Download 6/29/98 - RollaNet

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6/29/98
PHYS DX
Tympanic membrane (TM)
 To observe motion
 Have pt hold nose and do a quick swallow
 If serous fluid behind membrane => more concave (sinks in)
 If edema and swelling (otitis media) => more convex (bulges out)
 Blood vessels can dilate when child cries (heavy, frightened crying), let child relax
for a while, then try again
 Check for integrity of TM
 If perforation, no movement when pt holds nose and swallows
Otitis media
 Seventy-five percent of children have at least one attack by age 2
 Numbers relative to overall population—decrease by age 5 (not necessarily true for
individuals with chronic attacks)
 Do lymphatic stripping
 Check for allergies to milk or sugar
 Seek immediate help
 Change in consciousness
 High fever
 Stiff neck or headache
 Trouble breathing
 Monitor frequently if ear discharge
 Swelling behind ear—mastoiditis
 Watch for infant pulling at ear or hitting it
Otomycosis—fungal problem
 Often seen following use of antibiotics
Secretory/serous otitis media (OM)
 Older children and adults
 Viral infection, change in atmospheric conditions, or allergic reaction
 Air gets trapped in ear and pulls TM inward
 Sensation of plugged ear
 TM may look yellow, amber, orange
 Bony landmarks are more prominent
 Air or fluid bubbles may develop
 Tympanostomy tube
 Used when chronic cases of serous OM or a lot of scar tissue
 Must be kept clean
 Can work their way out
Tympanosclerosis
 Scarring—looks white
 May involve ossicles => significant conductive hearing loss
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PHYS DX
Progressive in nature
Patent
 Appears transparent
 Can see stuff inside
 Can still see motion if swallow if intact
Atrophic (adhesive) TM
 Adhesions to ossicles—immobile scar tissue
 Conductive hearing loss
Do not tell parents to take children off antibiotics (you can be sued) but seek to co-manage
with pediatrician and try to keep dosage levels down
Adults—can recommend they cut back if they feel okay using nutritional supplements you
recommend
CANNOT put stuff in ear if TM is perforated but should supplement:
B-complex
E, C, Mg
Flax seed oil
Garlic oil
Colosteoma—type of tumor
 Erosive in nature
 Middle ear and mastoid ear spaces
 Resembles yellow fatty tumor
 Slowly enlarges
 Monitor this situation
 If in middle ear, grows both ways
 Can lead to permanent damage to VII, VIII
 Both conductive and sensorineural hearing loss
Hearing Tests
1. Whisper Test (spoken word or voice test)
 Occlude one ear and whisper numbers or words from 12-24 inches away
 Determines gross hearing loss
 Have them ID at least one word you say
 OR can rub fingers together at least 6 inches away from ear
2. Watch Test
 Hold watch up to pt’s ear and compare with Dr.’s hearing
 Determines gross hearing loss
3. Tuning Fork Tests (512 Hz) ** comp boards—frequency important
 Normally air conduction is better that bone conduction
 Tests only accurate if pure conduction or pure sensorineural loss but
most patients are a combination of both losses
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6/29/98
PHYS DX
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Weber
 Strike tines of tuning fork, then place handle on midline of skull
 Ask pt if they her more in one ear then the other (lateralization) or if it is
in the middle (normal)
 Conductive hearing loss—lateralizes to affected ear
 Sensorineural loss—lateralizes to better ear
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Schwabach
 Compare pt’s hearing to Dr.’s with the tuning fork
 Not as sensitive of a test
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Rinne
 Compares air vs bone conduction
 Strike tuning fork and place on mastoid
 When pt no longer hears frequency, place in front of ear
 If pt still hears—Rinne + (AC > BC) ; normal
 If pt cannot hear—Rinne - (BC > AC); conductive hearing loss
 If pt has sensorineural loss (AC > BC); just not as long
NOTE: notation for Rinne Test is opposite to that for ortho test—Positive means normal
(ex.: Weber is midline and Rinne is positive—status of right ear is normal)
 Pt. presents with hearing problems
 Weber—pt hears better on right side = either conductive loss on right or
sensorineural loss on left
