ENT, Ophthalmic exam Flashcards
superficial temporal artery
passes right above ear where it is readily palpable
parotid gland
superficial and lies behind of the mandible becoming visible and mandible when enlarged
submandibular glands
deep to mandible below tongue w/ duct visible w/in oral cavity
common or concerning symptoms of HEENT
headache change in vision resulting in hyperopia, presbyopia, myopia, or scotomatas double vision (diplopia) hearing loss, earache, or tinnitus vertigo
Upper eyelid
covers portion of iris but does not cover pupil. opening between eyelids is palpebral fissure
sclera
white buff colored at periphery
conjuctiva
clear mucous membrane w/ two easily visible components
bulbar conjunctiva- covers most of anterior eyeball adheres loosely to underlying tissue and meets cornea at limbus
palpebral conjunctiva- lines upper and lower eyelids two parts merge in folded recess that permits movement of eyeball
Conjunctival injection: diffuse dilatation of conjunctival vessels with redness that tends to be maximal peripherally Mild discomfort rather than pain Vision is not affected except for temporary mild blurring due to discharge Watery, mucoid, or mucopurulent. Due to varied causes
Bacterial- crusted nasty stuff
Viral-
Allergic- bilateral in both eyes can see changes in conjunctiva cobblestone look
tarsal plates
w/in eye lid lie firm strips of connective tissue each plate contains parallel row of meibomian glands which open on lid margin.
levator palpebrae
muscle of upper eyelid
tear fluid
protects conjunctiva and cornea from drying and infection comes from lacrimal gland, conjunctiva glands, and meibomian glands
lacrimal gland
above eye drains medially through lacrimal punta and passes into lacrimal sac and onto nose through nasolacrimal duct atop small elevatoion of lower lid medially. sac rests inside bony orbit. and is not visible
Dacryocystitis swollen infected lacrimal sac.
Unlike in dry eye do not push on canthus to try and express fluids leading you to think of blocked lacrimal apparatus.
If blocked duct swollen not red and may be painful can push
cornea
transparent anterior portion of outer covering of eye
iris
: ciliary bodies control thickness of lens and allow for focusing, muscles of iris control size of pupil
ciliary body
muscles of this control thickness of lens allowing eye to focus on near or distant objects
produces clear liquid aqueous humor which helps control pressure inside eye and drains out through canal of schlem
fundus
posterior part of eye seen through otoscope.
optic nerve
enters eye posteriorly find it w/ opthalmoscope of optic disc where retinal arteries and veins converge. follow retinal vessels ventrally
fovea
lateral and slightly inferior to disc is darkened circular area surrounds small depression in retinal surface that marks point of central vsion
macula
surrounds fovea w/ no discernible margins no retinal vessels
retina
light sensitive membrane that covers fungus,
vitreous body
transparent mass of gelatinous material fills eyeball not usually visible through ophthalmoscope helps maintain shape of eye
seeing an image
light reflected from image must pass through pupil and be focused on sensor neurons in retina. image projected on retina upside down and reverse left to right. nerve impulses stimulated by light conducted through retina, optic nerve, and optic tract into brain.
snellen eye chart
have patient stand 20 ft. don’t wear reading but other contact or glasses. hold card over left eye and read smallest line possible on both eyes
first number equals distance of patient from chart second number distance at which normal eye can read line of letters
deter lesions in anterior and posterior pathway
static finger wiggle test
place hands 2 feet apart lateral to patients ears slowly move your wiggling finger of both hands along the imaginary surface of bowl toward central vision line have patient tell you when they see it. map out maximum extent of left and right monocular vision fields. if defect do boundaries to one eye at time look at opposite eye from defective toward center
kinetic red target test
move 5mm red topped pin along the boundary of each quadrant along a line bisecting the horizontal and vertical meridians have patient tell you when the pin first appears to be red. insect patients eye for position and alignment, width of palpebral fissures, edema and color, lesions, and condition and direction of eyelashes, adequacy of eyelid closure (when prominent, facial paralysis or when patient unconscious
inspecting eye
area over lacrimal gland and sac for swelling, look for excessive tearing or dryness.
sclera and conjunctiva ask patient to look up as you depress lower lids w/ your thumbs look for any nodules or swelling inspectiong color, vascular pattern looking at each side and down looking at sclera and bull conjunctive.
