Ears, Nose, Throat & Oral Cavity Assessment PDF 2024/25

Physical Assessment Ears, Nose, Throat, & Oral Cavity ` Dr. Ibtisam Al-Zaru First semester 2024/25 Chapter 13, p. 396 Chapter 14, p. 419  The Ear The ear consists of: - external, - middle, - inner structures. T...

Physical Assessment Ears, Nose, Throat, & Oral Cavity ` Dr. Ibtisam Al-Zaru First semester 2024/25 Chapter 13, p. 396 Chapter 14, p. 419  The Ear The ear consists of: - external, - middle, - inner structures. The eardrum and the three tiny bones conduct sound from the eardrum to the cochlea. The cochlea transmits the waves to the brain.  Middle Ear Tympanic membrane (ear drum) making the Lateral limits of the middle Ear. Middle ear is an air- Filled cavity transmits Sounds by three tiny bones, The ossicles (malleus, Incus, stapes). Connected by the eustachian Tube to the nasopharynx.  Pathway of Hearing Conductive phase: from the external ear through the middle ear: ear canal → eardrum → three tiny bones conduct sound from the eardrum → cochlea disorder causes conductive hearing loss Sensorineural phase: involving the cochlea & cochlear nerve. The cochlea transmits the waves → cochlear nerve → brain. disorder causes sensorineural hearing loss Pattern of hearing loss, Table 13-4, p. 417  Pathway of Hearing Vibration of sound pass through the air of external ear & transmitted through the ear drum & the 3 tiny bones (ossicles) of the middle ear to the cochlea. Cochlea senses & codes the vibration, nerve impulses are sent to the brain through the cochlear nerve.  Common/ Concerning Symptoms Hearing problems? How is your hearing? Hearing loss, one or both ears? Sudden or gradual loss? Earache (pain) and ear discharge, fever, sore throat, URT infection) Ringing in the ears (Tinnitus) (perceived sound that has no external stimuli, rushing or roaring) it increases with age Dizziness and vertigo, non specific term (feeling unsteady, light headed)  Common/ Concerning Symptoms -Vertigo: perception that the patient or the environment is rotating or spinning inner ear problem, central or peripheral lesion of CN V111 (acoustic). Nasal discharge (rhinorrhea) and nasal congestion Nosebleed (epistaxis) Function of CN V111 (acoustic) - hearing (cochlear division) - balance (vestibular division)  Common/ Concerning Symptoms Difficulty understanding people talk? – Sensorineural How does noise environment affect hearing? – Noisy environment worse -- sensorineural better-- conductive  Ear Exam Inspect auricle and surrounding tissues – Deformities – Lumps – Skin lesions If pain, discharge, inflammation palpate pinna and tragus for tenderness Tug test: – Pain in acute otitis externa (swimmer’s ear) inflammation of the ear canal. – Palpate mastoid process for tenderness -Tenderness behind ear in otitis media (inflammation of the middle ear).  Ear Canal and Drum Using the otoscope: Use the largest ear speculum that the canal will accommodate. In adults: gently pulling the auricle upward and backward & slightly away from the head. In children, the auricle should be pulled downward and backward. This process will move the acoustic meatus in line with the canal (Straighten ear canal) Hold the otoscope like a pen/pencil and use the little finger area as a fulcrum. This prevents injury should the patient turn suddenly. Direct it down and forward and through the hair in the canal if present  Ear Canal and Drum Examine: – External auditory canal Discharge, foreign bodies, redness, swelling, cerumen In acute otits externa (canal swollen, narrowed, moist, pale, tender) In chronic otitis externa (skin of canal thickened, red & itchy)  Ear Canal and Drum Inspect Tympanic membrane for – color (Pinkish gray, Abnormal: red, white, yellow) and translucency (transparent, Abnormal: opaque), and position (neutral, Abnormal: retracted, or bulging) of the drum – Note a bright reflection of light. – Identify the pars tensa with its cone of light. – Note any middle ear structures visualized through TMs position of: Handle of malleus, Short process of malleus, Incus, and the anterior and posterior folds of the pars flaccida (see p: 406).  Ear Canal and Drum Look for perforation, bulging, loss of shiny, no cone of light, opaque, purulent drainage, fluid behind the ear (serous effusion) **Red bulging in A cute purulent otitis media – Check mobility with pneumatic otoscope (rubber squeeze bulb)  Normal findings Auditory canal: some hair, often with yellow to brown cerumen Ear drum (Tympanic membrane) : -Pinkish gray in color, translucent and in neutral position -Malleus lies in oblique position behind the upper part of the drum. - Mobile with air inflation.  