Physical Assessment: Ears, Nose, Throat

Physical Assessment of Ears, Nose, Throat, and Oral Cavity

• This topic covers the physical assessment of the ears, nose, throat, and oral cavity.
• Information is presented in chapters 13 and 14.
• Specific page numbers are noted.

The Ear

• The ear is structured with external, middle, and inner components.
• Sound waves travel from the eardrum through tiny bones to the cochlea.
• The cochlea transmits these vibrations to the brain.

Middle Ear

• The tympanic membrane (eardrum) forms the lateral boundaries of the middle ear.
• The middle ear is an air-filled cavity that transmits sound via ossicles (malleus, incus, stapes).
• The eustachian tube connects the middle ear to the nasopharynx.

Pathway of Hearing

• Sound travels from the outer ear through the middle ear, with the ossicles transmitting vibrations to the cochlea in the inner ear.
• The cochlea senses and encodes these vibrations.
• Nerve impulses are sent through the cochlear nerve to the brain.

Common/Concerning Symptoms

• Hearing problems include loss (one or both ears), sudden or gradual loss, earache, ear discharge, fever, sore throat (possible URT infection), tinnitus, dizziness, and vertigo.
• Vertigo involves the perception of spinning.
• Nasal discharge and nasal congestion, nosebleeds are also considered concerning symptoms.

Ear Exam

• Inspecting the auricle and surrounding tissues, including checking for deformities, lumps, and skin lesions.
• Palpate the pinna and tragus to detect tenderness.
• Checking the tympanic membrane and the ear canal using an otoscope.
• The process involves using the appropriate sized speculum, gently pulling the auricle upward and backward for adults, or downward and backward for children.
• Ensure to hold the otoscope as a pen/pencil and use the finger area as a fulcrum to prevent injury during sudden movements.
• Checking the ear for discharge, foreign bodies, redness, swelling, cerumen, and for otitis externa (swelling, narrowed, moist, pale, tender), and chronic otitis externa (skin of canal thickened, red and itchy).
• Checking the tympanic membrane for color (normally pinkish-gray, but can be red, white, yellow), translucency (usually transparent, but can be opaque), and position (neutral, but can be retracted or bulging), and presence of bright light reflection.
• Checking for perforation, bulging, loss of shine, lack of cone of light, opaque tympanic membrane, purulent drainage, and fluid behind the eardrum (serous effusion).
• Checking mobility using a pneumatic otoscope.
• Conducting the Weber and Rinne tests to evaluate auditory acuity, lateralization of sound, and air versus bone conduction to detect sensorineural and/or conductive hearing loss.

Nose and Paranasal Sinuses

• The upper third of the nose is supported by bone; the lower two-thirds, by cartilage.
• Air enters the nasal cavity through the nares, moving through the widened vestibule into the narrow nasal passage to the nasopharynx.
• The vestibule is lined with hair-bearing skin.
• The nasal septum forms the medial wall of each nasal cavity and is supported by bone and cartilage. The septum's lining is a mucous membrane, well-supplied with blood.
• The turbinates aid in cleaning, humidifying, and regulating the temperature of inspired air.
• The middle meatus drains most of the paranasal sinuses, and the inferior meatus drains the nasolacrimal duct.
• The paranasal sinuses are air-filled cavities within the skull bones, lined with mucous membrane, and drain into the nasal cavities.

Throat and Oral Cavity

• The examination includes the throat and mouth.
• The anatomy of the mouth and pharynx is presented, identifying key structures such as the soft palate, uvula, tonsils, and tongue.
• Common/Concerning sore throat symptoms, sores or lesions in the mouth or tongue, hoarseness, gum swelling/bleeding gums (gingivitis), malodorous breath (halitosis), and toothache.
• Health considerations include any problems with hoarseness (overuse of voice, allergies, smoking, other inhaled irritants, infection, hypothyroidism, tumors), dysphagia (difficulty swallowing), gastroesophageal reflux disease, neurological problems, or esophageal cancer), and pharyngitis (swollen glands or lumps in the neck).
• Consideration of health history involves enlarged thyroid gland (goiter), thyroid function (temperature intolerance, palpitations, changes in weight).

Mouth and Throat Exam

• The examination will include the lips (color, moisture, presence of cracking, scaling, lesions, or lumps), looking for signs of pallor (shock or anemia), cyanosis (hypoxemia or chilling), cherry red lips (carbon monoxide poisoning/acidosis/ketoacidosis), herpes simplex (cold sores/fever blisters), angular cheilitis (ulceration at the corner of the mouth in people with nutritional deficiencies, mouth closure problems), edema, and cleft lip.
• The teeth and gums(intact or discolored/missing/diseased/loose/abnormal position teeth.
• Checking dentures (if the patient wears them), checking discolouration from excessive fluoride use or smoking of teeth, and inspecting for plaques and caries.
• Inspecting the gums for color (normally pink, but can be patchy brownish, especially in Black people), swelling, or ulcerations, detecting gingivitis (red, swollen, bleeding gums), and a dark line (lead poisoning).
• Inspecting the oral mucosa for color abnormalities and presence of abnormalities/leisions (ulcers, white patches, nodules), and checking for any mucosal irritation.
• Inspecting the tongue for color (normally pink and even), surface texture and characteristics (normally rough with papillae). Checking for smooth surfaces and identifying potential fissures or coatins (white patches/leukoplakia).

Pharynx-Examination

• Inspecting the pharyngeal wall's color and shape and looking for exudates or lesions. Identifying red, swollen areas with pus could indicate pharyngitis. Detecting grayish exudates might point toward diphtheria.
• Examining the palate and pillars, including the uvula. Tonsils should be inspected for color, symmetry, swelling, exudates, or ulcerations. Checking for possible enlargements or unilateral bulges, and pain, could indicate tonsillitis, lymphoma and/or peritonsillar abscesses.
• Inspecting the hard palate's color and general shape to look for a cleft palate (or other soft palate variations).
• Checking for palatal mobility. This may include asking the patient to say “Ah” while keeping their tongue down to examine the pharynx's integrity and mobility as they phonate. Checking for palatal deviation and paralysis is also important.
• Checking gag reflexes (glossopharyngeal CN IX and Vagus CN X).

This quiz focuses on the physical assessment of the ears, nose, throat, and oral cavity as covered in chapters 13 and 14. It includes information on the structure and function of the ear, the pathway of hearing, and the components of the middle ear. Test your knowledge and understanding of these key topics.