HENT Examination 2023 PDF

Pat Kenney-Moore EdD, PA-C Summer 2023      Be familiar with the structure and function of the ear, nose, mouth, throat and neck. Be familiar with the soft tissue and bony structures of the head and neck. Describe the following methods of determining auditory acuity, and discuss the underlying...

Pat Kenney-Moore EdD, PA-C Summer 2023      Be familiar with the structure and function of the ear, nose, mouth, throat and neck. Be familiar with the soft tissue and bony structures of the head and neck. Describe the following methods of determining auditory acuity, and discuss the underlying pathophysiology of an abnormal result: ◦       Be able to distinguish between a sensorineural and conductive hearing loss. Be familiar with the steps and purpose for the internal and external examination of the head, ears, nose, mouth and neck. Discuss the equipment and supplies necessary for the internal examination of the ear, nose, mouth and throat including: ◦     Weber test / Rinne test / gross hearing / audiogram Otoscope / insufflator / penlight and tongue blade / gloved hand Describe the expected normal physical findings in the examination of the ear, nose, mouth and throat. Describe the normal patterns of dentition in the adult. Palpebral fissure TMJ Nasolabial fold  Head position ◦ Should be upright, centered, and still   Inspect skull for size, shape, symmetry Inspect scalp (if not done as part of the skin exam) ◦ Part hair from front to back ◦ Behind ears, hairline, crown ◦ Should be without lesions, scabs, nits, scaling  Observe facial features ◦ Eyelids, eyebrows, palpebral fissures, nasolabial folds, mouth ◦ Some slight asymmetry is common  if significant, note pattern  Inspect area of external salivary glands  Palpate skull from front to back ◦ Should be symmetric and smooth ◦ Bones indistinguishable  Sagittal suture may be felt  Scalp should move freely over skull ◦ Nontender, without swelling or depressions  Check temporal arteries  Assess temporomandibular joint space ◦ Open and close mouth and palpate for clicking  Palpate over salivary glands - external Helix Tragus Lobule Mastoid area   Identification, localization and interpretation of sound Aids in maintenance of equilibrium   First - ask about use of hearing assistance devices Look at auricles ◦ Size, shape, symmetry, color  Should be same color as facial skin ◦ Lateral and medial aspects ◦ Position on head  Inspect external auditory canal ◦ Discharge or drainage?  Look behind ear at mastoid area    Draw imaginary line between lateral canthus of eye and most prominent protuberance of occiput Top of auricle should be at or above this line Draw vertical imaginary line perpendicular to previous line, just anterior to auricle ◦ Position should be almost vertical, with no more than 10-degree lateral posterior angle  Auricles ◦ Should be firm, mobile, without nodules ◦ If folded forward, should readily recoil ◦ Tug on helix and lobule – should be nontender  Mastoid ◦ Should be nontender Darwin tubercle  Whisper Test  Weber/Rinne Test  Conductive hearing loss ◦ Defect in the mechanism by which sound is transformed and conducted to the cochlea ◦ Obstruction from wax, thickening of TM from chronic infections problem  w sound inner ear Sensorineural hearing loss ◦ Due to disease/damage of the 8th cranial nerve commonly due to noise exposure / aging something is wrong w the auditory nerve 8 or the cochlea From Adams and Victor’s Neurology Chapter 15     Provider occludes the patient’s other ear Stand out of line of vision, about 1-2 feet away from side being tested Whisper word with 2 syllables and ask patient to repeat Move to other side, using a different and unrelated word with same number of syllables ◦ Example: “baseball” and “cupcake” 0 on ne s 512 Herts tuning fork     Used to assess unilateral hearing loss Place fork on midline of head Ask if sound is heard equally in both ears or is better in one ear Should be heard equally in both ears ask them which side is loudest an m I  Used to assess whether patient hears better by air or bone conduction Place fork against mastoid bone  Quickly place tines 1-2cm in front of ear   ◦ Ask pt when sound is no longer heard (time it) ◦ Ask patient if they can hear it ◦ Again as pt when sound is no longer heard (time it) Air conducted sound should be heard twice as long as bone conducted sound ◦ Typically, air conduction is greater than bone conduction AC>BC placing it measure near pts ear will Weber Rinne Normal Equal in both ears AC>BC Sensorineural hearing loss Better in good ear AC>BC (but less than 2:1) Better in bad ear BC>AC on affected side Conductive hearing loss good in ear means the ear they heard the sound louder   Inspection of external auditory canal and middle ear using an otoscope Hold in your dominant hand – hand that is comfortable ◦ Always use finger strut  Pull firmly (but gently) upward and back on auricle with other hand to straighten out external auditory canal ◦ Pull downward and out on pediatric patients  Use a strut!  