndrome

Treatment is dependent on the site of the disease.

If pituitary source, may need transsphenoidal hypophysectomy(surgery done to remove the pituitary gland)
Radiation of pituitary also appropriate
Adrenalectomy may be needed in case of adrenal hypertrophy
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 may be appropriate.

Assessment:

Patient History: Obtain a detailed medical history focusing on:

Symptoms: Weight gain, fatigue, muscle weakness, skin changes (striae, acne, hirsutism), hypertension, menstrual irregularities, mood swings, depression, sleep disturbances, etc.
Family History: Any history of Cushing’s or other endocrine disorders.
Medication History: Current medications, especially corticosteroid use, and previous treatments.

Physical Examination: Thoroughly assess for signs of Cushing’s, including:

Moon Face: Round, puffy face.
Buffalo Hump: Fat deposit on the upper back.
Purple Striae: Stretch marks on the abdomen, thighs, and breasts.
Thinning Skin and Easy Bruising: Due to collagen breakdown.
Hypertension: Elevated blood pressure.
Proximal Muscle Weakness: Weakness in the arms and legs.

Investigations:

Laboratory Tests:

24-Hour Urine Free Cortisol
Overnight Dexamethasone Suppression Test
ACTH Levels
Serum Cortisol Levels
Other Hormonal Tests: (TSH, Thyroid Function, etc.)

Imaging Studies:

MRI of the Pituitary Gland: For Cushing’s disease.
CT or MRI of the Adrenal Glands: For primary adrenal hyperplasia or carcinoma.

Reassurance and Explanation:

Communicate Clearly: Explain the diagnosis and treatment plan in a way that the patient understands.
Address Concerns: Answer any questions the patient may have.
Empathy and Support: Emphasize that Cushing’s can be effectively managed.
Provide Educational Resources: Offer reliable information about Cushing’s and its management.

Medical Management:

Treatment Goals:

Control Excess Cortisol: Reduce cortisol levels to a normal range.
Manage Symptoms: Address specific symptoms like hypertension, diabetes, and osteoporosis.
Prevent Complications: Minimize long-term risks associated with Cushing’s.

Treatment Strategies:

ACTH-Dependent Cushing’s:

Surgery: Pituitary tumor removal (transsphenoidal surgery).
Radiation Therapy: Used if surgery is not possible or unsuccessful.
Medical Therapy: Drugs like ketoconazole or pasireotide to suppress ACTH production.

ACTH-Independent Cushing’s:

Surgery: Removal of adrenal tumors.
Medical Therapy: Drugs like metyrapone, aminoglutethimide, or mitotane to block cortisol production.

Iatrogenic Cushing’s (Corticosteroid-Induced):

Tapering the Corticosteroid: Slowly reducing the dose under close monitoring.
Alternatives: Exploring non-corticosteroid treatments if possible.

Nursing Care:

Monitoring for Complications: Regularly assess for signs of hyperglycemia, hypertension, infection, electrolyte imbalance, and other potential complications.
Education and Support: Provide ongoing education about the disease and treatment plan.
Symptom Management: Assist with managing symptoms like weight gain, fatigue, skin problems, and mood changes.
Promote Self-Care: Encourage healthy lifestyle practices, including diet, exercise, and stress management.

Follow-up Care:

Regular Checkups: Schedule routine visits for monitoring and adjustments to treatment.
Laboratory Tests: Monitor cortisol levels and other relevant markers.
Imaging Studies: Periodic imaging to assess the tumor status if applicable.
Long-Term Management: Focus on controlling symptoms, preventing complications, and maintaining quality of life.

Hypophysectomy

Nursing care plan for Cushing’s syndrome:

