Nose, Mouth, Throat, Eye and Ear Assessment

Question 1

Anatomy of the nose

Answer 1

• First part of respiratory system
• Warms, moisten air
• Sensory for smell
• Ridge; external
• Tip
• Opening are nares
• Upper 1/3 of nose is bone and rest is cartilage
• Inside nasal cavity is lined with ciliated mucus membrane; helps filtered inhaled air
• Nasal mucosa is a lot darker red than oral; more vascular, important for inhaling it warms air before it enters lung (rich vascular supply does that)
• Divided in middle by septum; can be straight or deviated

Inside the nasal cavity

• Turbinates; bony projections that increase the surface area
• Olfactory receptors; merge into the olfactory nerve; transmits to the temporal lobe where we interpret smell

Question 2

Sinuses

Answer 2

• Provide mucus
• Opening from sinual cavity to nose are small; can become blocked
• Frontal, ethmoid, sphenoid, maxillary
• Only the frontal and maxillary are accessible on exam
• Ethmoid and sphenoid sit much deeper so we can’t access them

Question 3

Mouth anatomy

Answer 3

• Oral cavity; lips, palate, check, gums, salivary glands
• Hard palate; sits at front, feels harder
• Soft plate; softer, muscular, sits behind the hard palate
• Uvula; hanging projection at back of throat
• Tongue; muscle, contains many taste buds, bumps are called papillae
• At back on tongue are vallate papillae, bigger bumps
• Frenulum; piece of tissue that holds tongue to floor of mouth
• 3 pairs of salivary glands; secrete into mouth and start digestive process
• Pharynx; open space
• Tonsils; mass of lymphoid tissue, healthy ones are the same colour of mucous membrane; more pitted (cauliflower appearance)

Question 4

Nose, mouth, throat developmental considerations for infants and children

Answer 4

• Salvation doesn’t start until 3months; when we being to see infants drooling, takes a while to coordinate how to swallow saliva
• 6months; develop baby/deciduous teeth; erupt until end of second year (20 teeth)
• 6-7 years they fall out and in come permanent teeth (32)

Question 5

Nose, mouth, throat developmental considerations for pregnant persons

Answer 5

• Increased vascularity and increased blood volume
• Because nasal muscus membranes are so vascular it increases there; increased in size
• Stuffiness and nose bleeds are common
• Increased vascularity; gums appear redder and bleeding common when bushing teeth

Question 6

Nose, mouth, throat developmental considerations for older adults

Answer 6

• Nasal hair grows stiffer and coarser
• Decrease in olfactory nerve fibers; around 60 yrs
• As we age the number of taste buds decrease
• Gums receed and teeth erode at gum line; some may have tooth loss

Question 7

Nose subjective assessment

Answer 7

• Discharge: continuous, morning/evening, consistency
• Rhinorrhea (means runny nose)
• Cold: any usually frequent or severs
• Sinus pain: PRQSTU-AAA
• Trauma: accident or injury to nose, issue with breathing afterwards
• Epistaxis: nose bleed; how often, how much, estimate in cups to tbsp; one nostril or both, or consistently one side or either; how long it takes for them to stop
• Any nose bleed that last for 20 mins on longer needs to be addressed immediately; really high BP, bleeding/clotting issue, skull fracture
• Allergies: what it is, reaction, PQRSTU-AAA
• Altered sense of smell; expected as age but not in. younger person, can diminish with chronic cigarette smoking, chronic allergies, or post head injury

Question 8

Mouth and throat subjective assessment

Answer 8

• Throat: PQRSTU-AAA, any unusually frequent or severe
• Bleeding gums: some common
• Tooth ache: sensitivity to hot and cold, any present; teeth grinding (especially if presenting with head aches) or breakdown on teeth seen
• Hoarse voice: change in their voice; associated factors (illness, speaking a lot)
• Dysphagia: difficult swallowing
• Altered sense of taste
• Sleep apnea: most people don’t know; asking whether partner expressed if they’re snoring really loudly, period where they’re not breathing during the night, waking up gasping; waking up so tired everyday even though they are getting enough sleep
• Smoking/alcohol: (excessive) associated with poor oral health and with oral cancers
• Self-care: dental care, full dental exam last date

Question 9

Nose objective assessment

Answer 9

Inspect and Palpate the Nose

• Symmetry
• Inflammation
• Lesions
• Test for patency; occulde one nostril and sniff air

Inspect the nares

• Swelling, discharge, bleeding, foreign body
• Use pen light
• Nasal mucosa should be red, smooth, a bit moist
• Turbinates; should be consistent with side of nasal mucosa and same colour
• Polyps, unusual growths, out punching from nasal mucosa
• Septum deviation; not concerned unless blocks airflow

