Ear, Nose and Throat Flashcards
Inspection of ears
Inspect the auricles and mastoid 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.
Assess hearing through the following:
Response to questions during history
Response to a whispered voice
Response to tuning fork for air and bone conduction
Inspection of Nose and Sinuses
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, turbinates, and perforation.
Inspect the frontal and maxillary sinus area for swelling.
Palpate the frontal and maxillary sinuses for tenderness or pain, and swelling.
Inspection of Mouth
Inspect and palpate the lips for symmetry, color, and edema.
Inspect the teeth for occlusion, caries, loose or missing teeth, and surface abnormalities.
Inspect and palpate the gingivae for color, lesions, and tenderness.
Inspect the tongue and buccal mucosa for color, symmetry, swelling, and ulcerations.
Assess the function of cranial nerve XII (hypoglossal).
Palpate the tongue.
Inspection of the mouth CONT
Inspect the palate and uvula.
Inspect the oropharyngeal characteristics of the tonsils and posterior wall of pharynx.
Elicit gag reflex (cranial nerves IX and X).
External ear structures
Auricle
External auditory canal
External ear function
Protective
Helps gather and channel sound
Middle ear structure
Ossicles: malleolus, incus, stapes
Tympanic membrane
Middle ear function
Ossicles transmit sound from tympanic membrane to inner ear.
Tympanic membrane separates middle from external ear.
Inner ear structure
Vestibule
Semicircular canals
Cochlea
Inner ear function
Cochlea transmits sound to CN VIII.
Semicircular canals are involved in vestibular function
Function of nose, nasopharynx and sinuses
Odor identification
Passage of inspired and expired air
Humidification, filtration, and warmth of inspired air
Resonance of laryngeal sounds
External nose structure
Bone and cartilage
Nares
Internal nose structure
Septum Choanae Turbinates Cribriform plates Kiesselbach plexus Convergence of small fragile arteries and veins
Structure of sinuses
Sinuses
Maxillary
Frontal
Ethmoid
Sphenoid
Only the maxillary and frontal sinuses are accessible for physical examination.
Nasal floor is formed by the hard and soft palate.
Roof is formed by the frontal and sphenoid bone.
The adenoids lie on the posterior wall of the nasopharynx.
Function of mouth and oropharynx
Emission of air for vocalization and non-nasal expiration
Passage for food, liquids, saliva
Initiation of digestion by mastication and salivary secretion
Identify taste.
Structure of mouth
The oral cavity is divided into the mouth and the vestibule (space between the buccal mucosa and the outer surface of the teeth and gums).
The mouth, housing the tongue, teeth, and gums, is the anterior opening of the oropharynx.
The bony arch of the hard palate and the fibrous soft palate form the roof of the mouth.
Loose, mobile tissue covering the mandibular bone forms the floor of the mouth.
Structure of tongue, teeth and gums
The tongue is anchored to the back of the oral cavity at its base and to the floor of the mouth by the frenulum.
The gingivae, fibrous tissue covered by mucous membrane, are attached directly to the teeth and the maxilla and mandible.
The roots of the teeth are anchored to the alveolar ridges of the maxilla and mandible.
Structure of glands and tonsils
The parotid, submandibular, and sublingual salivary glands are located in tissues surrounding the oral cavity.
The oropharynx, continuous with but inferior to the nasopharynx, is separated from the mouth by bilateral anterior and posterior tonsillar pillars.
The tonsils lie in the cavity between these pillars.
Swallowing is initiated when food is forced by the tongue toward the pharynx.
Infants and children
Inner ear development in first trimester
External auditory canal in infants shorter than in adults
Eustachian tube in infants wider, shorter, more horizontal than in adults
Salivation increased by 3 months
Development of sinuses in children
Maxillary and ethmoid sinuses are present at birth but are very small.
Frontal and sphenoid sinuses begin to develop at about 3 years of age and complete development in late adolescence.
Teeth formation in children
Twenty deciduous teeth usually erupt between 6 and 24 months of age.
Permanent teeth begin forming in the jaw by 6 months of age.
Eruption of the permanent teeth begins about 6 years of age and is completed around 14 or 15 years of age in most races.