Assessment	Nursing Diagnosis	Goals/Expected Outcomes	Interventions	Rationale	Evaluation
1. Patient presents with central obesity, moon face, and buffalo hump.	Distrupted Body Image related to changes in physical appearance as evidenced by patient expressing dissatisfaction with appearance.	The patient will verbalize acceptance of body changes and demonstrate positive body image behaviors.	– Provide emotional support and encourage the patient to express feelings about body image changes. – Involve the patient in grooming and self-care activities to enhance self-esteem. – Refer to a counselor or support group specializing in chronic illness and body image issues.	Emotional support helps the patient cope with body changes. Involvement in self-care promotes a sense of control and improves self-esteem. Counseling and support groups offer a space for shared experiences and coping strategies.	The patient expresses acceptance of body changes and participates in self-care activities.
2. Patient reports fatigue, muscle weakness, and difficulty with physical activities.	Activity Intolerance related to muscle weakness and fatigue as evidenced by patient’s inability to perform daily activities without exhaustion.	The patient will demonstrate improved activity tolerance and participate in daily activities with minimal fatigue.	– Encourage rest periods between activities to conserve energy. – Assist with activities of daily living (ADLs) as needed. – Gradually increase physical activity as tolerated.	Rest periods prevent exhaustion and allow for energy conservation. Assistance with ADLs reduces the physical strain on the patient. Gradual increase in activity helps build endurance without overwhelming the patient.	The patient reports increased energy and is able to participate in daily activities with minimal fatigue.
3. Patient presents with hypertension, edema, and weight gain.	Excess Fluid Volume related to sodium and water retention as evidenced by edema, hypertension, and rapid weight gain.	The patient will demonstrate reduced edema and stable weight, with blood pressure within normal limits.	– Monitor daily weight, intake and output, and blood pressure regularly. – Administer diuretics as prescribed and monitor for effectiveness. – Restrict sodium intake as prescribed and educate the patient on a low-sodium diet. – Elevate edematous limbs to promote venous return.	Monitoring helps detect fluid retention and assess intervention effectiveness. Diuretics reduce fluid overload. Sodium restriction helps prevent further fluid retention. Elevation of limbs reduces edema and promotes circulation.	The patient shows reduced edema, stable weight, and blood pressure within normal limits.
4. Patient has elevated blood glucose levels and history of diabetes mellitus.	Risk for Unstable Blood Glucose Levels related to increased cortisol production as evidenced by hyperglycemia.	The patient will maintain blood glucose levels within the normal range.	– Monitor blood glucose levels regularly and adjust insulin or oral hypoglycemic agents as prescribed. – Educate the patient on the importance of adhering to prescribed diabetic diet and medication regimen. – Teach the patient to recognize signs and symptoms of hyperglycemia and hypoglycemia. – Collaborate with a dietitian to develop an appropriate meal plan.	Regular monitoring helps manage blood glucose levels. Adherence to diet and medication prevents blood glucose fluctuations. Early recognition of symptoms allows for prompt intervention. A meal plan supports stable blood glucose levels.
5. Patient reports difficulty sleeping, restlessness, and increased stress.	Disrupted Sleep Pattern related to elevated cortisol levels as evidenced by patient verbalizing difficulty sleeping and feeling restless.	The patient will experience improved sleep patterns and report feeling well-rested.	– Establish a regular sleep routine and create a restful environment. – Encourage relaxation techniques before bedtime, such as deep breathing or meditation. – Limit caffeine and fluid intake in the evening. – Administer prescribed sleep aids if needed and monitor their effectiveness.	A regular sleep routine promotes better sleep. Relaxation techniques help reduce stress and promote sleep. Limiting caffeine and fluids prevents sleep disturbances. Sleep aids may be necessary to manage sleep disturbances.	The patient reports improved sleep quality and feels more rested.
6. Patient presents with thin, fragile skin, bruises, and delayed wound healing.	Risk for Impaired Skin Integrity related to thinning of the skin and delayed wound healing as evidenced by bruising and skin tears.	The patient will maintain intact skin with no further breakdown or injury.	– Assess skin condition daily and document any changes. – Protect skin from injury by using padding on bony prominences and gentle handling. – Encourage a high-protein diet to promote skin healing. – Apply prescribed topical treatments to any wounds and monitor for signs of infection.	Daily assessment helps identify early signs of skin breakdown. Protecting the skin prevents injury and tears. A high-protein diet supports tissue repair and wound healing. Topical treatments aid in wound healing and prevent infection.

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Pheochromocytoma

Pheochromocytoma is a tumor that produces excessive amounts of catecholamines, including adrenaline (epinephrine) and noradrenaline (norepinephrine).

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

It is usually benign but can be malignant in some cases.

Pheochromocytomas can occur at any age but are commonly diagnosed in adults between the ages of 30 and 50.

