Eye & ENT Skills

Question 1

Eye exam 6 parts

Answer 1

1- general
2- pupils
3- visual acuity
4- ocular motility
5- fields
6- fundi

Question 2

Eye exam General

Answer 2

• symmetry or asymmetry
• what visual aids does Pt normally wear
• any trauma, contusions, swelling, lacs
• unilateral or bilateral ptosis
• colour of the sclera (yellow, blue, red)
• any exopthalmos (protruding eyes), proptosis (protruding organ)
• any discharge; colour, consistency, type
• epiphora (watery eyes)
• Pt blinking/rubbing eye/s

Question 3

Eye exam Pupils

Answer 3

Inspect:
Size, Shape, Symmetry

Reflexes:
- direct pupillary reflex
- consensual pupillary reflex
- swinging light test (looking for relative afferent pupillary defect RAPD)
- accommodation reflex
- cover test: Pt to focus on pen & then cover one eye
[no movement = normal, eyes move temporarily = convergent squint, eyes move nasally = divergent squint]

Question 4

Eye exam Visual Acuity

Answer 4

Snellen chart:
- 6/6 (6 m & read 6th line)

Fine print reading:
- cover one eye at a time & read a paragraph of small print in book or paper
- use normal visual aids
- document equal/>/<

Question 5

Eye exam Ocular Motility

Answer 5

Pt follows pen as U move it
- sit in front of Pt
- may need to support Pt’s chin to prevent head movement

Left-Right - left & right rectus muscles
Up - inferior rectus
Down - superior rectus
Up & outwards/Down & outwards - superior/inferior obliques
Pen toward nose - rectus muscle

Question 6

Eye exam Fields

Answer 6

Visual fields:
Used to detect hemianopias
(Loss of one half of visual field)
- test peripheral vision from all corners w one eye covered & Ex sitting 1m from Pt & mirroring covered eye.

Visual neglect/inattention:
- same sitting position, 1m from Pt
- Pt not to move head, Ex arms in periphery of Pt’s vision & test recognition of wriggling fingers - Pt to point at which ones are moving
- visual neglect (Pt only sees one moving when both are) suggests damage to frontal/parietal lobes

Question 7

Eye exam Fundi

Answer 7

Examin:
- cornea
- retinas
- inspect central retinal artery
- view macula
- palpate orbit

Orbit assessment:
- look for tenderness
- auscultate closed eye while Pt holds their breath
- bruits - suggestive of arteriovenous malformation/vascular tumour

Additional:
- everting upper eyelid to remove foreign body
- flourescein staining to identify: abrasion, ulceration, penetrating wound
- colour vision test: assess red-green colour perception

Question 8

Corneal abrasion assessment

Answer 8

Detailed Hx!!

Exam:
- may req local anaesthetic (amethocaine drop)
- assess visual acuity (snellen)
- examine eye lids & adnexa (all other elements around eye) for signs of ocular inflammation & trauma
- evert upper eyelid to look for foreign body
- once cleared, examine pupil size & reactivity
- perform fluorescein stain (& flush out)

Question 9

Corneal abrasion management

Answer 9

• they largely heal spontaneously so Rx is pain relief & infection prevention!

Topical ABs:
Chloramphenicol Ointment 1% topical nocte for 7/7
Chloramphenicol drops 0.5% topical 1 drop QID for 7/7
Note: esp important for high risk Pts: contact wearers or swimmers

Analgesia:
Orally - may help, though limited effect
Topically - NSAIDs appropriate
NEVER offer topical anaesthetics - inhibit corneal healing & obliterate normal corneal protective mechanism!

