Head, Neck, Airway Assessment Flashcards
What items do you exam in the oral cavity
- Lips
- Oral mucosa
- Gingiva
- Teeth
- Hard palate
- Tongue
- Soft palate
What nerves do you test in an oral cavity exam
Hypoglossal nerve (CN XII) - symmetry of tongue protrusion
Vagus nerve (CN X) - symmetry of uvula
What are the most common oral and throat concerning symptoms
- Sore throat
- Gum swelling/bleeding
- Hoarseness
- Malodorous breath
Pharyngitis
Associated with an acute URI
What commonly causes bleeding gums?
Brushing teeth or Gingivitis .
- ask about local lesions and any tendency to bleed or bruise elsewhere
- What medications are they taking
What can cause Hoarseness
- Disease of the larynx to extralaryngeal lesions that press on the laryngeal nerves
- Environment allergies/inhalation of irritants, Acid reflux, Smoking, Alcohol use, Overuse, Weight loss, Hemoptysis
- Acute: overuse, viral laryngitis, poss. trauma
- Chronic (>2wks): reflux, vocal cord nodules, hypothyroidism, head & neck cancers (thyroid masses)
- Nerve related issues: neurologic disorders like Parkinson disease, ALS, & MG
Common oral causes for Halitosis
The unpleasant or offensive odor emanating from the breath.
- poor oral hygiene
- tobacco smoking
- plaque retention on teeth
- mouth appliances
Systemic causes of Halitosis
Common:
- Sinusitis, tonsillitis, pharyngitis, foreign bodies, neoplasms, abscesses, & bronchiectasis
Uncommon:
- GERD, cirrhosis, DM, impaired fat digestion, inborn errors of metabolism (trimethylaminuria)
Name 3 factors out of 7 than can affect maskability
- Fatty airway/short thick neck
- Beard/facial hair
- BMI
- Sleep apnea
- Stiff lungs
- No teeth (edentulous)
- Blocking the mask seal: high nose, facial tumor, injury, burns)
What are the structures you look for in a Mallampati (not the score)
- Soft palate
- Anterior tonsillar pillar
- Posterior tonsillar pillar
- Uvula
- Fauces
What is a Class 1 Mallampati score
Visualization of soft palate, fauces, uvula, pillars
What is a Class 2 Mallampati score
Visualization of soft palate, fauces, portion of uvula (most of it)
What is a Class 3 Mallampati score
Visualization of soft palate, base of uvula
What is a Class 4 Mallampati score
Visualization of hard palate only
Thyromental distance is used to assess what?
The pliable compartment above the larynx that can fit the tongue when swept during intubation.
- short distance or noncompressible tissue = likely a difficult intubation
What does the 3-3-2 method measure?
- 3 fingertips between incisors
- 3 fingertips between jawline (mentum) & Hyoid bone (TMD)
- 2 fingertips between hyoid and thyroid notch (Adam’s apple)
Absence of one or more raises the likelihood of an “anterior” larynx
Name 3 out of the 7 Intubation Warning signs
- Long incisors
- < 3 cm between incisors
- High arched or narrow palate (teeth closer together)
- Overbite or buck teeth
- Snoring/OSA/Pregnancy
- TMD < 3 finger breadths
- ROM of the neck - can’t extend or flex
Which lymph nodes drain portions of the mouth, throat and face?
- Tonsillar nodes
- Submandibular nodes
- Submental nodes
During your comprehensive exam what is one clinical symptom that should automatically prompt you to check all lymph nodes?
Hemoptysis
- assess bilateral lymph nodes at the same time to compare
How can you differentiate a muscle or artery from a lymph node?
You should be able to roll a lymph node in 2 directions
- up & down
- side to side
Your patient is demonstrating generalized lymphadenopathy, what differential diagnoses should be applied (5)
- HIV or AIDs
- Infectious mononucleosis
- Lymphoma
- Leukemia
- Sarcoidosis
Enlarged supraclavicular lymph nodes especially on the left or commonly called _________ suggest what diagnoses?
- Virchow’s node
Diagnoses: - Metastasis from a thoracic or an abdominal malignancy
Tender nodes suggest what?
Hard or fixed nodes suggest what?
Inflammation
Malignancy
Your patient is undergoing surgery for a concerning symptom in the neck, what should your emergence from anesthesia include ?
