Module 3: HEENT Flashcards
What is the purpose of the confrontation test?
It is a gross measure of peripheral vision. It works by comparing the peripheral vision of the patient with that of the examiner by estimating the angle between the axis of the eye looking directly at the examiner and the peripheral axis where the object is first seen. (It assumes that the peripheral vision of the examiner is WNL.)
How do you perform the confrontation test?
- Stand 2 ft away at eye level with the patient.
- Pt covers one eye while the examiner covers their own opposite eye.
- Patient looks directly into the examiner’s eye while the examiner advances an object or finger from the periphery from a superior, inferior, nasal, and temporal direction.
- The patient indicates at which point the object or finger is seen.
Normal findings of the confrontation test?
The patient should see the finger/object of examiner at approx. the same time that it’s seen by examiner.
Approximates fields describe an angle of:
-50 degrees superiorly
-70 degrees inferiorly
-60 degrees nasally
-90 degrees temporally
What is a Tangent screen?
It provides a more precise measure of peripheral vision than the confrontation test. A patient is asked to stare at the center of a screen while the examiner maps the patient’s peripheral vision by noting the patient’s response to objects placed onto the screen.
What is the purpose of the cover test?
It detects phoria, a deviated alignment secondary to muscle weakness that may not be readily apparent on simple observation. This test works by disrupting the fusion reflex that normally keeps eyes parallel.
Example 1 of a cover test:
The patient is asked to gaze straight ahead. Both eyes gazed parallel until the examiner covers the left eye. When the left eye is covered, the right eye drifts medially. When the cover was removed, the right eye jerked back into parallel position. Why?
The right eye is weaker. The fusion reflex was disrupted.
Example 2 of a cover test:
A patient was asked to gaze straight ahead. Both eyes gazed parallel until the examiner covered the left eye. When the left eye was covered, the right eye continued to gaze straight ahead. When the cover was removed, the left eye jerked back into parallel position. Why? The left eye is weaker.
So what does the cover test do?
It detects small degrees of deviated alignment by interrupting the fusion reflex that maintains eyes in parallel alignment. During the test, the eye with weak muscles will drift when an eye is covered and will jerk back into alignment when uncovered.
What is it called when a weakness in eye muscles that occurs only when the fusion reflex is blocked?
A phoria (ex. strabismus and tropia are terms that referred to a constant misalignment of the eyes. Esotropia = turn inward. Exotropia = turn outward.
What is another name for the corneal light reflex test?
Hirscherg Test
What is the purpose of the corneal light reflex test?
It is used to detect strabismus. Especially important in children.
How do you perform the corneal light reflex test?
The examiner shines a light toward the patient’s eyes and observes the spot on the cornea where the light is reflected.
What is considered a normal finding for the corneal light reflex test?
In a patient with normal alignment, the light will be reflected at the same place on both corneas or very slightly medially on both pupils. If it is reflected at different places, this will indicate strabismus.
What does the Snellen chart measure?
Distance vision.
What is the procedure for testing visual acuity using the Snellen chart?
- Stand 20 ft away from chart. Should be eye level and a well lighted area.
- PRESCRIPTION Glasses/contacts should be worn. NOT READING GLASSES.
- Testing should occur with right eye covered, left eye covered , then both uncovered.
- The patient should read the smallest line possible without hesitancy, squinting, or leaning forward.
What is visual acuity in a child?
Visual acuity is usually less. A reading of 20/50 may be normal for a child of 3; 20/40 may be normal for child of 4; 20/30 may be normal for a child of 5. The upper limits of normal vary +/- 10 feet among different sources.
When is it important to test near vision?
In adults >40 years.
How do you test near vision?
A Rosenbaum chart is used. With one eye covered, the patient reads the smaller line of letters on a card held approximately 14 inches from the eye. Can also use a Jaeger Near Point Card.
What is normal near vision?
14/14
What does a near vision test screen for?
Presbyopia, a decrease in accommodation that occurs with aging.
What does the diagnostic positions test measure?