Pathophysiology

Pheochromocytomas arise from chromaffin cells, which are specialized cells in the adrenal medulla that produce and release catecholamines into the bloodstream. In pheochromocytoma, there is uncontrolled and excessive secretion of catecholamines, leading to episodic or sustained hypertension(high blood pressure). The excess catecholamines can stimulate adrenergic receptors in various organs and tissues, resulting in a wide range of symptoms.

Effects on Blood Pressure:

Catecholamines have potent effects on blood vessels and the heart. They can cause vasoconstriction, leading to elevated blood pressure. They can increase heart rate and cardiac contractility, further contributing to elevated blood pressure.

Clinical Presentation of Pheochromocytoma

Pheochromocytomas can cause a variety of symptoms, often due to the excessive release of catecholamines (epinephrine and norepinephrine). These symptoms can be sporadic or persistent.

Common Signs and Symptoms:

Headaches: Often severe and can be throbbing.
Sweating (Hyperhidrosis): Profuse and generalized sweating episodes.
Tachycardia: A rapid or racing heartbeat. Palpitations may also be present.
Hypertension: High blood pressure, which can be sustained or occur in sudden spikes (paroxysmal hypertension).
Pallor: A pale face, often accompanying episodes of high blood pressure.
Nausea and Vomiting: Feeling sick to the stomach.
Anxiety and Panic: Feelings of intense anxiety, nervousness, and impending doom.
Tremor: Shakiness or trembling, often in the hands.
Agitation: Feeling restless, irritable, and uneasy.
Chest Pain or Discomfort: May mimic angina.

Less Common Symptoms:

Visual Disturbances: Blurred vision.
Abdominal Pain: Less frequent, but possible.
Constipation: Due to the effects of catecholamines on the digestive system.
Weight Loss: Unexplained weight loss can occur.
Hyperglycemia: High blood sugar.
Orthostatic Hypotension: Drop in blood pressure upon standing.
Seizures: In rare cases, very high blood pressure can lead to seizures.

Diagnosis and Investigations:

History and Physical Examination: A careful medical history, focusing on symptom onset, duration, and severity, is crucial. Physical examination may reveal signs of hypertension, tachycardia, and tremor.

Biochemical Testing:

Plasma and Urine Catecholamine Levels: Measurement of epinephrine, norepinephrine, and metanephrines (breakdown products of catecholamines) in plasma and urine is the primary diagnostic tool.
Plasma Free Metanephrines: This test is highly sensitive and specific for pheochromocytoma.

Imaging Studies:

Abdominal Computed Tomography (CT) Scan: Used to visualize the adrenal glands and identify any tumors.
Magnetic Resonance Imaging (MRI) Scan: Provides detailed anatomical images, particularly helpful in differentiating tumors from other adrenal masses.

Genetic Testing: Recommended in cases with a family history of pheochromocytoma or associated genetic syndromes.

How the tumor 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 of Pheochromocytoma

Aims of management

The primary goals of managing pheochromocytoma are;

to control symptoms
stabilize blood pressure
ultimately remove the tumor.

1. Pre-operative Management (Medical Management)

Alpha-Adrenergic Blockers: These are the cornerstone of pre-operative management.

Mechanism: Alpha-blockers (e.g., phenoxybenzamine, doxazosin, prazosin) block the effects of norepinephrine on blood vessels, preventing vasoconstriction and reducing blood pressure.
Duration: Typically administered for 1-3 weeks before surgery to allow for adequate blood pressure control and expansion of blood volume.
Goal: To achieve adequate blood pressure control (target usually <130/80 mmHg) and minimize the risk of hypertensive crisis during surgery.

Beta-Adrenergic Blockers:

Use: Beta-blockers (e.g., propranolol, metoprolol) are only initiated after adequate alpha-blockade has been established.
Mechanism: Beta-blockers help control tachycardia (rapid heart rate) and arrhythmias caused by excess catecholamines.
Caution: Starting beta-blockers before alpha-blockers can lead to unopposed alpha-adrenergic stimulation, resulting in a dangerous hypertensive crisis.

Calcium Channel Blockers:

Use: May be used as adjunctive therapy or in patients who cannot tolerate alpha-blockers.
Mechanism: They help relax blood vessels and lower blood pressure.

Metyrosine:

Use: An alternative or adjunct to alpha and beta blockers.
Mechanism: Inhibits tyrosine hydroxylase, an enzyme involved in catecholamine synthesis.
Benefit: Can help reduce catecholamine levels and improve blood pressure control.

