Surgery 3
Surgery 3
Surgery 3
The ear suffers a number of health conditions. The most common problems include:-
OTITIS MEDIA
The terms used in relationship to otitis include:-
Otitis – inflammation of the ear
Otitis externa – inflammation of the external ear
Otitis media – inflammation of the middle ear
Otitis interna – inflammation of the internal ear
Otitic hydrocephalus – a form of hydrocephalus associated with chronic ear infection
especially mastoiditis.
The middle ear is in continuity with the nasopharynx and is thus prone to infection arising from
the pharynx.
Chronic otitis media occurs when a middle ear infection becomes persistent.
Permanent damage may occur to the tympanic membrane and to the ossicles, resulting into
deafness.
A large central perforation of the tympanic membrane and a persistent pus discharge may occur.
Persistent pus discharge from the ear is termed as chronic supurative otitis media.
Pathophysiology
The presence of serous otitis media becomes a convenient culture media for the invading bacteria
usually from the pharynx that ascend to the middle ear via the Eustachian tube.
The middle ear mucosa becomes inflamed and the cavity fills with pus.
Pus escapes by bursting out through the tympanic membrane into the external ear.
Predisposing factors
Infections such as common cold
Acute respiratory tract infections
Measles
Trauma to the tympanic membrane
Clinical features
The patient who is usually a child with a cold develops an ear ache of increasing intensity.
Pain reduces when the tympanic membrane raptures.
The child may be plucking the ear
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There may be vomiting
The child may be seen rolling the affected ear on a pillow
There may be an offensive pus discharge especially in chronic supurative otitis media
Other features include:-
- Headache - General malaise
- Fever - On examination, the tympanic
- Anorexia membrane is red, bulging or raptured
- .
MANAGEMENT
The condition may be managed medically or surgically.
Medical management
The patient is admitted on a medical or pediatric ward and allowed to have complete bed
rest until the acute stage subsides.
Proper history should be taken to establish the cause.
Vital observations such as temperature, pulse, respiration and blood pressure are taken and
recorded.
Physical examination [otoscopy] is done to visualize the extent of inflammation of the
tympanic membrane.
The general body condition is assessed.
Warm compresses using a covered hot bottle if applied to the ear is very helpful.
Instillation of warm olive oil drops soothes the inflamed ear drum.
A pus swab is taken to the laboratory for culture and sensitivity to isolate the causative
organism and determine the most effective antibiotic.
A throat swab in case of non-supurative otitis media may also be obtained for culture and
sensitivity.
Drugs:
Any of the following drugs may be given depending on the culture and sensitivity results.
- Gentamycin
- Chloramphenicol
- Ceftriaxone
- Amoxicillin and clavulanic acid [co-amoxiclav]
- Cotrimoxazole
Frequent ear mopping to ensure dryness
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Allow the child to lie on the affected side to allow free drainage of the discharge from the
ear.
Surgical management
If the medical management does not provide a lasting solution to otitis media, surgical
measures may be adopted.
When the ear has been free from pus for several months, it is considered suitable for
surgical repair of the perforated tympanic membrane; a procedure known as
myringoplasty
A thin piece of fascia is taken from the surface of the temporalis muscle and grafted over
the perforation.
Similarly, any loss of ossicular continuity can be corrected by repositioning the damaged
ossicle or by replacing it with a piece of bone or prosthesis; an operation known as
tympanoplasty.
Other nursing care
Continuous reassurance Nourishing diet
Good hygiene Observations
Health education on the likely causes and predisposing factor.
Complications of otitis media
Permanent deafness Labyrinthitis
Meningitis Chronic otitis media
Brain abscess Bacterial endocarditis
Mastioditis Otitic hydrocephalus
Peritonsilar abscess
Prevention
Immunization against childhood diseases such as measles
Early detection and treatment of ear infections.
Early detection and treatment of respiratory tract infections to prevent spread to the middle
ear.
ACUTE MASTOIDITIS
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This condition usually occurs when untreated or inadequately treated acute otitis media spreads
from the middle ear to the surrounding bone- the mastoid process.
Clinical features
Pain/tenderness of the mastoid process occurs about 2 or more weeks following otitis
media.
An abscess may form in the bone
There may be swelling and the pinna is pushed sideways and down ward.
A creamy profuse discharge may drain from the ear.
Hearing loss is progressive
There may be fever, headache, nausea and malaise.
Investigations
A computed tomography (CT scan) shows that the ear cells (spaces in the bone that contain air) in
the mastoid process contain fluid.
Treatment
Intravenous broad spectrum antibiotics may be helpful
A sample of the ear discharge is sent to the laboratory for culture and sensitivity; and hen the drug
of choice is given for 2 weeks.
In case of an abscess in the mastoid process, surgical drainage is the process. Surgical drainage is
the option. Daily drainage till the patient has improved.
Analgesics/antipyretics may be given the first 3 days.
Daily nursing care is given until the patient is better.
Complications of mastoiditis
Deafness Brain abscesess
Blood poisoning sepsis Death
Meningitis
WAX
Wax or cerumen is a normal substance produced in the external ear canal.
It is made up of epithelial scales mixed with secretions from special glands in the skin of the outer
ear
Ear wax may block the auditory canal.
In most people, the wax escapes as it is formed but in some, it remains in the ear canal obstructing
it and causing deafness.
Signs and symptoms
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Itching of the ear
Pain
Temporary loss or impaired hearing
Wax may be seen in the auditory canal on otoscopy
Management
Olive oil or liquid paraffin ear drops will soften the impacted wax and then removed by ear
syringing.
If the patient has ever had an ear discharge, perforated ear drum, or recurrent outer ear infections,
ear syringing (ear irrigation) is not allowed.
Ear syringing or irrigation
The water in the syringe should be at body temperature so as not to stimulate the inner ear to
cause dizziness.
The jet of water is directed at the upper wall of the ear canal and the wax is washed out.
A receiver is held beneath the ear to receive the waste water.
The patient’s clothes are protected by a mackintosh and towel.
After irrigation the ear must be gently dried and then examined by the doctor to exclude any
damage to the tympanic membrane
FOREIGN BODIES
A variety of materials can be placed in the auditory canal accidentally or deliberately by children.
Examples of foreign bodies include:
Seeds eg beans, ground nuts, maize, beads etc
Pieces of metal, glass, or plastic
Any other foreign material that can enter the ear such as insects.
Clinical features
The child may complain of hearing impairment
Reports from other children about the incident
The foreign body may be visible
There may be bleeding especially if the child tries to remove it by self or other children.
Management
Metal, plastic, glass or beads can be flushed out if not stuck.
Seeds like beans, groundnuts must not be flushed with water because the absorb water,
swell and complicate removal.
The doctor removes such objects with a blunt hook
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Anaesthesia may be given to an uncooperative child/ patient so that removal of deeply
placed objects becomes easy.
Insects that enter the canal may be killed by instillation of mineral oil and also helps with
removal.
Complications
Injury to the auditory canal infection
Injury to the tympanic membrane
BOILS
A boil or furuncle is an acute inflammation of the subcutaneous tissue including glands and hair
follicles.
It is usually found in the outer hair-bearing skin of the auditory canal.
It is very painful because the skin at this site is firmly tethered to the underlying cartilage.
Cause
Like boils on any other body part, it is caused by staphylococcus.
Treatment
Antibiotics are necessary only when the symptoms are severe or if it tends to be big in
size.
Analgesics are necessary for pain relief
If large and supurative, surgical incision and drainage followed by daily dressing and
antibiotics is the way to go
CONDITIONS OF THE NOSE
RHINITIS
Rhinitis refers to inflammation of the mucous membrane of the nose.
It may be acute [short lived], or chronic [long lived]
TYPES OF RHINITIS
1. Acute rhinitis – it is a usual sign of common cold. It is usually caused by a variety of
viruses and also some bacteria.