Pregnancy women
Elevated levels of estrogen cause increased vascularity of upper respiratory tract. Capillaries in nose, pharynx, and ears engorge. Nasal stuffiness and fullness in ears Decreased smell and impaired hearing Epistaxis Laryngeal changes Hoarseness and cough Vocal changes
Older Adults
Nearly a third of adults older than 65 years have hearing loss
Age-related hearing loss is associated with:
Degeneration of hair cells in the organ of Corti
Loss of cortical and organ of Corti auditory neurons
Degeneration of the cochlear conductive membrane
Decreased vascularization of the cochlea
Hearing loss in older adults
Sensorineural hearing loss first occurs with high-frequency sounds and then progresses to tones of lower frequency.
Conductive hearing loss may result from:
Excess deposition of bone cells along the ossicle chain, causing fixation of the stapes in the oval window
Cerumen impaction
Sclerotic tympanic membrane
taste and smell in older adults
Deterioration of the sense of smell results from loss of olfactory sensory neurons beginning at about 60 years of age.
The sense of taste begins deteriorating at about 50 years of age as the number of papillae on the tongue and salivary gland secretion decreases.
Mouth and ear structural changes in older
Continuing cartilage formation in ear and nose:
Ears and nose larger and more prominent
Mouth soft tissue changes:
Cheeks more prominent
Gingival tissue less elastic and more vulnerable to trauma
Teeth and tongue changes in older
Teeth are lost.
Difficulty chewing
Altered motor function of tongue
Difficulty swallowing
HPI: Vertigo
Time of onset, duration of attacks Description of attack Associated symptoms Unsteadiness, loss of balance, falling Medications: ototoxic, salt retaining
HPI: Epistaxis
Frequency and amount of bleeding
Predisposing factors
Site of bleeding
Medications
HPI: Sinus pain
Fever, malaise, cough, headache, maxillary toothache, eye pain
Nasal congestion, colored nasal discharge
Tenderness or pressure over sinuses, pain increases when bending forward
HPI: Dental problems
Pain
Swollen or bleeding gums, mouth ulcers or masses, tooth loss
Dentures or dental appliances
Malocclusion
Medications: phenytoin, cyclosporine, calcium channel blockers, mouth rinses
HPI: Mouth lesions
Intermittent or constantly present, duration, painful or painless
Associated with stress, foods, seasons, fatigue, tobacco use, alcohol use, dentures
Variations in tongue character
Lesions any place else on the body
Medications: mouth rinses
HPI: Sore throat
Pain with swallowing
Exposure to dry heat, smoke, or fumes
Medications: antibiotics, nonprescription lozenges or sprays
HPI: Hoarseness
Onset: acute, chronic
Change in voice quality
Associated problems
HPI: Difficulty swallowing
Solids, liquids, or both
Feeling of food in throat, tightness, or substernal fullness
Drooling
PMHx
Systemic disease
Ear: frequent ear infections during childhood, surgery, labyrinthitis, antibiotic use; dosage and duration
Nose: trauma, surgery, chronic nosebleeds
Sinuses: chronic postnasal drip, recurrent or chronic sinusitis, allergies
Throat: frequent documented streptococcal infections, tonsillectomy, adenoidectomy
FH
Hearing problems or hearing loss, Ménière disease
Allergies
Hereditary renal disease
Personal and Social Hx
Environmental hazards Nutrition Oral care patterns Tobacco use Alcohol use Intranasal use of cocaine
Hx for infants and childrens
Prenatal history Prematurity Erythroblastosis fetalis, bilirubin greater than 20 mg/100 mL serum Infections Breast-feeding, secondary tobacco smoke exposure, out-of-home childcare Congenital defect Playing with small objects Behaviors indicating hearing loss Dental care
Pregnancy Women
Weeks of gestation or postpartum
Presence of symptoms before pregnancy
Pattern of dental care
Exposure to infection
Hx for older adults
Hearing loss causing any interference with daily life
Physical disability
Deterioration of teeth, extractions, difficulty chewing
Dry mouth (xerostomia)
Medications that decrease salivation
Equipment
Otoscope with pneumatic attachment Nasal speculum Tongue blades Gauze Gloves Tuning fork (500 to 1000 Hz) Penlight, sinus transilluminator, or light from otoscope Vials with different odors such as mint, banana, coffee
Inspect the external ear
Inspect auricles Size, shape, and symmetry Landmarks and position on head Color Presence of deformities, lesions, or nodules Inspect external auditory canal Discharge and odor
Otoscopic examination
Used to inspect external auditory canal and middle ear Inspect auditory canal from meatus to tympanic membrane. Discharge Redness Scaling Lesions Foreign bodies Cerumen
MORE otoscopic examination
Inspect tympanic membrane. Landmarks Color Contour Perforation Use pneumatic attachment to evaluate mobility and compliance of tympanic membrane
Hearing evaluation
Evaluate auditory function. Response to questions and directions Whispered voice test Compare air to bone conduction. Weber test Rinne test
Hearing evaluation CONT
Distinguish type of hearing loss.
