Otoscopy Exam

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Questions and Answers

What is an important aspect to assess when inspecting the auricles and surrounding tissue?

Asymmetry (correct)

Deformities (correct)

All of the above

Skin Lesions (correct)

What should the healthcare provider do when using an otoscope?

Lift the auricle up and back (correct)

Hold the otoscope with all fingers

Insert the speculum sharply into the ear canal

Position the patient's head so you can't see through the otoscope

What should the healthcare provider ask about during the subjective history?

History of frequent ear infections (correct)

History of frequent colds

History of allergic reactions

History of surgery to the nose

What should the healthcare provider assess for when palpating the auricle, tragus, and mastoid?

Tenderness or pain Signup and view all the answers

What should the healthcare provider ask the patient about during the review of systems?

New hearing loss Signup and view all the answers

What is the correct direction to insert the speculum into the ear canal?

Down and forward Signup and view all the answers

When should the healthcare provider lift the auricle up and back?

When using the otoscope Signup and view all the answers

How should the healthcare provider hold the otoscope?

Between the thumb and first couple of fingers Signup and view all the answers

What is the normal color of the tympanic membrane?

Pale, gray, and ovoid Signup and view all the answers

What is the purpose of the Weber test?

To test for lateralization of sound Signup and view all the answers

What is a common finding in serous otitis media?

A retracted and immobile tympanic membrane Signup and view all the answers

What is a characteristic of the eustachian tube in infants and children?

It is shorter and wider than in adults Signup and view all the answers

What is a common finding in otitis externa?

A scaling or crusting of the ear canal Signup and view all the answers

What is a characteristic of cerumen in older adults?

It becomes harder and more brittle Signup and view all the answers

What is the purpose of the Rinne test?

To test air conduction Signup and view all the answers

What is a characteristic of the tympanic membrane in older adults?

It becomes thicker and more opaque Signup and view all the answers

What is a common finding in bacterial otitis media?

A red, swollen ear canal Signup and view all the answers

What is the purpose of inspecting the ear canal?

To identify any abnormalities or foreign bodies Signup and view all the answers

What is the main reason for the lens to lose elasticity and cannot change shape to accommodate for near vision in older adults?

Age-related changes Signup and view all the answers

What is a characteristic of the lens in older adults that can lead to vision problems?

It becomes thicker and more opaque Signup and view all the answers

What is a type of deposit that can accumulate under the retina in older adults, but does not affect vision?

Drusen Signup and view all the answers

What is a common finding in sudden increases in intracranial pressure, severe hypertension, and diabetes?

Retinal hemorrhages Signup and view all the answers

What is a characteristic of the optic disc in glaucoma?

It appears fuzzy due to swelling Signup and view all the answers

What can cause floaters to appear in the vitreous humor?

Debris in the vitreous humor Signup and view all the answers

What is a characteristic of age-related macular degeneration?

Drusen accumulation Signup and view all the answers

What can cause visual disturbances, headaches, and nausea in patients?

Glaucoma Signup and view all the answers

What is the leading cause of vision loss and blindness among older adults?

Age-related Macular Degeneration Signup and view all the answers

What is the most common type of Age-related Macular Degeneration?

Dry (Atrophic) Signup and view all the answers

What is the characteristic symptom of Wet (Neovascular) Age-related Macular Degeneration?

Straight lines appear wavy Signup and view all the answers

What is the cause of Glaucoma?

Blockage preventing outflow of vitreous humor Signup and view all the answers

What is the characteristic symptom of Chronic-open Angle Glaucoma?

Reduced night vision Signup and view all the answers

What is the characteristic symptom of Cataracts?

Cloudy/Blurred vision Signup and view all the answers

What is a risk factor for Chronic-open Angle Glaucoma?

All of the above Signup and view all the answers

What is the characteristic effect of Age-related Macular Degeneration on central vision?

Blind spot in central vision Signup and view all the answers

What is the purpose of using oblique lighting when inspecting the cornea and lens?

To look for opacities and abrasions Signup and view all the answers

What is the normal size of the pupils?

3-5mm Signup and view all the answers

What is anisocoria?