It is used to identify extraocular muscle dysfunction that may result from paralysis or cranial nerve dysfunction. It is used to identify nystagmus that may occur with certain conditions such as disease invoking the semicircular canals, multiple sclerosis, etc.
How do you conduct a positions test?
Examiner has the patient follow an object (held at a distance of +/- 12 inches) with the eyes while keeping the head still. The object is moved through the 6 cardinal fields of gaze while the patient tracks movement of the object with the eyes.
Diagnostic Positions Test interpretation:
Eye movements are coordinated by cranial nerves III, IV, VI and by the extra ocular muscles. A normal response is parallel tracking of all movements.
What does Nystagmus indicate?
May indicate an inner ear or neurological problem. May also indicate inebriation. Mild nystagmus at extreme lateral gaze is a normal finding. See chart on slide 44 to determine which muscle/cranial nerve is not functioning properly.
What is another name for the diagnostic positions test?
The test of extra ocular movement or EOMS.
What does the accommodation test measure?
Pupillary constriction and convergence of the aces of the eyes that normally occurs when eyes adjust for near vision.
How do you perform an accommodation test?
Have the patient focus on a distant object (this causes the pupils to dilate), then ask the patient to shift the gaze to the examiner’s finger which is held about 3 in from the patient’s nose. A normal response is constriction of the pupils and convergence of the eye’s axes.
How to interpret an accommodation test:
An absence of either constriction or convergence or an asymmetric response is abnormal. (Ex. CN III damage will result in pupil dilation and lateral deviation of the eye.)
What is the purpose of the Ishihara Test?
Tests color vision
How do you perform the Ishihara test?
With one eye covered, the patient is asked to identify numbers or objects on a slide within a time frame of +/- 3 seconds. Patients who have various types of color vision will not be able to identify colored numbers or objects within patterns of dots.
What is the purpose of the Amsler Grid?
Used to test for defects in the central visual field. Such defects are typical of macular degeneration.
How do you test central vision with the Amsler Grid?
The Amsler grid is held at +/- 14 inches away. (Reading glasses may be worn.) With one eye covered, the patient stares at the central dot on the grid. Repeat with the other eye.
What are some abnormalities with the Amsler Grid?
Abnormalities indicated by wavy, crooked, or bent lines. Variances in box shape or size. Missing or discolored lines.
Patient reports that he is beginning to have difficulty seeing road signs until he gets close to them. What test would you use?
A test of visual acuity using the Snellen chart will determine if distance vision is a problem.
You notice that your patient didn’t flinch as an object fell within inches of his left temple. It was only after it crashed that it caught your patient’s attention. You suspect a deficit in his peripheral vision. How would you test his visual fields?
In order to screen for approximate peripheral vision, you would use the confrontation test. For more accurate testing, a tangent screen would be used.
A mother states “I think my son has lazy eye.” How would you test for this?
The cover test is designed to detect “lazy eye” by disrupting the fusion reflex.
What are the tests of Visual Acuity?
Snellen Chart = Distance vision
Rosenbaum or Jaeger Cards = Near vision
What helps tests peripheral vision?
Confrontation test and Tangent screen
What helps tests Central vision?
Amsler grid
What are tests of EOM function?
Corneal light reflex (Hirshberg test), cover test, diagnostic positions test.
Which tests check for color blindness?
Ishihara Test
What are some common or concerning symptoms with the head?
Headache, Head Injury
What are some common or concerning symptoms with the eyes?
Visual disturbances, spots (scotomas), flashing lights, use of corrective lenses, pain, redness, excessive tearing, double vision (diplopia)
What are some common or concerning symptoms with the ears?
Hearing loss, ringing (tinnitus), vertigo, pain, discharge
What are some common or concerning symptoms with the nose?
Drainage (rhinorrhea), congestion, sneezing, nose bleeds (epistaxis)
What are some common or concerning symptoms with the oropharynx?
Sore throat, gum bleeding, hoarseness,
What are some common or concerning symptoms with the neck?
Swollen glands, goiter
When you assess the head, what do you want to inspect and palpate?
