ENT assessment Flashcards
patient scenario:
A 45-year-old patient presents with
hearing loss, ringing in one ear, frequent
sinus infections, and a chronic sore
throat.
external ear anatomy
- Protects the middle and inner ear
- Called the Auricle or Pinna
- Made of movable cartilage and skin
- Funnels Sound Waves
external ear anatomy - auditory canal
- Auditory Canal
- 2 ½ to 3 cm long
- Outer 1/3 cartilage, Inner 2/3 bone
- Stops at tympanic membrane (ear drum)
- Lined with glands that secrete cerumen (ear wax)
- Lubricates and protects ear, not an indicator of poor hygiene
middle ear anatomy
- Tiny air-filled cavity inside the temporal
bone - Opens to the outer ear and inner ear
middle ear anatomy - eustachian tube
- Eustachian Tube
- Connects middle ear with nasopharynx
- Allows passage of air
- Opens when swallowing or yawning
- Equalizes pressure
middle ear anatomy - tympanic membrane
normal TM looks pearly gray and slightly concave
inner ear anatomy
- Contains bony labyrinth
- Holds sensory organs for:
- Equilibrium
- Hearing
- Holds sensory organs for:
cochlea
- Cochlea houses the organ of Corti
- Primary sensory organ for hearing
what are the external, middle, and inner ear infections?
Otitis externa: Also known as swimmer’s ear, this infection affects the skin and soft tissue of the ear canal. It can occur if water remains in the ear after swimming or bathing, or if the ear canal is irritated by a cotton swab. Symptoms include pain, itchiness, discharge, and sometimes a golden crust.
Otitis media: This infection affects the air-filled space behind the eardrum. It can be caused by bacteria or viruses, such as those that cause colds. Symptoms include pain, fever, and tugging at the ear
common conditions of the ear - otitis media (exam)
- Otitis Media
- Early signs:
- Absent light reflex on the tympanic membrane
- Early signs:
common conditions of the ear - presbycusis (exam)
- Presbycusis (age-related hearing loss)
- High-frequency tone loss
- Slow progression
- Garbled sounds
- Difficulty hearing consonants
common conditions of the ear
- Conductive vs. Sensorineural Hearing
loss - Tinnitus
- Impacted Cerumen
- Otitis Externa
- Vertigo
types of hearing loss of the ear
conductive
sensorineural (or perceptive)
mixed
the pathways of hearing - air conduction (exam)
the primary and most efficient method
the pathways of hearing - bone conduction (exam)
it bypasses the outer and middle ear, transmitting sound via the skull and vibrations to the CN VIII
what are some common causes of hearing loss
conductive: ruptured membrane, packed in ear wax, foreign bodies, perforated membrane
sensorineural: nerve damage, trauma, hereditary, noise
subjective data of ENT
- Earache
- Infections
- Discharge
- Hearing loss
- Environmental noise
- Tinnitus
- Vertigo
things to inspect and palpate of the external ear
- Shape and Size
- No swelling
- Thickening
- Skin Condition
- Color
- consistent with facial skin
- Color
- Intact
- No lumps or bumps
- Darwin tubercle
- No lumps or bumps
- Tenderness
- Move the pinna and push on the tragus
- Should feel firm w/ no pain
- Palpate mastoid process
- Should not be painful
- Move the pinna and push on the tragus
- External Auditory Meatus
- Note the size of the opening
- to direct choice of speculum
- Swelling
- Redness
- Discharge
- Note the size of the opening
- Cerumen color and texture
how to do a otoscopic examination
- Tilt the client’s head slightly away from you
- Pull pinna up and back for adult and older
child- Straighten S-shape of the canal
- Pull pinna down on infants and children
under 3- Adjusts shorter, straighter canal for
better visualization.
