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1 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 2 6/29/98 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 3 6/29/98 PHYS DX 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 Schwabach Compare pt’s hearing to Dr.’s with the tuning fork Not as sensitive of a test 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 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 Complete sensorineural loss = no bone conduction, no air conduction—NO sound appreciated Bone conduction goes directly to inner ear 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 4 6/29/98 PHYS DX 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” 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” 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 Branches of V Olfactory nerve Humidifies inspired air (also warms and filters it) 5 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 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? Infection—also see sore throat, etc—mucopurulent discharge Trauma—may see bleeding with obstruction Vasomotor rhinitis—nasal sprays 6 6/29/98 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 Sinus disease Pain is most common symptom To stop it Ice on back of neck Tissues and pressure