looking at pupils
inspect each cornea and lens for opacities shine penlight from eye toward light look for shadow on medial side of iris suggesting glaucoma inspect pupils. Go down 1-2mm. Check direct and consensual reaction
oblique lighting and distant gaze get pupillary reaction swing light to other light for consensual reaction in opposite eye.
look alternately at it and in distant look for constriction w/ near effort
Abnormal: When light goes into ABNORMAL eye both dilate slightly due to afferent nerve stimuli decreased so efferent also reduced, net dilation. Afferent pupillary defect
ocular alignment
arising from extra ocular muscles. 2 ft. shine light onto patients eye looking at it inspect reflections in corneas should be visible slightly nasally to center of pupil.
conjugate movement from eye in any direction, deviation from normal nystagmus (rhythmic oscillation of eyes), lid lag moving up and down
H in air to patients extreme right, upward, down, up to extreme left upward and down. horizontal, diagonal, vertical rotary nystagmus look for jerking movement of eyes as patient looks to far left right and up and down. lid lag or hyperthyroidism do it again up to down in midline looking for right lid of sclera above iris. convergence of eyes can only keep track up to 5-8 in.
opthalmoscope
small light to avoid hybus or spasm of ciliary muscle. 80% of full brightness minimizing pupillary constriction, 0 diopter look over shoulder using eye and hand of patients side.
15 in. away and 20 degrees lateral to patient line of vision onto pupil thumb of other hand on eyebrow. red reflex on orange glow of pupil opacity interrupting reflux toward pupil until ophthalmoscope is close to eye almost touching thumb. bring optic disc into sharper focus noting color of disc, size of central physiology cup, disc margin, cup to disc ratio 1:3 can be elevated in glaucoma. note symmetry of eyes and fundi normal optic disc yellowish orange to creamy pink or round or oval w/ well-demarcated margins. papillemeda swelling of optic disc and bulging of cup singles intercrnaial pressure of edema subarachnoid hemorrhage. retina, arteries and veins extend to periphery size and color of narrower lighter arteries surrounding retina for lesions size shape color and distribution. fovea and surrounding macula to direct lateral into light tiny reflection. repeat on left eye using opposite hadn’t and eye
ear
external ear (auricle- cartilage covered by skin curved outer ridge is helix parallel and anterior is anti helix fleshy part is lobule and ear canal- behind trigs curves inward 24 mm long surrounded by bone and thin hairless skin) captures sound waves for transmission into middle and inner ear middle ear (tympanic membrane ear drum, mastoid portion of temporal bone mastoid process palpable behind lobule inter ear (ear filled cavity that transmits sound by way of eardrum and three tiny bones ossicles, malleus, inca, and stapes . cochleae semicircular canals, and distal end of cochlea. assessed by testing auditory conduction
examining ear
inspect auricle and surrounding tissue for deformities lumps or skin lesions, if ear pain, discharge or inflammation present do tug test to test for otitis externa move auricle up and down press trigs and mastoid bone behind ear (mastoiditis)
otoscope
grab auricle in adult upward back and slightly away from head insert gently into ear canal downward and forward bracing hand
note cerumen, discharge, foreign bodies, redness of skin or swelling. pars flaccid and pars tensa, color and content of eardrum w/ cone of light should be pearly grey, translucent should be able to see through or pinkish.
If no cone of light pressure or fluid in middle ear cavity right ear is around 5 o’clock left ear is 7 o’clock if missing or moved pathology such as fluid, retraction of membrane note position of handle of malleus inspect short process of malleus, handle w/ gumbo at tip crosses obliquely from cone of light upward toward short process.
whispered voice test
one ear at a time 2 feet behind seated patient occlude non tested ear rub trigs to prevent transfer of sound exhale for quiet voice whisper thee numbers and letter until identify words if incorrect change it up and test again 3/6 numbers and letter correctly repeating it
weber test
base of vibrating tuning fork onto hear or forehead is it louder in one ear or same in both ears hear equally on both side.
rinne test
lightly vibrating tuning fork on mastoid behind ear and level w/ canal when indicates no longer hear near ear canal U of fork face forward maximizing sound heard longer though ear than bone do both
- Discuss the following common or concerning symptoms, and formulate open-ended questions to elaborate the history of present illness for a chief complaint of:
• Hearing loss
unilateral or bilateral? sudden (if sudden usually stroke or infection) or gradual onset? Other associated symptoms (earache, vertigo, tinnitus)? Difficult understanding people when they talk (sensorineural loss w/ noisy environments make hearing worse difficulty understanding speech. ) or in a noisy environment (conductive loss will be able to hear w/ noise)? presbycusis- degernating hair cells in ear lead to gradually progressive hearing loss, for high-frequency sounds and is a common age-related cause also associated w/ disease.
