The primary function of the pulmonary system is ventilation and respiration (Figure 9-1). Respiration maintains life by supplying oxygen to organs, tissues, and cells and allowing for the removal of carbon dioxide (a waste product of metabolism). This process is made possible by ventilation (the bellowslike action of the chest) and healthy lung tissue that is adequately perfused with blood. Breathing is controlled by the central nervous system; nerve stimulation of breathing begins in the medulla oblongata and pons. Pulmonary circulation is composed of pulmonary arteries that carry deoxygenated venous blood from the heart to the lungs; pulmonary capillaries in which gas exchange occurs; and pulmonary veins, which return the freshly oxygenated blood to the heart for systemic circulation. Lung tissue itself is supplied with oxygen and nutrients by the blood supply that is carried to it by the bronchial arteries.

FIGURE 9–1 Normal lower respiratory system.

The lungs, along with the kidneys, have a major metabolic function: the maintenance of acid-base (pH) balance of the blood. Lack of oxygen with hypercapnia (increased carbon dioxide in the blood) causes respiratory acidosis; hyperventilation may produce hypocapnia (a decreased amount of carbon dioxide in the blood), causing respiratory alkalosis. In both conditions, arterial blood gases are abnormal. The kidneys work to adjust bicarbonate in the blood in response to carbon dioxide.

In the lungs, oxygen inhaled from the air is exchanged with carbon dioxide from the blood; this process is called external respiration. Internal respiration refers to the exchange of gases between the blood and tissue cells. Carbon dioxide then is exhaled as a waste product. Inhaled and exhaled air passes through the respiratory tract, which includes the nose, pharynx, larynx, and trachea (Figure 9-2). E9-1

FIGURE 9–2 Normal upper respiratory system.

In the chest, the trachea bifurcates into the bronchi. Each bronchus enters a lung, where it further divides into increasingly smaller air passages called bronchioles. At the end of each bronchiole is a saclike cavity called an alveolus. There are approximately 300 million alveoli in each lung. The vital exchange of carbon dioxide for oxygen takes place through capillaries that lie next to the walls of the alveolus.

A muscular, dome-shaped partition called the diaphragm attaches to the lower ribs and separates the thoracic cavity from the abdominal cavity. On inspiration, the diaphragm contracts, pulling downward and causing air to be sucked into the lungs. During expiration, the diaphragm relaxes, pushing upward and forcing air out of the lungs (Figure 9-3). The expansion of the chest cavity, along with diaphragmatic contraction, is an active, energy-requiring process. Exhalation occurs as the stretched chest cavity springs back to its resting state along with the relaxation of the diaphragm. This is a passive process.

FIGURE 9–3 Diaphragm and chest movement on inspiration and expiration.

The membrane called the visceral pleura encases the lungs, and the parietal pleura lines the inside of the chest or thoracic cavity. The potential space between the visceral and parietal pleura is called the pleural cavity. Approximately 5 to 6 ml of pleural fluid is contained in the space between the pleurae, preventing friction and allowing the pleurae to slide easily on each other. Between the lungs is the mediastinum, where the heart, great vessels, trachea, esophagus, and lymph nodes are located.

Respiratory failure can be caused by the inability to ventilate, which results in an increasing buildup of carbon dioxide. Additionally, respiratory failure can result from the impairment of alveolar-arterial gas exchange, which results in a decrease of oxygen in the blood. Diseases of the respiratory system result from infection, circulatory disorders, tumors, trauma, immune diseases, congenital defects, central nervous system damage or diseases, inflammatory disturbances, or environmental conditions.

Chief symptoms indicating respiratory tract disorders that should receive medical attention include:

• Chest pain

• Dyspnea (difficulty in breathing)

• Productive or nonproductive cough that is acute or chronic

• Hemoptysis (spitting up blood)

• Dysphonia (hoarseness)

• Chills

• Low- or high-grade fever

• Wheezing

• Fatigue

Common Cold/Upper Respiratory Tract Infection

Description

The common cold, also referred to as an upper respiratory tract infection (URI), is an acute inflammatory process that affects the mucous membrane that lines the upper respiratory tract.

