Cristie Roush DNP GNP BC VA Ann Arbor

Cristie Roush, DNP, GNP- BC VA Ann Arbor Healthcare System

-Review of ENT anatomy -Discuss an assortment of ENT problems related to the older adult: Important History Sign and Symptoms Physical Findings Treatment/Work Up When to Refer to ENT

�History �Previous impactions �Hearing aid use �Ear Surgery* �Anticoagulation therapy* �Diabetes* �Immunocompromised state* *Refer to ENT �Symptoms �Hearing loss �Pain, itching �Fullness, tinnitus �Cough, drainage, odor �Dizziness

�Treatment �Cerumenolytic agents* Carbamide Peroxide (Debrox) Chlorine Salicylate and Glycerol (Audax, Earex Plus) Instill several drops three times a day for 714 days *Do not use if the status of the TM is unknown � Advantages �Easy to use �Effective-not superior � Disadvantages �Otitis Externa �Pain/Vertigo if perforation �Allergic reactions �Transient hearing loss

�Treatment �Irrigations Vinegar/Water H 2 O 2/H 2 O � Advantages � � Disadvantages � � �Manual Removal Effective TM Perforation Pain/Vertigo EAC Trauma Otitis Externa Failure � Advantages � Effective � Disadvantages � � Special Skills Pain, EAC trauma

� Inappropriate interventions �Oral Jet irrigators �Cotton-tipped Swabs �Ear Candles Limited research Seely et al-found no negative pressure Complications �Referral �Unclear diagnosis �Hx of ear surgery/Known perforation �Anticoagulation therapy �Diabetes �Immunocompromised state

� History �Hearing aid use, ear surgery, Diabetes �RAPID onset (within 48 hours) in the past 3 weeks AND � Symptoms �Otalgia of EAC inflammation (often severe), itching/fullness �Tenderness of the tragus/pinna/both or diffuse canal edema/erythema �MAY have hearing loss or jaw pain �MAY have otorrhea/lymphadenitis/TM erythema or cellulitis of the pinna and adjacent skin

� Treatment Pain Management �Irrigations �NSAIDS-Ibuprofen �Vinegar/Water �MAX 800 mg/ 3200 mg daily May add opiates No clinical trial to assess topical benzocaine otic solution irrigations BID – BEFORE instilling medicated drops �Topical drops Cortisporin – if no perforation Ciprofloxacin/Prednisolone Regardless of topical agent used, 65%- 90% of patients had resolution within 7 -10 days.

� Inappropriate interventions �Systemic antimicrobial therapy Not indicated unless there is extension outside the ear canal or other modifying factors �–Diabetes �-HIV infection �-Other immunocompromised states. �Referral �Failed initial therapy �Extensive debris in canal �Extensive edema of canal �Reminder �Keep aids out �Canal open to air

Ear Wick

� History �Seasonal allergies �Environmental allergies �Smoker �Nasal/sinus surgery �Nasal trauma �Epistaxis �Use of nasal sprays �Asthma � Symptoms �Clear rhinorrhea �Nasal congestion �No fever �Worse in Spring/Fall �Worse at meal times*

Stringy Rhinorrhea

� Treatment�Remove Nasally allergens if possible �Nasal saline irrigation �Steroid nasal sprays � Flunisolide -BID � Beclomethasone dipropionate- Dry � Budesonide� Fluticasone propinonate �Other Sprays Azelastine-Antihistamine BID Cromolyn Sodium-Mast Cell inhibitor-3 -4 x daily Ipratropium bromide. Anticholingergic 2 -3 x daily � Treatment- Orally (Second generation –non-drowsy) �Loratadine 10 mg daily �Fexofenadine hydrochloride 60 mg daily twice a day �Cetirizine 5 -10 mg daily �*Conditions of rhinitis do not need CT imaging.

� Referral �Abnormal nasal exam *May warrant CT imaging – Non contrast maxillofacial CT, axial and coronal cuts �Failure of initial therapy State medications tried/failed

� History �How long? Recent URI/Pneumonia? Intubation? �Smoker? How long? How much? �ETOH abuse? How long? How much? �Vocal use – hx of singer, coach, other vocal overuse �Heartburn History � Symptoms �Dysphagia/Odynophagia �Dyspnea/Hemoptysis �Unexplained wt loss �Unilateral ear pain �Heartburn/Indigestion Frequency, medicated �Altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related quality of life.

2 1 1. Reinke’s edema 2. Bilateral vocal cord nodules 3. Vocal Cord Polyp 3

Vocal Cord Paralysis Presbylarynx – bowing of vocal cords

Laryngeal Cancer

� Referral �For flexible nasopharyngeal scope �May consider trial of H 2 blocker (randitine 150 mg BID) or PPI (omeprazole 20 mg daily) if suspect GERD �Symptoms which persist > 3 months � Not �CT recommended imaging w/o LAD �Oral Corticosteroids �Oral antibiotics

Hope you had fun!

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