EARS, NOSE, MOUTH/THROAT, HEAD, NECK FACE

Question 1

eyes should be

Answer 1

symmetrical

Question 2

eyelids

Answer 2

Assess if eyelids approximate completely when eyes are closed

• If eyelids do not close completely = risk for corneal damage
• Should be no swelling, discharge, or lesions
• Ptosis = drooping of upper lid

Question 3

eyeballs

Answer 3

• Should be aligned normally, no protrusion or sunken appearance
• Exophthalmos = protruding eyes

Question 4

sclera

Answer 4

Have patient look up, using thumbs, slide lower lids along the bony orbital rim
* Should be “china white”

• Dark skinned patients
• May have small brown macules (like freckles) or yellow deposits
• Color may also appear gray-blue or “muddy”Look for:
• Redness
• Scleral icterus (yellowing)
• Tenderness
• Foreign body
• discharge

Question 5

Lacrimal Apparatus

Answer 5

Check by pressing index
finger against the sac

• Just inside lower orbital rim
• Be careful not assess side of
  nose

Abnormal response =
* Red
* Swollen
* Tender to pressure
* Regurgitation of fluid
* May indicate blocked duct

Question 6

eye movement

Answer 6

Diagnostic Positions (6 cardinal
positions of gaze)

• Will reveal any muscle weakness during
  movement
• Have patient hold head steady, follow
  your finger with only the eyes
• Your finger should be about 12 inches
  away from face
• Progress with clockwise movements,
  coming back to center after each
  movement
• Expected response = parallel tracking of
  finger with both eyes

Abnormal response = eye movement not
parallel

Could indicate weakness of eye muscle or
dysfunction of cranial nerve

also assess for nystagmus = fine,
oscillating movements

Question 7

eye assessment

Answer 7

Pupillary Light Reflex
* Darken Room * Ask patient to gaze into distance * Advance light from the side and
note response

Expected Response:
* Direct light reflex
* Consensual light reflex
* Abnormal Response
* Dilated pupils
* Dilated and fixed
* Unequal or no response

measurement
-gauge pupil size in diameter
-before and after light reflex
expected size= 3,4,5 mm
-increases in response to light

Question 8

external ear

Answer 8

auricle or pinna

Consists of movable cartilage and skin

Characteristic shape serves to funnel sound waves into its
opening, which is called the external auditory canal.

Question 9

auditory canal

Answer 9

–A cul-de-sac 2.5 to 3 cm long in adults that terminates at
eardrum, or tympanic membrane

–Lined with glands that secrete cerumen, a yellow waxy material
that lubricates and protects ear

–Lymphatic drainage of external ear flows to parotid, mastoid,
and superficial cervical nodes

Question 10

tympanic membrane

Answer 10

eardrum, separates the external and middle ear

–translucent membrane with pearly gray color
parts of the malleus show through translucent drum

Pars flaccida: small, slack, superior section of TM

• Pars tensa: remainder of TM, thicker, and more taut
• Annulus: outer fibrous rim of the TM

Question 11

middle ear

Answer 11

Tiny air-filled cavity inside temporal bone

• Contains tiny ear bones, or auditory ossicles:
  malleus, incus, and stapes
• Several openings are present.
• To the outer ear and inner ear eustachian tube: opening that connects middle ear with nasopharynx
  and allows passage of air
• Normally closed, but opens with swallowing or yawning

                                Three functions 1) Conducts sound vibrations from outer ear to central hearing apparatus in inner ear

2)Protects inner ear by reducing amplitude of loud sounds

3) Eustachian tube allows equalization of air pressure on each side of TM so that it does not rupture.

Question 12

inner ear

Answer 12

Contains the bony labyrinth, which holds sensory organs for equilibrium and hearing.

Vestibule and semicircular canals within bony labyrinth compose the vestibular apparatus.

Cochlea contains central hearing apparatus.

Although the inner ear is not accessible to direct examination, its functions can be assessed.

