Download Chapter 12 Ears, Nose, and Throat Much can be learned about the

Chapter 12
Ears, Nose, and Throat
Much can be learned about the function of the respiratory and digestive tracts from their
accessible orifices—the ears, nose, mouth, and throat.
The special senses of smell, hearing, equilibrium, and taste are also located in the ears, nose,
and mouth.
Physical Examination Preview
Ears
Inspect the auricles and mastoid area for size, shape, symmetry, landmarks, color, position, and
deformities or lesions.
Palpate the auricles and mastoid area for tenderness, swelling, and nodules.
Inspect the auditory canal with an otoscope, noting cerumen, color, lesions, discharge, or foreign
bodies.
Inspect the tympanic membrane for landmarks, color, contour, perforations, and mobility.
Ears (Cont.)
Assess hearing through the following:
Response to questions during history
Response to a whispered voice
Response to tuning fork for air and bone conduction
Nose and Sinuses
Inspect the external nose for shape, size, color, and nares.
Palpate the ridge and soft tissues of the nose for tenderness, displacement of cartilage and bone,
and masses.
Evaluate the patency of the nares.
Inspect the nasal mucosa and nasal septum for color, alignment, discharge, turbinates, and
perforation.
Inspect the frontal and maxillary sinus area for swelling.
Palpate the frontal and maxillary sinuses for tenderness or pain, and swelling.
Mouth
Inspect and palpate the lips for symmetry, color, and edema.
Inspect the teeth for occlusion, caries, loose or missing teeth, and surface abnormalities.
Inspect and palpate the gingivae for color, lesions, and tenderness.
Inspect the tongue and buccal mucosa for color, symmetry, swelling, and ulcerations.
Assess the function of cranial nerve XII (hypoglossal).
Palpate the tongue.
Mouth (Cont.)
Inspect the palate and uvula.
Inspect the oropharyngeal characteristics of the tonsils and posterior wall of the pharynx.
Elicit gag reflex (cranial nerves IX and X).
Anatomy and Physiology
Ears and Hearing
Sensory organ that functions in identification, location, and interpretation of sound
Aids in the maintenance of equilibrium
Three parts
External
Middle
Inner
Ears and Hearing (Cont.)
External structures
Auricle
External auditory canal
External functions
Protective
Helps gather and channel sound
Ears and Hearing (Cont.)
Middle ear structures
Ossicles: malleolus, incus, stapes
Tympanic membrane
Ears and Hearing (Cont.)
Middle ear functions
Ossicles transmit sound from tympanic membrane to inner ear.
Tympanic membrane separates middle from external ear.
Ears and Hearing (Cont.)
Inner ear structures
Vestibule
Semicircular canals
Cochlea
Inner ear functions
Cochlea transmits sound to CN VIII.
Semicircular canals are involved in vestibular function.
Ears and Hearing (Cont.)
Ears and Hearing (Cont.)
Hearing is interpretation of sound waves that travel through the ear to the brain.
Sound is also transmitted by bone directly to the inner ear.
Nose, Nasopharynx, and Sinuses
Function
Odor identification
Passage of inspired and expired air
Humidification, filtration, and warmth of inspired air
Resonance of laryngeal sounds
Nose, Nasopharynx, and Sinuses (Cont.)
Structure
External nose
Bone and cartilage
Nares
Internal nose
Septum
Choanae
Turbinates
Cribriform plates
Kiesselbach plexus
Convergence of small fragile arteries and veins
Nose, Nasopharynx, and Sinuses (Cont.)
Structure (Cont.)
Sinuses
Maxillary
Frontal
Ethmoid
Sphenoid
Only the maxillary and frontal sinuses are accessible for physical examination.
Nose, Nasopharynx, and Sinuses (Cont.)
Structure (Cont.)
Nasal floor is formed by the hard and soft palate.
Roof is formed by the frontal and sphenoid bone.
The adenoids lie on the posterior wall of the nasopharynx.
Mouth and Oropharynx
Function
Emission of air for vocalization and non-nasal expiration
Passage for food, liquids, saliva
Initiation of digestion by mastication and salivary secretion
Identify taste
Mouth and Oropharynx (Cont.)