Palpate the sinuses
- Patient should feel pressure and not pain

Question 10

Mouth and throat objective assessment

Answer 10

Inspect the Mouth

• Lips; inside of mouth should be reddish, moist, free of lesions
• Teeth; gross screen for anything that looks diseased or decayed; expect white, straight, evenly spaced
• Alignment of jaw; bite down and assess, should be lining up
• Gums; pink, where they meet the teeth shouldn’t be swollen

Tongue

• stick out, papillae, might have thin white coating at back; 2 veins present underside of tongue
• Be sure to check all sides of tongue; oral cancer hides

Buccal mucosa

• inside of cheeks, pink, smooth, moist, free of lesions
• Stensen’s duct; little dimple by second molar
• Fordyce’s granules; benign sebaceous cysts, insignificant

Palate
- Torus palatinus; unexpected shape, instead of concave hard palate comes down

Uvula

• Midline, moves up when patient says ‘AH’
• Bifid uvula; split into 2

Question 11

Grading the size of the tonsils

Answer 11

• Pitted
• Should be the same colour as the oral mucosa
• Shouldn’t have nay exudate on them (such as white or yellow spots)

1+; visible
2+; half way between the pillar (side of throat) and uvula
3+; tonsils are touching the uvula
4+; touching each other - kissing tonsils (concerned about oral airway)

• 1-2+ is considered health as long as they’re not bright red
• Any bright red, swollen, exudate we are concerned about and should do testing

Question 12

Ear anatomy

Answer 12

• Central for hearing
• Also for equilibrium
• 3 main parts;
• External eat; from pinna until the tympanic membrane
• Middle ear; tympanic ear until oval/round window
• Inner ear; hearing apparatus and equilibrium centre

Question 13

External ear anatomy

Answer 13

• Pinna; what we know as the ear; funnels sound waves into ear
• Tragus; body process that we can occlude to stop hearing
• Lobule; where you have an ear piercing
• External auditory canal; opening of ear all they way in until it hits the tympanic membrane
• Lines with glands that secrete cerumen (earwax) which protects and lubricates the ear; traps foreign substances from reaching the ear drum
• As we talk and swallow it is pushed to the outside of the ear
• Tympanic membrane; ear drum; separate the external ear from the middle ear
• Translucent colour, concave and healthy; when looking with light there is a cone of light

Question 14

Middle ear anatomy

Answer 14

• Tiny air-filled cavity that contains auditory bones

Auditory Ossicles

• Malleus
• Incus
• Stapes

Functions of the Middle ear:

• Conducts sound
• Protects the inner ear
• Equalizes air pressure on either side of the eardrum

3 places it could open;

• Tympanic membrane (into external side),
• Oval and round window (into inner ear)
• Connected middle ear with nasal pharynx though eustachain tube

Question 15

Inner ear

Answer 15

• Contains bony labrynith which hold organs for hearing and equilibrium

Structures contain the central hearing apparatus

• Vestibule
• Semicircular canals
• Cochlea

Question 16

Hearing processes

Answer 16

1) Sound waves - external auditory canal - vibrations on the tympanic membrane
2) Vibrations carried through the middle ear ossicles - oval window
3) Vibrations travel through the semicircular canals, vestibule and chochlea and dissipate at the round window
4) Basilar membrane lining the inner ear vibrates according to the frequency of sound being transmitted - causes the organ of corti to move
5) Organ of corti transmit the vibrations into electrical impulses - CN VIII
6) Brainstem- binaural interaction (lets up know which side of the body the sounds came from)
7) Cortex- interpret the meaning of sound

Question 17

Hearing loss

Answer 17

Conductive hearing loss
- Mechanical dysfunction of the external or middle ear
- Sound waves not reaching inner ear
- Can be external or middle ear
In older people, really impacted earwax
- Little kids; lodges foreign body
Perforated ear drum; can no longer vibrate to carry sound further

Sensorineural hearing loss

• Dysfunction of the inner ear, cranial nerve VIII or the auditory areas of the cerebral cortex
• Sound can’t be processed properly
• Could also have mixed loss; happen to have both at same time

Question 18

Equilibrium

Answer 18

• Labyrinth in the inner ear provides information to the brain about the body’s position in space
• Vertigo; nausea, have to wait for the inflammation to subside

Question 19

Ears developmental considerations; infants and children

Answer 19

Rubella
- infection during pregnancy; 1st trimester can lead to damage of organ of corti in the fetus and impaired hearing

Children eustachian

• easier for secretions or infection to move up and into the inner ear
• common for little kids to develop ear infection after a cold
• Anytime the tube is open; it can move up and affect the ear

Question 20

Ears developmental considerations; adults

Answer 20

Otsclerosis

• gradual hardening and stiffening of 3 ear bones
• become fixed and can’t do job to transmit message
• occurs around age 20-40
• Cause unsure