- Discuss the following common or concerning symptoms, and formulate open-ended questions to elaborate the history of present illness for a chief complaint of:
• earache
unilateral or bilateral? sudden or gradual onset? pain (otalgia)? pressure? itchy? discharge (otorrhea)? fever? headache? numbness? Pain in otitis externa (inflammation of external ear canal) and otitis media- inflammation and infection of middle ear deeper w/in ear. Pain may be referred from other structures in mouth, throat, or neck.
- Discuss the following common or concerning symptoms, and formulate open-ended questions to elaborate the history of present illness for a chief complaint of:
• tinnitus
perceived sound that has no external stimulus like a musical ringing, rushing, popping or roaring in one or both ears accompanies hearing loss) common increasing in frequency w/ age. when found w/ hearing loss and vertigo suspect Meniere disease
- Discuss the following common or concerning symptoms, and formulate open-ended questions to elaborate the history of present illness for a chief complaint of:
• discharge
earache or trauma associates found in acute otitis externa and acute or chronic otitis media w/ perforation presenting w/ yellow-green discharge
- Discuss the following common or concerning symptoms, and formulate open-ended questions to elaborate the history of present illness for a chief complaint of:
• Vertigo
- sensation of true rotational movement of patient or surroundings (tilting) pointing to problem in labyrinth of inner ear, peripheral lesions of CN 8 or lesions in central pathway or nuclei in brain. Dizziness (room spinning) Dizziness is a non specific term that encompasses several disorders. A thorough history is necessary in order to identify the etiology. Vertigo is defined as a spinning sensation accompanied by nystagmus and ataxia, Presyncope is a feeling of faintness or lightheadedness, Disequilibrium is unsteadiness or imbalance, Psychiatric causes of dizziness include: anxiety and panic disorder, depression, Multifactorial or unknown etiology and light-headedness usually accompany foundin presncope, weakness, unsteadiness, and disequilibrium. important to check for nausea, vomiting, double vision, and gait disturbance looking at nystagmus. represents vestibular disease, from peripheral cuases in inner ear such as benign positional vertigo, labyrinthitis, vestibular neuri- tis, and Ménière disease. Ataxia, diplo- pia, and dysarthria signal central neurologic causes in the cerebellum or brainstem such as cerebral vascular disease or posterior fossa tumor; also consider migraine.32 Feeling light- headed, weak in the legs, or about to faint points to presyncope from arrhyth- mia, orthostatic hypotension, or vaso- vagal stimulation.
- Discuss the following common or concerning symptoms, and formulate open-ended questions to elaborate the history of present illness for a chief complaint of:
• Nosebleed
• - (epistaxis) bleeding from nasal passages or in paranasal sinuses or naso pharynx and may go into throat ask where it comes from or was it coughed up (hemoptysis) or vomited (hematemesis). epitstaxis include trauma (nose-picking), inflammation, drying and crusting of nasal mucosa, tumors, and foreign bodies.
- Discuss the following common or concerning symptoms, and formulate open-ended questions to elaborate the history of present illness for a chief complaint of:
• Sore throat
• - usually associated with URI
- Discuss the following common or concerning symptoms, and formulate open-ended questions to elaborate the history of present illness for a chief complaint of:
• hoarseness
• - change in the voice quality, sounding husky, rough, harsh, or lower pithced than usual. Caused by disease of larynx, extralaryngeal lesions pressing on laryngeal nerves. Ask about allergies, acid reflux, smoking, alcohol use, inhalations, and frequency of talking. If acute, consider voice overuse, acute viral laryngitis, and possible neck trauma. If hoarseness lasts over 2 weeks, refer for laryngoscopy and consider causes such as hypothyroidism, reflux, vocal cord nod- ules, head and neck cancers including thyroid masses, and neurologic disorders like Parkinson disease, amyotrophic lateral sclerosis, or myasthenia gravis
Auricle
- external cartilage covered by skin and has firm elastic consistency
Antihelix
- external, parallel and anterior to helix is curved prominence
Cochlea-
inner ear containing semicircular canals, distal end of auditory nerve, vestibulococchlear nerve or CN8. moements of stapes virbate perilymph in labyrinth of semicircular canals and hair cells and endolymph in ducts of cochlea, producing electrical electrical nerve impulses transmitted by auditory nerve to brain. much of middle ear and all of inner ear inaccessible to direct examination.