Structure
The oral cavity is divided into the mouth and the vestibule (space between the buccal
mucosa and the outer surface of the teeth and gums).
The mouth, housing the tongue, teeth, and gums, is the anterior opening of the
oropharynx.
Mouth and Oropharynx (Cont.)
Structure (Cont.)
The bony arch of the hard palate and the fibrous soft palate form the roof of the mouth.
Loose, mobile tissue covering the mandibular bone forms the floor of the mouth.
Mouth and Oropharynx (Cont.)
Structure (Cont.)
The tongue is anchored to the back of the oral cavity at its base and to the floor of the
mouth by the frenulum.
The gingivae, fibrous tissue covered by mucous membrane, are attached directly to the
teeth and the maxilla and mandible.
Mouth and Oropharynx (Cont.)
Structure (Cont.)
The roots of the teeth are anchored to the alveolar ridges of the maxilla and mandible.
Mouth and Oropharynx (Cont.)
Structure (Cont.)
The parotid, submandibular, and sublingual salivary glands are located in tissues
surrounding the oral cavity.
The oropharynx, continuous with but inferior to the nasopharynx, is separated from the
mouth by bilateral anterior and posterior tonsillar pillars.
The tonsils lie in the cavity between these pillars.
Swallowing is initiated when food is forced by the tongue toward the pharynx.
Infants and Children
Inner ear development in first trimester
External auditory canal in infants shorter than in adults
Eustachian tube in infants wider, shorter, more horizontal than in adults
Salivation increased by 3 months
Infants and Children (Cont.)
Maxillary and ethmoid sinuses are present at birth but are very small.
Frontal and sphenoid sinuses begin to develop at about 3 years of age and complete
development in late adolescence.
Infants and Children (Cont.)
Twenty deciduous teeth usually erupt between 6 and 24 months of age.
Permanent teeth begin forming in the jaw by 6 months of age.
Eruption of the permanent teeth begins about 6 years of age and is completed around 14 or 15
years of age in most races.
Pregnant Women
Elevated levels of estrogen cause increased vascularity of upper respiratory tract.
Capillaries in nose, pharynx, and ears engorge.
Nasal stuffiness and fullness in ears
Decreased smell and impaired hearing
Epistaxis
Laryngeal changes
Hoarseness and cough
Vocal changes
Older Adults
Nearly a third of adults older than 65 years have hearing loss
Age-related hearing loss is associated with:
Degeneration of hair cells in the organ of Corti
Loss of cortical and organ of Corti auditory neurons
Degeneration of the cochlear conductive membrane
Decreased vascularization of the cochlea
Older Adults (Cont.)
Sensorineural hearing loss first occurs with high-frequency sounds and then progresses to tones
of lower frequency.
Conductive hearing loss may result from:
Excess deposition of bone cells along the ossicle chain, causing fixation of the stapes in
the oval window
Cerumen impaction
Sclerotic tympanic membrane
Older Adults (Cont.)
Deterioration of the sense of smell results from loss of olfactory sensory neurons beginning at
about 60 years of age.
The sense of taste begins deteriorating at about 50 years of age as the number of papillae on the
tongue and salivary gland secretion decreases.
Older Adults (Cont.)
Continuing cartilage formation in ear and nose:
Ears and nose larger and more prominent
Mouth soft tissue changes:
Cheeks more prominent
Gingival tissue less elastic and more vulnerable to trauma
Older Adults (Cont.)
Teeth are lost.
Difficulty chewing
Altered motor function of tongue
Difficulty swallowing
Review of Related History
History of Present Illness
Vertigo (a false sense of motion)
Time of onset, duration of attacks
Description of attack
Associated symptoms
Unsteadiness, loss of balance, falling
Medications: ototoxic, salt retaining
History of Present Illness (Cont.)
Ear pain
Onset, duration, course
Concurrent upper respiratory infection, frequent swimming, trauma to head
Associated symptoms
Method of ear canal cleaning
Medications: antibiotics, ear drops
History of Present Illness (Cont.)
Hearing loss: one or both ears
Onset
Hears best
Speech
Associated symptoms
Management
Medications: ototoxic
History of Present Illness (Cont.)