ICD-9-CM Code 460

ICD-10-CM Code J00 (Acute nasopharyngitis (common cold))

Symptoms and Signs

Although the common, or “head,” cold is confined to the nose and pharynx, the same viruses can infect the larynx (see “Laryngitis” section) and various areas of the lungs (see “Acute and Chronic Bronchitis” section). The suffix “-itis” is added to the anatomical location where most of the inflammation is occurring (i.e., pharyngitis, laryngitis, tracheitis, or bronchitis). The symptoms of a cold tend to be subjective, and to some extent, depend on which virus is responsible; they include nasal congestion and discharge, sneezing, watering eyes, sore throat, hoarseness of the voice, and coughing. When this highly contagious inflammatory process first begins, the nasal discharge is usually clear and thin. In the adult, the symptoms usually abate in 5 to 7 days and without antibiotic therapy. In some cases the cold progresses and the discharge becomes greenish yellow and thick. Headache, a slight fever, and chills often accompany a cold. A high fever and malaise, however, are more likely to be symptoms of influenza (see “Influenza” section).

The benefit to be gained from taking oral antihistamines to treat a cold is controversial. Antibiotics are of little value in treating viral infections; however, patients with recurring attacks of bronchitis (see “Acute and Chronic Bronchitis” section) or frequent middle ear infections may receive some protection against these bacteria-caused complications by taking antibiotics. There is some data to suggest that taking zinc lozenges may shorten (slightly) the course of the common cold.

Prognosis

The common cold is usually benign and self-limiting. Patients who are immunocompromised may be more vulnerable to developing frequent colds and complications. Possible complications can include secondary bacterial infections as listed previously under the “Etiology” section.

Prevention

The mechanisms of transmission of cold viruses are not always clearly defined. Because, in many cases, the mode of transmission is airborne respiratory droplets and hand-to-hand contact, prevention is difficult.

Patient Teaching

Colds are more common in children than adults and are a frequent cause of absenteeism. Once infected, children can easily transmit new strains to family members. Frequent, thorough hand washing, and isolation during the acute stage of illness are commonsense measures that can help control transmission. Stress to the patient that antibiotics do not cure the common cold. Instruct the patient to avoid overuse of drugs, such as nasal sprays and to take all medications only as instructed. List the warning signs of complications that should be reported to the health care provider (i.e., shortness of breath, severe headache, chest pain, high fever, and symptoms of dehydration or stiff neck).

Sinusitis

Description

Sinusitis is acute or chronic inflammation of the mucous membranes of the paranasal sinuses.

ICD-9-CM Code 461.9 (Acute, unspecified)

473.9 (Unspecified sinusitis, chronic)

ICD-10-CM Code J01.90 (Acute sinusitis, unspecified)

(J01.90-J01.91 = 2 codes of specificity)

J32.9 (Chronic sinusitis, unspecified)

(J32.0-J32.9 = 7 codes of specificity)

Sinusitis is classified by location, type, and extent of pathology. Refer to the physician’s diagnosis and then to the current editions of the ICD-9-CM and ICD-10-CM coding manuals for greatest specificity.

Symptoms and Signs

The sinuses, cavities behind the facial bones that shape the nose, cheeks, and eye sockets, are normally air filled. In sinusitis, the frontal sinuses (located in the forehead above the eyes) and the maxillary sinuses (located under the maxillary bones in the face) are the most commonly involved sinuses (Figure 9-4). When the frontal sinuses are affected, a headache is common over one or both eyes, especially upon waking in the morning. Pain and tenderness, felt just above the eyes and that usually intensifies when bending over, are also common symptoms. Pain in the cheeks and upper teeth is a symptom of sinusitis in the maxillary sinuses. Drainage, if present, will be a thick and greenish yellow mucopurulent discharge. The course of acute sinusitis is 3 to 4 weeks.

FIGURE 9–4 Sinusitis. (From Damjanov I: Pathology for the health-related professions, ed 4, St Louis, 2011, Saunders.)

Patient Screening

Individuals with symptoms of acute sinusitis (fever, sinus congestion, facial tenderness and pain, and severe headache) are encouraged to seek medical attention as soon as possible.