High-Sodium Diet and Fluid Intake:

Rationale: Pheochromocytomas can cause chronic vasoconstriction and reduced blood volume.
Goal: To expand blood volume and prevent hypotension after tumor removal.

Patient Education:

Importance: Patients need to understand the importance of medication adherence and monitoring blood pressure regularly.
Symptom Management: Educate patients on how to recognize and manage symptoms of catecholamine excess.

2. Surgical Management

Surgical Resection: The definitive treatment for pheochromocytoma.

Laparoscopic Adrenalectomy (“Keyhole” Surgery):

Approach: Preferred approach for most pheochromocytomas.
Advantages: Smaller incisions, less pain, shorter hospital stay, faster recovery.

Open Adrenalectomy:

Indications: Larger tumors, suspicion of malignancy, or when laparoscopic surgery is not feasible.
Approach: Requires a larger incision in the abdomen or flank.

Bilateral Adrenalectomy:

Indication: For bilateral pheochromocytomas (tumors in both adrenal glands).
Considerations: Requires lifelong hormone replacement therapy (glucocorticoids and mineralocorticoids).

Intraoperative Management:

Anesthesia: Requires careful monitoring and management by an experienced anesthesiologist.
Medications: Anesthesiologists use medications to manage blood pressure fluctuations during surgery.
Post-Resection Hypotension: Be prepared for hypotension after tumor removal due to sudden drop in catecholamine levels. Volume expansion and vasopressors may be required.

3. Management of Malignant Pheochromocytoma

Surgery: Resection of primary tumor and any metastases, if feasible.

Radiation Therapy: May be used to control local tumor growth or palliate symptoms.

Chemotherapy:

Regimens: Often involves a combination of cyclophosphamide, vincristine, and dacarbazine (CVD).
Efficacy: Response rates are variable.

Targeted Therapy:

Tyrosine Kinase Inhibitors (TKIs): (e.g., sunitinib) may be used in some cases.

Peptide Receptor Radionuclide Therapy (PRRT):

Mechanism: Uses radiolabeled somatostatin analogs to target tumor cells.

Radiofrequency Ablation (RFA) or Cryoablation:

Use: To treat liver or bone metastases.

4. Nursing Care

Pre-operative Care:

Monitoring: Frequent monitoring of vital signs (blood pressure, heart rate).
Medication Administration: Ensure accurate and timely administration of alpha and beta blockers.
Patient Education: Provide clear instructions about medications and potential side effects.

Post-operative Care:

Monitoring: Continuous monitoring of vital signs.
Fluid Management: Careful management of fluid balance to prevent hypotension or fluid overload.
Pain Management: Administer pain medication as prescribed.
Wound Care: Monitor incision site for signs of infection.
Hormone Replacement: If bilateral adrenalectomy was performed, initiate hormone replacement therapy and educate the patient on how to take the medications.

Long-Term Follow-Up:

Monitoring: Regular monitoring of blood pressure, catecholamine levels, and imaging studies to detect recurrence.
Genetic Counseling: Offer genetic counseling and testing, especially for patients with a family history of pheochromocytoma or associated genetic syndromes.

Nursing Care Plan: Pheochromocytoma

Assessment

Nursing Diagnosis

Goals/Expected Outcomes

Interventions

Rationale

Evaluation

Patient presents with hypertension, palpitations, headaches, excessive sweating, and anxiety. Laboratory results show elevated catecholamines.

Risk for Hypertensive Crisis related to excessive catecholamine secretion as evidenced by severe hypertension, palpitations, and headaches.

– Patient’s blood pressure will be maintained within normal limits.

– Patient will report reduced episodes of palpitations and headaches.

– Patient will avoid triggers that exacerbate symptoms.

1. Monitor blood pressure and heart rate frequently.

2. Administer prescribed antihypertensive medications (alpha-blockers and beta-blockers).

3. Educate patient on avoiding triggers like stress, caffeine, and strenuous activity.

4. Prepare patient for surgical removal of the tumor (adrenalectomy) if indicated.

5. Monitor for signs of hypertensive crisis (severe headache, visual disturbances, seizures).

1. Early detection of hypertensive episodes helps prevent complications.

2. Controls blood pressure and prevents complications.

3. Reduces catecholamine surges and symptom exacerbation.

4. Definitive treatment to remove the source of excessive catecholamine secretion.

5. Prevents life-threatening complications like stroke or myocardial infarction.

– Patient maintains stable blood pressure.