Unequal pupils Signup and view all the answers

What is the purpose of the corneal light reflex test?

To diagnose strabismus Signup and view all the answers

What is the normal result of the corneal light reflex test?

The light hits both eyes in the same spot, slightly nasal to the center of the pupils Signup and view all the answers

What is the purpose of the direct and consensual pupillary light reflex test?

To assess the pupils' response to light Signup and view all the answers

What is the difference between miosis and mydriasis?

Miosis is abnormal constriction, while mydriasis is abnormal dilation Signup and view all the answers

What is the purpose of the accommodation test?

To assess the ability of the eyes to focus Signup and view all the answers

What is the normal appearance of retinal vessels?

Arteries appear bright red than veins, may also note a thin strip of white down the center of the arteries Signup and view all the answers

What is the A:V Ratio in normal retinal vessels?

2:3 Signup and view all the answers

What happens to the retinal vessels as they move away from the optic disc?

They become smaller Signup and view all the answers

What is the phenomenon where a small artery (arteriole) is seen crossing a small vein (venule), which results in the compression of the vein with bulging on either side of the crossing?

Arteriovenous nicking Signup and view all the answers

What is the medical condition where the optic nerve at the back of the eye becomes swollen due to a buildup of pressure in or around the brain?

Papilledema Signup and view all the answers

How many sets of retinal vessels are normally present in each quadrant?

Paired vein and artery Signup and view all the answers

What is the location of the superior nasal vessels?

Nasal quadrant Signup and view all the answers

What is the characteristic of retinal vessels that allows them to be identified?

Their color Signup and view all the answers

What type of refractive error is characterized by impaired close vision?

Presbyopia Signup and view all the answers

What is the term for the cloudy or opaque natural lens in the eye that affects vision?

Cataract Signup and view all the answers

What is the term for the yellowish deposits that can accumulate in the macula of the eye, leading to age-related macular degeneration?

Drusen Signup and view all the answers

What is the term for the progressive damage to the optic nerve that can lead to vision loss?

Glaucoma Signup and view all the answers

What is the term for the examination of the eye using a Snellen chart to assess visual acuity?

Snellen test Signup and view all the answers

What is the term for the measurement of the pressure inside the eye?

Tonometry Signup and view all the answers

What is the term for the condition characterized by a cloudy or opaque natural lens in the eye that affects vision?

Cataract Signup and view all the answers

What is the term for the age-related condition characterized by damage to the macula of the eye, leading to central vision loss?

Age-related Macular Degeneration Signup and view all the answers

What is the purpose of inspecting the iris during an eye exam?

To identify opacities and abrasions Signup and view all the answers

What is the abnormal condition where the pupils are unequal in size?

Anisocoria Signup and view all the answers

What is the purpose of the Corneal Light Reflex test?

To identify any problems with the Cornea or Lens Signup and view all the answers

What is the normal result of the Corneal Light Reflex test?

The light hits both eyes slightly nasal to the center of the pupils Signup and view all the answers

What is the term for the abnormal constriction of the pupils?

Miosis Signup and view all the answers

What is the purpose of the Direct and Consensual Pupillary Light Reflex test?

To identify any problems with the Pupillary Light Reflex Signup and view all the answers

What is the term for the abnormal dilation of the pupils?

Mydriasis Signup and view all the answers

What is the purpose of inspecting the pupils during an eye exam?

To evaluate the size, shape, and symmetry of the pupils Signup and view all the answers

What should the conjunctiva appear as during inspection?

Moist and glossy Signup and view all the answers

What is the purpose of the direct and consensual pupillary light reflex test?

To assess the sensitivity of the pupil to light Signup and view all the answers

What is being assessed during the extraocular muscle assessment?

Eye movement and alignment Signup and view all the answers

What is being evaluated during the lacrimal apparatus evaluation?

The swelling around the lacrimal gland and lacrimal sac Signup and view all the answers

What is the purpose of the corneal light reflex test?

To assess the alignment of the eyes Signup and view all the answers

What should the healthcare provider do when inspecting the conjunctiva and sclera?