Question 13

inspection and palpation of the external ear

Answer 13

–size & shape
ears are equal and bilateral with no swelling or thickening

ears of unusual size and shape may be normal familiar trait with no clinical significance

skin condition
–skin color consistent with the person’s facial skin color
–skin intact with no lumps or lesions
DARWINS TUBERCLE: a small painless nodule at the helix: congenital variation and not significant

tenderness
–move pinna and push on tragus; should feel firm with mvmt– no pain
–palpating mastoid process should not produce any pain

note any: redness, swelling, lesions, foreign bodies, or discharge

Question 14

tympanic membrane

Answer 14

Color and characteristics

• Systematically explore landmarks
• Normal TM shiny and translucent, with a pearl-gray color
• Cone-shaped light reflex prominent in anterior-inferior quadrant, a reflection of
  the otoscope light
• Sections of malleus are visible through translucent drum: the umbo, manubrium, and short process.
• At periphery annulus looks whiter and dense

Question 15

test for hearing acuity

Answer 15

Screening for hearing deficit begins during history; how well does a person hear conversational speech?

• Ask the person directly if there is a hearing difficulty.
• If answer is yes, perform audiometric testing or refer for audiometric testing.
• If the answer is no, screen using the whispered voice test.
• Useful to document presence of hearing loss
• Refer any abnormal findings for more accurate measures with pure tone audiometry.

Question 16

whispered voice test

Answer 16

Test one ear at a time while masking hearing in other ear by placing one finger on tragus and rapidly pushing it in and out of auditory meatus.

• Shield your lips so the person cannot compensate for a hearing loss (consciously
  or unconsciously) by lip reading or using the “good” ear.
• With your head 30 to 60 cm (1 to 2 ft.) from the person’s ear, exhale and whisper slowly some two-syllable words.
• Normally, the person repeats each word correctly after you say it.

Question 17

nasal cavity

Answer 17

First segment of respiratory system

Upper third made up of bone; rest is
cartilage

Nasal cavity divided medially by septum
into two slit-like air passages

Anterior part of septum holds a rich
vascular network, Kiesselbach’s plexus, most common site of nosebleeds.

Lateral walls of each nasal cavity contain
three parallel bony projections: superior,
middle, and inferior turbinates.

Underlying each turbinate is a cleft, the
meatus, which is named for turbinate
above.

Sinuses drain into middle meatus, and
tears from nasolacrimal duct drain into
inferior meatus.

Question 18

structure and function: Nose

Answer 18

Two pairs of sinuses are accessible to
examine.

Ø Frontal sinuses in frontal bone
above and medial to orbits

Ø Maxillary sinuses in maxilla
(cheekbone) along side walls of
nasal cavity

Ø Other two sets are smaller and
deeper.

– Ethmoid sinuses between the
orbits

–Sphenoid sinuses deep within
skull in the sphenoid bone

Only maxillary and ethmoid sinuses
are present at birth

Question 19

inspection and palpation: nose

Answer 19

External nose

Ø Normally nose is symmetric, in midline, and in proportion to other facial features.

Ø Inspect for any deformity, asymmetry, inflammation, or skin lesions.

• If an injury is reported or suspected, palpate gently for any pain or break in contour.

Test patency of nostrils.

                     Nasal cavity Ø Use your pen light to assess nasal cavity Ø View each nasal cavity with the person’s head erect and then with head tilted back.

• Inspect nasal mucosa, noting its normal red color and smooth moist surface.
• Note any swelling, discharge, bleeding, or foreign body.

               Nasal septum Ø Observe nasal septum for deviation. Ø Note any perforation or bleeding in septum.

Question 20

structure and function: Mouth

Answer 20

First segment of digestive system and an
airway for the respiratory system

Oral cavity: short passage bordered by lips,
palate, cheeks, and tongue

Lips: anterior border of oral cavity, transition
zone from outer skin to inner mucous
membrane lining the oral cavity

Ø Palate: arching roof of mouth divided into
two parts

Ø Hard palate: anterior part made up of bone

Ø Soft palate: posterior part, an arch of muscle
that is mobile

Ø Uvula: free projection hanging down from
middle of soft palate

Ø Cheeks are the side walls of oral cavity.

Question 21

inspection of the mouth

Answer 21

Begin with anterior structures and move posteriorly; use tongue blade to retract structures and bright light for optimal visualization.

                           Inspect lips: Ø For color, moisture, cracking, or lesions; retract lips and note inner surface.

Ø African Americans normally may have bluish lips and a dark line on gingival margin.

                      Inspect Teeth * Condition of teeth is an index of the person’s general health. * Note any diseased, absent, loose, or abnormally positioned teeth.

                      Inspect Tongue * Check tongue for color, surface characteristics, and moisture.