2. Chronic rhinitis – this is usually caused by smoking, air pollution and allergies.
It may also result from infections like syphilis, TB, leprosy, leishmaniasis, blastomycosis
and histoplasmosis. These infections destroy the soft tissues, cartilage and the nasal bone.
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3. Atrophic rhinitis – it is the chronic rhinitis in which the mucous membrane thins
(atrophies) and hardens causing the nasal passage to widen, and this the major difference
between atrophic rhinitis and other forms of rhinitis.
The cause of atrophic rhinitis is unknown although a bacterial infection is most likely
involved.
4. Vasomotor rhinitis – this is also a chronic form marked by swollen blood vessels in the
mucous membrane of the nose, sneezing and a runny nose.
Its cause is unknown but doesn’t appear to be an allergy.
5. Allergic rhinitis – allergic rhinitis (hay fever) is a type I hypersensitivity reaction. It is the
reaction of the nasal mucosa to a specific antigen (allergen) attacks of seasonal rhinitis are
caused by allergy to pollen from trees, flowers, grasses or weeds.
Clinical features of rhinitis
Runny nose, sneezing as well as itching
Nasal stuffiness and blockage
There may be pus discharge (in case of infection)
In some cases, epistaxis occurs
Loss of sense of smell (anosmia)
Loss of appetite
Other general symptoms may include:
Fever headache
Malaise
Management
The symptoms can be relieved by phenyl ephedrine nasal spray.
Antibiotics such as bacitracin sprayed into the nose kills bacteria.
Oestrogens, vitamins A and D sprayed into the nose or taken by mouth may be helpful.
Increased humidity from a humidified central heating system or vapourizer may be
beneficial.
It is also believed that a diet rich in vitamin C (from citrus fruits) is useful.
Avoidance of the allergen/triggering factor is the best remedy;
Avoid house dust especially on all house articles such as those in the bed room.
Avoid mold spores: mold spore growth is promoted by darkness and dampness.
Avoid pollen: stay indoors especially during high pollen seasons.
Avoid pet allergens, remove pets (e.g. cats) from interior of the house or home
Avoid smoke: smoke worsens all symptoms.
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SINUSITIS
This refers to the inflammation of the paranasal sinuses.
Sinuses are air filled cavities lined with mucous membrane.
The paranal sinuses include:
Frontal sinus Sphenoid sinus
Ethmoid sinus maxillary sinus
Aetiology
Sinusitis develops when the ostia [exit] from the sinus is narrowed or blocked due to
inflammation or hypertrophy (swelling) of the mucosa.
The secretions that accumulate behind the obstruction provide a rich media for the growth and
multiplication of bacteria, viruses and fungi all of which cause infection.
Bacterial sinusitis is commonly caused by:
Streptococcus pneumonia betahaemolyticus streptococcus
haemophilus influenzae klebsiella pneumonia etc.
Moraxella catarrhalis
Viral sinusitis usually follows an upper respiratory tract infection in which the virus penetrates the
mucous membrane and reduces cilliary activity. Examples of such viruses include:
Rhino virus Adenovirus
Para influenza virus
Fungal sinusitis is uncommon and is usually found in patients who are immunocompromised.
Note:
Acute sinusitis usually results from an upper respiratory tract infection, allergic rhinitis,
swimming or dental manipulation. These cause inflammatory changes and retention of
secretions
Chronic sinusitis generally results from repeated episodes of acute sinusitis that results in
irreversible loss of the normal ciliated epithelial lining of the sinus cavity.
Clinical manifestations
Bacterial sinusitis presents with a stuffy nose followed by pressure over the involved
sinuses.
Pain caused by accumulation of pus and absorption of air behind the blocked ostium.
General malaise and the patient feels sick
Persistent cough
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Post nasal drip
Headache that changes in intensity with change in posture.
Slightly elevated or normal temperature
Anosmia
Poor sound resonance
The taste of food may be affected
Loss of appetite
The symptom worsen over 48 to 72 hours resulting into severe localized pain and tenderness over
the involved sinus.
In acute frontal and maxillary sinusitis:
Pain appears 1 to 2 hours after awakening
There may be bloody or blood tinged discharge from the nose in the first 24 to 48 hours.
The discharge becomes thick green, blocking the nose.
The throat becomes inflamed and sore and there may be a purulent discharge.
Diagnosis
On examination:
Hyperaemic and oedematous mucosa
Enlarged turbinates
Tenderness over the affected sinuses
Conventional x-rays [CT and MRI] and rhinoscopy may help.
Management
Aims
To relieve pain To treat the cause
To ensure shrinkage of the nasal Prevention of complications
mucosa
Drugs
Ibuprofen 200-400 mg TDS for 3 days
Sometimes codein 30 mg TDS is given to relieve pain
Oral decongestants e.g. puedoephedrine
Any of the following antibiotics may be given:
Amoxicillin + clavulanate potassium [augementin]
Doxycillin
Clarithromycin
Azithromycin
IV amphotericin B is given in fungal sinusitis eg aspergillus and mucor infections.
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Some patients may also benefit from:
Saline nasal spray steam from a shower or humidifier.
Hot wet packs applied to the face over the infected sinus 4 times a day.
Note: acute frontal sinusitis with pain, tenderness and oedema of the frontal or sphenoid sinus
may require hospitalization due to the risk of intracranial complications and osteomyelitis.
Severe fungal sinusitis may occur in:
Patients with transplant
Patients on chemotherapy
Patients with AIDS
Patients with uncontrolled diabetes mellitus.
Preoperative care
Ensure the patient understands the surgical procedure
Clarify the misconceptions and respond to the concerns raised by the patient and his relatives.
Ensure the consent form is signed.
Explain that the patient will:
Have nothing by mouth for 6-8 hours preoperatively.
Feel pressure not pain during surgery
Have a nasal pack for 24-48 hours postoperatively
Have “black eyes” and swelling around the nose and eyes for 1-2 weeks postoperatively.
Be give analgesics and antibiotics for pain and infection prevention respectively.
The general postoperative care is given
Types of sinus surgery
1. Functional endoscopic sinus surgery – carried out in case of chronic sinusitis and
removal of polyps.
2. Cald well – luc [radical antrum perforation – carried out for chronic maxillary sinusitis
3. Transnasal external or tranantral ethmoidectomy – used in chronic ethmoid and
sphenoid sinusitis.
Frontal sinusectomy – a complete removal of the diseased mucosa of both frontal sinusitis.
4. Ethmoid sinus surgery– performed in chronic sphenoid sinusitis.
Postoperative care
Position the patient in a lateral or side to prevent swelling due to aspiration of blood
drainage.
Administer cool mist via a face tent or collar or provide a humidifier.
When the patient is awake, remind him/her to expectorate the secretions and not to
swallow them.
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Encourage mid fowler’s position when fully awake to promote drainage and decrease
oedema.
Apply cold compress over the nose, maxillary and frontal sinuses in the early
postoperative period.
Monitor the patient for:
Excessive epistaxis (may be evidenced by repeated swallowing)
Decreased visual acuity; this indicates damage to the optic nerve or muscles of the globe
of the eye.
Complaint of pain over individual sinuses which may indicate infection or inadequate
drainage.
Fever – temperature should be taken regularly.
Give frequent mouth care before and after meals to improve the appetite and prevent oral
infections respectively.
The nasal pack is changed when soiled.
Encourage oral fluid intake to counteract thirst since the patient breathes through the
mouth.
The patient is taught to:
Avoid blowing the nose for at least 48 hours after removal of the pack
Avoid sneezing but keep the mouth open if must sneeze
Avoid lifting heavy loads
Report signs of infection (fever, purulent discharge)
Expect tarry stools from swallowed blood for a few days.
Avoid constipation; straining may cause haemorrhage.
Expect that ecchymosis of the nose and eyes will change colour over the next 1-2
weeks.
Take antibiotics, analgesics and any other prescribed drugs and complete the
course of treatment.