Ask the patient to look up Signup and view all the answers

What is the normal result of the corneal light reflex test?

The light reflex is present and symmetric Signup and view all the answers

What is being assessed during the pupillary light reflex test?

The sensitivity of the pupil to light Signup and view all the answers

What is the purpose of shining a pen light onto the eye from the side during the pupillary light reflex test?

To assess the direct reaction of the pupil Signup and view all the answers

What is the normal response of the pupils when a patient focuses on a finger moving closer to their face?

The pupils will normally constrict and converge Signup and view all the answers

Which cranial nerve innervates the superior oblique muscles?

Cranial nerve IV (trochlear) Signup and view all the answers

What is the purpose of the corneal light reflex test?

To assess the alignment of the eyes Signup and view all the answers

What is the normal response of the eyes when following a finger through the six cardinal positions of gaze?

The eyes will move in a parallel track Signup and view all the answers

What is the term for the fine oscillating movement of the eyes?

Nystagmus Signup and view all the answers

What is the purpose of testing the near reaction?

To assess the convergence and accommodation of the eyes Signup and view all the answers

What happens to the pupils when a patient is focusing on a distant object?

The pupils will normally dilate Signup and view all the answers

What is the result of a right optic tract cut?

Left homonymous hemianopsia Signup and view all the answers

What is the characteristic of the optic disc in a normal eye?

Round or oval with a physiologic cup Signup and view all the answers

What is the location of the macula in relation to the optic disc?

Temporal to the optic disc Signup and view all the answers

What is the normal color of the retinal background?

Light red to dark brown-red Signup and view all the answers

What is the part of the ophthalmoscope that is used to view the retinal vessels?

Eyepiece Signup and view all the answers

What is the result of an optic chiasm cut?

Bitemporal hemianopsia Signup and view all the answers

What is the purpose of the ophthalmoscope?

To view the retina and retinal vessels Signup and view all the answers

What is the characteristic of the retinal vessels in a normal eye?

Arterioles are smaller than venules Signup and view all the answers

What is the leading cause of vision loss and blindness among older adults?

Age-related Macular Degeneration Signup and view all the answers

What is the characteristic symptom of Chronic-open Angle Glaucoma?

Halo effect Signup and view all the answers

What is the characteristic symptom of Wet (Neovascular) Age-related Macular Degeneration?

Straight lines appear wavy Signup and view all the answers

What is the cause of Glaucoma?

Abnormal increase in IOP due to a blockage preventing outflow of vitreous humor Signup and view all the answers

What is the characteristic symptom of Cataracts?

Cloudy/Blurred vision Signup and view all the answers

What is a risk factor for Chronic-open Angle Glaucoma?

Family history, diabetes, hypertension, and severe myopia Signup and view all the answers

What is the characteristic effect of Age-related Macular Degeneration on central vision?

Blind spot in central vision Signup and view all the answers

What is the most common type of Age-related Macular Degeneration?

Dry (Atrophic) Signup and view all the answers

Study Notes

Inspecting the Ear

Inspect the ear canal, noting any discharge, foreign bodies, redness of the skin, swelling, or cerumen.
Inspect the tympanic membrane, noting its color, contour, and the presence of a cone of light.
Look for perforations in the tympanic membrane.

Normal Tympanic Membrane

The normal tympanic membrane is pale, gray, ovoid, and semi-transparent.
It is flat, slightly pulled at the center, and flutters if the patient performs the Valsalva maneuver.
A light reflex (cone of light) is present at 5:00 in the right ear and 7:00 in the left ear.
Sections of the malleus may be visible.

Testing Auditory Acuity (Gross Hearing)

Conversational voice test
Finger Rub Test
Whisper Test
If abnormal, perform Weber and Rinne tests.

Weber Test

Testing for lateralization: briskly stroke the prongs or strike the fork to start vibrations and place it on top of the patient's head.
Ask the patient if the sound is louder in one ear.
Normally, the sound is heard midline (equally).

Rinne Test

Testing air conduction: compare air conduction (AC) to bone conduction (BC).
Normal result: AC > BC (positive Rinne).