Question 21

Ears developmental considerations; older adults

Answer 21

• Coarser cilia, more stiff; earwax stuck easier and impact; can experience ear loss
• After irrigation improved hearing

Presbycusis

• nerve degeneration
• impact hearing
• higher frequency sounds go first

Question 22

Ears subjective assessment

Answer 22

• Ear ache/pain: PQRSTU-AA; cold, sore throat, sinus, issue, trauma to ear or hear
• Infection: frequent or sever, PRQATU-AAA
• Otorrhea; ear discharge, ear pain, bursting or popping; quire concerns about any kind of ear discharge
• Hearing loss; familiar, onset (acute, sudden, gradual)
• Noise exposure: work, home; how they protect ears
• Tinnitus; ringing/buzzing in the ear; something they can hear always; can be caused by many things (meds, infection, illness, etc)
• Vertigo
• Self-care; hearing tests, caring for ears

Question 23

Ears objective assessment

Answer 23

Inspect and Palpate the External Ear

• Size & shape; symmetrical
• Skin condition; should be consistent with facial skin colour, intact, no lesions
• Darwin’s Tubercle; small painless lump at the top of the pinna, cogenital and insignificant
• Tenderness; shouldn’t be
• External auditory canal; no swelling, discharge, free of debris

Inspect with the Otoscope

• Tympanic membrane
• Shiny, translucent, pearly grey
• Cone of light
• Flat/slightly concave
• No perforations

Question 24

How to hold otoscope

Answer 24

• Helpful is client tilts head slightly away from you to opposite shoulder
• Adult; pull pinna up and back
• Infants/children; lobule area back and down
• Everyone’s ear anatomy is slightly different; might need to move around
• Hold ear for entire exam
• Holding it upside down; fingers rest against head, more stable position
• Brace it against their head; angle scope a bit and pull on ear a bit until see vision

Question 25

Testing hearing acuity and vestibular apparatus

Answer 25

Tympanostomy tubes; tubes put in children’s ear to drain fluid

Whispered voice test; for acuity, no tuning forks used; occlude ear and test

Romberg test; equilibrium test, feet together, arms at side, eyes closed; some swaying okay but overall balance

Question 26

External eye anatomy

Answer 26

• Palpebral fissures; top creases in the eyelids
• Canthus; corner of the eyes; medial and lateral (angle where 2 eyelids meet)
• Caruncle; medical canthus; fleshy mass, sebaceous gland that keeps eye moisturized
• Conjuctiva; boarder of eyelid, can pull down and look at mucous membranes; has many small blood vessels in it
• Sclera; white of eye, top protective covering
• Cornea; translucent layer that covers pupil and iris
• Limbus; area between
  Iris; coloured part with pupil sitting in middle
• Lacrimal gland; above upper eyelid, constant irrigation to the eye, releases tears that drains through the puncta; drain into the lacrimal sac and into the nose

Question 27

Extra-ocular muscles

Answer 27

• 6 muscles that attach to eye to help it move
• Each eye is coordinated to the other one
• Eye muscles controlled by CN III, IV, VI

Question 28

Internal eye anatomy

Answer 28

• Sclear; outer white layer
• Choroid; middle layer; vey vascular, delivers blood to retina; has darker pigmentation, helps to prevent light from refracting from within the eyeball, continuous with the ciliary body which controls the thickness of the lens
• Lens; transparent disc distal to the pupil helps focus our vision
• Anterior and posterior chambers; have aqueous humous fluid, deliver fluids to nourish the eye and remove wastes
• Vitreous body; jelly-like, clear gel that fills the space between the lens and the retina
  Retina; visual reception layer, light ray are processed into nerve impulses, and sent to brain

Question 29

Retina

Answer 29

• Optic disc; yellow/orange circle; where the optic nerve converges
• Retinal vessels; arteries and veins, smooth, no tangles
• Macula; darker red circle
• Fovea centralis; sharpest area of vision, most focused point of vision

Question 30

Visual pathways and visual fields

Answer 30

• Light rays are refracted into the eye to the retina
• Translated to impulse at the retina
• Optic nerve into visual cortex
• Occipital lobe to be process (posterior portion of the brain)
• Upside and backwards to how they appear in the world
• Optic chaism; crossover; let optic tract only has fibers from left have of each retina of each eye

Question 31

Visual reflexes

Answer 31

Pupillary Light Reflex

• Direct light reflex; constriction of pupils when lights gets shined on them
• Consensual light reflex; other eye also constricts simentaneosly

Fixation
- Micro rapid movements of the eye that keep whatever we’re looking at in the fovea centralis

Accomodation
- Change in pupil that changes when wee look at near and far objects

Question 32

Eye developmental considerations; infants and children

Answer 32

• Not fully formed until 4 months and mature at 8 months
• Not seeing extremely clearly until that point
• Eye reaches adult size at 8yrs