Question 22

inspection of buccal muscosa

Answer 22

Observe uvula

–Normally looks like fleshy pendant hanging in midline; ask a person to say “ahhh” and note soft palate and uvula rise in midline

— Tests one function of cranial nerve X, the vagus nerve

Question 23

structure and function of the mouth:

Answer 23

Mouth contains three pairs of salivary glands.
–Parotid gland lies within cheeks in front of ear.

–Submandibular gland lies beneath mandible at
angle of jaw.

Sublingual gland, the smallest, almond-shaped, lies within floor of mouth under tongue and has many small openings along sublingual fold under tongue.

Glands secrete saliva, the clear fluid that
moistens and lubricates the food bolus,
starts digestion, and cleans and protects the mucosa.

Adults have 32 permanent teeth; 16 in each
arch.
Each tooth has three parts: crown, neck, and root.

Question 24

structure and function of the throat// pharynx

Answer 24

Area behind mouth and nose
Oropharynx: separated from mouth by a fold of tissue on each side, the anterior tonsillar pillar

Tonsils: behind folds, each is a mass of lymphoid tissue look more granular, and surface shows deep crypts

Tonsillar tissue enlarges during childhood until puberty.

Posterior pharyngeal wall is seen behind these structures.

Nasopharynx: continuous with oropharynx above oropharynx and behind nasal cavity

Pharyngeal tonsils (adenoids) and eustachian tube openings are located here

Question 25

inspection of throat

Answer 25

Enlarge your view of posterior pharyngeal wall by depressing tongue with tongue blade.

• Scan posterior wall for color, exudate, or lesions.
• Notice any breath odor, halitosis.
• Usually due to local cause; poor oral hygiene, consumption of odoriferous foods, alcohol, smoking, or
  dental infection
• Observe oval, rough-surfaced tonsils.
• Color is same pink as oral mucosa, and their surface peppered with indentations, or crypts; there
  should be no exudate on tonsils.
• Tonsils graded in size as follows:
• 1+ Visible
• 2+ Halfway between tonsillar pillars and uvula
• 3+ Touching uvula
• 4+ Touching each other

Question 26

head and neck

Answer 26

inspect and palpate skull
* Note general size and shape: Normocephalic
* Assess shape: place fingers in person’s hair and palpate scalp
* Skull normally feels symmetric and smooth
* There is no tenderness to palpation

      Palpate temporomandibular joint * as the person opens the mouth, and note normally smooth movement with no limitation or tenderness
                       Inspect face * Note facial expression and appropriateness to behavior or reported mood * Facial structures always should be symmetric * Note any involuntary movements (tics) in facial muscles; normally none occur

Question 27

palpate lymph nodes

Answer 27

Preauricular, in front of ear

• Posterior auricular (mastoid), superficial to
  mastoid process
• Occipital, at base of skull
• Submental, midline, behind tip of mandible
• Submandibular, halfway between angle and tip
  of mandible
• Jugulodigastric, under angle of mandible
• Superficial cervical, overlying sternomastoid
  muscle
• Deep cervical, deep under sternomastoid
  muscle
• Posterior cervical, in posterior triangle along
  edge of trapezius muscle
• Supraclavicular, just above and behind
  clavicle, at sternomastoid muscle

Question 28

hearing involves

Answer 28

hearing involves the auditory system @ the peripheral brainstem, cerebral cortex lvl

the ear transmits sound & converts its vibrations into electrical impulses

Question 29

conductive hearing loss (partial hearing loss)

Answer 29

a mechanical dysfunction of the external or middle ear

cause: cerumen buildup, ostosclerosis and ototoxic

Question 30

sensorineural// perceptive hearing loss

Answer 30

pathologic condition of the inner ear, cranial nerve 8

causes: presbycusis–age related gradual degeneration of the nerve & ototoxic drugs which affect the cochlea

Question 31

mixed hearing loss

Answer 31

results from conductive and sensorineural causes

Question 32

in adults younger than 40 (hearing)

Answer 32

otosclerosis is common cause of conductive hearing loss

Question 33

hearing in the aging adult

Answer 33

hearing acuity may decrease because because of the coarse and stiff cilia lining in the ear, impacted cerumen, and nerve degeneration in the inner ear

Question 34

for subjective data for hearing

Answer 34

ask about ear aches & past infection; discharge from the ears, hearing loss and environmental noise, tinnitus and vertigo and cleaning of the ears

Question 35

objective data for the ear

Answer 35

inspect and palpate the external ear

Question 36

function of the nose

Answer 36

warms, moistens, and filters inhaled air and is the
sensory organ of smell, innervated by cranial nerve I