Chapter 10: Ears, Nose, and Throat

Question 1

Physical Exam Components: Ears

Answer 1

Inspect the auricles and surrounding area for size, shape, symmetry, landmarks, color, position, and deformities or lesions.

Palpate the auricles and mastoid area for tenderness, swelling, and nodules.

Inspect the auditory canal with an otoscope, noting cerumen, color, lesions, discharge, or foreign bodies.

Inspect the tympanic membrane for landmarks, color, contour, perforations, and mobility.

Hearing assessment
Universal newborn hearing screening
Infant/children/adolescent -Brain Evoked Auditory Response, Play or pure tone audiometry
Adult through responses to: Questions, Whispered voice, Tuning fork for air and bone conduction

Question 2

Physical Exam Components: Nose and Sinuses

Answer 2

Inspect the external nose for shape, size, color, and nares.

Palpate the ridge and soft tissues of the nose for tenderness, displacement of cartilage and bone, and masses.

Evaluate the patency of the nares.

Inspect the nasal mucosa and nasal septum for color, alignment, discharge, swelling of turbinates, and perforation.

Inspect the frontal and maxillary sinus area for swelling.

Palpate the frontal and maxillary sinuses for tenderness or pain, and swelling.

Question 3

Physical Exam Components: Mouth

Answer 3

Inspect and palpate the lips for symmetry, color, and edema.

Inspect teeth for occlusion, caries, loose or missing teeth, and surface abnormalities.

Inspect and palpate the gingivae and buccal mucosa for color, lesions, and tenderness.

Inspect the tongue for color, symmetry, swelling, and ulcerations.

Assess the function of cranial nerve XII (hypoglossal).

Palpate the tongue.

Inspect the palate, uvula, tonsils, and pharynx.

Elicit gag reflex (cranial nerves IX and X).

Inspect the oropharyngeal characteristics of the tonsils and posterior wall of the pharynx.

Question 4

History of Present Illness: ear pain

Answer 4

Onset, duration, course
Concurrent upper respiratory infection, frequent swimming, head trauma
Associated symptoms
Method of ear canal cleaning
Medications: antibiotics, ear drops

Question 5

HPI: Hearing loss: one or both ears

Answer 5

Onset
Hears best
Speech
Associated symptoms
Management
Medications: ototoxic

Question 6

History of Present Illness: infants and children

Answer 6

Prenatal factors
Oxygenation issues
Infection
Congenital abnormalities
Medications: ototoxic
Head trauma
Hypoxic episode
Family history of permanent hearing loss

Question 7

HPI: adults

Answer 7

Exposure to industrial/recreational noise
Genetic disease
Neurodegenerative/autoimmune disorders
Syphilis
Medications: ototoxic

Question 8

HPI: vertigo

Answer 8

(a false sense of motion)
Onset, duration, circumstances, past episodes
Description of sensation
Associated symptoms
Unsteadiness, loss of balance, falling
Medications: ototoxic, salt retaining

Question 9

HPI: nasal discharge

Answer 9

Character
Associated symptoms
Seasonality of symptoms
Tenderness over sinuses, face pain, headache, postnasal drip, cough, recent injury

Question 10

HPI: snoring

Answer 10

Change in snoring pattern
Daytime sleepiness

Question 11

HPI: nosebleed

Answer 11

Frequency, duration, amount, obstruction
Predisposing factors
Site of bleeding

Question 12

HPI: sins pain

Answer 12

Fever, malaise, cough, headache, maxillary toothache, eye pain
Nasal congestion, nasal discharge
Tenderness or pressure over sinuses, pain increases when bending forward
Medications: decongestants

Question 13

HPI: dental problems

Answer 13

Pain
Swollen or bleeding gums, mouth ulcers or masses, tooth loss
Dentures or dental appliances
Malocclusion
Medications: phenytoin, cyclosporine, calcium channel blockers, mouth rinses

Question 14

HPI: mouth lesions

Answer 14

Intermittent or constantly present, duration, painful or painless
Associated with stress, foods, seasons, fatigue, tobacco use, alcohol use, dentures
Variations in tongue character
Mucosal lesions elsewhere
Medications: mouth rinses

Question 15

HPI: sore throat

Answer 15

Pain with swallowing
Exposure to dry heat, smoke, or fumes
Medications: antibiotics, nonprescription lozenges, or sprays

Question 16

HPI: hoarseness

Answer 16

Onset: acute, chronic
Change in voice quality
Associated problems

Question 17

HPI: difficulty swallowing

Answer 17

Solids, liquids, or both
Feeling of food in throat, tightness, or substernal fullness
Drooling, swallowed liquids coming out of nose, coughing, or choking when swallowing

Question 18

PMH

Answer 18

Systemic disease
Ear: frequent ear infections during childhood; surgery; trauma; labyrinthitis, antibiotics
Nose: trauma; surgery; allergies; chronic nosebleeds
Sinuses: chronic postnasal drip; recurrent or chronic sinusitis; allergies
Throat: frequent documented streptococcal infections; tonsillectomy; adenoidectomy