Inspect hair distribution, quantity, scalp-scaling, nevi, skull-size, contour, face-expression, contours, skin-color, pigmentation, hair distribution, lesions
Palpate hair texture, skull for lumps, face-sinuses, skin-texture, temperature
What do you want to inspect the eyes for?
Position and alignment, eyebrows-quantity, distribution, eyelids-width of palpebral fissures, edema, color, lesions, condition and direction of lashes, adequacy of closed eyelids, lacrimal apparatus - lacrimal glad and sac for swelling, conjunctiva and sclera-color, vascular pattern, cornea and lens - opacities, iris-markings clearly defined, pupil size, shape, symmetry, reaction to light (direct and consensual)
Tips for using Ophthalmoscope
- Darken the room and have the patient look off in the distance
- Switch the ophthalmoscope light and turn the lens disc to the large round beam of white light
- Turn lens disc to the 0 diopter
- Hold the ophthalmoscope in your right hand to examine the patient’s right eye with your right eye; hold it in your left hand to examine the patient’s left eye with your left eye
- Stand directly in front of the patient, 15 inches away, and start at an angle of 15 degrees lateral to the patient’s line of vision
- Shine the beam of light onto the pupil and look for an orange glow; this is the red reflex
- Follow the red reflex and move inward towards the nasal aspect of the visual field
What do you want to inspect and palpate the ears for?
Inspect the auricle for redness, lesions, ear canal for discharge or foreign bodies, redness, swelling, tympanic membrane for color and contour, palpate the auricle for lumps or tenderness.
Testing Auditory acuity:
Test one ear at a time!
How to perform the Whisper test:
Standing 1-2 feet behind patient, softy say a word or phrase.
Which test helps determine air and bone conduction?
Weber and Rinne
What is the Weber test?
Lateralization of sound to impaired ear; suspect unilateral conductive hearing loss
What is the Rinne test?
Compare time of air vs. bone conduction
If bone conduction is equal or greater than air conduction, then suspect conductive loss.
What to inspect in the nose and sinuses?
Inspection- Anterior and inferior surface – asymmetry or deformity
Inside of nose- Mucosa – color, swelling, bleeding, exudate, ulcers, or polyps
Septum – deviation, inflammation, or perforation
Turbinates – use otoscope to view middle and inferior turbinates
Palpation of sinuses – frontal and maxillary
When using the otoscope to inspect inside the nose, which structure is not visible?
Superior turbinate - By directing the speculum posteriorly, you should be able to see the inferior and middle turbinates.
What to look for when assessing the mouth and pharynx?
Lips-Note color, moisture, lumps, ulcers, cracking,or scaliness
Oral mucosa-Note color, ulcers, and nodules
Gums and teeth-Note color, presence, and position of teeth
Roof of mouth-Note color
Tongue and floor of mouth-Note color and texture, ulcers, nodules
Pharynx: soft palate, anterior and posterior pillars, uvula, tonsils, and pharynx
Note color, symmetry, presence of exudate, swelling, ulceration, or tonsillar enlargement
Mouth and Pharynx inspection and palpation continued:
Inspection
Symmetry, masses, scars, enlarged glands or lymph nodes
Trachea – position, alignment
Thyroid gland - symmetry
Palpation
Lymph nodes (size, shape, delimitation, mobility, consistency, tenderness)
Preauricular, posterior auricular, occipital, tonsillar, submandibular, submental, superficial cervical, posterior cervical, deep cervical chain, supraclavicular
How do you assess the thyroid gland?
- Flex neck slightly forward
- Place fingers of both hands with index fingers just below the cricoid cartilage
- Ask patient to swallow; feel for the thyroid isthmus rising up under your finger pads (not always palpable)
- Displace trachea to the right and palpate laterally for the right lobe of the thyroid; repeat on the left side
- Note the size, shape, and consistency
- Identify any nodules or tenderness
- If enlarged, listen over lateral lobes to detect a bruit
When palpating the thyroid, which of the following is true?