Sensorineural
Conductive
Refer patients with loss for thorough auditory examination.
External nose inspection
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.
Inspection of nasal cavity
Inspect nasal mucosa. Color Discharge Masses or lesions Swelling of turbinates Inspect nasal septum. Position, straightness, and thickness Perforations, bleeding, or crusting The sense of smell (cranial nerve I) is often tested with recognition of different odors.
Sinuses Inspection
Inspect the frontal and maxillary sinus areas for swelling.
Palpate frontal and maxillary sinuses for tenderness.
Transillumination of the frontal and maxillary sinuses may be performed if sinus tenderness is present or infection is suspected.
Lips
Inspect and palpate lips. Symmetry Color Edema Surface abnormalities
Buccal mucosa, teeth and gums
Inspect buccal mucosa.
Stenson ducts
Color and moisture
Ulcers or Fordyce spots
Inspect teeh
Occlusion and alignment
Color and stains
Number of missing teeth
Wear, notches, or caries
Inspect tongue
Swelling
Variation in size or color
Coating
Ulceration
Inspect oral cavity
Ask the patient to extend the tongue while you inspect for:
Deviation
Tremor
Limitation of movement
Oral cavity CONT
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 retropharyngeal wall.
Elicit gag reflex.
Tests the glossopharyngeal and vagus nerves (cranial nerves IX and X)
ears in infants
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.
Evaluate infant hearing using sound stimuli.
Nose and sinuses in infants
Inspect for symmetry and positioning.
Determine nasal patency.
Paranasal sinuses are poorly developed during infancy, and examination is generally unnecessary.
Mouth in infants
Inspect lip shape and irregularities.
Inspect buccal mucosa color and moisture.
Observe for drooling.
Inspect gums, teeth, and tongue.
Inspect palatal arch and soft palate.
Evaluate suck reflex.
Avoid depressing the tongue because this stimulates a strong reflex protrusion or the tongue, making visualization of the mouth difficult.
Children
Because the young child often resists otoscopic and oral examinations, it may be wise to postpone these procedures until the end.
Be prepared to immobilize if encouraging the child to cooperate fails.
Another person, usually the parent, may be needed to effectively hold the child.
Ears in childrne
Otoscopic examination
Pull auricle down to view tympanic membrane.
Pneumatic otoscope 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 young children beginning at 3 to 4 years of age.
Nose and sinuses in children
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 5 to 6 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 in children
Inspect teeth for grinding, decay, and brown spots.
Check gag reflex, enabling brief view of mouth and oropharynx.
Inspect buccal mucosa.
Inspect tonsils and epiglottis.
Inspection in pregnant women
Inspect nose and pharynx for edema and erythema.
Inspect for nasal congestion and sinusitis.
Inspect tympanic membrane for retraction or bulging.
Inspect gums for hypertrophy.
Older adults: ears and hearing
If hearing aid is worn, inspect auditory canal for irritation.
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.
Older adults: Nose and mouth
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.
Ear abnormalities
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
Otits externa
Inflammation of the auditory canal and external surface of the tympanic membrane
Hearing loss
Conductive hearing loss
Hearing loss resulting from reduced transmission of sound to the middle ear
Sensorineural hearing loss
Hearing loss resulting from a disorder of the inner ear, damage to cranial nerve VIII, genetic disorders, systemic disease, ototoxic medication, trauma, tumors, and prolonged exposure to loud noise
Vertigo
Illusion of rotational movement by a patient, often due to a disorder of the inner ear
Ménière disease
Sinusitis
Sinusitis
Bacterial infection of one or more of the paranasal sinuses
Acute pharyngitis
Infection of tonsils or posterior pharynx by microorganisms such as group A β-hemolytic streptococci or other streptococcal species, Neisseria gonorrhea, Mycoplasma pneumoniae
Oral cancer
Cancer involving the oral cavity or related structures
Most often squamous cell