Insert speculum approximately ½ inch – it MUST go inside the canal ◦ Avoid bony walls of canal (inner 2/3rds)   Inspect EAC for discharge, scaling, erythema, cerumen, foreign bodies Use focusing dial on newer models to improve view ◦ Should see minimal cerumen, uniformly pink color, and hairs in outer third of canal ◦ Cerumen should be odorless  Inspect the tympanic membrane  Should be translucent and pearly gray  Landmarks should be visible ◦ Umbo, handle of malleus, light reflex  No perforations  Slightly conical contour with concavity at umbo  Pneumatic attachment to evaluate mobility of TM and presence of middle ear fluid – ◦ Only performed when patient has an ear condition such as a possible infection   Speculum must seal all air from outside Gentle squeeze and release of bulb ◦ Observe TM moving toward middle ear then back out again ◦ Watch cone of light  No movement expected if perforation or tubes present Can try Valsalva if seal is poor  Identify odors  Provide passage for inspired/expired air  Turbinates humidify, filter, and warm inspired air  Provide resonance of laryngeal sound  Hairs and mucus carry debris and bacteria from inspired air to nasopharynx for swallowing or expectoration  Inspection ◦ Color should be same as face ◦ Tip midline ◦ Nares should be oval, symmetric, free of discharge  Palpation ◦ From nasal bridge to tip ◦ Should be firm & stable, non tender and without masses onesideofthe nose onefingeronbreath ◦ Patency of nares and in have pt ◦ Occlude one naris and ask patient to breathe IN only with mouth closed  Should be noiseless and easy Septumdeiration pushto one side   Hold scope however comfortable, but use strut! Insert speculum ◦ DON’T TOUCH SEPTUM!  Inspect color, discharge, swelling, polyps ◦ Mucosa should be deep pink and glistening ◦ Turbinates should be deep pink and firm  Inspect septum for alignment, bleeding ◦ ◦ ◦ ◦ Should be midline and fairly straight Anterior thicker than posterior Clear discharge often present Look for Kiesselbach plexus Tryingtoget pain not sound during palpation Nobody really knows! 1. To decrease weight of head (air-filled) 2. Add resonance to voice 3. “Crumple zone” – protects eyes and brain in case of severe facial trauma 4. Warm and humidify air passing through nose 5. Produces mucus, which helps clear unwanted material from nose   Inspect frontal/maxillary for swelling  Palpate ◦ Frontal: thumbs pressing up under bony brow ◦ Maxillary: press along zygomatic process  Percuss ◦ Lightly tap over each sinus with index finger  Place your finger over sinus and percuss your finger ◦ Should be nontender philitrum atthetopof thftp.p.w     Emit air for vocalization and non-nasal expiration Provide passage for food, liquid, and saliva Initiate digestion by solid food mastication and salivary gland secretion Identify taste  Color should be pink with Caucasian patients ◦ Increased pigmentation a normal variant in other races   Should be symmetrical at rest and with movement Vermillion border should not be interrupted by lesions    First ask about use of dental prostheses Use penlight and tongue blade Gingival mucosa – along gum lines along the teeth ◦ Pink in Caucasians, may be hyperpigmented in other races  Buccal mucosa alongthecheek ◦ Should be pink, smooth, moist ◦ Check salivary duct openings  Wharton ducts & Stenson ducts Parotids: cover the angleqtw.tk  Stensen ducts  Buccal mucosa, opposite 2nd molar on each side of upper jaw Submandibulars:  Wharton ducts  Each side of frenulum under tongue  Tongue ◦ Dull red, moist, glistening ◦ Anterior portion rough with papillae, fissures ◦ Posterior portion – circumvallate papillae  Floor of mouth ◦ Tongue tip to palate ◦ Ventral surface should be pink, smooth, with large veins ◦ Wharton ducts on each side of frenulum  Soft/hard palate ◦ Whitish hard palate should be dome shaped with transverse rugae  Bony protuberance at midline – torus palatinus ◦ Soft palate is pinker  Note breath ◦ Tonsils should be same pink color and without exudate ◦ Posterior wall should be smooth, glistening, pink Check Dentition Use naming convention for documentation purposes rather than numbering convention     Palpation reserved for observed problems and to assess for hidden problems Use gloves Gingiva should be non tender and without lesions or masses Wrap tongue with gauze, patient holds ◦ Complete inspection of lateral tongue ◦ Palpate floor of mouth with one gloved finger to detect hidden growths  Palpate any area that appears abnormal  All should be smooth and even, no nodules or ulcers Anterior triangle Posterior Triangle Inspection: Look all the way around  Anterior/posterior/lateral – look at angle of the head  Sternocleidomastoid and trapezius should be symmetric  Trachea should be midline  Note any distension of jugular veins and/or pulsation of carotid arteries  Nodes should not be visible upon inspection  Thyroid (discussed later) Palpation: Palpate all sides  Vertebrae  Musculature Inspect  Should not be enlarged, swollen or red Palpate  Use pads of index, long and ring fingers  Press lightly in circular motion, increasing pressure gradually  If enlarged, check for mobility, tenderness  Easily palpable nodes usually NOT found in healthy adults ◦ “Shotty” nodes