Pt Advice:
- most heal within 24-72hrs
- if symptoms persist/worsen: see GP
- Review 48-72hrs
Note: persisting symptoms may indicate developing corneal ulcer - referral for specialist review

Note: patching NOT recommended for anyone

Referral:
- large abrasions or abrasions in central visual axis (ophthalmologists within 24hrs)
OR:
- foreign body visualised
- contact lens wearers w worsening symptoms
- persistent symptoms >48hrs
- recent surgery to affected eye
- issue involving Pt’s only seeing eye
- dry eyes
- recurrent corneal abrasions
- presence of ulcer in staining
- Hx herpetic keratitis

Question 10

Disorders of the Cornea

Answer 10

Keratitis: inflammation of cornea
- bacterial
- HSV
- fungal
- interstitial (scarring due to chronic inflamm of stroma (middle tissue layer of cornea)
- acanthanoeba (rare) swimming in contaminated water

Photokeratitis:
UV related; snow/water without protective eyewear

Other:
- dystrophies, keratotonus, kertaoconus

DDx:
- foreign body
- conjunctivitis
- acute anterior uveitis
- acute angle closure glaucoma

Question 11

Fluorescein stain Indications x 5

Answer 11

• eval* suspected eye abrasion
• eval* suspected Non-Penetrating foreign bodies of the eye
• infections of the eyes
• pepper spray exposure
• welding arc flame exposure

Question 12

Fluorescein stain Contraindications x 2
(2x precautions)

Answer 12

Contraindications:
- prev reactions
- penetrating foreign body to the eye!!! (NO anaesthetics either)

Precautions:
- permanently stains soft contact lenses; remove for procedure & not replace for several Hrs post
- beware of using topical anaesthetics before staining: some Pts develop superficial punctate keratitis - could confuse Dx.

Question 13

Seidel test

Answer 13

Used to assess anterior chamber leakage in the cornea

• instil large amount of stain by profusely wetting strip
• examine eye for small stream of fluid leaking from the globe: it will fluoresce blue/green in contrast to orange appearance of fluorescein stain

Question 14

Ear exam Hx

Answer 14

Outer ear
- itch, erythema, discharge
- pain or irritation (esp kids)
- when, severity, frequency

Middle ear:
- infection, pain, purulent discharge
- deafness

Inner ear:
- deafness
- balance probs inc vertigo
- tinnitus
- drugs

Risk factors:
- Hx of URTI
- exposure to passive smoke/er
- swimming
- dusty environment

PHx:
- ? First presentation
- prev acute otitis media - w/without perforation
- chronic ear discharge
- operations: what, when, effectiveness
- hearing loss/tests
- current ENT specialist/audiologist

Question 15

Ear Exam tests

Answer 15

• inspection
• palpation
• otoscopy
• tuning fork assessments
• test hearing
• peripheral vestibular exam

Some cases;
- lower cranial nerve assessment also indicated

Question 16

Ear exam physical & otoscopy

Answer 16

Phys exam:
- note: skin, shape, size, & deformity of pinna (swelling or nodules)
- gently pull the pinna back to assess for pain
- external inflammation or signs of discharge
- palpate mastoid process; tenderness, heat, swelling
- palpate occiput, around the ears, & neck bilaterally to check for lymph gland swelling

Otoscopy:
- gently advance largest speculum into ear canal
- check: discharge, wax, swelling, erythema or foreign bodies
- examine: tympanic membrane- light reflection off pearly grey translucent membrane
- IF erythematous = inflammation
- look for perforation or scarring
- note: fluid behind ear drum suggest otitis media w effusion

Ear canal straightening:
<3yo = earlobe down & out
>3yo = pinna up & back

Insertion direction:
<3yo = upward
>3yo = down & forward

Question 17

Ear exam Gross hearing ass

Answer 17

Test:
- explain yr going to say a number/word & U’d like them to repeat it back (prevent lip reading)
- from behind, w other ear muffled, whisper a word/number ~ 15cm away from Pt’s ear
- if correct: test again at arm’s length
- repeat on other side
- document findings

Question 18

Ear exam Vestibular tests

Answer 18

Test for nystagmus:
- Pt in seated position, use finger to test for nystagmus as Pt follows yr hand across their visual field

Conduct Dix-Hallpike

Unterberger’s test
- march on the spot w eyes closed for 50 steps
Note: Pt will rotate to the side of damaged labyrinth if present

Fistula test:
- repeatedly compress the tragus against tot external auditory meatus
Note: if this triggers sense of imbalance/vertigo w nystagmus - abnormal communication between middle ear & vestibular apparatus (eg; erosions due to cholesteatoma)

Additional:
- cranial nerve exam
- audiometry

Question 19

Ear foreign body retrieval

Answer 19

Ind:
- well visualised foreign body in external auditory canal
- & uncomplicated first attempt is probable

Contraindications:
- presence of tympanic membrane perforation
- foreign body in contact w tympanic membrane
- incomplete visualisation of auditory canal
- case where button batteries/hearing aid batteries are involved!