Question 33

Eye developmental considerations; older adults

Answer 33

• Feeling of dryness in eye is common
• Arcus senilis; halo ring around iris, caused by deposits of lipid material
• Lens more rigid; affects ability to change shape, noticed most for near vision
• Presbypoa; 40 years, lose ability to see things close up
• Floaters; debris that accumulate inside the viterous humor inside the eye; looking at something and something will pass their vision and disappear, will float by
• Macula degeneration; breakdown of the cells in the macula, loose central vision compromised
• Cataracts; lens becomes cloudy instead of clear, clumps of protein that form on the lens, easily surgically treated
• Glaucoma; increase in intra-ocular pressure, decrease in peripheral vision
• Retinopathy; result of damage to the tiny blood vessels in the retina; blood leaks out and causes clouding in vision, usually affects both eyes

Question 34

Eye subjective assessment

Answer 34

• Vision difficulty; seeing, blurring, one eye, both eyes; any acute or sudden onset of blurring or double vision is medical emergency (worry of stoke)
• Eye pain; PQRSTU-AAA (time, eye stress, screen/computers, pain or sensitivity to bright lights)
• Strabismus; crossed eyes
• Diplopia; double vision
• Redness/swelling; one or both, associated with infection, allergy, PQUSTU-AAA
• Watering discharge; description, associated factors, allergies, infection
• History; injury, surgery, allergies affecting the eye
• Glaucoma; Fhx, testing
• When prescription last checks
• Self care; optomirtist, meds for eyes

Question 35

Eye objective assessment: Visual acuity

Answer 35

Snellen chart

• 20ft away
• cover one eye at time
• with corrective lenses on, read the smallest line possible, line with only 2 errors
• 20/20 is healthy vision
• top number is distance pt is stand, bottom is healthy eye distance

Jaeger;

• 40 or older, or reporting problems;
• similar to Snellen test but close up
• 14cm away, one eye, corrective lens on; same concept
• 14/14 perfect score
• Keep in mind; person knows how to read and understand English language; also different language and pictorial versions

Question 36

Eye objective assessment: visual fields

Answer 36

Confrontation

• gross measure of peripheral vision
• screening against yourself
• cover eye on same side (opposite eyes)
• 4 positions saying when they see you finger, should be same time you see it

Corneal light reflex

• alignment of eye
• pen light 30cm away
• pointing middle between eyes
• looking for reflection of light in eyes
• looking for symmetry (same spot on each eye on same level)
• If asymmetry; weakness in the muscles of the eye, alignment off

Cover-uncover

• more sensitive test for muscle weakness
• cover one eye and stare at object
• if other eye muscles are weakened, the eye will relax and shift
• when uncovered if eye moves to focus on object we suspect muscle weakness

Diagnostic positions

• ossilation or stagnus or uncoordinated movements of eye
• 6 point star and eyes move in smooth coordinated fashion

Question 37

Eye objective assessment; exterior eye

Answer 37

Inspect the External Ocular Structures

• General; seeing everything, moving around with issues, or bumping into thing, squinting
• Eyebrows; coordinated fashion, with expressions
• Eyelids/lashes; upper eyelid to just over lap the top part of iris at rest, when closed both eyelids should approximate
• Skin around should be intact with no redness/swelling/discharge/lesion
• Ptosis; drooping of eyelids; sleepy look; damage to CN III
• Periorbiual edema; swelling around eye, CV issues, fluid backup, crying a lot, trauma
• Lashes evenly distributed
• Styes; usually cause by staphococcal infection, clogged eyelash; resolves with warm compress or antibiotic drops
• Eyeballs; aligned,
• Protuding eyeballs; exophthalmos; usually due to head trauma, increase intraoccular pressure
• Sunken eyeballs; enohthlamos; severely dehydrated

Question 38

Eye objective assessment: anterior eyeball

Answer 38

Inspect the Anterior Eyeball Structures

• Cornea & Lens; take pen light and shine across eye; clear and glossy
• Corneal abrasions; looks like glass chip or shattered glass
• Iris & Pupil; expect pupil to be equally round, reactive to light, accommodating and iris, round regular and even in colour
• Pupillary light reflex
• Accomodation
• PERRLA

Question 39

Inspecting the ocular fundus

Answer 39

• Helpful to darken the room; pupils get very dilated and easier to look in
• Both people should remove protective lenses
• Scope viewing aperture; diopter indicator to accommodate for your vision; lens selector dial, want to select the biggest round white light
• Pt looks straight ahead, don’t blink
• Want to hold scope right up to cheek; other hand on pt forehead
• Have to go diagnonally
• Start 25cm away, come in from side
• Red light reflex; see the red in the eye
• Optic disc; yellow part where fibers converge in optic nerve
• Macula; darker circle area where fovea centralis is
• Goal is just to see something; even just reddish background