Chapter 2: Management of Patients with Upper Respiratory Tract Disorders (Part 2)

Chronic Pharyngitis

- persistent inflammation of the pharynx

- common in adults who work in dusty surroundings, use their voice to excess, suffer from chronic cough, or habitually use alcohol and tobacco

3 types of chronic pharyngitis

1. Hypertrophic

2. Atrophic

3. Chronic granular

Hypertrophic chronic pharyngitis

characterized by general thickening and congestion of the pharyngeal mucous membrane

Atrophic chronic pharyngitis

probably a late stage of the first type (the membrane is thin, whitish, glistening, and at times wrinkled)

Chronic granular pharyngitis

characterized by numerous swollen lymph follicles on the pharyngeal wall

Signs and Symptoms of Chronic Pharyngitis

- constant sense of irritation

- fullness in the throat

- mucus that collects in the throat and can be expelled by coughing

- difficulty swallowing

- often associated with intermittent postnasal drip that causes minor irritation and inflammation of the pharynx

Management of Chronic Pharyngitis

- same with Acute Pharyngitis

- avoidance of alcohol, tobacco, second hand smoke, occupational pollutants

- encourage oral fluids (plenty)

- gargle with warm saline

- lozenges to moisten the throat

tonsillectomy

surgical management of chronic pharyngitis

N95 mask

type of mask to be worn for chronic pharyngitis

GABHS (Group A Beta-hemolytic Streptococcus)

most common organism causing bacterial tonsillitis and adenoiditis

Epstein-Barr Virus/Cytomegalovirus

organism causing viral tonsillitis and adenoiditis

Signs and Symptoms of Tonsillitis and Adenoiditis

- sore throat

- fever

- snoring

- difficulty swallowing

Signs and Symptoms of Tonsillitis and Adenoiditis

Enlarged adenoids may cause:

- mouth breathing

- earache

- draining ears

- frequent head colds

- bronchitis

- foul-smeling breath

- voice impairment

- noisy respiration

Complications of Tonsillitis and Adenoiditis

- Infection can extend to middle ear-otitis media

- mastoiditis

- deafness

RADT (rapid antigen detection test) or throat swab culture

- diagnostic tests for Tonsillitis and Adenoiditis

- used to determine whether bacterial or viral

Penicillin or Cephalosporins

DOC for bacterial tonsillitis and adenoiditis

Tonsillectomy

- surgical management for tonsillitis and adenoiditis

- may be with or without adenoidectomy

Indications for Tonsillectomy

- if the patient has had repeated episodes of tonsillitis despite antibiotic therapy

- hypertrophy of the tonsils and adenoids that could cause obstruction and obstructive sleep apnea

- repeated attacks of purulent otitis media; and suspected hearing loss

Indications for Adenoidectomy

- chronic nasal airway obstruction

- chronic rhinorrhea

- ear infections and abnormal speech

Prone with head turned to side

positioning of patient immediate post-op for tonsillectomy and adenoidectomy

Nursing Considerations for Tonsillectomy and Adenoidectomy

- application of ice collar to the neck

- watch out for bleeding: patient is expectorating bright red blood before swallowing it

- Increase PR, Increase temp, patient is restless- NOTIFY the PCP immediately- risk for shock

Materials at bedside for post-op tonsillectomy and adenoidectomy

- light

- a mirror

- gauze

- curved hemostats

- waste basin

Nursing Considerations for Tonsillectomy and Adenoidectomy

- if no bleeding, water and ice chips may be given

- instruct patient ot refrain from too much talking and coughing

- instruct the importance of antibiotic compliance

- explain to the patient that a sore throat, stiff neck, minor ear pain, and vomiting may occur in the first 24 hours

Nursing Considerations for Tonsillectomy and Adenoidectomy

- soft diet

- avoid spicy, hot, acidic, or rough foods

- avoid milk and milk products (removal of mucus more difficult

for some patients)