Etiology

Sinusitis can be caused by either viral, fungal, or, more commonly, bacterial infections that travel to the sinuses from the nose, often after the patient has been infected by a common cold. This occurs easily because the mucous membranes that line the nasal cavity extend into and also line the sinuses. One is predisposed to sinusitis by any condition that blocks sinus drainage and ventilation (e.g., a deviated nasal septum, or nasal polyps). Sinusitis also may result as a consequence of swimming or diving, tooth extractions, or tooth abscess, as well as allergies that affect the nasal passages. The cause of chronic sinusitis may never be determined; however, common variable immunodeficiency disease may be involved (see Chapter 3).

Diagnosis

The diagnosis of sinusitis is made by evaluating the findings of a physical examination, the patient history, sinus radiographic studies, CT scanning, and endoscopic sinuscopy. Sinuses that are air filled appear as dark patches on a radiographic film, whereas fluid-filled sinuses appear as white areas. Bedside transillumination can suggest the presence of sinusitis. Additionally, a specimen of nasal secretions may be taken for culture to identify or rule out bacterial agents.

Treatment

Treatment of sinusitis can include saline nasal spray, corticosteroid nasal sprays, broad-spectrum antibiotics, oral corticosteroids, antihistamines, and decongestants. Decongestants alleviate symptoms by shrinking the swollen mucous membranes and drying up the nasal discharge. This expands the airway and eases breathing. Oral and topical corticosteroids decrease the inflammation of the affected area and decrease the sensitivity to aggravating stimuli. Oral antibiotics are used in the presence of bacterial infection and may include amoxicillin, doxycycline, sulfamethoxazole-trimethoprim, or cephalosporins. Other antibiotics may be used depending on the infecting organism. Determination of allergic sinusitis may include allergy testing followed by appropriate desensitization with immunotherapy and corticosteroids. If the inflammation persists, a minor surgery called sinusotomy may be advised by the physician. With the patient under local anesthesia, the physician pierces the maxillary sinus, allowing drainage and relief of pressure. Often the physician instills sterile water into the sinus to flush out any residual material. Analgesics usually are given for pain relief.

Explain the importance of complying with the treatment plan and returning for follow up appointments. List the warning signs of complications, such as chills, fever, facial edema, severe headache, stiff neck, lethargy, or confusion. Prepare the patient for diagnostic testing or surgery by explaining each procedure and what to expect in terms of preparation and care afterwards.

Pharyngitis

Description

Pharyngitis (sore throat) is acute or chronic inflammation or infection of the pharynx.

ICD-9-CM Code 462

ICD-10-CM Code J02.9 (Acute pharyngitis, unspecified)

(J02.0-J02.9 = 3 codes of specificity)

Symptoms and Signs

Pharyngitis may be acute or chronic and often involves inflammation of the tonsils, uvula, and palate. A sore throat with dryness, a burning sensation, or the sensation of a lump in the throat is common. Clinical manifestations vary with the type of pharyngitis. Generally chills, fever, dysphonia, dysphagia, and cervical lymphadenopathy are common. Upon examination of the throat, the mucosa of the pharynx is found to be red and swollen with or without tonsillar exudate, depending on the causative organism.

Patient Screening

An individual complaining of a persistent sore throat with systemic symptoms should be seen by a physician within 24 hours. Advise the patient not to initiate antibiotic therapy before the appointment because this can preclude accurate diagnostic testing.

Etiology

The most common cause of pharyngitis is a viral infection; tonsillitis is the most important cause. In children, it is often an extension of a bacterial streptococcal infection from the tonsils, adenoids, nose, or sinuses. Persistent infection, or chronic pharyngitis, occurs when an infection (respiratory, sinus, or oral disease) spreads to the pharynx and remains. Acute pharyngitis may be secondary to systemic viral infections, such as chickenpox and measles, whereas chronic pharyngitis may accompany diseases, such as syphilis and tuberculosis. Gonococcal pharyngitis may result from oral-genital sexual activity with an infected partner. Pharyngitis also can be caused by irritation and inflammation without infection. Occasionally, inhalation or swallowing of irritating substances, such as tobacco smoke and alcohol, is responsible for trauma to the mucous membranes of the pharynx; breathing in excessively heated air or chemical irritants and swallowing sharp objects (e.g., a large ice chip or hard candy) also can cause trauma. Seasonal allergies may induce pharyngitis.