Ear Exam Auditory acuity Weber test (lateralization) Rinne test (to compare AC & BC)  Ear Exam Auditory Acuity: Assess hearing one ear at a time with whisper test, tuning fork (512 Hz), ticking watch, or others. If hearing is abnormal, perform the Weber and Rinne tests to assess for sensorineural and/or conductive hearing loss  Weber Test (lateralization) Vibrating fork (512 Hz) Place on top of patient head or midforehead Ask patient in which ear sound heard best (the sound should be heard equally well in both ears)  Weber Test (lateralization) If sound is heard asymmetrically, it means one of two things: – Conductive hearing loss on side with increased sound. Unilateral conductive hearing loss as in acute otitis media, perforation of eardrum, obstruction of ear canal by cerumen (Sound lateralized to the impaired ear*) – Unilateral Sensorineural hearing loss on side with decreased sound ( lateralized to good ear).  Rinne Test (To compare AC & BC) The vibrating tuning fork is placed on the mastoid process. When patient can no longer hear sound, put lateral to the ear. Ask if patient can still hear sound.  Rinne Test (To compare AC & BC) A positive Rinne test is a normal test: air conduction (AC) > bone conduction (BC). Conductive hearing loss produces a negative Rinne test: BC ≥ AC. Sensorineural hearing loss produces a positive Rinne test: AC>BC. If air conduction is more than twice as long as bone conduction, then suspect sensorineural loss.  Diseases Causing Hearing Loss Conductive Hearing loss: Lesion between the receptors and environment (Ossicle lesion, otitis media, otosclerosis, perforated eardrum, impacted cerumen) Sensorineural hearing loss: Lesion of the receptors or its pathway (Aging, drug toxicity, noise damage, acoustic neuroma) Structure and function: Nose First segment of respiratory tract Warms, moistens and filters air Nasal cavity extends back to the roof of the mouth, divided into 2 septum Nasal hair filter the air Cavity holds olfactory receptors- sense of smell It is the site of speech resonance Anatomy of the Upper Airway The Nose and Sinuses  Nose & paranasal sinuses Upper third of the nose is supported by bone Lower two thirds by cartilage Air enters nasal cavity by anterior naris widened area (vestibule) narrow nasal passage to the nasopharynx Vestibule: lined with hair bearing skin  Nose & paranasal sinuses Nasal septum: Formed the medial wall of each nasal cavity Supported by both bone &cartilage Covered by moucous membane Well supplied with blood Turbinates aids the nasal cavities in their function: -Cleansing -Humidification -Temperature control of inspired air  Nose & paranasal sinuses Nose latererally: Middle meatus (drain most of the paranasal sinuses) Inferior meatus (drains the nasolacrimal duct) Para Nasal Sinuses  Paranasal sinuses Are air filled cavities within the bones of the skull Lined with mucous membrane Drains into the nasal cavities  The Nose Health history: – Rhinorrhea— Nasal discharge or runny nose--Continuous, watery, purulent, mucoid, bloody Nasal congestion---stuffy nose, sneezing, watery eyes, throat discomfort, itching eyes, nose, throat. – Frequent or severe colds Upper respiratory tract infection (URTI) How often? Remedies? – Sinus pain Headache, tenderness, fever Post-nasal drip  The Nose Health history: – Trauma Breath through nose? Any obstruction? – Epistaxis– bleeding from nose How much? Teaspoon, does it pour out? From one or both nostrils? How do you treat them? Difficult to stop? – Allergies Pollen, dust? How did you know? Aggravating environment Inhalers? Spray, drops – Any change in sense of smell  The Nose Inspect external nose: – asymmetry, deformity, lesions, inflammation, nasal bone fracture. – inspects the anterior & inferior surfaces of the nose by gentle pressure on the tip of the nose using penlight or otoscope light Palpation – If injury, palpate gently – Test for nasal obstruction/patency test: Press on each ala nasi in turn and asking the patient to breath in (sniff inward).. Inspect using nasal speculum Inspect nasal mucosa (covers septum & turbinates), nasal septum, any abnormalities – Color and integrity of nasal mucosa—normal red color, smooth moist surface – Swelling, discharge, bleeding, foreign body, exudates, polyps, ulcers – Septum– deviation, perforation (cocaine), bleeding, inflammation. – Turbinates (middle and inferior turbinates)—light red color, any exudates/pus, swelling/hypertrophy. – polyps (smooth pale grey, a vascular, mobile, non-tender) – Ulcers  The Nose Palpate sinus areas with thumbs – Frontal sinus, below eyebrows: press up on the frontal sinuses from under the boney brows. – Maxillary sinus, below cheekbones – Firm pressure, no pain – Note tenderness (chronic allergy, acute infection sinusitis) – An inflamed sinus does not illuminate. Figure 14.22B Palpating the maxillary sinuses. Middle turbinate Inferior turbinate Figure 16-7 p. 380 Transillumination of sinuses  Normal Findings The septum is in the middle and the turbinates project into the nasal