Have the patient fully awake and negative pressure breathing before you extubate
Key components of Head and Neck exam include
- Examine the hair & scalp
- Examine the skull
- Inspect the skin on the head & face
- Palpate cervical lymph nodes
- Examine the trachea
- Examine thyroid gland
You palpate the thyroid and you understand if the gland is soft it represents _______, if it is tender ________, and if it is firm ________.
Soft = Graves disease
Tender = Thyroiditis
Firm = Malignancy
As you auscultate the trachea of your patient with Graves disease what do you anticipate ?
Continuous bruits
- also seen in patients with MT goiter
In an eye exam the visual field extends farthest in what quadrant/side ?
Temporal side
- normally limited by the brows above, the cheeks below, and the nose medially
Due to lack of retinal receptors at the optic disc where do you anticipate the patients blind spot to be in each eye?
15 degrees temporal to the line of gaze
What is it called when two visual fields overlap?
Area of binocular vision
- this phenomenon allows for stereopsis (3D depth perception)
What are the initial sensory pathways for vision?
- Retina
- Optic n. (CNII)
- Optic tract (diverges in the midbrain)
What is pupillary accommodation
- An increased convexity of the lenses caused by contraction of the ciliary muscles (behind the iris & is not visible to the examiner
What are the autonomic pupil reactions? Parasympathetic vs. Sympathetic
PSNS = pupillary constriction SNS = pupillary dilation & raising of upper eyelid (Muller's muscle)
The extraocular muscles are innervated by three cranial nerves:
- Abducens (VI) - innervates the lateral rectus m.
- Trochlear (IV) - supplies the superior oblique m.
- Oculomotor (III) - supplies all the rest of the extraocular m.
Difficulty visualizing close objects suggests?
Hyperopia (farsightedness) or presbyopia (aging vision)
Difficulty visualizing distant objects suggests?
Myopia (nearsightedness)
Vision loss that is sudden, unilateral & painless could suggest what? (5)
- Vitreous hemorrhage from Diabetes or trauma
- Macular degeneration
- Retinal detachment
- Retinal vein occlusion
- Central retinal artery occlusion (cholesterol or clot)
What are causes of painful vision loss?
Usually in the cornea & anterior chamber:
- Corneal ulcer
- Uveitis
- Traumatic hyphema (presence of blood within the aqueous fluid of the anterior chamber)
- Acute angle closure glaucoma
- Optic neuritis from MS (requires immediate referral)
Bilateral and sudden vision loss can result from?
Painless
- Vascular etiologies
- Stroke or non-physiologic causes
Painful
- Intoxication
- Trauma
- Chemical or radiation exposures
Bilateral and gradual vision loss can result from?
- Cataracts
- Slow central loss = Macular degeneration
- Peripheral loss = advanced open angle glaucoma
What CN palsy will display horizontal diplopia
CN III - oculomotor
or
CN VI - abducens
What CN palsy will display vertical diplopia
CN III - oculomotor
or
CN IV - trochlear
If your patient has unilateral diplopia the problem is associated with?
- The ocular surface, cornea, lens, or macula
not in the brain
What is the visual acuity test?
Snellen eye chart
Simple anisocoria?
A difference in pupillary diameter >0.4 mm without a known pathologic cause
- considered benign if it is equal in dim & bright light
- & there is a brisk pupillary constriction to light
Lagophthalmos
Failure of the eyelids to close
- From neuromuscular palsy, trauma, & thyroid ds.
- will need lubricant before tapping down
When might you see sustained nystagmus?
- Ketamine administration
- Congenital disorders
- Labyrinthitis (inflammation of the inner ear)
- Cerebellar disorders
- Drug toxicity
Contraindications for mydriatic drops, name 3
- Head injury
- Coma
- Suspicion of narrow-angle glaucoma
Your patient presents with Papilledema, increased IOP, emergency what are some anesthetic considerations?
- NO succ., or ketamine
- No trendelenburg
- Soften the larynx w/ lidocaine w/ the LTA kit
- Minimize intubating time (best personnel, & glidescope)
- IV lidocaine or narcotics to blunt SNS
What is Larson’s point?
Area around the mastoid process you can press on to send signal to the vagus n. and prevent laryngospasm
What is the conductive hearing pathway
External ear through the middle ear (conductive phase)
What is the sensorineural hearing pathway?
