3. Ears - Tagged.pdf

Ears Dr. Laura Graafland, DNP, MS, AGPCNP-BC, CBCN 6.2023 Frank Rodrigues 1 Subjective - History Frank Rodrigues Past Medical History Ask about:...

Ears Dr. Laura Graafland, DNP, MS, AGPCNP-BC, CBCN 6.2023 Frank Rodrigues 1 Subjective - History Frank Rodrigues Past Medical History Ask about: Hx of frequent ear infections – As an adult or as a child? Known hearing loss Tube placement Hx of surgery to ear Family hx of hearing loss Frank Rodrigues 3 Review of Systems Ask the patient if they have: New hearing loss Pain in the ear Discharge from ear Ringing in the ears (tinnitus) Dizziness/vertigo Nausea/vomiting Exposure to noise Trauma Self care behaviors Frank Rodrigues 4 Objective – Physical Assessment Frank Rodrigues Inspect & Palpate External Ear Inspect the auricles and surrounding tissue for: – Symmetry – Deformities – Lumps – Pits – Skin Lesions Move and palpate the auricle, tragus and mastoid – Assessing for tenderness/pain Frank Rodrigues 6 Inspect the Ear Canals and Tympanic Membranes Use an otoscope with the largest speculum that inserts easily into the ear canal. Position patient’s head so you can see through otoscope easily Lift the auricle up and back (down and back for children < 3y/o) Hold the otoscope between your thumb and first couple fingers while bracing your remaining fingers against the patient’s face. Frank Rodrigues 7 Inspect the Ear Canals and Tympanic Membranes Insert the speculum gently into the ear canal, directing it somewhat down and forward. As you insert – inspect the ear canal noting any: – Discharge – Foreign bodies – Redness of the skin – Swelling – Cerumen Inspect the tympanic membrane – Note color – Note contour – Cone of light – Look for perforations Frank Rodrigues 8 Normal Right Tympanic Membrane Pale, gray, ovoid and semi- transparent Flat, slightly pulled at the center and flutters if pt performs Valsalva Light reflex (cone of light) 5:00 in R ear 7:00 in L ear Sections of malleus may be visible Frank Rodrigues 9 Testing Auditory Acuity (Gross Hearing) Conversational Finger Rub Test Whisper Test If abnormal whipster/finger rub test, perform Weber and Rinne Frank Rodrigues 10 Weber Test – Testing for Lateralization Briskly stroke the prongs or strike the fork to start vibrations and place on top of the patient’s head Ask the patient if the sound is louder in one ear Normally, sound is heard midline (equally) Frank Rodrigues 11 Rinne Test – Testing Air Conduction Bone Conduction Air Conduction Frank Rodrigues Normal is a positive test AC>BC 12 Normal Hearing Weber Rinne Frank Rodrigues No lateralization AC > BC (positive Rinne) 13 Conductive Loss Weber Test Rinn e Frank Rodrigues Lateralization to bad ear AC = BC or AC < BC (negative Rinne 14 Sensorineural Loss Weber Test Rinne Test Frank Rodrigues Lateralization to good ear AC > BC (positive Rinne), however overall reduced 15 Abnormal - Cerumen When impacted causes partial deafness (conductive hearing loss) tinnitus, or dizziness Frank Rodrigues 16 Abnormal - Exostosis Discreet, hard, round or oval outcropping formation of new bone on the surface of a bone Seen in swimmers and surfers develop over many years and Frank Rodrigues can result in infections, pain, plugging and 17 Abnormal – Otitis Externa Scaling or crusting, inflammation and discharge in canal Pain on movement of tragus May have palpable lymph nodes Frank Rodrigues Ask about swimming, frequent cleaning 18 Abnormal - Foreign Body Frank Rodrigues 19 Abnormal – Serous Otitis Media TM is retracted and has decreased mobility Thin serous effusion give a yellowish appearance Bubbles apparent if eustachian tube Frank Rodrigues is blocked 20 Abnormal – Bacterial Otitis Media Frank Rodrigues 21 Abnormal - Perforated TM Frank Rodrigues 22 Abnormal - Scarred TM Frank Rodrigues 23 Tympanostomy Tube Frank Rodrigues 24 Developmental Considerations Infants and Children Inner ear starts to develop early in 4th week of gestation Eustachian tube is shorter and wider and more horizontal Slope of auditory canal is shorter and different slope Eardrum exam is mandatory for illness or fever Best to wait for this until toward end of exam Pull pinna down on infant or child under 3 Frank Rodrigues N4050 25 Developmental Considerations Older Adults Cilia lining ear canal become coarse and stiff which may cause decreased hearing and cerumen to accumulate and oxidize Presbycusis Auditory reaction time increases after age 70 TM may be whiter in color and more opaque. High tone frequency hearing loss Frank Rodrigues N4050 26 Documenting Your Exam Frank Rodrigues Write-up ROS - Subjective: – Denies hearing loss, discharge, tinnitus, or vertigo. Exposure to environmental noise, cleans ears with washcloth. Physical Exam - Objective – Whispered words heard bilaterally. Weber midline without lateraliza­tion. Rinne ‑ AC > BC. No tenderness, masses, lesions, scaling, discharge, or discharge noted with inspection/palpation of pinna and tragus. Ear canals clear, without discharge or erythema. Tympanic membrane pearly gray, landmarks Frank Rodrigues intact, no perforation noted. 28