Procedure:
- position Pt comfortably
- Repeat otoscopy to confirm location & depth
- move otoscope lens to one side, carefully introduce forceps through the lens
- advance forceps gently until U can grasp FB
- gently withdraw FB from auditory canal
- re-examine to confirm complete removal & no trauma caused

Note:
- additional management may include irrigation - see Clin guidelines
- important to know when something is irretrievable or when complications occur
- pivotal signs: bleeding, oedema, or increasing pain
- if present: STOP & consider referring on
- repeated attempts can lead to infection, perforation, or further complications

Question 20

Nose exam elements

Answer 20

Nasal obstruction:
- persistent unilateral obstruction is often due to deviated septum (congenital/trauma)
- bilateral obstruction may be rhinitis, w/without sinusitis or polyps

Nasal discharge:
- watery: suggest allergic or vasomotor rhinitis
- purulent: bacterial infection
- Beware; head injured Pt’s, may be CSF leakage

Epistaxis:
- anterior or posterior
- causes: infection, trauma, allergy, neoplasms, sneezing, heat
- check anticoagulant use!

Sneezing:
- protective mechanism to foreign body
- irritants/allergens most common cause

Nasal deformity:
- if trauma related: swelling & contusion can last for ~ 2/52
- if there has been a bony injury - displacement can be permanent

Pain:
- rare, aside from trauma/sinusitis
- external discomfort is excessive wiping

Hx:
- recent trauma
- regarding URTI
- allergies that result in nasal symptoms
- full drug Hx: prescribed, OTC & recreational use
- nasal bleeding/congestion
- nasal surgery/polyps
- skin cancers

Question 21

Nose Examination

Answer 21

Inspect:
- external surface & appearance - evidence of skin Dx or deformity
- stand behind Pt & look down nose - any deformity
- ask Pt to tilt head back & gently elevate the tip of their nose w thumb

Otoscopy:
- any deviation/perforation of anterior septum
- colour of mucosa
- any: swelling, bleeding, exudate
- any: polyps (most often seen near the middle meatus)
- foreign body
- presence & nature of any discharge
- size & colour of turbinates

Palpate:
- nasal bones to distinguish bone from cartilage deformity
- place metal spatula under nose & look for equal condensation marks OR lightly occlude each nostril & ask Pt to sniff
- Hx of anosmia: test CN I by asking Pt to close eyes & identify familiar smell

Question 22

Neck exam General Insp

Answer 22

Observe:
- does Pt look: well, fever, cachexia, lethargy
- any obvious masses or lymphadenopathy
- surgical scars (tracheostomy)
- overlying skin: rash or erythema
- goiter
- ask Pt to swallow & then stick out tongue, while watching their thyroid: thryoglossal cyst moves on tongue protrusion

Question 23

Neck exam Palpitation

Answer 23

Palpation:
- <1 cm is often normal shape

Consistency:
- hard - typical of CA
- rubbery - lymphoma
- tethering to other structures - suggests CA

From behind Pt:
1- Anterior lymph nodes & thyroid process
- start at submental nodes (anterior-inferior to mandible)
- submandibular
- juglodigastric (tonsillar)
- down anterior cervical chain
- Stop @ Thyroid gland: note; size, consistency & any abnormalities
- get Pt to swallow & poke out tongue
- complete anterior cervical chain

2- Posterior lymph nodes:
- posterior cervical chain from bottom upward to mastoid process
- occipital
- post-auricular
- pre-auricular

From front of Pt:
- supraclavicular lymph node examined by placing fingers in supraclavicular fossae
- palpate each carotid artery in turn

Special notes:
- palpate w finger tips
- palpate as tho giving a massage - esp anterior & posterior cervical chains (while hand around Pt’s neck)
- roll the lymph nodes over deep muscle/bone to properly palpate