passages. There is sufficient room for the nasal passages. The nasal mucous membrane is redder than the oral mucosa and compact over the turbinates. There may be a small amount of thin secretions. Viral rhinitis: mucosa is reddened and swollen. Allergic rhinitis: pale, bluish, or red **(normal: presence of red color at the hard palate through the mouth). Throat and Oral Cavity Chapter 14, p. 419 Mouth & Pharynx anatomy Common/ Concerning Symptoms – Sore throat How frequent? Since when? Cough, fever, fatigue, headache, postnasal drip Worse when arising? Humidity, dryness? – Sores or lesions in mouth or tongue For how long? Single or multiple? Stress, food, season change? – Hoarseness: change in voice quality – Gum swelling/Bleeding gums—gingivitis – Malodorous breath (halitosis) – Toothache, self care behaviors (oral health)  Mouth and Throat Health history: – Hoarseness—Acute or chronic Overuse of voice Allergy, smoking, other inhaled irritants, acute infection Hypothyroidism Tumors – Dysphagia—difficulty swallowing Gastroesophageal reflux disease, neurological, esophageal cancer – Pharyngitis-- Swollen glands or lumps in neck  The Mouth and Throat Health history: – Enlarged thyroid gland—goiter – Thyroid function— Temperature intolerance – Do you prefer hot or cold weather – Do you dress more warmly or less warmly than other people? Palpitations? Change in weight?  Mouth and Throat Exam Inspect the followings: – The Lips Color, moisture, cracking, Scaliness, lesions, lumps Pallor—shock and anemia Cyanosis– hypoxemia and chilling Cherry red lips– carbon monoxide poisoning, acidosis, ketoacidosis herpes simplex (cold sore, fever blister); HSV produces recurrent & painful vesicular eruptions of the lips & surrounding skin.  Angular Cheilities (an ulceration of the corner of the mouth) as in nutritional deficiency or over closure of the mouth as in people with no teeth Edema Cleft lip  The Teeth and Gums Condition of teeth, diseased, Missing teeth or absent, mobility (loose), caries; abnormal position; misshape; discolored Dentures : instruct the patient to remove dentures if he /she wears them Discolored—brown from excessive flouride use, Yellow—smoking Plaque, Carries—tooth decay Put glove on to palpate any detected suspicious ulcers, nodules, lesions. Check for looseness with your gloved thumb & index finger.  Inspects the Gum Color of gums (normally pink, patchy brownness may be present especially in black people). swelling or ulceration of gum margins & interdental papillae Gingivitis: red swollen bleeding gums, Hypertrophy of gums Dark line on gingival margins—lead poisoning Mucosa: using good light & tongue blade inspect the oral mucosa for: – color: pallor anemia, cyanosis (central or peripheral) – if structures are intact, any lesions, ulcer (aphthous ulcer), white patches & nodules, irritation  The Tongue (Inspect) Color— normally pink and even surface texture & characteristics: normally rough with papillae – Smooth tongue: vitamin or iron deficiency – Fissures Coating—Thick white patch (leukoplakia), resulted from frequent chewing of tobacco, local irritant that may lead to cancer.  The Tongue (Inspect) Moisture – Dry mouth with dehydration, fever, deep vertical fissures, Decreased/ excess saliva Persistent ulcer or nodule Enlarged with indentation —mental retardation, hypothyroidism, acromegaly Symmetry: hypoglossal nerve (CN XII) with tongue protruding, deviation toward paralyzed side, lesion Tremor (fine tremor with hyperthyroidism, cerebral palsy), loss of movement  Under the Tongue Inspect the U-shape under the tongue Note white patches, redness, nodules, ulcerations Any lesion or ulcer persisting more than 2 weeks should be followed Use gloved hand to palpate any lesions Place other hand under jaw while palpating to locate any abnormality Note any thickening/hardening or infiltration (induration) of tissues See table 14-4 p. 438 fissured tongue  Pharynx Pharyngeal wall– note color, any exudate, lesions – Redness, swelling, pus : (Pharyngitis: Viral, Strep) – Grayish exudate (Diphtheria) Inspect soft palate, anterior and posterior pillars, uvula, tonsils, and pharynx — color, symmetry, exudates, swelling, ulceration, tonsillar enlargement Enlarged Tonsils (Normal, Tonsillitis, Lymphoma) Unilateral red bulge and painful: (Peritonsillar abscess) Tonsil exudates: streptococcal pharyngitis and acute tonsillitis; bright red pharynex with red, swollen tonsils, pillar & uvula.  Pharynx Inspect color and shape of hard palate (roof of mouth) – Cleft palate – Midline lobulated bony growth Ask patient to say “Ah” while depressing tongue to check pharynx—note integrity and mobility as person phonates – Failure of soft palate to raise with "aah" and deviation to opposite side: (Paralysis of Vagus CN X) – Check gag reflex (Glossopharangeal CN IX, and Vagus CN X)