Involves the cochlea & the cochlear branch of CN VIII
Air conduction (AC)
Sound waves travel through the air & are transmitted from the external & middle ear to the cochlea
Bone conduction (BC)
Used for testing purposes
Bypasses the external & middle ear
A vibrating tuning fork, placed on the head, sets the bone of the skull into vibration & stimulates the cochlea directly
In an individual with normal hearing which is more sensitive air conduction (AC) or bone conduction (BC)
Air conduction is more sensitive than bone conduction
Conductive hearing loss (external and middle ear) causes:
External:
- cerumen impaction
- infection (otitis externa)
- Trauma
- Squamous cell carcinoma
- Benign bony growths (exostosis, osteoma)
Middle:
- Otitis media
- Congenital conditions
- Otosclerosis
- Tympanosclerosis
- Tumors
- Tympanic membrane perforation
Sensorineural hearing loss (inner ear) causes:
- Congenital & hereditary conditions
- Presbycusis (age related hearing loss)
- Viral infections: rubella, cytomegalovirus
- Meniere disease
- Noise exposure
- Ototoxic drugs
- Acoustic neuromas (hearing & balance issues)
How do you communicate with someone who has conductive loss compared to sensorineural loss?
Conductive = talking louder helps
Sensorineural = talking louder is worse and patient only hears mumbling
What are the 4 paired air-filled cavities:
- Maxillary sinus
- Ethmoid sinus
- Frontal sinus
- Sphenoid sinus
Which sinuses are accessible during the clinical exam?
Frontal and maxillary sinuses
Which medications can cause permanent hearing loss?
Aminoglycosides (e.g., gentamicin)
&
Chemotherapeutic agents (e.g., cisplatin & carboplatin)
Inner hearing loss
Temporary damage to hearing may be caused by?
- Aspirin
- Nonsteroidal anti-inflammatory agents
- Quinine
- Loop diuretics (e.g., furosemide)
Conductive hearing loss
Diagnosis for external canal pain
Otitis externa
Diagnosis for middle ear pain
Otitis media
- may be referred from other structures (mouth, throat, or neck)
- perforation = yellow or green discharge
When should you suspect your patient has Meniere disease?
Tinnitus (ringing in the ear) assoc. w/ fluctuating hearing loss and vertigo
Vertigo
Sensation of true rotational movement of the patient or the surroundings.
- Problem in the labyrinths of the inner ear
Or
- Peripheral lesions of CN VIII
- Ataxia, diplopia, & dysarthria
Presyncope
Feeling lightheaded, weak in the legs, or about to faint
- not due to the ear
- Possibly from:
- Arrhythmia, orthostatic hypotension, or vasovagal stimulation
What is Rhinorrhea and the assoc. causes ?
Drainage from the nose
- Viral infections
- Allergic rhinitis (itchching)
- Vasomotor rhinitis
- Drug induced rhinitis: overuse of OTC decongestants; cocaine
How do you determine if the patient has acute bacterial sinusitis (rhinosinusitis)
Considered unlikely until viral URI symptoms persist more than 7 days; both purulent drainage & facial pain should be present for diagnosis
- nasal obstruction & smell disorder
How do you test auditory acuity or gross hearing
The whispered voice test
- detects significant hearing loss > than 30 dB
- Have the patient occlude one ear
- Stand arms length behind the patient & whisper a combo of 3 letters and numbers
- formal hearing test is still the reference standard
What is the Weber test used for ?
Test for lateralization.
- set the tuning fork into light vibration & place on top of the patients head
- Can they hear it on one side or both?
Normal = vibration is heard in the middle or equally in both ears
Patients w/ bilateral conductive or sensorineural deficits will not lateralize
What is the Rinne test used for?
Compares air conduction and bone conduction.
- lightly vibrating tuning fork is placed on the mastoid bone
- when the patient can no longer hear the sound , quickly place the prongs of the fork close to the ear canal
Normal= sound is heard longer through air than bone (AC > BC)
Conductive hearing loss = if sound is = or BC > AC
Sensorineural hearing loss = will test normal
Clinical presentations of viral rhinitis
The mucosa is reddened and swollen
Clinical presentations of allergic rhinitis
The mucosa is pale, blushish, or red
Will complain of itching
Causes of septal perforation/ulcers
- Trauma
- Surgery
- Intranasal cocaine or meth use
Describe nasal polyps and the concern for anesthesia.
Pale saclike growths of inflamed tissue
- Can obstruct the air passage
- seen in allergic rhinitis, aspirin sensitivity, asthma, chronic sinus infections, & cystic fibrosis