- maintain good hydration

Nursing Considerations for Tonsillectomy and Adenoidectomy

- avoid vigorous toothbrushing or gargling because these activities can cause bleeding

- air humidifier at home

- avoid smoking and heavy lifting for 10 days

Peritonsillar Abscess

- also known as quinsy

- most common major suppurative complication of sore throat

- the infection can spread over the palate and to the neck and chest

Causative agents of Peritonsillar Abscess

- S. pyogenes

- S. aureus

- Neisseria species

- Corynebacterium species

Edema

- complication of peritonsillar abscess

- obstruction of airway

- life threatening

Signs and Symptoms of Peritonsillar Abscess

- severe sore throat

- fever

- trismus

- drooling

- difficulty to swallow saliva

trismus

inability to open the mouth

Penicillin

DOC for Peritonsillar Abscess

Management of Peritonsillar Abscess

- Antibiotic

If abscess does not resolve:

- Needle aspiration

- Incision and drainage (I&D) under local and GA with simultaneous tonsillectomy

- Gargle gently, using saline or alkaline solutions

40.6° to 43.3°C/105° to 110°F

temperature of saline or alkaline solutions for peritonsillar abscess

Needle aspiration

preferred management of peritonsillar abscess, high efficacy, low cost, and patient tolerance

Laryngitis

- an inflammation of the larynx

- can occur as a result of voice abuse, exposure to dust, chemicals and other pollutants

reflux laryngitis

laryngitis associated with gastroesophageal reflux

virus

common cause of laryngitis

Signs and Symptoms of Laryngitis

- aphonia

- severe cough

- sudden onset made worse by cold dry wind

- throat feels worse in the morning and improves when the patient is indoors in a warmer climate

aphonia

loss of voice

Management of Lryngitis

- resting the voice

- avoiding the irritants (smoking) including second hand smoking

- if bacterial: antibiotics to eliminate infection

- Corticosteroids

- PPI

Beclomethasone

- corticosteroid for laryngitis

- anti-inflammatory

Omeprazole

PPI for reflux laryngitis

Obstructive Sleep Apnea

- cessation of breathing during sleep usually caused by repetitive upper airway obstruction

- often found in patients with hypertension

Risk factors for Obstructive Sleep Apnea

- Obesity (major risk factor)

- Male

- Postmenopausal women

- Advanced age

- Structural change

Signs and Symptoms of Obstructive Sleep Apnea

- 3S (snoring, sleepiness, significant other report of sleep apnea episodes)

- pts unaware of nocturnal upper airway obstruction during sleep

Obstructive Sleep Apnea

characterized by frequent and loud snoring with breathing cessation for 10 seconds or longer, for at least five episodes per hour, followed by awakening abruptly with aloud snort as the blood oxygen level drops

Management of Obstructive Sleep Apnea

- weight loss

- avoidance of alcohol

- positional therapy (no sleeping on their backs)

- oral appliances (mandibular advancement devices)

Surgical Management for Obstructive Sleep Apnea

- Tonsillectomy: with larger tonsils

- Uvulopalatopharyngoplasty

- Nasal septoplasty

- Maxillomandibular surgery

Uvulopalatopharyngoplasty

- resection of pharyngeal soft tissue and removal of approximately 15 mm of the free edge of the soft palate and uvula

- more effective in eliminating snoring than apnea

Nasal septoplasty

surgical management for nasal septal deformities causing obstructive sleep apnea

Maxillomandibular surgery

may be performed ot advance the maxilla and mandible forward in order to enlarge the posterior pharyngeal region

Pharmacologic Management for Obstructive Sleep Apnea

- Modafinil

- Armodafinil

- Protriptyline (Tricyclic Antidepressant)

Modafnil

use in patients who have residual daytime sleepiness (daily, 200-400 mg)

Armodafinil

more potent than modafinil because it is pure R-modafinil

R-modafinil

the most psychoactive compound of modafinil

Priotriptyline

- TCA

- during bedtime, may increase respiratory drive and improve upper airway muscle tone