– Patient reports reduced palpitations and headaches.

– Patient adheres to lifestyle modifications.

Patient reports episodes of anxiety, excessive sweating, and restlessness. Patient appears nervous and agitated.

Anxiety related to catecholamine excess as evidenced by restlessness, tachycardia, and diaphoresis.

– Patient will verbalize reduced anxiety and use coping strategies.

– Patient’s vital signs will remain stable.

– Patient will participate in relaxation techniques.

1. Assess level of anxiety and provide a calm environment.

2. Teach relaxation techniques (deep breathing, guided imagery).

3. Administer prescribed anxiolytics if indicated.

4. Reassure the patient and provide psychological support.

5. Educate the patient on the physiological cause of symptoms.

1. Minimizes stress, which can trigger catecholamine release.

2. Helps the patient manage anxiety episodes.

3. Controls severe anxiety and autonomic symptoms.

4. Reduces fear and emotional distress.

5. Enhances understanding and reduces uncertainty.

– Patient verbalizes reduced anxiety.

– Patient demonstrates relaxation techniques.

– Vital signs remain within normal range.

Patient reports headaches, dizziness, and episodes of fainting.

Risk for Decreased Cardiac Output related to excessive catecholamine secretion as evidenced by tachycardia, hypertension, and palpitations.

– Patient will maintain stable cardiac function with normal heart rate and blood pressure.

– Patient will remain free from syncope and dizziness.

– Patient will adhere to prescribed medications and treatments.

1. Monitor ECG for arrhythmias and signs of myocardial strain.

2. Assess for signs of heart failure (dyspnea, edema, chest pain).

3. Administer beta-blockers or calcium channel blockers as prescribed.

4. Encourage adequate hydration and sodium intake (if not contraindicated).

5. Educate the patient about the importance of adherence to treatment.

1. Detects potential cardiac complications early.

2. Prevents worsening of cardiac function.

3. Helps regulate heart rate and blood pressure.

4. Prevents dehydration-related hypotension.

5. Ensures effective symptom management.

– Patient remains hemodynamically stable.

– No episodes of dizziness or syncope.

– Patient follows medication regimen.

Patient is scheduled for surgical tumor removal (adrenalectomy). Patient expresses fear and uncertainty about the procedure.

Deficient Knowledge related to unfamiliarity with pheochromocytoma and its management as evidenced by patient’s questions and concerns.

– Patient will verbalize understanding of the disease and treatment plan.

– Patient will express reduced fear and anxiety about surgery.

– Patient will adhere to preoperative and postoperative care instructions.

1. Explain pheochromocytoma, its effects, and treatment options.

2. Educate patient on preoperative preparation, including medication use (e.g., alpha-blockers).

3. Inform the patient about potential postoperative complications.

4. Provide written educational materials for reinforcement.

5. Encourage patient to ask questions and express concerns.

1. Increases patient understanding and reduces uncertainty.

2. Ensures safe surgery by preventing hypertensive crisis.

3. Helps the patient anticipate and manage postoperative recovery.

4. Supports learning and recall of important information.

5. Promotes active patient participation in care.

– Patient demonstrates understanding of condition and treatment.

– Patient verbalizes reduced fear about surgery.

– Patient follows preoperative and postoperative instructions.

Patient is unable to engage in normal activities due to fatigue, dizziness, and palpitations.

Activity Intolerance related to catecholamine-induced cardiovascular instability as evidenced by fatigue, dizziness, and exertional dyspnea.

– Patient will gradually resume activities without excessive fatigue.

– Patient will report improved tolerance to physical exertion.

– Patient will engage in energy-conserving techniques.

1. Assess activity tolerance and monitor for symptoms of intolerance.

2. Encourage rest periods between activities.

3. Teach energy conservation strategies.

4. Gradually reintroduce physical activity as tolerated.

5. Monitor blood pressure and heart rate during activity.

1. Prevents overexertion and worsening of symptoms.

2. Conserves energy and prevents fatigue.

3. Helps the patient manage limited energy levels.

4. Improves endurance and quality of life.

5. Ensures hemodynamic stability during exertion.

– Patient engages in activities with minimal fatigue.

– Patient reports improved energy levels.

– Vital signs remain stable during exertion.

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