Have adequate rest and sleep
Keep the head elevated for proper breathing
Avoid aspirin or any product containing aspirin to avoid bleeding
NASAL FRACTURE
Fracture of the nasal bones (ethmoid and sphenoid) is most often caused by trauma of substantial
force to the middle of the face.
Classification of nasal fractures
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a. Unilateral fractures: typically produces little or no displacement.
b. Bilateral fractures: it is themost common and it give the nose a flattened appearance.
c. Complex fractures: complex fractures are caused by powerful frontal blows. This force
may also shutter the frontal bones.
Signs and symptoms
Inability to breathe through the nose due to nasal obstruction by oedema.
Presence of visible oedema of the injured soft tissues.
There may be evidence of septal deviation
Epistaxis or clear drainage which indicates leakage of cerebrospinal fluid.
There may be ecchymosis under one or both eyes.
Pain or tenderness over the nose bridge
Visible cosmetic disfigurement due to a flattened appearance.
Diagnosis - depends on:
History of the incident
Direct observation
X-ray findings
On inspection, the nurse should assess the patient’s ability to breathe through each side of
the nose.
Note should also be taken of the presence of oedema, haemorrhge or haematoma.
Management
Aims of management
To reduce oedema so as to ease breathing
To prevent complications such as infection
To provide emotional support
To ensure proper alignment of the nasal bones and minimize deformity.
The patient is managed on an ENT or general surgical ward in a clean dust free environment.
Position in bed – preferably a sitting up position to ease breathing.
The patient’s particulars, vital observations are taken and recorded for reference.
The general preoperative procedure is carried out
When the fracture is confirmed by x-ray, the patient is taken to theatre for realignment of the
fractured bones using open or closed reduction [septoplasty or rhinoplasty]
Postoperative care
The respiratory status of the patient is assessed to ensure a patent air way when the pack has been
removed.
The surgical site is observed for haemorrhage and oedema.
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The patient is discouraged from taking aspirin-containing drugs for at least 2 weeks to
prevent/reduce bleeding.
The patient should be educated about self-care at home and how to watch out for complications
because he stays in hospital for few [2-3] days and then discharged
The patient is instructed not to blow the nose. He/she should open the mouth when coughing,
sneezing to maintain the correct position of the pack.
Apply a cold compress to the incisional area to promote vasoconstriction and reduce oedema.
Analgesics such as paracetamol 500mg to 1g TDS
The patient may be taught non-pharmacological measures eg elevation of the head or cold
compress to relieve pain.
The patient is also taught gentle cleaning techniques such as use of cotton swabs with hydrogen
peroxide to clean the crusting and application of water soluble jelly to lubricate the nose when the
pack has been removed.
The prescribed antibiotics are given to prevent infection.
The use of bed side humidifiers to decrease drying of the mucosa and promote comfort.
Complications
Air way obstruction Cosmetic deformity
Epistaxis Infection
EPISTAXIS
Defn: Epistaxis refers to bleeding from the nose.
Nose bleeds have a variety of causes.
Most often, blood comes from kiesselbach’s area, which is located in the frontal part of the nasal
septum and contains numerous blood vessels.
Causes
Localized infections: vestibulitis (infection of the area inside the opening of the nostrils),
sinusitis.
Dried mucous membrane in the nose due to injury eg
Repeated injury from picking the nose
Fracture of the nose.
Disorders causing bleeding tendency such as:
- aplastic anaemia - Liver disease
- leukaemia. - Hereditary blood disorders
- Thrombocytopenia such as haemophilia
Arteriosclerosis (narrowing of the arteries)
Hypertension
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Viral haemorrhagic fevers
MANAGEMENT
Aims
control bleeding
prevent infection
prevent aneamia
First aid management
Bleeding can be controlled by pinching the sides of the nose together for 10-15 minutes.
The patient is reassured.
General management
Temporarily pressure is applied inside the nose with a piece of cotton or gauze saturated
with phenyl ephedrine and lidocain.
The patient is asked to lean forward to minimize inhalation of blood.
Meanwhile, he should breathe through the mouth.
He is instructed not to blow the nose.
A cold compress is applied on the forehead and nose bridge to enhance vasoconstriction.
Note: the nasal pack may be left insitu for 48-72 hours. This may be painful so a mild
narcotic analgesic eg codein is administered.
An inflatable balloon may be used as nasal packs.
Upon cessation of bleeding, the doctor cauterizes the bleeders with silver nitrate or
electrocautery.
In case of a bleeding tendency, cauterization is not done due to a risk of recurrence.
Instead doctor gently presses gauze saturated with petroleum jelly against the bleeders.
After bleeding has stopped, the disorder is identified and corrected.
Sometimes the doctor may ligate the artery supplying the area.
Patients with malformed blood vessels (hereditary haemorhagic telangiectasia) may have
several severe nose bleeds resulting into severe persistent anemia.
A graft onto the nasal septum reduces the nose bleeds and then anamia is corrected.
In case of severe blood loss, blood transfusion may be instituted.
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ACUTE PHARYNGITIS
Pharyngitis refers to inflammation of the throat [pharyngeal wall].
It may include the tonsils, palate and uvula.
Aetiology
Pharyngitis may be caused by numerous organisms such as:
Haemolytic streptococci Corynebacterium diphtheria
Staphylococci Candida albicans (fungal pharyngitis)
Neisseria gonorrhea Viral infections such as common
cold, influenza
Signs and symptoms
Dryness of the throat is the initial feature
Soreness may range from slight scratchiness to severe pain and malaise
Difficulty in swallowing
A dry hacking cough may be present
On examination;
The throat appears reddish
There is elevated body temperature
There may be a purulent exudate, oedema of the tonsils, palate and uvula.
Vesicles may be present on the pharyngeal wall and tonsils due to gonococcal or viral
pharyngitis.
Cervical lymphadenopathy
A whitish plaque is observed in the mouth or on pharyngeal wall if due to fungi.
Treatment
Warm salt-water gargles can relieve throat discomfort
Adults less or more than 18 years may take oral acetylsalicylic acid.
Lozenges containing a mild anaesthetic may relieve local soreness.
A liquid diet is better tolerated up to 2.5 litres per day is advised.
Oral hygiene not only prevents mouth complications but also prevents drying and cracking of lips
and usually refreshes the mouth
Adequate rest is vital especially if the patient is febrile.
A throat swab should be sent to laboratory for culture and sensitivity to aie appropriate antibiotic
administration.
The drugs of child include;
-phenoxymethyl penicillin (pen v) 500mg 6hourly.
-Tbs Erythromycin 250-500m 6hourly.
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-Candida infections are treated with Nystatin plus antibiotics
-Citrus fruit juices should be haulted because they irritate mucus membrane.
Advice on discharge
Complete the prescribed treatment.
Avoid overcrowding
Ensure a dust free environment especially the house at home.
All RTIs should be treated early enough to prevent complications.
Plenty of oral fluids are help full.
Complications
-Rheumatic fever
-Peritonsillar abscess.
Note: ASA use in children may cause Reye’s syndrome. Reye’s syndrome is characterized by
encephalopathy and hepatic failure in children resulting from viral infection, aspirin use.
LARYNGITIS
Acute laryngitis is an infection of the mucus membrane lining the larynx (voicebox) ,
accompanied by oedema of the vocal cords.
Causes
Viral infection (e.g common cold) of the upper air way.
It may also accompany bronchitis, pneumonia, influenza, whooping cough (pertussis),
measles, diphtheria,
May follow any inflammation or infection of the upper air way.
Exercise use of the voice eg musicians, teachers.
Allergic reactions
Inhalation of irritants such as cigarette smoke.
Clinical manifestations
Hoarseness or even loss of voice
The throat may be painful and feel tickled
Cough may be present
Difficulty in swallowing due to sore throat.
Difficulty breathing due to Oedema of the larynx.
On examination using a small angled mirror, a doctor sees a mild to marked reddening of
the larynx.
Management
Treatment depends on the cause.
For viral laryngitis, symptomatic treatment is all that has to be given
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Resting the voice by not speaking or speaking in a whisper.
