Ears Nose and Throat Flashcards
- What are the components of the ears, nose, throat, and neck exam?
a. Ears: Auricle (if suspect otitis, move auricle up/down + press on tragus; press firm behind ear), Ear Canal & eardrum; Attempt to visualize: cone light, umbo, handle malleus, pars flaccida, incus, pars tensa; Hearing (whisper test, Weber (lateralization), Rinne (air vs. bone conductance)
b. Nose/Sinuses: External nose; W/Speculum: nasal mucosa over septum/turbinates (color, swelling), nasal septum position/integrity; palpate frontal and maxillary sinuses
c. Mouth/Pharynx: Lips, oral mucosa, gums, teeth, roof mouth, tongue (papillae, symmetry, lesions), floor mouth, pharynx (color/exudate, presence/size tonsil, symmetry soft palate “ah” (test vagus for uvula deviation, test hypoglossal nerve by having them stick their tongue out), sublingual glands, parotid glands, buccal mucosa
d. Neck: inspect neck (scars, masses, torticollis = abnorm neck position); Lymph nodes; inspect/palpate pos’n trachea; inspect thyroid gland (@rest/swallow; isthmus/lateral lobes)
- What are some common or concerning symptoms related to the ears, nose, throat, and neck (added common/concerning symptoms for HEENT from Bates pocket guide)?
. Headache, change vision, double vision (diplopia), hearing loss, earache, tinnitus (ringing ear), vertigo, nosebleed (epistaxis), sore throat/hoarseness, swollen glands, Goiter, dysphagia (difficulty swallowing), odynophagia (painful swallowing), tooth ache
- What are the roles of air conduction and bone conduction with regard to normal hearing and testing of hearing?
. Normal: AC > BC, sound travels as waves in air, picked up as vibrations on eardrum → propagate vibrates to malleus, incus, stapes (bone conduction) → vibrations translated to neural signal in inner ear → hearing sensation
a. Conductive loss: Weber = lateralizes to IMPAIRED ear; Rinne = BC > AC
b. Sensorineural loss: Weber = lateralized to GOOD ear, Rinne = AC > BC
- For each test of auditory function (whispered voice, Weber, and Rinne tests), what is the (1) proper examination technique, (2) purpose of the test, and (3) expectations regarding a normal level of function?
. Whisper voice: 2 ft behind patient, whisper combination of numbers and letters, and changeup the combo if patient gets one combo wrong; or rub your fingers together near ear and slowly move away (up to full extension) and note where patient stops hearing it
a. Weber (test for lateralization): place base of lightly vibrating tuning fork firmly on top of patients head/forehead, ask the patient where they hear the sound, on one side or both
i. Normal: midline or equally in both ears
b. Rinne (air vs. bone conduction): place base of lightly vibrating tuning fork on mastoid bone, behind ear and level with the canal. When the patient can no longer hear the sound, place fork close to ear canal. “U” shape should be facing forward to maximize its sound
.Normal: sound is heard longer through air than through bone
- How would you differentiate between conductive and neurosensory hearing loss?
a. Conductive - problem hearing faint sounds due to loss of ability to conduct sound waves
i. Conductive hearing loss: If lateralization more to R ear, the R ear is impaired. Indicates that for R ear, Bone conduction is greater than air conduction. This is CONDUCTIVE hearing loss because the patient has no trouble noticing vibrations (which bypass the external and middle ears and
are directed to inner ear). Thus, if patient can hear with bone conduction but less so with air conduction, it must be due to conductive hearing loss.
b. Neurosensory - problem lies with the vestibulocochlear nerve (CN VIII)
.Sensorineural hearing loss: Weber test shows that sound lateralizes to GOOD ear. Less vibration heard to one side indicates that the CN VIII in the inner ear cannot perceive the bone conduction. When conducting Rinne test, air conduction will be greater than bone conduction since the patient has no trouble conducting the signal through the external and inner ear, which subsequently is transmitted to the inner ear. But, bone conduction strictly test the inner ear’s capabilities. Without bone conduction you know that the pts inner ear is impaired and may have
- What is the proper technique for examining the thyroid gland?
. Use the cues from visual inspection (trachea midline? etc.). Find your landmarks—the notched thyroid cartilage and the cricoid cartilage below it. Locate the thyroid isthmus, usually overlying the second, third, and fourth tracheal rings. → pg 253, 11th ed. for details (Posterior approach– flex neck to relax SCM, index beneath cricoid swallowing, palpating)
a. Visualize before palpating with tangential lighting directed downward from patient’s chin (when their head of extended, aka retracted). Patient’s swallowing should produce elevation of thyroid cartilage, cricoid cartilage and thyroid.
b. Palpation: use cues from visual inspection and first locate the thyroid isthmus (not always palpable), which is inferior to the cricoid cartilage, overlying the 2-4th cartilaginous tracheal rings.
c. If anterior exam: backward bending of neck is helpful. If posterior exam, forward flexion (with SCM relaxation) is better.
d. Note size, shape, consistency and note any nodules or tenderness.
e. If enlarged: use stethoscope to detect a bruit (non-cardiac type of bruit).
- Complete an examination of the ears, nose, throat, and neck, and document all findings.
Head - Skull normocephalic/atraumatic (NC/AT); hair w/ average texture and distribution.
Eyes - Visual acuity 20/20 bilaterally; Sclera white; Conjunctiva pink; Pupils constrict 4mm to 2 mm, equally round and reactive to light and accommodations (PERRLA); Optic disc margins sharp; no hemorrhages or exudates; no arteriolar narrowing
Ears - Acuity good (whisper test); Tympanic membranes grey w/ good cone light, no bulging or erythema; Weber midline; AC > BC (Rinne) [indicating patient may have sensorineural hearing loss –only if clinician or patient notes a loss in gross hearing, as air should be greater than bone conduction (see 20b above)].
Nose - Nasal mucosa pink, septum midline; no sinus tenderness, no exudate or excessive discharge, inferior (and possibly middle) turbinates visualized
Throat/Mouth - Oral mucosa pink; dentition good; uvula midline; pharynx w/o erythema or exudates
Neck - Trachea midline; Neck supple; Thyroid isthmus palpable, lobes not felt; Lymph nodes - No cervical, axillary, epitrochlear, inguinal adenopathy”