Question 19

FMH

Answer 19

Hearing problems or hearing loss
Ménière disease
Allergies
Hereditary renal disease

Question 20

PMH/SMH

Answer 20

Environmental hazards
Nutrition
Oral care patterns
Tobacco/alcohol use
Intranasal cocaine use
Environmental noise

Question 21

History of Infants and Children

Answer 21

Prenatal history
Prematurity
Hyperbilirubinemia
Infections
Secondary tobacco smoke exposure, out-of-home child care, siblings in the home
Congenital abnormalities and syndromes
Snoring/daytime somnolence
Playing with small objects
Behaviors indicating hearing loss
Language development failure
Dental care

Question 22

History of preg pt

Answer 22

Weeks of gestation or postpartum
Presence of symptoms before pregnancy
Pattern of dental care
Exposure to infection

Question 23

History of older adults

Answer 23

Hearing loss causing any interference with daily life
Physical disability
Deterioration of teeth, extractions, difficulty chewing
Dry mouth (xerostomia)
Medications that decrease salivation

Question 24

Physical Exam: Ears and Hearing

Answer 24

External ear
Inspect auricles.
Size, shape, symmetry landmarks, color, position on head
Presence of deformities, lesions, or nodules
Inspect external auditory canal.
Discharge and odor

Palpate auricles and mastoid area.
Tenderness, swelling, nodules

Consistency of auricle should be firm and mobile, without
nodules.

Question 25

Physical Exam: Otoscopic

Answer 25

Inspect external auditory canal and middle ear.
Discharge, redness, scaling, lesions, foreign bodies, cerumen

Inspect tympanic membrane.
Landmarks, color, contour, perforation, effusion

Use pneumatic attachment to evaluate mobility and compliance of tympanic membrane.

To examine the adult’s ear with the otoscope, straighten the external auditory canal by pulling the auricle up and back.

Question 26

Hearing evaluation

Answer 26

Evaluate auditory function (CNVIII).
Response to questions and directions
Whispered voice test

Compare air to bone conduction.
Weber test
Rinne test

Distinguish type of hearing loss.
Sensorineural
Conductive

Refer patients with loss for thorough auditory examination.

Question 27

Physical Exam: Nose, Nasopharynx, and Sinuses

Answer 27

External nose
Inspect nose and nares. -Nose for shape, size, and color, Nares for flaring, narrowing, or discharge
Palpate nose. -Displacement of bone or cartilage, tenderness, masses, Evaluate patency of nares.

Nasal cavity
Inspect nasal mucosa. -Color, discharge, masses, lesions, swelling of turbinates
Inspect nasal septum. -Position, straightness, thickness, perforations, bleeding, or crusting
The sense of smell (cranial nerve I) is tested with recognition of different odors.

Sinuses
Inspect the frontal and maxillary sinus areas for swelling.
Palpate frontal and maxillary sinuses for tenderness.
Transilluminate the frontal and maxillary sinuses if sinus tenderness or suspected infection.

Question 28

Physical Exam: Mouth and Oropharynx

Answer 28

Lips
Inspect and palpate lips. -Symmetry, color, edema, surface abnormalities

Buccal mucosa, teeth, and gums
Inspect buccal mucosa. -Stenson ducts, color/moisture, ulcers, Fordyce spots

Oral cavity
Inspect teeth. -Occlusion and alignment; color and stains; number of missing/loose teeth; wear, notches, or caries
Inspect tongue. -Swelling, variation in size or color, coating, ulceration

Ask the patient to extend the tongue while you inspect for:
Deviation, Tremor, Limitation of movement
Inspect floor of mouth and ventral surface of tongue. -Swelling or varicosities, frenulum, sublingual ridge, Wharton ducts
Palpate tongue. -lumps, nodules, or ulceration

Oropharynx
Inspect palate and uvula.
Evaluate movement of soft palate.
Inspect oropharynx with tongue blade. -Observe tonsillar pillars; note size of tonsils if present. Note integrity of posterior wall of pharynx.
Elicit gag reflex. -Tests the glossopharyngeal and vagus nerves (cranial nerves IX and X)

Question 29

Physical Exam: Infants

Answer 29

Ears
Inspect auricle for full formation and flexibility.
Auditory canals should be examined in first few weeks of life.
Tympanic membrane becomes conical after first few months of life.
Universal Newborn Hearing Screening

Nose
Inspect for symmetry and positioning.
Determine nasal patency.
Paranasal sinuses are poorly developed during infancy, and examination is generally unnecessary.

Mouth
Inspect lip shape and irregularities.
Inspect buccal mucosa color and moisture.
Inspect gums, teeth, and tongue.
Inspect palatal arch and soft palate.
Evaluate suck reflex, hard/soft palates.
Observe for drooling.