- Adjusts shorter, straighter canal for
- Hold pinna gently but firmly
- Do not release traction until the exam is
completed and the otoscope removed - Insert speculum slowly and carefully
along the axis of the canal
- Do not release traction until the exam is
otoscopic exam on the external canal
- Note any redness, swelling, lesions, foreign
bodies, or discharge- If any discharge is present, note the
color and odor- Head injury: Clear or blood drainage
could indicate basil skull fracture
- Head injury: Clear or blood drainage
- If any discharge is present, note the
- Clean the speculum before examining
the other ear to avoid contamination - If wearing a hearing aid, note irritation
of the canal from poor fit.
otoscopic exam - tympanic membrane
- Color and Characteristics
- Normal:
- Slightly Concave
- Shiny
- Translucent
- Pearly gray color
- Abnormal
- Bulging
- Perforation
- Effusion (Fluid)
- Absence of light reflex
- Normal:
why do we pull the pinna up for adults but down for children during an exam
this is because the adults canal is in an S shape, and kids canals are shorter (which is why they sometimes get more infections)
how to test hearing acuity
Ask the person directly if there is a hearing difficulty
* If the 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 the presence of
hearing loss
what is the whispered voice test
- Test one ear at a time while masking hearing in the other ear by placing one finger on the tragus and rapidly pushing it in and out of
the 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
- Stand arm’s length behind the person(2 ft.) from the person’s ear, exhale, and whisper slowly some two-syllable words (one ear at a
time) - Normally, the person repeats each word correctly after you say it
what do tuning fork tests do
- Measure hearing air conduction (AC) or bone conduction (BC), in which sound vibrates through cranial bones to the inner ear
- AC route through the ear canal and middle ear is usually the more sensitive route
- To activate the tuning fork, hold it by
the stem and strike the tines softly on the back of your hand - Perform Weber and Rinne tests
the weber test
- Normal finding—sound is equally heard in both ears
- Abnormal finding—sound lateralizes to one ear
- Conductive loss—Sound lateralizes to poorer ear
- Sensorineural loss—Sound lateralizes to better ear
rinne test
Normal finding—AC greater than BC, noted as a positive finding
* Abnormal finding relates to:
* Conductive loss: AC = BC or even longer (AC less than BC)
* Sensorineural loss: Normal ratio intact but
reduced; the person hears poorly both ways
how do we assess cranial nerve VIII
sensorineural tests
- weber and rinne, whisper test
the vestibular apparatus - romberg test
Assesses the ability of vestibular apparatus in the inner ear to help maintain standing balance
* Also assesses intactness of cerebellum and proprioception as it is part of the neurologic system
* Tests for balance and proprioception.
* Positive Romberg = loss of balance when eyes are closed → possible inner ear dysfunction.
nose structure and function - first segment
- serving as an air passageway and a filter.
- composed of bone (upper third) and cartilage (lower two-thirds).
nose structure and function - nasal septum
- divides the cavity
- The anterior portion contains Kiesselbach’s plexus, a common nosebleed site
nose structure and function - turbinates
(superior, middle, inferior)
* increase surface area for warming, filtering, and humidifying air.
nose structure and function - sinuses
- drain into the middle meatus; nasolacrimal duct drains into the inferior meatus
- Frontal and maxillary sinuses accessible for examination; Ethmoid and sphenoid sinuses smaller and deeper
- If blocked, it can lead to pain and pressure
- Help lighten skill and provide resonance for voice and produce mucus
nose structure and function - olfactory receptors
- Hair cells
- Lie at roof of nasal cavity and upper third of septum
- Merge into olfactory nerve, Cranial nerve I
why do sinus infections cause facial pain
from built up fluid and pressure in the sinuses
subjective data findings of assessment of the nose
- Discharge
- Frequent colds (upper respiratory infections)
- Sinus pain
- Epistaxis (nosebleeds)
- Allergies
- Altered smell
best way to stop epistaxis or nosebleed (exam)
- Best way to stop a nosebleed is to sit up, lean forward, and pinch the nose.
what is the most common site of nosebleeds and why?
finding objective data with the nose
- Preparation
- Position a person sitting up straight with his or her head at your eye level.
- If the person wears dentures, offer a paper towel and ask the person to remove them.
equipment for obtaining objective data with the nose
Otoscope with short, wide-tipped nasal speculum
Penlight
Two tongue blades
Cotton gauze pad, 4 × 4 inches
Gloves
inspection of the external nose
- Check for symmetry, deformities, inflammation, and lesions.
- Test the patency of each nostril by occluding one side and asking the patient to breathe
inspection of the nasal cavity
- Attach a short, wide-tipped speculum to the otoscope head and insert the apparatus into the nasal vestibule
- View each nasal cavity with the person’s head erect and then with the head tilted back
- Observe nasal mucosa—should be pink, moist, and without swelling or discharge.