Diagnosis

Physical examination usually shows red, swollen mucous membranes. This, along with the patient history, is usually sufficient for determining the diagnosis of acute pharyngitis. For chronic pharyngitis, the physician needs to identify and locate the primary source of the infection or irritation. Further examination of the nasopharyngeal area, a CBC, and sinus radiographic films may be necessary.

Treatment

Home treatment using lozenges, mouthwashes, salt water gargles, an ice collar, and antiinflammatory medication may be helpful for viral infections. Note: Aspirin is not given to children because of the threat of Reye’s syndrome. When symptoms persist for longer than a few days, a physician should be consulted. Since most cases of pharyngitis are viral in origin, antibiotics are not prescribed. However, acute bacterial infections necessitate systemic administration of antibiotics or sulfonamides. Documented streptococcal pharyngitis is treated with a 7- to 10-day course of antibiotics. Chronic tonsillitis, adenoiditis, and adenoid hypertrophy may be treated by surgical excision. Bed rest and copious amounts of fluids may be advised.

Instruct the patient to take the entire course of antibiotic therapy and keep follow-up appointments to ensure a cure and help prevent complications. Provide a list of comfort measures, such as safe use of analgesics, warm saline gargles, adequate fluid intake, and a soft diet. Advise patients with chronic pharyngitis to stop smoking; refer them to a support group.

Note: A more serious condition may appear initially as a routine pharyngitis. Ludwig’s angina involves a cellulitis on the floor of the mouth, whereas epiglottitis involves an infection of the structure overlying the voice box (larynx). Both are often characterized by fever and severe sore throat. However, drooling and difficulty breathing may occur and indicate some compromise to the respiratory tract. Patients should seek emergent medical attention if these symptoms develop.

Nasopharyngeal Carcinoma

Description

Nasopharyngeal tumors arise in the area of the pharynx, which opens into the nasal cavity anteriorly and the oropharynx inferiorly. They are unique among head and neck cancers in that they are not as strongly linked to tobacco use. Instead, they are often linked to dietary intake or Epstein-Barr virus infection.

ICD-9-CM Code

Neoplasms are coded by such known factors as anatomic site, behavior, and nature (morphology). Greatest specificity is obtained by referring to the physician’s diagnosis and then to the current edition of the ICD-9-CM coding manual.

ICD-10-CM Code C11.9 (Malignant neoplasm of nasopharynx, unspecified)

(C11.0-C11.9 = 6 codes of specificity)

Symptoms and Signs

Because of the anatomic location of the nasopharyngeal tumor, patients are often asymptomatic during the early stages of the disease. The classic clinical triad of symptoms is neck mass, nasal obstruction with epistaxis, and serous otitis media. Although it is rare to find all three symptoms in a single patient, the individual symptoms occur frequently. Other symptoms include headache, hearing loss, tinnitus, pain, and impaired function of the cranial nerves.

Patient Screening

Provide the first available appointment to the individual reporting a neck mass or related symptoms.

Etiology

Although nasopharyngeal carcinoma is a rare disease in the United States and Western Europe, several populations do have a relatively high incidence. These include people from southern China, areas around the Mediterranean Sea, Southeast Asia, and the Arctic. It is two to three times more common in males than females and has peak incidences in persons between the ages of 10 and 25 or 50 and 60. Several known risk factors in the high-risk areas include consumption of salted fish as a diet standard, foods with high levels of nitrates (such as processed meats), and Chinese herbs; infection with the Epstein-Barr virus (EBV); and having a first-degree relative with nasopharyngeal carcinoma. Use of alcohol and tobacco is a risk factor in low-risk areas.