The patient is advised to remain indoors in an even temperature and to avoid talking for
some days/ weeks depending on the extent of inflammation.
Steam inhalation relieves symptoms and promotes healing of sore areas.
Antibiotic cover for any existing respiratory tract infection may help improve the
laryngitis
The patient is encouraged to takeplenty of oral fluids to guard against dehydration and
drying of the throat.
If the patient is a known smoker, the vice should be dropped.
Note:
Chronic laryngitis may prevail in persons who use their voices excessively.
Habitual smokers
Work continuously in areas with irritating fumes.
Hoarseness is usually worse in the morning and evening.
The patient may have a dry harsh cough.
Treatment of chronic laryngitis
-Remove the irritant -Mouth care.
-Steam inhalation -Additional oral fluids are important
-Correction of faulty voice habits
.
Advice on discharge
It is the nurse’s role to health educated the patient on the following:
Need to take a full course of the prescribed antibiotics.
Need to increase oral fluid intake
Smokers must stop the habit
Need to avoid smoky environment.
The patient referred to a support of persons waiting to stop smoking.
Precautions to be observed in using steam inhalation.
CHRONIC ENLARGEMENT OF THE TONSILS AND ADENOIDS
Tonsils and adenoids are lymphoid tissue structures located in the oropharynx and nasopharynx
respectively.
They reach full size in adulthood and then begin to atrophy during puberty.
When adenoids hypertrophy usually due to chronic infection (but sometimes due to unknown
reason), they cause nasal obstruction.
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Clinical manifestation
- The patient breathes through the mouth
- Snores loudly
- May have a dull facial expression
- Reduced appetite due to interference with swallowing resulting from blocked
nasopharynx.
- Note: hypertrophy of the tonsils usually does not block the oropharynx but may affect
speech, swallowing and cause mouth breathing.
Management
The tonsils and adenoids are surgically removed (tonsillectomy/adenoidectomy):
When they hypertrophy and cause features of obstruction.
When they are chronically infected
In case of repeated attacks of tonsillitis or repeated episodes of Peritonsillar abscess.
Note: chronic infections of these structures do not usually respond to antibiotics and may remain a
source of infection that may spread to the heart and kidneys.
Key points in the postoperative care following tonsillectomy
Position in bed – the patient is positioned on the side until she is fully awake from general
anesthesia, then into a mid-fowler’s position when a wake.
Monitoring for haemorrhage:
- Frequent swallowing (inspect the throat for bleeding)
- In case of bright red vomitus
- Rapid pulse
- Restlessness
Comfort:
- Ensure comfort in a well-made, clean and warm bed.
- The patient is given 30% cool mist via a collar.
- Apply ice collar to the neck (it reduces bleeding by vasoconstriction)
- Analgesics such as acetaminophen instead of Acetyl salicylic acid to minimize the risk of
haemorrhage.
- Ensure a clean, noise-free ward environment to promote rest and sleep.
Food and fluids:
- Ice-cold fluids and bland foods are given during the initial period.
- Give not milk because it increases mucus that may that tempt the patient to clear the
throat.
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- The patient may advance to normal diet as soon as possible.
Patient and family advice
Avoid throat clearing immediately following surgery. This may cause bleeding.
Avoid coughing, sneezing, vigorous nose blowing and vigorous exercise for atleast 1-2
weeks
Adequate oral fluid intake (2-3liters a day) until mouth odour ceases
Avoid hard scratchy food eg popcorn or toast, until the throat is healed.
Report features of bleeding to the physician immediately.
Inform the patient to expect more throat discomfort between the 4th and 8th postoperative
day due to membrane separation
The patient should expect black or dark stool for a few days due to swallowed blood.
Resume normal life style activity as long as it is not stressful and does not require
straining.
CANCER OF THE NASOPHARYNX
This may occur in child hood and young adults
Cause
The Epstein Barr virus which causes infectious mononucleosis plays a role in the occurrence of
nasopharyngeal cancer.
Clinical features
Persistent blockage of the nose and Eustachian tube
Accumulation of fluid in the middle ear due to blockage of the Eustachian tube.
There may be pus or blood discharge from the nose.
Rarely part of the face becomes paralysed.
Enlarged cervical lymph nodes due to metastases
Diagnosis
Biopsy is done to study the nature of cells of the tumour.
Treatment
Radiotherapy
Surgery is done if the tumour is large, persists but with no metastases
Note: the general preoperative and postoperative care principles are followed.
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Clinical feature
Sore throat – usually the initial symptom
Pain that often radiates to the ear on the side of the affected tonsil
There may be a lump in the neck resulting from the cancer spreading to the lymph
nodes.
Diagnosis
Biopsy of the tonsil
Since smoking and alcohol are linked to other cancers, the following examinations are
also done:
- Laryngoscopy – examination of the larynx
- Bronchoscopy – examination of the bronchial tubes
- Oesophagoscopy – examination of the oesophagus
Treatment
Radiotherapy
Surgery
Surgery may involve removal of the tumour itself, lymph nodes in the neck and part of the jaw.
Note:
If metastasis has already occurred, surgery may not be helpful
For postoperative care, refers to care following tonsillectomy
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Treatment depends on the actual location of the malignancy within the larynx
While still in the early stages, surgery and radiotherapy are the usual measures.
If the vocal cords are affected, radiotherapy is the best alternatives to preserve the normal
voice.
For patients in advanced stage, surgery is the alternative and it may involves total
laryngectomy followed by radiotherapy.
After total removal of the vocal cords, no voice is produced.
Anew voice can be created in any of the following ways:-
Oesophageal speech – the patient is taught to take air into the oesophagus while inhaling and
gradually expels the air to produce a sound.
Tracheoesophgeal fistula – in this method, a one way valve is surgically inserted between the
trachea and oesophagus, this helps to produce sound.
Electrolarynx – it is a device that acts as a sound source when it is held against the chest.
Note: sound produced by the above methods is converted into speech by help of the mouth, nose,
teeth, and tongue and lips though the produced voice sounds artificial and is much weaker than
the natural voice.
DENTAL AND ORAL CONDITIONS
To ensure healthy teeth, an individual must remove plaque daily with a tooth brush and
dental floss.
In all efforts to reduce the risk of tooth decay (dental caries), it is very important to reduce
the amount of sugar consumed.
Luckily enough, fluoridated water helps to reduce the risk.
Avoiding both alcohol and cigarette smoking keeps the mouth and teeth healthy too.
Whether chewed, smoked or dipped, tobacco worsens gum disease.
Tobacco, alcohol and worse still a combination of the two, is highly linked to the cause of
cancer of the mouth.
Examples of dental and oral diseases include:
1. Dental caries 4. Gingivitis 7. Fracture of the jaw
2. Pulpitis 5. Periodontitis
3. Periapical abscess 6. Oral cancer
DENTAL CARIES
Cavities (dental caries) are decayed areas in the teeth that result from a process which gradually
dissolves a tooth’s hard outer surface (enamel) and progresses towards the interior.
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Dental caries is a common disease in civilized populations due to their feeding habits
characterized by sugars.
If untreated, cavities continue growing and eventually lead to tooth loss.
Cause
Caries result from progressive destruction of the enamel and dentine of the tooth due to acid
produced by oral bacteria which are part of oral normal flora.
Pathophysiology
The bacteria convert carbohydrate such as sugar and starch to acid.
This lactic acid slowly dissolves the hard teeth tissues
Dental plaque, a film lying on uncleaned teeth is the site where bacteria act to produce lactic acid.
Despitethe various types of normal flora in the mouth, the most common causes of dental caries
are streptococcus mutans and lactobacilli.
Forms of dental caries
Decay develops differently depending on the location in the tooth.
1. Smooth surface decay: It is the most preventable and reversible type that grows slowest.
Bacteria dissolves calcium of the enamel.
It usually begins between 20 and 30 years of age.
2. Pit and fissure decay: a rapidly progressing tooth decay which usually starts during
teenage in the permanent teeth.