Nasal discharge
Character
Associated symptoms
Seasonality of symptoms
Tenderness over sinuses, face pain, headache
Snoring
Change in snoring pattern
Daytime sleepiness
History of Present Illness (Cont.)
Nosebleed
Frequency and amount of bleeding
Predisposing factors
Site of bleeding
Medications
Sinus pain
Fever, malaise, cough, headache, maxillary toothache, eye pain
Nasal congestion, colored nasal discharge
Tenderness or pressure over sinuses, pain increases when bending forward
History of Present Illness (Cont.)
Dental problems
Pain
Swollen or bleeding gums, mouth ulcers or masses, tooth loss
Dentures or dental appliances
Malocclusion
Medications: phenytoin, cyclosporine, calcium channel blockers, mouth rinses
History of Present Illness (Cont.)
Mouth lesions
Intermittent or constantly present, duration, painful or painless
Associated with stress, foods, seasons, fatigue, tobacco use, alcohol use, dentures
Variations in tongue character
Lesions any place else on the body
Medications: mouth rinses
History of Present Illness (Cont.)
Sore throat
Pain with swallowing
Exposure to dry heat, smoke, or fumes
Medications: antibiotics, nonprescription lozenges or sprays
Hoarseness
Onset: acute, chronic
Change in voice quality
Associated problems
History of Present Illness (Cont.)
Difficulty swallowing
Solids, liquids, or both
Feeling of food in throat, tightness, or substernal fullness
Drooling
Past Medical History
Systemic disease
Ear: frequent ear infections during childhood, surgery, labyrinthitis, antibiotic use; dosage and
duration
Nose: trauma, surgery, chronic nosebleeds
Sinuses: chronic postnasal drip, recurrent or chronic sinusitis, allergies
Throat: frequent documented streptococcal infections, tonsillectomy, adenoidectomy
Family History
Hearing problems or hearing loss, Ménière disease
Allergies
Hereditary renal disease
Personal and Social History
Environmental hazards
Nutrition
Oral care patterns
Tobacco use
Alcohol use
Intranasal use of cocaine
Infants and Children
Prenatal history
Prematurity
Erythroblastosis fetalis, bilirubin greater than 20 mg/100 mL serum
Infections
Breast-feeding, secondary tobacco smoke exposure, out-of-home child care
Congenital defect
Playing with small objects
Behaviors indicating hearing loss
Dental care
Pregnant Women
Weeks of gestation or postpartum
Presence of symptoms before pregnancy
Pattern of dental care
Exposure to infection
Older Adults
Hearing loss causing any interference with daily life
Physical disability
Deterioration of teeth, extractions, difficulty chewing
Dry mouth (xerostomia)
Medications that decrease salivation
Examination and Findings
Equipment
Otoscope with pneumatic attachment
Nasal speculum
Tongue blades
Gauze
Gloves
Tuning fork (500 to 1000 Hz)
Penlight, sinus transilluminator, or light from otoscope
Vials with different odors such as mint, banana, coffee
Ears and Hearing
External ear
Inspect auricles
Size, shape, and symmetry
Landmarks and position on head
Color
Presence of deformities, lesions, or nodules
Inspect external auditory canal
Discharge and odor
Ears and Hearing (Cont.)
Palpate auricles and mastoid area
Tenderness or pain
Swelling
Nodules
Consistency of auricle should be firm and mobile, without nodules
Ears and Hearing (Cont.)
Otoscopic examination
Used to inspect external auditory canal and middle ear
Inspect auditory canal from meatus to tympanic membrane
Discharge
Redness
Scaling
Lesions
Foreign bodies
Cerumen
Ears and Hearing (Cont.)
Otoscopic examination (Cont.)
Inspect tympanic membrane.
Landmarks
Color
Contour
Perforation
Use pneumatic attachment to evaluate mobility and compliance of tympanic membrane.
Ears and Hearing (Cont.)
Hearing evaluation
Evaluate auditory function.
Response to questions and directions
Whispered voice test
Compare air to bone conduction.
Weber test
Rinne test
Ears and Hearing (Cont.)
Hearing evaluation (Cont.)
Distinguish type of hearing loss.
Sensorineural
Conductive
Refer patients with loss for thorough auditory examination.