Normal Hearing

Weber test: no lateralization
Rinne test: AC > BC (positive Rinne)

Conductive Loss

Weber test: lateralization to the bad ear
Rinne test: AC = BC or AC < BC (negative Rinne)

Sensorineural Loss

Weber test: lateralization to the good ear
Rinne test: AC > BC (positive Rinne), but overall reduced.

Abnormal - Cerumen

Impacted cerumen causes partial deafness (conductive hearing loss), tinnitus, or dizziness.

Abnormal - Exostosis

Discreet, hard, round or oval outcropping formation of new bone on the surface of a bone.
Seen in swimmers and surfers, develops over many years, and can result in infections, pain, or plugging.

Abnormal - Otitis Externa

Scaling or crusting, inflammation, and discharge in the canal.
Pain on movement of the tragus.
May have palpable lymph nodes.

Abnormal - Foreign Body

Presence of a foreign body in the ear canal.

Abnormal - Serous Otitis Media

TM is retracted and has decreased mobility.
Thin serous effusion gives a yellowish appearance.
Bubbles apparent if the Eustachian tube is blocked.

Abnormal - Bacterial Otitis Media

Infection of the middle ear.

Abnormal - Perforated TM

Presence of a hole in the tympanic membrane.

Abnormal - Scarred TM

Presence of scarring on the tympanic membrane.

Tympanostomy Tube

A small tube inserted into the tympanic membrane to drain fluid.

Developmental Considerations

Infants and children: inner ear starts to develop early in the 4th week of gestation, Eustachian tube is shorter and wider, and the slope of the auditory canal is shorter.
Older adults: cilia lining the ear canal become coarse and stiff, leading to decreased hearing and cerumen accumulation.

Subjective - History

Ask about past medical history, including hearing loss, tube placement, and surgery to the ear.
Ask about family history of hearing loss.

Review of Systems

Ask the patient about new hearing loss, pain in the ear, discharge, tinnitus, dizziness, nausea, vomiting, exposure to noise, trauma, and self-care behaviors.

Objective - Physical Assessment

Inspect and palpate the external ear, looking for symmetry, deformities, lumps, pits, and skin lesions.
Move and palpate the auricle, tragus, and mastoid, assessing for tenderness or pain.

Central vision loss due to degeneration of the macula
Leading cause of vision loss and blindness among older adults
Two types: Dry (Atrophic) and Wet (Neovascular)
Dry type:
- Develops gradually over time
- Early symptom: blurred vision
- Blind spot in central vision, starts small and grows larger over time
Wet type:
- Develops more rapidly
- Early symptom: straight lines appear wavy
- Blind spot may be visible in central vision

Glaucoma

Abnormal increase in intraocular pressure (IOP) caused by blockage preventing outflow of vitreous humor
Two types: Chronic-open angle and Acute Closed Angle
Chronic-open angle:
- Slow increase in IOP
- Genetic risk factors: family history, diabetes, hypertension, severe myopia, older adults
- Symptoms: halo effect, reduced night vision, report of eye "aching"
Acute Closed Angle:
- Rapid increase in IOP due to sudden blockage
- Medical emergency - immediate treatment is needed
- Risk factors: eye trauma, eye surgery
- Symptoms: halo effect, photophobia, eye pain, lack of pupil constriction, decreased visual acuity

Cataracts

Gradual clouding of the lens
Can be age-related, genetic, or result of trauma from UV exposure
Can occur in newborns with maternal rubella infection
Symptoms:
- Cloudy/blurred vision
- Colors appear faded or yellowed
- Patient may report glares and difficulty with night time driving
- May also report halo effect

Documenting Your Findings

ROS (Review of Systems): ask about recent changes in vision, use of contacts/glasses, eye pain, etc.
Physical Exam: assess visual acuity, inspect lids and lashes, conjunctiva, sclera, iris, cornea, etc.
PMH (Past Medical History): ask about history of ocular problems, glaucoma, cataracts, eye trauma, etc.