Diagnosis

Diagnosis is made following a full clinical examination of the head and neck and an endoscopic examination of the nasopharynx with biopsy of suspicious lesions. Fine-needle aspiration biopsy of the neck mass also may be performed. Staging is determined according to the TNM (Tumor, Node, Metastasis) system, in which T reflects the extent of tumor invasion into adjacent structures and N incorporates lymph node location, as well as size. An MRI of the head and neck, a bone scan, and a CT scan or PET scan are used to aid in staging.

Treatment

Because of the anatomic constraints of the nasopharynx, surgery is usually not performed. Nasopharyngeal carcinoma commonly is quite radio-sensitive, and most patients with early stage cancer are treated with radiation therapy with or without adjuvant chemotherapy. Those with recurrent or more advanced carcinomas are generally treated with chemoradiotherapy. Patients should have close follow-up after completion of therapy to assess for recurrence.

Prognosis

Because early neoplasms rarely cause symptoms, most patients have advanced carcinoma, and many already have distant metastases to the bone, lung, or liver. If the tumor has extended to involve one of the cranial nerves or has metastasized to the cervical lymph nodes, the prognosis is worse. In addition, the presence of high plasma levels of EBV (Epstein-Barr virus) DNA at the time of diagnosis or following treatment can correlate with a poorer outcome.

Prevention

It is possible to detect circulating EBV DNA in the serum of affected individuals. Still, screening for EBV in first-degree relatives of patients with nasopharyngeal carcinoma is not currently performed, except in southern China where it is most prevalent.

Patient Teaching

Prepare the patient for diagnostic testing by providing information about endoscopy of the nasopharynx and biopsy of any lesion in the nasopharnyx. Tell the patient when to expect results. After diagnosis, explain the treatment of choice and possible side effects. Encourage the patient to ask questions, and defer to the physician for prognosis. Provide information regarding cancer support groups.

Laryngitis

Description

Inflammation of the larynx (hoarseness), including the vocal cords, is called laryngitis.

ICD-9-CM Code 464

ICD-10-CM Code J04.0 (Acute laryngitis)

Laryngitis coding includes modifiers that specify causative agents and factors, such as obstruction. Refer to the physician’s diagnosis and then to the current editions of the ICD-9-CM and ICD-10-CM coding manuals for the appropriate modifiers.

Symptoms and Signs

Because the opening of the larynx is narrow, inflammation of the larynx sometimes interferes with breathing. Symptoms vary with the severity of the inflammation, but the main symptom of laryngitis is hoarseness, which causes aphonia. Fever, malaise, a painful throat, dysphagia, and other symptoms associated with influenza occur in more severe infections.

Patient Screening

Laryngitis associated with recent trauma requires immediate medical attention. A sensation of swelling in the throat, difficult breathing, and laryngitis is to be considered a medical emergency. An individual reporting persistent hoarseness and symptoms of infection should be seen in the medical office within 24 hours.

Etiology

The cause of laryngitis can be either viral or bacterial infection, and the condition can be either chronic or acute. URIs such as the common cold, tonsillitis, pharyngitis, and sinusitis are the most common causes of inflammation of the larynx. Laryngitis also occurs with bronchitis, pertussis, influenza, pneumonia, measles, mononucleosis, diphtheria, syphilis, and tuberculosis. Occasionally, laryngitis is caused by irritation without infection. Reflux laryngitis may result from repeated attacks of acid reflux. Inclement weather, tobacco smoke, drinking alcohol, inhalation of irritating materials, and excessive use of the voice are all predisposing factors, especially in the case of chronic laryngitis. Hoarseness can also be caused by benign or malignant lesions of the larynx. In most cases the pathology is benign, but malignancy must be ruled out.

Diagnosis

Laryngoscopic examination reveals mildly or highly inflamed mucosa, and vocal cord movement may be limited. If no inflammation is present, laryngitis is not the cause of dysphonia, and further diagnostic tests are needed to determine the underlying condition.