Nose, Nasopharynx, and Sinuses
External nose
Inspect nose and nares.
Nose for shape, size, and color
Nares for flaring, narrowing, or discharge
Palpate nose.
Displacement of bone or cartilage
Tenderness
Masses
Evaluate patency of nares.
Nose, Nasopharynx, and Sinuses (Cont.)
Nasal cavity
Inspect nasal mucosa.
Color
Discharge
Masses or lesions
Swelling of turbinates
Nose, Nasopharynx, and Sinuses (Cont.)
Nasal cavity (Cont.)
Inspect nasal septum.
Position, straightness, and thickness
Perforations, bleeding, or crusting
The sense of smell (cranial nerve I) is often tested with recognition of different odors.
Nose, Nasopharynx, and Sinuses (Cont.)
Sinuses
Inspect the frontal and maxillary sinus areas for swelling.
Palpate frontal and maxillary sinuses for tenderness.
Transillumination of the frontal and maxillary sinuses may be performed if sinus
tenderness is present or infection is suspected.
Mouth and Oropharynx
Lips
Inspect and palpate lips.
Symmetry
Color
Edema
Surface abnormalities
Mouth and Oropharynx (Cont.)
Buccal mucosa, teeth, and gums
Inspect buccal mucosa.
Stenson ducts
Color and moisture
Ulcers or Fordyce spots
Mouth and Oropharynx (Cont.)
Oral cavity
Inspect teeth.
Occlusion and alignment
Color and stains
Number of missing teeth
Wear, notches, or caries
Mouth and Oropharynx (Cont.)
Oral cavity (Cont.)
Inspect tongue.
Swelling
Variation in size or color
Coating
Ulceration
Mouth and Oropharynx (Cont.)
Oral cavity (Cont.)
Ask the patient to extend the tongue while you inspect for:
Deviation
Tremor
Limitation of movement
Mouth and Oropharynx (Cont.)
Oral cavity (Cont.)
Inspect floor of mouth and ventral surface of tongue.
Swelling or varicosities
Frenulum
Sublingual ridge
Wharton ducts
Palpate tongue.
Lumps, nodules, or ulceration
Mouth and Oropharynx (Cont.)
Oropharynx
Inspect palate and uvula.
Evaluate movement of soft palate.
Inspect oropharynx with tongue blade.
Observe tonsillar pillars; note size of tonsils if present.
Note integrity of retropharyngeal wall.
Elicit gag reflex.
Tests the glossopharyngeal and vagus nerves (cranial nerves IX and X)
Infants
Ears
Inspect auricle for full formation and flexibility.
Auditory canals should be examined in first few weeks of life.
Tympanic membrane becomes conical after first few months of life.
Evaluate infant hearing using sound stimuli.
Infants (Cont.)
Nose and sinuses
Inspect for symmetry and positioning.
Determine nasal patency.
Paranasal sinuses are poorly developed during infancy, and examination is generally
unnecessary.
Infants (Cont.)
Mouth
Inspect lip shape and irregularities.
Inspect buccal mucosa color and moisture.
Observe for drooling.
Inspect gums, teeth, and tongue.
Inspect palatal arch and soft palate.
Evaluate suck reflex.
Avoid depressing the tongue because this stimulates a strong reflex protrusion or the
tongue, making visualization of the mouth difficult.
Children
Because the young child often resists otoscopic and oral examinations, it may be wise to
postpone these procedures until the end.
Be prepared to immobilize if encouraging the child to cooperate fails.
Another person, usually the parent, may be needed to effectively hold the child.
Children (Cont.)
Ears
Otoscopic examination
Pull auricle down to view tympanic membrane.
Pneumatic otoscope is especially important for differentiating a red tympanic
membrane caused by crying (the membrane is mobile) from that resulting
from disease (no mobility).
Evaluate toddler’s hearing by observing response to whispering, noisemakers,
and speech.
Audiometric evaluation should be performed in all young children beginning at 3
to 4 years of age.
Children (Cont.)
Nose and sinuses
To inspect the internal nose, shine a light while tilting the nose tip upward with your
thumb.
Palpate the paranasal sinuses after they have developed (maxillary sinuses by 4 years of
age and frontal sinuses by 5 to 6 years of age).