Question 30

Physical exam: children’

Answer 30

Ears
Otoscopic examination
Pull auricle down to view tympanic membrane.
Pneumatic otoscopy is especially important for differentiating a red tympanic membrane caused by crying (the membrane is mobile) from that resulting from disease (no mobility).
Evaluate toddler’s hearing by observing response to whispering, noisemakers, and speech.
Audiometric evaluation should be performed in all children and adolescents at regular intervals.

Nose and sinuses
To inspect the internal nose, shine a light while tilting the nose tip upward with your thumb.
Palpate the paranasal sinuses after they have developed (maxillary sinuses by 4 years of age and frontal sinuses by 7 to 8 years of age).
Note any tenderness indicating a potential sinus infection in the child with an upper respiratory infection that has not improved after 10 days.

Mouth
Inspect teeth for grinding, decay, and colored spots.
Check gag reflex, enabling brief view of mouth and oropharynx.
Inspect buccal mucosa.
Inspect tonsils and epiglottis.

Question 31

Physical exam preg pt

Answer 31

Inspect nose and pharynx for edema, erythema, nasal congestion, and sinusitis.
Inspect tympanic membrane for retractionor bulging.
Inspect gums for hypertrophy.

Question 32

Physical exam: older adult

Answer 32

Ears and hearing
Inspect auditory canal irritation by hearing aid.
Inspect for coarse hair on auricle.
Inspect tympanic membrane for sclerotic changes.
Note presence of sensorineural (presbycusis) or conductive hearing loss.
Inspect for cerumen impaction.

Nose
Look for dry mucosa.
Men: look for increase of hairs in vestibule.

Mouth
Look for reduced salivary flow.
Check for thinning buccal mucosa.
Examine tongue for fissures and varicose veins.
Inspect dental occlusion.
Evaluate xerostomia due to medications.
Look for tooth changes.

Question 33

Ear Abnormalities

Answer 33

Otitis externa
Inflammation of the auditory canal and external surface of the tympanic membrane

Otitis media with effusion
Inflammation of the middle ear resulting in the collection of serous, mucoid, or purulent fluid (effusion) when the tympanic membrane is intact

Acute otitis media
Inflammation in the middle ear, associated with a middle ear effusion that becomes infected by bacterial organisms

Cholesteatoma
Abnormal squamous epithelial tissue behind the tympanic membrane

Hearing loss
Conductive hearing loss -Reduced transmission of sound to the middle ear
Sensorineural hearing loss -Reduced transmission of sound in the inner ear
Ménière disease -Inner ear disorder characterized by episodes of hearing loss, vertigo, tinnitus, ear fullness
Vertigo -Illusion of rotational movement by a patient, often due to a disorder of the inner ear. Ménière disease

Question 34

Sinuses, Mouth, and Oropharynx Abnormalities

Answer 34

Sinuses
Sinusitis
Bacterial infection of one or more of the paranasal sinuses

Mouth and oropharynx
Acute bacterial pharyngitis -Infection of tonsils or posterior pharynx by microorganisms
Peritonsillar abscess -Deep infection in the space between the palatine capsule and pharyngeal muscles
Retropharyngeal abscess -A life-threatening deep neck space infection that has the potential to occlude the airway
Oral cancer -Cancer involving the oral cavity or related structures; most often squamous cell
Periodontal disease -Chronic infection of the gums, bones, and other tissues that support and surround the teeth
Oropharyngeal clefts -Cleft lip, Cleft palate, Cleft lip and palate

Question 35

A thickening along the upper ridge of the helix is called:

Preauricular pit
Darwin tubercle
Preauricular tag
Tophi

Answer 35

ANS: B

Rationale: A Darwin tubercle is a thickening along the upper ridge of the helix of the ear.

Question 36

The pregnant patient can expect to experience:

More nasal stuffiness
A sensitive sense of smell
Drooling
Enhanced hearing

Answer 36

ANS: A

Rationale: Physiologic changes of pregnancy include nasal stuffiness, decreased sense of smell, impaired hearing, epistaxis, and a sense of fullness in the ears. Increased vascularity and proliferation of connective tissue of the gums also may occur.

Question 37

Damage to CN VIII is:

Conductive hearing loss
Sensorineural hearing loss
Cholesteatoma
Otitis media

Answer 37

ANS: B

Rationale: Sensorineural hearing loss is a result of damage to CN VIII.

Question 38

For best results, an otoscopic and oral examination in a child should be:

Conducted at the beginning of the assessment
Done after inspection
Performed at the end of the examination
Performed before palpation

Answer 38

ANS: C

Rationale: Because young children often resist otoscopic and oral examinations, it may be wise to postpone these procedures until the end, after you have gained some trust.

Question 39

Trapped epithelial tissue behind the tympanic membrane that is often the result of untreated otitis media is:

Cholesteatoma
Effusion
Endolymphatic hydrops
Otosclerosis

Answer 39

ANS: A

Rationale: A cholesteatoma is trapped epithelial tissue behind the tympanic membrane that is often the result of untreated otitis media.