It forms in the narrow grooves in on the chewing surface and the cheek side of the back
teeth.
3. Root decay: it begins on the bone-like tissue covering the root surface (cementum).
It occurs in people past middle age.
Root decays results from difficulty cleaning the root areas and from a diet rich in high
sugars.
4. Decay in the enamel: decay begins in the enamel and after penetrating into the dentin
(which is somewhat softer), spreads faster to the pulp which contains nerves and blood
vessels.
Symptoms
Pain/tooth ache upon taking a cold drink or eating candy.
Pain on chewing
There may be pus in the socket of the affected tooth.
Swelling in the gum that is adjacent to the decayed tooth
Difficulty eating food due to pain
On inspection, the dentist may identify a cavity.
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Note:
Not all tooth aches are caused by cavities. Some may result from roots that are exposed
but not decayed, forceful chewing or fractured jaw/tooth.
Sinus congestion can make the upper teeth sensitive.
Diagnosis
The dentist uses dental instruments to test for sensitivity and softness.
An x-ray may show the extent of tooth damage.
Prevention
If a cavity is treated before it starts to hurt, damage to the pulp may be reduced.
Every individual, young or old should have dental check up every 6 months.
Not every examination will require an x-ray unless need be.
The five general strategies that are key in the prevention of dental caries are:
1. Oral hygiene
This involves brushing teeth before and after breakfast and before bed time.
Rinsing the mouth with plenty of clean and safe water after each meal/drink
Daily flossing removes plaque to control smooth surface decay.
Brushing prevents cavities from forming on the sides of teeth and flossing removes debris
between teeth where the brush cannot reach.
Food debris should be removed from between the gums margins, cheeks, tongue, and
palate with a rubber-tipped gingival stimulator.
2. Diet
All simple sugars including table sugar (sucrose), honey, fruits (fructose) are not friendly
to teeth.
Streptococcus mutans in plaque is capable of converting sugar in diet to acid in just 20
minutes of contact with sugar.
A person who develops cavities should minimize the consumption of sweet snacks.
3. Fluoridation
Fluoride makes the enamel more strong and resistant to acid hence resistant to cavities.
Consumption of foods fortified with fluoride helps the growing and hardening of teeth
until 11 years of age.
Water fluoridation is very useful in the prevention of cavities.
Use of fluoridated tooth paste should be encouraged.
Dentists sometimes apply fluoride to the teeth of any person who is at risk of tooth decay.
4. Sealants
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After thorough cleaning of the teeth, conditions the enamel and places a liquid plastic in
and over the grooves of the teeth.
The sealant then hardens forming a barrier so that bacteria inside the grooves does not
access food from which it would produce lactic acid.
A sealant may protect teeth for 1-10 years depending on its effectiveness.
5. Antibacterial therapy
Some people have active decay bacteria in the mouth and a parent may pass this bacteria
to the child through kissing.
Such a child may have cavities, a tendency that may seem to be familial
The dentist first removes decayed areas, seals all cavities and fissures in teeth.
Then he prescribes a powerful mouth rinse (chlorhexidine) for several weeks to kill the
remaining bacteria that is later replaced by harmless normal flora.
Treatment
If decay is halted before reaching the dentine, the enamel can repair itself.
Once decay reaches the dentine, the decayed part must be removed and replaced by a feeling
(restoration)
1) Fillings – these are made of various materials and may be put in and around the tooth.
Silver amalgam – it is used for fillings in back teeth where strength is important. Its colour
is not fair on front teeth
It lasts an average of 14 years.
Gold fillings (inlays) – these are stronger and can be used in very large cavities but are
more expensive.
Composite resins and porcelain fillings –are used in front teeth where the colour of silver
is not desirable.
Although they bear the colour of teeth, they are more expensive than silver amalgam and
are not as strong as silver amalgam to bear the full force of chewing in the back teeth.
Glass ionomer – a tooth coloured filling formulated to release fluoride once in place.
They benefit people who are prone to decay at the gum line.
They are useful in the restoration of areas damaged by vigorous brushing.
2) Root canal treatment and tooth extraction
In advanced tooth decay, the only way to eliminate pain is to remove the pulp by root
canal (endodontic) treatment or tooth extraction.
After tooth extraction mouth care must be ensured to prevent infection.
PULPITIS
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The pulp is the innermost part of the tooth that contains nerves and blood vessels.
Causes
Tooth decay – the most common cause
Injury – the second most common cause
Because the pulp is encased inside the tooth, it has no room for swelling when inflamed. It only
increases pressure inside the tooth.
It is the increased pressure that damages the pulp.
Symptoms
There is intense tooth ache
Inability to masticate food
There may be swelling of the jaw on the affected side
Diagnosis
Application of cold stimulus reveals sensitivity
The dentist may use an electric pulp tester which indicates whether the pulp is alive or not.
Sensitivity tapping on the tooth to ascertain whether inflammation has spread to the
surrounding tissues and bone.
X-rays can confirm tooth decay
Treatment
Inflammation stops when the cause is treated
If detected early, filing the cavity can eliminate pain.
A temporary filling containing a sedative can be left in place for 6-8 weeks and the
replaced with a permanent filling.
Sometimes a permanent filling may be instituted immediately.
Incase pulp damage is extensive/irreversible, the dentist can eliminate pain by rmoving the
pulp through root canal treatment or tooth extraction.
PERIAPICAL ABSCESS
A periapical abscess refers to collection of pus resulting from an infection that has spread from a
tooth to the surrounding tissues.
Cause
In an inflammatory process, the body attacks infection with a vast number of leukocytes.
Pus therefore results from accumulation of leukocytes and dead tissues
Pus from a tooth infection drains to the gum which swells near the root of the tooth.
Pus may then drain to the skin, throat, mouth or skull.
Treatment
The abscess or cellulitis is treated by:
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Oral surgery (incision and drainage)
Root canal treatment
Antibiotics to help eliminate the infection
GINGIVITIS
This refers to inflammation of the gum [gingiva = gum]
It is an extremely common condition and can develop any time following loss of a tooth.
Most periodontal diseases inflame and destroy the surrounding structures that support the teeth
especially the gums, bone and the tooth root.
These diseases are mainly caused by accumulation of bacteria.
Dental conditions can also be affected by other general health problems such as:
Diabetes mellitus
Malnutrition
Leukaemia
HIV/AIDS
Smoking
Cause
Inadequate brushing and flossing allows plaque to accumulate along the gum line of teeth
Note: plaque is a soft sticky film made of bacteria which accumulates in faulty fillings,
around teeth that are next to poorly cleaned dentures and orthopaedic appliances.
When plaque stays on teeth for more than 72 hours, it hardens into tartar [calculus] which
cannot be completely removed by brushing and flossing.
Some drugs may cause overgrowth of gums, complicating plaque removal and gingivitis
often occurs. Such drugs include:
o Phenytoin – for control of seizures
o Cyclosporine – taken following organ transplant
o Nifedipine – used to control hypertension and heart rhythm disturbance
o Birth control pills or injections can also aggravate gingivitis.
Signs and symptoms
The gums appear to be red instead of pink colour
The gums swell and become moveable instead of being firm against the teeth
Bleeding from the gums during brushing and masticating food
Painful gums; this is worse when masticating food.
There may be many small white or yellow sores in the mouth and on the gums.
The patient may in the long run develop halitosis
The patient eventually refuses food in fear of pain.
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Treatment
Medical conditions that may cause or worsen gingivitis should be treated or controlled.
Vitamin c and niacin deficiencies can be treated with appropriate vitamin supplementation
and improved diet.
An anaesthetic mouth rinse can relieve pain during eating and drinking.
A dentist may prescribe corticosteroid tablets or corticosteroid paste that is applied
directly to the gums
In case of gingivitis due to leukaemia, bleeding is prevented by gently wiping the gums
and teeth with gauze pads or sponge instead of brushing and flossing.