Note any tenderness indicating a potential sinus infection in the child with an upper
respiratory infection that has not improved after 10 days.
Children (Cont.)
Mouth
Inspect teeth for grinding, decay, and brown spots.
Check gag reflex, enabling brief view of mouth and oropharynx.
Inspect buccal mucosa.
Inspect tonsils and epiglottis.
Pregnant Women
Inspect nose and pharynx for edema and erythema.
Inspect for nasal congestion and sinusitis.
Inspect tympanic membrane for retraction or bulging.
Inspect gums for hypertrophy.
Older Adults
Ears and hearing
If hearing aid is worn, inspect auditory canal for irritation.
Inspect for coarse hair on auricle.
Inspect tympanic membrane for sclerotic changes.
Note presence of sensorineural (presbycusis) or conductive hearing loss.
Inspect for cerumen impaction.
Older Adults (Cont.)
Nose
Look for dry mucosa.
Men: look for increase of hairs in vestibule.
Mouth
Look for reduced salivary flow.
Check for thinning buccal mucosa.
Examine tongue for fissures and varicose veins.
Inspect dental occlusion.
Abnormalities
Abnormalities
A – preauricular skin tag, B – Auricular sinus, C – Darwin tubercle, D – Cauliflower ear, E – Tophi,
F – Sebaceous cysts
Ear
Otitis media with effusion
Inflammation of the middle ear resulting in the collection of serous, mucoid, or purulent
fluid (effusion) when the tympanic membrane is intact
Ear (Cont.)
Acute otitis media
Inflammation in the middle ear, associated with a middle ear effusion that becomes
infected by bacterial organisms
Ear (Cont.)
Otitis externa
Inflammation of the auditory canal and external surface of the tympanic membrane
Ear (Cont.)
Cholesteatoma
Trapped epithelial tissue behind the tympanic membrane that is often the result of
untreated or chronic recurrent otitis media
Ear (Cont.)
Hearing loss
Conductive hearing loss
Hearing loss resulting from reduced transmission of sound to the middle ear
Sensorineural hearing loss
Hearing loss resulting from a disorder of the inner ear, damage to cranial nerve
VIII, genetic disorders, systemic disease, ototoxic medication, trauma,
tumors, and prolonged exposure to loud noise
Ear (Cont.)
Hearing loss
Ménière disease
Disorder of progressive hearing loss that in some cases has a genetic mode of
transmission
Vertigo
Illusion of rotational movement by a patient, often due to a disorder of the inner ear
Ménière disease
Sinuses
Sinusitis
Bacterial infection of one or more of the paranasal sinuses
Mouth and Oropharynx
Acute pharyngitis
Infection of tonsils or posterior pharynx by microorganisms such as group A β-hemolytic
streptococci or other streptococcal species, Neisseria gonorrhea, Mycoplasma
pneumoniae
Mouth and Oropharynx (Cont.)
Peritonsillar abscess
Deep infection in the space between the soft palate and tonsil
Mouth and Oropharynx (Cont.)
Retropharyngeal abscess
Life-threatening infection in the lateral pharyngeal space that has the potential to occlude
the airway; most commonly occurs in children
Mouth and Oropharynx (Cont.)
Oral cancer
Cancer involving the oral cavity or related structures
Most often squamous cell
Abnormalities - Children
Cleft lip and Palate
Question 1
A thickening along the upper ridge of the helix is called:
A. Preauricular pit
B. Darwin tubercle
C. Preauricular tag
D. Tophi
Question 2
The pregnant woman can expect to experience:
A. More nasal stuffiness
B. A sensitive sense of smell
C. Drooling
D. Enhanced hearing
Question 3
Damage to CN VIII is:
A. Conductive hearing loss
B. Sensorineural hearing loss
C. Cholesteatoma
D. Otitis media
Question 4
For best results, an otoscopic and oral examination in a child should be:
A. Conducted at the beginning of the assessment
B. Done after inspection
C. Performed at the end of the examination
D. Performed before palpation
Question 5
Trapped epithelial tissue behind the tympanic membrane that is often the result of untreated OM
is:
A. Cholesteatoma
B. Effusion
C. Endolymphatic hydrops
D. Otosclerosis