- Pale, swollen, or gray can indicate allergies
inspection of the nasal septum
assess for deviation, perforation, or bleeding
inspection of nasal turbinates
Middle and inferior turbinates visible; Superior turbinates may not be in view
* Should be light red in color; note any swelling
* Check for nasal polyps—soft, painless growths that can obstruct airflow
turbinates are (exam)
- Turbinates are quite vascular and tender to touch; avoid touching them during the exam to prevent pain.
palpation of the nose and sinuses
Palpate frontal sinuses and maxillary sinuses
* Using thumbs, press frontal sinuses by pressing up and under the eyebrows and over
maxillary sinuses below cheekbones
* Tenderness or swelling suggests sinusitis.
what is a common complaint with meningitis
stiff neck
- may also see high fever, bad headache, pressure points in weird spaces where they may get a rash
how do we assess the sinuses, and what findings suggest infection and why?
palpation to see if there is any tenderness or swelling
the mouth is
the first segment of the digestive and respiratory systems
mouth structure and function
Oral Cavity
* Short passage bordered by lips, palate, cheeks, and tongue
* Contains salivary glands
Tongue
* Striated muscle that can change shape and position
* Functions: Mastication, swallowing, cleansing teeth, taste sensations, and formation of speech
Parotid gland
* largest, located in cheeks, Stensen’s duct drains into the buccal mucosa.
Submandibular gland
* under the jaw, Wharton’s duct drains into the floor of the mouth.
Sublingual gland
* smallest, multiple openings under the tongue.
Saliva
* aids digestion, moistens food, and protects mucosa.
what role do salivary glands play in digestion?
they contain enzymes to help break down and digest starches in foods
the throat or pahrnyx
the area behind the mouth and nose
the oropharynx
Separated from the mouth by a fold of tissue on each side, the anterior tonsillar pillar
the 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 the oropharynx and behind nasal cavity
- Pharyngeal tonsils (adenoids) and eustachian tube openings are located here
- Oral cavity & throat have a rich lymphatic network
subjective data of the mouth and throat
- Sores or lesions
- Sore throat
- Bleeding gums
- Toothache
- Hoarseness
- Dysphagia
- Altered taste
- Smoking, alcohol consumption
- Patient-centered care
- Dental care pattern
- Dentures or appliances
assessment of the mouth
Lips
* Check for color, moisture, cracking, and lesions.
Teeth
* Look for caries, missing or misaligned teeth.
Gums
* Should be pink and firm without swelling or bleeding.
Tongue
* Inspect for color, moisture, and texture.
* Dry mucosa with deep fissures on the tongue suggests dehydration.
* Ventral surface should be smooth with visible veins.
* Any white patches or lesions should be palpated.
* Candidiasis (oral thrush) appears as a while, with cheesy patches in the mouth. Common after chemotherapy.
Buccal mucosa
* Look for lesions, ulcers, or discolorations.
what is important to look for on the tongue (exam)
a dry mucosa with deep fissures on the tongue suggests dehydration
what should candidiasis look like (exam)
appears as a white, with cheesy patches in the mouth
assessment of the throat
Tonsils
* Grade them from 1+ (visible) to 4+
(touching each other).
Pharyngeal wall
* Look for redness, swelling, or exudate.
* Untreated strep throat can lead to rheumatic fever, a serious complication.
Uvula
* Should rise midline on phonation (tests
cranial nerve X, the vagus nerve).
Palpate for lumps or asymmetry in oral
structures.
what can untreated strep lead to (exam)
can lead to rheumatic fever
how do we grade tonsil enlargement and what does it indicate
1+ to 4+
- 1+ = normal, are barely visible
- 4+ = touching each other or close to it, not good
developmental competence - aging adult
Infants & Children:
* Salivation begins at 3 months (drooling normal).
* Deciduous teeth erupt by 2½ years.
* Tonsils are proportionally larger in children.
Pregnant Women
* May experience nasal stuffiness, epistaxis, and gum hypertrophy due to increased
vascularity.
Aging Adults
* Loss of subcutaneous fat makes the nose more prominent.
* Decreased sense of taste and smell affects appetite.
* Increased risk of oral infections and malnutrition.
what does ear wax do (exam)
ear wax lubricates and protects the ear, it is not an indicator of poor hygiene
what can clear or blood drainage indicate (exam)
a basal skull fracture, TBI, or spinal cord injury
positive rinne test
would show the AC to be about 2x greater/longer than the BC
- when abnormal BC would be greater than AC