Chlorhexidine mouth wash helps to control plaque and also controls mouth infections.
In case of excess gum tissue, surgical removal is done followed by a course of antibiotics.
Prevention
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Leukopenia AIDS
Note: periodontitis progresses quickly in people with AIDS
Symptoms and signs
Bleeding from the gums
Reddening of the gums
Halitosis
Pain on mastication
As more of the bone is lost, the tooth loosens and changes position
In case of front teeth, they tilt outward.
Treatment
Periodontitis requires professional care.
A professional dentist usually cleans the pockets using scaling and root planning
Thorough removal of the tartar and the diseased root surface is done.
For pockets hat are deep, surgery is required
A dentist or periodontist may remove part of the separated gum so that the rest of the gum
can reattach tightly to the teeth.
A suitable antibiotic may be administered to counteract the rate of infection.
Antibiotic impregnated filaments may also be inserted by the dentist into the deep pocket
to increase drug concentration.
In case of a sore mouth after surgery, a one minute chlorhexidine mouth rinse twice a day
may be temporarily substituted for brushing and flossing.
FRACTURE OF THE JAW.
Trauma of the jaw causes pain and usually changes the way the teeth fit together.
Jaw fracture may be pathological ie as a complication of osteomyelitis.
Causes:
Road traffic car accidents
Some games such as boxing
Pathologic eg as a complication of osteomyelitis
May be a complication of a large dental cyst or neoplasm
Domestic violence as in fighting
Clinical features of jaw fracture.
Difficulty opening or closing the mouth
The mouth may deviate to one side when opening or closing
Factures of maxilla may cause double vision (because muscles of the eye attach nearby)
Numbness in the skin below the eye(due to injuries of nerves)
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Irregularity in the cheekbone, felt when running a finger along it
The above features may be accompanied by swelling of tissues at the injury part
First Aid management
If a jaw fracture is suspected, the jaw should be held in place with teeth together and immobile
The jaw may be held with a hand or preferably with a bandage wrapped under the jaw and cover
the top of the head several times
Ensure breathing is not impaired during bandaging
The patient should be transported to hospital in a prone position
Management in the hospital
An x-ray is useful as it may help to identify the nature of bone trauma
The patient is reassured and then prepared for theatre, the upper and the lower jaws may
be wired together
Wiring may remain in place for 6/52 to allow bone healing. During this period, the patient
only drinks liquids through a straw.
Multiple jaw fractures can be repaired surgically with a metallic plate screwed into the
bone on each side of the fracture.
In multiple fracture,the jaw is immobilized for only a few days, and then soft foods can be
eaten for several weeks.
Ensure a free air way. The patient should not lie flat on the back in fear of the tongue
falling back and obstruct the air way
In children immobilization may not be necessary. Restricted motion is enough and normal
activities resumes in a few weeks.
Antibiotic therapy is considered for a patient with a compound fracture to counteract
infection.
Oral hygiene must not be neglected. A mouth wash with 0.2% chlorhexidine twice a day is
useful.
Complications of jaw fracture.
Injury to the cervical spine
Spinal damage
Concussion or bleeding within the skull
Osteomyelitis of the affected bone
Oral inflections eg stomatitis, gingivitis etc
Bleeding in case of compound fracture
CONDITIONS OF THE EYE
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The following principles are important in the nursing care of patients with eye conditions
1. Attention to minute detail is essential.
2. Asepatientic or non-touch technique should be maintained when treating the patient
3. The terms guttae (gutt) and oculentum (oc) indicate eye drops and eye ointment
respectively and are commonly used.
4. Dropper tips may touch the eyelids or eyelashes that harbor pathogens thereby
contaminating the eye,they have been replaced by the single dose containers.
5. All drops should be carefully checked for type, indication and expiry date as instillation of
wrong drops may damage the eye.
6. In case of a purulent eye discharge, the eye must not be covered to allow the discharge to
escape
7. In case if abrasions or wound of the eye, or a foreign body has been removed, a pad and
bandage should be applied to the eye to offer relief from straining and pain.
8. In most eye conditions, only the affected eye require covering. However,certain conditions
eg before and after retinal detachment, both eyes must be recovered.
9. A patient with both eye padded should be treated as though he/she is blind
10. After excision of the eye:-
Immediately post operatively, a firm pad and damage are required to reduce swelling and
bruising
The socket will require instillation of drops or ointment of a suitable antibiotic until
healing has occurred
A plastic shell is worn for 3 to 4 weeks to prevent shrinkage and to sharp the socket until a
prosthesis is worn
CONJUNCTIVITIS
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V. Inclusion conjunctivitis - A purulent inflammation of conjunctiva due to chlamydia
trachomatis.
VI. Vernal conjunctivitis - An allergic spring conjunctivitis.
CAUSES
Mechanical trauma eg sunburn.
Infections such as staphylococcus, strepatientococei, haemophilus influenza
Sexually transmitted agents ie chlamydia trachomatis and Neisseria gonorrhea
Allergic reaction to dust, mold, pollen, wind, smoke and other types of air pollution
External irritants eg poison, cosmetics
Viral agents include human adenovirus,
Signs and symptoms
A gritty (sand) sensation in the affected eye(s)
Photophobia may be present
The eye appears red
Eye discharge which may be thick or purulent in bacterialconjunctivitis or clear in viral or
allergies
Eyelids may swell and itch especially in allergic conjunctivitis
MANAGEMENT.
Treatment of conjunctivitis depends on the cause.
It also involves careful cleansing of eyelids and lashes.
The use of topical antibiotics plays a vital role
Treatment
A warm moist compress may be used to gently remove adherent crusts from eyes especially in the
morning.
Procedures for applying warm moist compress
Aseptic technique is used when infection or ulceration is present. A clean technique may
be used in allergy
Separate equipment are used for bilateral eye infection
Hand washing before treating each eye
Change compress every 5 minutes. Always wash hands first
Never exert pressure on the eyeball
Sterile petroleum may be applied on skin around eyes if desired to protect the skin
If sterility is not vital, moist heat may be applied by means of a clean face towel or a cloth
Since the drainage material may be infectious, it should be disposed carefully
Drugs:
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Antibiotics and antiviral drugs:
- Polymyxin B bacitracin - Idoxuridine (IDU)
- Polymyxin B neomycin - Gentamicin sulfate (garamycin)
- Bacitracin - Chloramphemical (chloramycin)
Steroids.
-
- Prednisolone acetate - Triamcinolone
- Prednisone - Dexamethasone
- Methylprednisolone (depomedrol) - Flourometholone
- .
Cycloplegic and mydriatic action.
- Atropine sulphate - Homatrophine hydrobromide
- Cyclopentolate hydrochloride (isopromide)
(cyclogyl) - Scopolamine hydrobromide
- Tropicamide (mydriacyl)
Note
Antibiotics may be used inform of ointment or drops
Ointment remains in contact with eye much longer giving a prolonged effect. However
eye drops are absorbed much faster than ointments
Patient education:
The patient is taught about the cause of diseases and its Rx
Avoid crowding places and keep hands away from eyes
Frequent hand washing is very important
The patient is taught the right way to instill the eye drops
The ointment is gently placed on to the exposed conjunctiva from medial to lateral aspects
Avoid contamination of tips of dropper by eyelashes
The patient is informed of blurring of vision
In case ointments and drops are co-used, ointment is applied first
Treatment at bed time minimizes side effects of blurred vision
Complications of conjunctivitis:
Ulceration of the cornea
Perforation of the eyeball esp. due to Neisseria gonorrhea
Involvement of the cornea may lead to loss of eye – though rare
In severe complicated cases, blindness may result
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TRACHOMA
33
Systemic antibiotics
Topical tetracycline is modest in action and may not eradicate severe chlamydial infection.
Oral tetracycline was the systemic antibiotic of choice but is out of date because of its side
effects (staining of teeth in children, teratogenicity, and retarded bone growth in children).
Azithromycin is a new antibiotic and has shown great promise.