Cone of light
middle ear umbo where eardrum meets tip of malleus light reflection fans downward and anteriorly
Ear canal-
external curves inward and is 24mm long. cartilage encases its outer 2/4s, skin is hairy and contains glands that produce cerumen (wax). inner third of canal is surrounded by bone and lined by thin, hairless skin.
Eustachian tube-
proximal end of Eustachian tube connects middle ear of nasopharynx.
Helix
- External cartilaginous surface on outer of ear, prominent curved outer ridge.
Incus
- middle ear part one of ossicles hammer shaped
Lobule
- external lower lobe of ear where you pierce someone’s ear. Inferiorly fleshy projection of earlobe
Malleus
- middle ear anvil shaped located behind tympanic membrane visble through it and angled obliquely and held other ossicles inward. have handle and short process of malleus.
Mastoid process-
behind ear canal is msdtoid process of temporal bone on external area. palpable behind lobule. can develop mastoiditis as a result of pain, swelling, and erythema behind ear begins w/ acute totiis left untreated or recent URI look behind ear swelling and erythema treat it aggressively go in surgically and must drain childs ear or hav eto remove mastoid ear cells
Ossicles-
middle ear making up the malleus, incus, and stapes transforming sound vibrations into mechanical waves for inner ear.
Stapes
- saddle shaped bone connected to cocchlea
Tragus-
External triangle shaped outcropping covering of nodular protrusion points backward over entrance to canal. external acoustic meatus, ear canal opens behind
Tympanic membrane-
lateral eardrum, marking medial limit of external ear. external ear captures sound waves for transmission into middle and inner ear.
Tympanic membrane-
lateral eardrum, marking medial limit of external ear. external ear captures sound waves for transmission into middle and inner ear.
- Compare and contrast conductive hearing loss and sensorineural hearing loss.
First part of hearing pathway, external to middle ear is conductive. Air conduction describes normal first phase in hearing pathway. AC more sensitive than bone conduction (BC).
sensorineural, second part of pathway involving chochlea and cochlear nerve. Labyrnth of three semicircular canals in the inner ear senses the position and movements of head and helps maintain balance. see weber and rinne test
conductive loss- Initiates from pathology in the external or middle ear
Interference with vibration transmission to sensory apparatus. Sick can hear it louder in that ear caused bu impaction, infection of external or middle perforated membrane, interference w/ vibratory trnasmition external or middle ear for conductive loss.
Common causes: Cerumen impaction
Otitis Externa
Otitis Media
Perforated TM
Tumors/Growths
sensorineural loss
Initiates from pathology in the inner ear, cochlear nerve or central brain connections w/ oval window and beyond vestibule, cochleae etc. .
Difficulty with higher frequency sounds
Hard to hear their own voice
Common causes:
Presbycusis (older person hearing loss)
Noise-induced (damaged internal structures of inner ear)
Meniere’s Disease (vertigo, hearing loss, pain in ear, and tinnittus.)
Ototoxic medications
Tumor/Growths
Systemic Disease
Sudden hearing loss (alarm symptom)
- Given a diagram or picture of the nose and sinuses, identify the following structures:
Ethmoid sinus, Frontal sinus, Maxillary sinus, Nares, Nasal septum, Nasopharynx, Sphenoid sinus, Turbinates (S/M/I)- curving bony structures covered by highly vascular mucous membrane, protrude into nasal cavity. temperature control warming up air before getting to lungs, cleansing
below each is a groove or meatus named according to turbinate above it. nasolacrimal duct drains into inferior metaus, most of paranasal sinuses drain into middle meatus w/ nonvisble opening usually visible. additional surface area provided by turbinates and overlying mucosa aids nasal cavities in principal functions: cleansing, humidification, and temperature control of inspired air. Vestibule- air enters nasal cavity through anterior naris on either side, passes into widened area of this and on through narrow nasal passage. lined with hair-bearing skin, not mucosa.