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Normally AC is 2.5 times greater than BC so if bone conduction = 10 sec., air conduction
should be at least 20 sec. So time it
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Complete sensorineural loss = no bone conduction, no air conduction—NO sound
appreciated
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Bone conduction goes directly to inner ear
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If Weber is normal, don’t have to do Rinne in a standard exam but during testing situation
(NB or State) do both and tell examiner what you expect to see---Tuning Fork Tests
Video—Nose and Throat Paranasal Sinuses
Nose
 Examine externally
 To check for patency, have pt cover one side and breathe in (usually one side is
more patent)
 Can check septum by shining light in one side while looking in on other side
 Turbinates—usually only see inferior and middle ones
 Palpate sinus areas
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6/29/98
PHYS DX
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Under brow ridge
Under zygomatic arch
Mouth
 Observe as pt opens and closes mouth
 Palpate TMJ as pt opens and closes mouth
 Observe gums
 Use tongue blade to check teeth
 Observe buccal mucosa, parotid duct
 Observe tongue—top, sides, bottom (more malignancies here)
 Inspect floor of mouth
 Submandibular ducts
 Sublingual glands
 Examine pharynx
 Hard palate is normally white
 Soft palate is normally pink
 Pt says “ahh”
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Uvula, tonsils, arches
Nose
 Lower 1/3 is cartilage
 Rest is nasal bones + frontal + maxilla
 Turbinate = concha
 Lower turbinate has semierectile tissue (can swell up and occlude
passageway)
 Meatus below each turbinate
 Inferior—nasal lacrimal duct
 Middle—
 Superior—post ethmoid sinus
 Retrograde infections are a problem
 Retrograde infections are bad in “triangle of death”
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Be careful when popping zits
 NOTE: sinuses can get so infected as to rupture
 Sphenoid sinus does not drain directly into nose
 Congestion, obstruction, nose bleeds
 Turbinates—very vascular
 Little’s area—responsible for nose bleeds
 Nerve supply
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Branches of V
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Olfactory nerve
 Humidifies inspired air (also warms and filters it)
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6/29/98
PHYS DX
Why do an examination on the nose?
 Part of complete physical
 Complaint of obstruction/blockage
 Discharge
 Bleeding
 Complaint of facial pain in sinus areas
Risks
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Trauma
Repeated sinus infection
Tobacco use (irritant, increased carcinoma)
Headaches
History of polyps
Recreational drug use (inhaled)
Obstruction
 Most common symptom of nasal disease
 Term—rhinitis
 Stuffy nose
 Congestion of nasal mucosa
 Symptoms
 Obstruction
 Sneezing
 Clear, watery discharge
 Polyps
 More problem at night
 Snoring
 Breath through mouth
 Associated with allergies or asthma
Questions to be asked in examine
 Onset
 Unilateral or bilateral
 Polyp, trauma
 Seasonal
 Do you have allergies?
 Associated with stress?
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Infection—also see sore throat, etc—mucopurulent discharge
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Trauma—may see bleeding with obstruction
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Vasomotor rhinitis—nasal sprays
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PHYS DX
Late stage pregnancy => VM rhinitis
Discharge
 Thin and watery = viral or allergy
 Thick and purulent = bacterial
 Bloody = trauma, neoplasm, fungal
 Foul smell
 Foreign bodies
 Chronic sinusitis
 Malignant disease
 Clear, watery that increases with bending of head or coughing—CSF (from
trauma)
Nose bleeds
 Trauma or spontaneous
 Frequency
 Amount
 Tx
 Difficulty in stopping
 Nose picking
 Chronic sinusitis
 Malignancy in sinuses
 Cocaine abuse
 Overly dry air
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Sinus disease
 Pain is most common symptom
 To stop it
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Ice on back of neck
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Tissues and pressure