Single dose of 1 gram for adults is effective, at least from clinical research!
It has been shown “that a single dose of oral Azithromycin is as effective as a long course
of topical tetracycline for the treatment of active trachoma
Consists of applying antibiotic ointments containing tetracycline or erythromycin 6 hourly
for 4 to 6 weeks
Surgicalconsideration
If the condition causes deformities of the eye lid (entropion), conjunctiva or cornea, surgery may
be needed.
Surgical intervention for trichiasis, followed by topical ointment for seven days after
surgery
Bilamellartarsal rotation to direct the lashes away from the globe
Epilation (eyelash removal) for areas without surgical intervention program
Complications
- Severe conjunctival scarring causes shortening of the tarsal plate and in-turning of the
eye lid margin (entropion)
- With severe upper lid entropion, the eyelashes turn inward (trichiasis) and touch and
abrade the cornea resulting in scarring.
Prevention
A multifaceted approach to stop the infliction and impact of trachoma
SAFE strategy
think of the environmental risk factors of trachoma to prevent infection and possible re-
infection:
Contain fecal matter in latrines to limit fly population
Sanitation and Hygiene:
- The 6 D’s: Dryness, dust, dirt, dung, discharge, density (overcrowding)
- The 5 Fs: flies, feces, faces, fingers, and fomites
Include azithromycin in proposed “medical cocktail” of Ivermectin and Albendazole to
prevent the seven neglected tropical diseases
STYE
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Stye also known as Hordeolum is an infection usually a staphylococcal infection of one or more
glands at the edge of the eyelid or under it
An abscess forms and tends to rapture, releasing a small amount of pus.
Sometimes stye occurs simultaneously with or as a result of blepharitics
Clinical features
An acute swelling appears on the eyelid margin
It is red, tender, and round
The pustule gradually resolves or raptures
The eye may water, become photophobic
A feeling of something in the eye may be present
Usually only a small area of the eyelid is swollen
Often a tiny yellowish spot develops at the centre of the swelling.
Treatment
Although antibiotics are applied, they seem not to help much
A warm compress for 10 minute several times a day is the best treatment.
The warmth help thestye come to head, rapture and drain.
If the stye is severe and does not rupture, the pustule is incised in caseit does not dissolve
spontaneously.
In case of recurrence more than once, the patient should perform lid scrubs daily
More still, appropriate ointments or drops may be indicated if there is a tendency for
recurrence.
FOREIGN OBJECTS.
Commonly, eye injuries occur to the sclera, cornea,conjunctiva caused by foreign bodies.
Though most of the injuries are minor, penetration of the cornea, or development of an infection
from a cut or scratch on the cornea can be serious.
Causes
Poorly fitted lenses may fall off scratching the cornea.
Forcefully removed lenses
Sand particles
Flying pieces of glass, metal as in metal fabricating
Falling tree branches and sticks
Falling debris
Symptoms
Any injury to the surface of the causes pain
35
A feeling of a foreign body in the eye
The eye may be sensitive to light (photophobia)
Redness of the eye
Bleeding from the eye blood vessels of the surface may occur.
There may be swelling of the eye and eyelid
Blurred vision
Treatment
Any foreign object in the eye must be removed
Special eye drops containing fluorescein dye make the foreign body more visible and
reveal any surface abrasion on the conjunctiva or eye ball
Anaesthetic drops may be instilled to numb the surface of the eye ball
Using a special lighting instrument to view the surface in detail, the ophthalmologist then
removes the object.
A foreign object can be lifted out with a moist sterile cotton swab
Sometimes it can be flushed out with sterile water.
In case of a small superficial corneal abrasion an antibiotic ointment may be applied for
several days.
Larger corneal abrasions require additional treatment
The pupil is kept dilated using drugsand then antibiotic drops are instilled.
The eye is then kept closed by applying a shield.
Fortunately the surface cells of the eye regenerate rapidly; may heal in 1-3 days
For deeper ulceration of the eye, an ophthalmologist must be consulted for emergency
management
LUNT INJURIES OF THE EYE
A blunt impact forces the eyeball into its socket, possibly damaging the structures at the surface
(ie the lid, conjunctiva, sclera, cornea and lens)
It may also damage structures at the back of the eye (ie retina, nerves and blood vessels)
Such an impact can also break the bones around the eye.
Domestic assault is one of the most common causes.
Symptoms
Blood may leak into the skin around the eye producing a bruise (contusion) known as
black eye.
Red eye due to bleeding into the surface of the eye
Blurred vision resulting in increased intraocular pressure due to bleeding in the anterior
chamber (hyphema).
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There may be pain and tenderness
Swelling of tissues around the eye ball
Visible foreign body
Absent eye movement
Tearing
Treatment
Application of a cold compress using ice packs may reduce swelling and ease pain of a
black eye.
By the second day after trauma, warm compresses can help the body tissues to absorb
excess blood that has accumulated.
In case of soft tissue lacerations, surgical toilet and suturing [STS] may be done preferably
by an ophthalmologist to minimize deformities of the eye lid.
For laceration of the eye, drugs that dilate the pupil are administered along with
analgesics.
The ophthalmologist may prescribe antibiotic drops.
A metal shield is applied to protect the eye against further injury.
In case the patient has increased intraocular pressure, acetazolamide may be given.
Amino caproic acid is given to reduce bleeding
However, any drug containing acetylsalicylic acid should be avoided.
Complications
Retinal detachment
Rapture of the eye ball – in severe injuries
Glaucoma
Displacement of the lens
Loss of site especially in severe cases
Infection resulting into orbital cellulitis
GLAUCOMA
Glaucoma is a disorder in which pressure in the eye ball increases damaging the optic nerve
causing loss of vision.
It is not one disease but rather a combination of disorders characterized by:-
- Increased intraocular pressure and the consequences of elevated pressure.
- Optic nerve atrophy
- Peripheral visual loss
Normally the anterior and posterior chambers are filled with aqueous humour.
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This fluid is produced in the posterior chamber, passes through the pupil into the anterior
chamber.
It drains from the eye through the outflow channels.
If the flow is interrupted by obstruction that prevents out flow from anterior chamber, intraocular
pressure increases.
Classification
- Open angle glaucoma
- Closed angle glaucoma
- Congenital glaucoma
Open angle glaucoma
In open angle glaucoma, fluids drain too slowly from the anterior chamber.
Pressure gradually rises in almost always both eyes resulting in optic nerve damage and gradual
loss of vision.
It is the most prevalent type and commonly occurs after 35 years of age but may also occur in
children.
Open angle glaucoma tends to run in families and is common in diabetics or people with myopia
(near sightedness).
Clinical features
Initially there may be no symptoms
Later, the symptoms may include:
- Narrowing peripheral vision
- Mild headache
- Vague visual disturbance
- Difficulty adopting to darkness
- Eventually the patient develops tunnel vision (extreme narrowing of visual fields hence
difficulty seeing anything on either side when looking forward), may develop.
Treatment
This is more likely to be effective if started early.
Production of intraocular fluid may be reduced by beta blockers such as:
Timolol
Betaxolol
Carteolol
Levobunolol
Metipranolol
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Out flow of the fluid can be improved by drugs like:
Epinephrine carbachol
Dipivefrin
In case drugs do not help, the ophthalmologist can improve drainage from the anterior
chamber by using laser therapy to create a hole in the iris.
Closed angle glaucoma
It causes sudden attacks of raised intraocular pressure usually in one eye.
In such patients, the space between the cornea and iris where the fluid filters out of the eye is
narrower than normal.
Blockage of the fluid drainage by the iris may be due to anything that dilates the pupil such
as;
- Dim light
- Eye drops that dilate the pupil
- Some oral or injectable medication
Symptoms
- Slight decrease in vision
- Coloured halos around lights
- Pain in the affected eye
- Headache
- These features may last only a few hours before a major attack occurs which presents
with:
- Rapid loss of vision
- Sudden severe throbbing pain in the eye
- Nausea and vomiting is common
- The eyelid swells, eye gets watery and red
- The pupil dilates and does not respond to bright light
Treatment
Pressure in the eye can be decreased by:
Drinking a mixture of glycerin and water. This medication also prevents an attack
Other drugs include:
- Acetazolamide
- Pilocarpine eye drops – constrict the pupil
- Beta blockers are also useful
39
In severe cases, mannitol is given intravenously to reduce the pressure.