Percussion:
- for retrosternal goitre

Auscultate:
- thyroid bruits
- carotid bruits

Question 24

Mouth exam

Answer 24

Anterior-posterior approach:
- remove dentures
- examine lips: symmetry, colour, presentation, pigmentation, ulcers, cracks (esp Cnrs)
- ask: open & close mouth (check jaw mobility & occlusion of teeth)
- palpate: temporal mandibular joint (TMJ) for; crepitus, tenderness, referred pain from ear (open & closed)
- inspect: anterior-inferior area between lower lip & gum, buccal mucosa, roof, palate, pharynx, & Stensen’s ducts (using tongue depressor)
- note: mucosal colour & assess hydration
- ask: stick tongue out - look for deviation, mucosal change/fasciculation
- ask: deviate tongue to each side to visually assess
- look: hard palate - note any cleft, abnormally arched or telangiectasia (spider veins)
- look: oropharynx - ask Pt to say AHH to get better view of uvula, tonsils & posterior throat (also tests CN X)
- tonsils: note symmetry, size, colour, discharge or membrane
- touch: posterior pharyngeal wall gently to illicit gag reflex & check for symmetry of soft palate (tests CN IX & X)
- any lesions: put on gloves & palpate w one hand outside & fingers inside; use SPACESPIT

Parotid gland abnormal/enlarged:
- examine facial nerve to check if deep lobe is displaced medically

• check: cervical lymph nodes
• note: any odours

Question 25

Dental exam

Answer 25

Adult:
32 permanent teeth: incisors, canines, premolars & molars

Common complaints:
- trauma - broken/dislodged
- toothache
- dental abscess

Hx:
- complaint
- PQRST
- self Rx & effectiveness
- associated symptoms: bleeding, referred pain, inflammation, infection, odour
- systemic issues
- last dental visit: Rx program/surgeries
- braces/plates/implants
- general dental hygiene

Exam:
- gross assess noting: gen hygiene, condition, caries & missing teeth
- look for: bleeding, plaque, obvious holes
- smell for odour
- inspect gums: inflammation, ulcers, trauma
- assess bite
- look for jewellery
- investigate: swellings; noting size, bleeding, pus & systemic signs of infection
- palpate teeth: tenderness, integrity, position & stability
- document

Question 26

Dental Abscess management

Answer 26

Periapical abscess: end of tooth
Periodontal abscess: in the gum

Symptoms:
- intense, throbbing pain in affected tooth or gum
- may come on suddenly & gets gradually worse
- radiation: ear, jaw, neck on affected side
- pain worsens when lying flat, disturbing sleep

Findings:
- redness & swelling of face
- tender, discoloured &/or loose tooth
- shiny, red, swollen gum
- sensitivity to heat & cold
- halitosis or unpleasant taste
- earache
- fever

Assessment:
- detailed Hx
- standard clinical Obs
- diabetic: BGL (& ketones)
- inspect oral cavity: swelling - may be a collection of pus
- inspect & palpate face & lymph nodes
- check Pt ability to open mouth, swallow, breathe without stridor

Intervention:
- dental referral req!
- No POABs for localised dental abscess
- simple analgesia
- direct Pt to have warm saline mouth rinses until seen by dentist

Question 27

Pharyngeal abscess management

Answer 27

Pharyngeal abscess: collection of pus/WBCs in pharynx

Findings:
- pain in neck/jaw
- mass or tender tissue in affected area
- muffled voice and tendency to drool
- difficulty breathing (& poss swallowing)
- headache
- fever
- sore throat

Treatment:
- analgesia: simple, step wise
- POABs:
- O2 therapy of SOB
- IV fluids - where hard to swallow
- REFER!!

Complications:
- if untreated, will spread to other teeth/gum regions
- can form cyst in jaw
- eventually this process will create a tunnel/fistula & scar tissue
- can lead to systemic infection

Airway Compromise:
- specialist assistance immediately: ETT or tracheostomy req

Adverse outcomes if not Rx’d promptly:
- paralysis of vocal cords; bleeding in the ear, mouth or nose; & rupture of carotid artery.

Advice:
- better oral hygiene, healthy eating & reg check ups w dentist (dental) or Dr (pharyngeal)