A. Flex the neck slightly backward
B. Place the index fingers just above the cricoid cartilage
C. The thyroid isthmus may not be palpable
D. A bruit auscultated over the lateral lobe is expected
C.The thyroid isthmus may not be palpable
Ask the patient to swallow and feel for the thyroid isthmus rising up under your finger pads (not always palpable)
Flex the neck slightly forward
Place fingers of both hands with index fingers just below the cricoid cartilage
If enlarged, listen over lateral lobes to detect a bruit
Sinuses are normally filled with what?
AIR! If you illuminate the hard palate and it’s red, this means there is AIR in the sinuses. If it is not red, its fluid/pus filled!
Allergic Rhinitis differs from rhinitis:
Turbinates are boggy pale blue
Who will you see chronic rhinitis in?
Smokers!
Rhinitis is what?
Inflammation of nose! Redness and edema!
Nasal polyps cause what?
Happen between middle turbinates. Interferes with smell and taste!
What is the easiest way to palpate the submandibular gland on a patient?
From behind.
How do you palpate the carotid?
One at a time! Also, Listen for bruits and have patient hold his breath!
What’s the best way to find the external jugular?
Have the patient valsalva down which will I nhibit venous return!
Why should you ask the patient to smile?
By asking the patient to smile, you can look for facial weakness, which is one of the 5 cardinal symptoms of ear disease.
How do you pull the pinna wih an adult?
Up, outward, and back
How do you pull the pinna of an ear in a child?
Pull the pinna down and back.
What does a normal tympanic membrane look like?
You should see the handle of the malleus, the light reflex, pars tensa and paras flaccidity.
When will the lymph nodes be palpable?
May not be palpable until a toddler.
Is nuchal rigidity a good sign of meningitis in an infant?
No, not reliable until after 2.
When do the anterior/posterior fontanels close?
Anterior measures 4-6 cm at birth and close between 4-26 months of age. Posterior measures 1-2 cm at birth and close by 2 months.
Red Light Reflex
Absence may indicate congenital glaucoma, cataract, retinal detachment, or retinoblastoma.
Strabismus
If present after 10 days of age, may indicate poor vision or CNS disease.
When do teeth first show?
Around 6 mo. then usually a tooth each month until 2 years, 2 mo.
When is tonsil peak growth?
May be enlarged in healthy child; peak growth of tonsillar tissue between 8-16 years.
What is one of the most common symptoms in clinical practice?
Headache.
What are the most important attributes of a headache?
Severity and chronological pattern.
Where do tension headache arise?
Temporal areas. Cluster headaches may be retro-orbital
If a headache is severe and sudden what would anticipate?
subarachnoid hemorrhage or meningitis.
New and persisting progressively severe headaches would raise concern for?
TUMAH, abscess, or mass lesion
N/V are common with migraines but could also occur in what?
Brain TUMAHS and subarachnoid hemorrhage
What is hyperopia?
Farsightedness
What is myopia?
Nearsightedness
What is presbyopia
Agining vision
Is sudden bilateral vision loss common?
NO it is RARE.
What is diplopia
Double vision, can be vertical or horizontal. Can be caused by lesions on the brainstem or cerebellum or from weakness or paralysis of one or more extra ocular muscles.
Hearing Loss…
May be congenital from single gene mutation.
What are the two types of hearing loss?
Conductive loss, which results from problems in the external or middle ear and Sensorineural loss, from problems in the inner ear, the cochlear nerve, or its central connections in the brain. Ask patient if they have special difficulty understanding people as they talk or if noisy environments makes it work.
What medications affect hearing?
Aminoglycosides, aspirin, NSAIDS, quinine, furosemide, and others.
What is tinnitus
It is a perceived sound that has no external stimulus-commonly a musical ringing or a rushing or roaring noise. It increases in frequency with age. When associated with hearing loss and vertigo, it suggests Meniere’s Dx.
What is vertigo?
Refers to the perception that the patient or the environment is rotating or spinning. Problem in labyrinth of inner ear, peripheral lesions of CN VIII, or lesions in its central pathways or nuclei in brain.
What does excessive use of decongestants cause?
Rhinitis medicamentosa
What causes bleeding gums?
Gingivitis
What two salivary glands lie near the mandible?
Parotid gland and submandibular gland.
What is the term for excessive facial hair?
Hirsutism.