Laser therapy creates a hole in the iris to allow drainage, helps to prevent future attacks and
may cure the disorder permanently.
In case laser therapy does not help, surgery is performed to create a hole in the iris
Secondary glaucoma
Occurs due to damage of the eye resulting from:
Infection
Inflammation
Tumour
An enlarged cataract
Any eye disorder that interrupts fluid drainage from the anterior chamber (eg uveitis).
Other common causes include:
Ophthalmic vein blockage
Eye injury due to trauma or surgery
Medication eg corticosteroids can also increase intraocular pressure.
Treatment
Depends on the cause.
If it is due to inflammation, corticosteroids help to decrease inflammation along with drugs
that keep the pupils large.
Sometimes, surgery is the best option.
CATARACT
A cataract refers to the cloudiness or opacity in the eye’s lens that impairs vision.
It produces a progressive painless loss of vision.
Cataracts are the third leading causes of preventable blindness.
Aetiology
Cataracts are generally classified as:
1. Senile cataracts – these are associated with ageing.
2. Traumatic cataracts – they are associated with injury.
The injury may be blunt or penetrating. They may also be due to radiation or exposure
to ultraviolet rays.
3. Congenital cataract–it is usually present at birth. Maternal rubella infection is a risk
factor for the baby.
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4. Secondary cataract – it occurs after other diseases such as measles and diabetes
mellitus.
Drugs such as systemic corticosteroids or long term use or topical corticosteroids and
ocular inflammation are thought to be contributors.
Risk factors associated with cataracts
1. Age: the incidence increases dramatically after 65 years.
2. Sex: cataracts are slightly more common in females than in males.
3. Ultra violet light exposure:
More common in people living in warm sunny climate
More common in people who work out door extensively.
4. High dose radiation exposure
5. Drug effect: corticosteroids, phenothiazines and selected chromotherapeutic agents.
6. Poorly controlled diabetes mellitus: leads to accumulation of sorbitol (products of
glucose)
7. Trauma to the eye: may be blunt or penetrating.
Cataracts may also result from:-
Ingestion of injurious substances such as dinitrophenol or naphthalene.
Systemic absorption of hair dyes.
Eye diseases such as uveitis or eye trauma
Systemic diseases eg diabetes mellitus, galactosaemia or sarcodiosis.
Clinical presentation
The patient complains of a decrease in vision
Abnormal colour perception
Gradual painless blurring and loss of vision
Vision loss is more worse at night and in bright light
A cloudy white opacity on the pupil may be seen.
Glare annoys the patient when there is bright light
Management
The diagnostic tests of cataract include the following:-
Visual acuity measurement
Direct or indirect ophthalmoscopy
Slit lamp microscopy
Blood testing and potential acuity testing in selected patients
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Keretometrics and A- scan ultrasound
Visual field perimetry
Drugs
Medication play no role in the management of cataract.
Anaesthetics, anti-inflammatory agents and antibiotics are used post operatively.
Non-surgical therapy
Strong reading glasses or magnifiers may be given
Increased lighting in the patient’s environment
Life adjustment and reassurance
Surgery
This is the definitive treatment for cataracts.
It is considered when the non-surgical interventions no longer provide accepatientable level
of vision.
Common surgical procedures for cataract
Removal of the lens
- Phacoemulsification
- Extracapsular extraction
Correction of surgical aphakia (absence of the lens of an eye)
Intraocular lens implantation – this is the most frequent type of correction.
Note: most cataract surgery is performed in ambulatory surgical centres. Few patients require
admission to hospital.
Immediate postoperative care
Recumbent position or the patient is positioned on unoperated side to prevent pressure
in the operated eye.
Bed side rails are kept up to protect the patient from falling off the bed
The bed side table should be placed on the side of unoperated eye.
Place a call light within the patient’s easy reach or a bell may be used.
Avoid actions that increase intraocular pressure eg coughing, sneezing, vomiting,
straining.
Avoid sudden bending over with the head below the waist.
Avoid entry of soap and water into the operated eye.
The patient and caretaker are advised on eye/face hygiene to minimize contamination.
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The patient and family are taught about the signs of infection to facilitate early
recognition and treatment of infection.
Instruct the patient to instill eye drops using aseptic technique
The patient is encouraged to comply with the prescribed medication, monitor and
report pain
Follow appointment date is emphasized to maximize potential visual outcome. This is
arranged preferably weekly or two for 6 weeks.
Note:
For a few weeks postoperatively, antibiotic eye drops or ointment is used to prevent
infection and promote healing.
Eye glasses or a metallic eye shield is used to protect the eye against disturbance until
healing is complete.
CORNEAL ULCER
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Minor abrasions heal spontaneously without scarring
Some corneal ulcers may heal with treatment but may leave a cloudy fibrous material
that causes scarring and impairs vision.
A serious corneal ulcer is an emergency which should be treated by an
ophthalmologist.
To visualize the ulcer properly, the ophthalmologist instills fluorescein dye drops
Antibiotic eye drops may be instilled for a considerable period of time.
Surgical repair may be necessary.
Face/eye hygiene is very vital in the care of the patient.
Complications
Scarring may result in visual Perforation of the cornea
impairment Displacement of the iris
Deep-seated infection Destruction of the entire eye ball
ORBITAL CELLULITIS
Orbital cellulitis refers to an infection of the tissues around the eye ball.
The inflammatory process of soft tissues of the orbit usually follows sinusitis causing
proptosis and diplopia [proptosis=protrusion of the eye ball, diplopia=double vision].
The infection may spread from the sinuses, tooth, blood stream or it may develop after an eye
injury.
Signs and symptoms
Extreme eye pain The eye may be tearing
Bulging eye [proptosis] The patient may complain of
Reduced eye movement photophobia
Swollen eye lids Impaired vision
Fever
Management
Orbital cellulitis can be recognized without using diagnostic tests.
However, further assessment may be done including:-
Examination of the mouth and teeth.
X rays or computerized tomography [CT] scan of the sinuses.
Swabs may be obtained from the conjunctiva, throat, and skin then taken to the
laboratory for culture and sensitivity.
Blood culture and sensitivity may be helpful.
Drugs - Antibiotics eg cloxacillin, ceftriaxone, benzyl penicillin (x-pen) are given
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Surgery – sometimes surgery may be required to drain pockets of infection (abscess), or an
infected sinus. Daily dressing is key in postoperative care
Note: the postoperative care is similar as for most eye conditions especially as for eye injury.
Complications
Infection of the central nervous system
Blood clots in the brain
Blindness if not adequately treated
Severe cases may .lead to loss of the affected eye.
Other eye conditions
Chalazion – refers to inflammation of the sebaceous glands in the eyelids.
Keratitis – is the inflammation of infection of the cornea
Uveitis- is an acute inflammation of the uvea
Blepharitis–it is the chronic bilateral inflammation of the eyelid margin.
Coloboma – a developmental defect in the upper eye lid of the new born.
Entropion – refers to turning in of the eyelids
Ectropion – the eye lid turns out ward
Iritis - is the inflammation of the iris
Retinal detarchment – is the separation of the retina from its underlying support.
Diabetic retinopathy - it is a disorder of the retina due to the effect of uncontrolled diabetes
mellitus
Hypertensive encephalopathy – a disorder of the retina due to high blood pressure.
Exophthalmos – an abnormal bulging of one or both eyes.
Strabismus [squint] – an abnormality of the eyes due to uncoordinated action or extraocular
muscles.
Nystagmus – refers to involuntary to and fro movement of the eye ball.
Assignment:Read and make notes on the above conditions
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