Treatment

Treatment of viral laryngitis includes the following palliative measures: absolute voice rest, bed rest in a well-humidified room, liberal fluid intake, no tobacco or alcohol consumption, and the use of lozenges and cough syrup. Improvement should be seen in 4 or 5 days. Antibiotic administration gives good results when laryngitis occurs in conjunction with bacterial infection. Corticosteroids may be used to decrease inflammation when symptoms are more severe. When hoarseness persists for longer than 1 week, the condition may be chronic. Treatment of chronic laryngitis is based on elimination, as much as possible, of the causative factors.

Explain the importance of resting the voice and taking medications as prescribed, along with drinking plenty of fluids. When the cause of chronic laryngitis has been determined to be irritation from excessive alcohol intake or smoking, provide information on support groups that offer help to those with such addictions, if appropriate.

Deviated Septum

Description

A crooked nasal septum (the cartilage partition between the nostrils) is called a deviated septum (Figure 9-5).

FIGURE 9–5 Deviated septum. (From Monahan FD, Neighbors M: Medical-surgical nursing: foundations for clinical practice, ed 2, Philadelphia, 1998, Saunders.)

ICD-9-CM Code 470 (Acquired)

ICD-10-CM Code J34.2 (Deviated nasal septum)

Symptoms and Signs

A deviated septum causes narrowing and obstruction of the air passage, making breathing somewhat difficult. Other than mild breathing problems or a slightly increased tendency to develop sinusitis, no significant symptoms are associated with a deviated septum. The nose can appear normal on the exterior, with the deviation visible only on examination with a nasal speculum.

Patient Screening

Unless the deviated septum is severe, it may not be noted until inadvertently found as a consequence of a routine physical examination. The condition may be of no consequence until aggravated by trauma to the nose. In that case, schedule the first available appointment for evaluation.

Treatment is not usually necessary unless compromise of the air passage is noted. The septum can be straightened surgically to repair a significant obstruction or for cosmetic reasons. Straightening a deviated septum involves removing the cartilage (rhinoplasty or septoplasty). Once removed, the cartilage can be reshaped and repositioned in the nose, if needed, to maintain the nasal structure.

ICD-10-CM Code J33.9 (Nasal polyp, unspecified)

(J33.0-33.9 = 4 codes of specificity)

Nasal polyps are coded by anatomic site and underlying pathology. Refer to the physician’s diagnosis and then to the current editions of the ICD-9-CM and ICD-10-CM coding manuals for greatest specificity.

Symptoms and Signs

Nasal polyps are not harmful but can become large enough to obstruct the nasal airway, making breathing difficult. Polyps often affect or impair the sense of smell (see “Anosmia” section). When polyps obstruct one of the sinuses, symptoms of sinusitis are present (see “Sinusitis” section).

Patient Screening

Nasal polyps may be found in the patient exhibiting symptoms of allergic rhinitis and/or sinusitis. The degree of urgency for an appointment is based on severity of symptoms.

Etiology

Polyps are caused by the overproduction of fluid in the cells of the mucous membrane. This overproduction is often the result of a condition called allergic rhinitis. Some aspirin-sensitive persons have the triad of nasal polyps, asthma, and urticaria (hives).

Diagnosis

The physician examines the inside of the nose using an instrument called a nasal speculum. Polyps appear as pearly gray lumps along the nasal passage.

Treatment

Surgical removal is the treatment of choice; however, considerable relief may be obtained through the injection of a steroid directly into the polyps. This procedure is repeated at 5- to 7-day intervals until relief is obtained. Removal of polyps is a minor procedure necessitating a local anesthetic. When the lining of the sinus also must be removed, a general anesthetic is used.

ICD-10-CM Code R43.0 (Anosmia)

R43.1 (Parosmia)

R43.2 (Parageusia)

(R43.0-R43.9 = 5 codes of specificity)

A chronic condition, such as nasal polyps and allergic rhinitis, is the most common cause of anosmia. Intranasal swelling accompanying an upper respiratory condition causes temporary anosmia. Sometimes a phobia concerning a particular odor accounts for a psychologic basis for anosmia. It may, however, be the result of damage to the olfactory nerves caused by a head injury or, rarely, a symptom of a brain tumor.

Diagnosis

If on examination the physician does not find any physical abnormality, or the patient history does not reveal recent head trauma or an allergic condition, a neurologist may be consulted to perform diagnostic tests.