Developmental Considerations - Older Adults

Skin loses elasticity, causing drooping, fat tissues, and muscles atrophy
Cornea may show arcus senilis (degenerative lipid material around the limbus)
Pupils decrease in size, lens loses elasticity, and cannot change shape to accommodate near vision (presbyopia)
Lens discolors and thickens (cataract)
Floaters may appear from debris in vitreous humor

Yellow deposits (made up of lipids and proteins) under the retina
Normal in aging adults, does not affect vision
Seen in normal aging or age-related macular degeneration

Identifying Retinal Vessels

4 sets of retinal vessels: paired vein and artery in each quadrant
Arteries appear bright red, may also note a thin strip of white down the center of the arteries
A:V Ratio = 2:3
Vessels get smaller the further away they are from the optic disc

Abnormal Findings

Arteriovenous Nicking (AV nicking): small artery crossing a small vein, resulting in compression of the vein with bulging on either side
Papilledema: a serious medical condition where the optic nerve at the back of the eye becomes swollen due to a buildup of pressure in or around the brain
Strabismus: a weakness or paralysis of one or more of the extraocular muscles, due to a congenital defect, an orbital fracture, trauma, or CVA-related palsy
Retinal Hemorrhages: bleeding in the retina, can be superficial, preretinal, or deep, seen in sudden increases in intracranial pressure, severe hypertension, and diabetes

Eye Exam

Inspect the eyes for opacities and abrasions using oblique lighting
Check the size, shape, and symmetry of both pupils, which should be 3-5mm in size
Miosis refers to abnormal constriction of the pupils, while mydriasis refers to abnormal dilation
Anisocoria refers to unequal pupils

Corneal Light Reflex

Shine a light towards the eyes to check for corneal light reflex
The light should hit both eyes in the same spot, slightly nasal to the center of the pupils
If the reflex is abnormal, it may indicate a problem with the extraocular muscles (EOMs)

Pupillary Light Reflex

Test for direct and consensual pupillary light reflex
Shine a pen light onto the eye from the side while the patient gazes into the distance
Direct reaction: the pupil exposed to bright light should constrict
Consensual reaction: the opposite pupil should also constrict

Accommodation

Test for near reaction: convergence and accommodation
Hold a finger in front of the patient's nose and have them focus on it
Pupils should normally dilate when focusing on a far object and constrict when focusing on a near object

Extraocular Muscles

Test the extraocular muscles by having the patient follow a finger through the six cardinal positions of gaze
Check for parallel tracking of the eyes and look for nystagmus (fine oscillating movement) or lid lag

Visual Fields

Assess the range of peripheral visual fields
Check for any defects or abnormalities in the visual fields

Visual Pathways

Review the visual pathways, including the optic nerve, optic chiasm, and optic tract
Visual fields are projected upside down and reversed right to left
Nerve impulses are conducted through the retina, optic nerve, optic chiasm, and optic tract on each side

Subjective History

Ask about the patient's medical history, including any ocular problems, strabismus, glaucoma, cataracts, or eye trauma
Ask about medications, including eye drops, and any prior surgeries involving the eyes
Ask about family history of genetic eye conditions

Physical Exam

Assess visual acuity using the Snellen test
Inspect the lids, lashes, conjunctiva, sclera, iris, and cornea
Check the shape and size of the pupils
Test the corneal light reflex, pupillary light reflex, and accommodation
Assess the extraocular muscles and visual fields
Perform a funduscopic examination

Abnormalities

Myopia (nearsightedness) and hyperopia (farsightedness) can cause impaired vision
Glaucoma can cause abnormal increase in intraocular pressure (IOP) and lead to vision loss
Cataracts can cause gradual clouding of the lens and lead to vision loss
Age-related macular degeneration (ARMD) can cause central vision loss due to degeneration of the macula
Optic nerve or optic tract cuts can cause visual field defects

Documentation

Document the findings of the eye exam, including any abnormalities or defects
Use a clear and concise format to record the results of the exam

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Description

Inspect the ear canal and tympanic membrane for signs of abnormalities, including discharge, foreign bodies, redness, swelling, and cerumen. Observe the color, contour, and cone of light on the tympanic membrane.