Treatment

Treatment is aimed at the cause of the condition. When polyps are found, they are removed. Correction of nerve damage may not be possible. For allergic rhinitis, a series of injections containing increasingly stronger concentrations of the offending allergen is used to desensitize the patient.

ICD-10-CM Code R04.0 (Epistaxis)

Symptoms and Signs

Hemorrhage from the nose, known as epistaxis, is a common, sudden emergency. Bleeding usually occurs from only one nostril, and often no apparent explanation for the bleeding is known. Most nosebleeds are seldom a cause for concern. They are unlikely to be a symptom of any other disorders, unless injury has occurred or associated serious systemic conditions are present. With significant blood loss, systemic symptoms will occur, such as vertigo, an increase in pulse, pallor, shortness of breath, and drop in blood pressure. Epistaxis is more common in children than in adults.

Patient Screening

Hemorrhage from the nose that persists for 10 minutes or more after constant pressure is applied is considered severe and requires immediate emergency care. If the patient reports a severe headache at the onset of epistaxis, or is experiencing sequential nosebleeds, arrange for an immediate appointment.

Etiology

Common causes of epistaxis are colds and infections, such as rhinitis, sinusitis, and nasopharyngitis, which can cause crusting that damages the mucous membrane lining the nose or causes the rupture of tiny vessels in the anterior septum of the nose. Direct trauma to the nose, picking the nose, and the presence of a foreign body are the most common causes of epistaxis. Nasal hemorrhage also has been encountered in relation to many systemic disorders, such as measles, scarlet fever, pertussis, rheumatic fever, hypertension, congestive heart failure, and chronic renal disease. Epistaxis may be the foremost symptom of conditions, such as hemophilia, thrombocytopenia, agranulocytosis, and leukemia. Risk factors include vitamin K deficiency, hypertension, aspirin ingestion, high altitude, and anticoagulant therapy. An infrequent cause of epistaxis is extensive hepatic disease.

Diagnosis

The diagnosis of epistaxis is made on the basis of the patient history regarding the frequency of the nosebleeds, whether an injury has occurred, or whether the symptoms indicate that systemic disease may be present. All medications, dietary supplements, and herbal preparations taken by the patient are noted to help identify contributing offenders.

Treatment

First the severity of blood loss is assessed. Mild hemorrhage may be controlled by applying constant direct pressure on either side of the bridge of the nose for 5 to 10 minutes. Persistent bleeding is treated with local application of epinephrine followed by cauterization with silver nitrate or laser cauterization. If bleeding continues, a posterior nasal packing left in place for 1 to 3 days may be necessary. A mild sclerosing agent also may be injected into a bleeding vessel if it can be visualized by the physician. Additional measures such as surgical ligation of a bleeding artery may be necessary if other measures fail.

Demonstrate first aid measures for controlling epistaxis—sitting with the head tilted forward while applying constant local pressure by compressing the side of the nose against the septum. Tell the patient to report repeated or severe nosebleed immediately to the health care provider. Discuss measures for preventing recurrences.

Tumors of the Larynx

Description

Growths or tumors on the larynx may be either benign or malignant.

ICD-9-CM Code 140-239 (Neoplasms)

ICD-10-CM Code C00-D49

The above general codes represent the broad category of neoplasms that are classified by such diagnostic criteria as malignant or benign, as primary or secondary, or according to site, function, and morphology. Refer to the physician’s diagnosis and then to the current editions of the ICD-9-CM and ICD-10-CM coding manuals to ensure the greatest specificity of pathology.

Symptoms and Signs

Dysphonia is usually the only symptom of a tumor on the larynx. No influenza-like symptoms occur as with laryngitis (see “Laryngitis” section), but when the tumor is malignant, dysphagia may be experienced. In children with tumors, a high-pitched crowing sound called stridor is present because of their small airways. Hoarseness caused by a benign tumor is usually intermittent, whereas hoarseness caused by cancer is continuous and gradually becomes worse. Neither type of laryngeal tumor is common, but malignant tumors are slightly more common in men than women.