Chapter 12 Ears Nose and Throat an imprint

S It is the supreme art of the teacher to awaken joy in creative

Ears, Nose, and Throat S Much can be learned about the function of the

Ears S Inspect the auricles and mastoid area for size, shape, symmetry, landmarks, color,

Ears (Cont. ) S Assess hearing through the following: S Response to questions during

Nose and Sinuses S Inspect the external nose for shape, size, color, and nares.

Mouth S Inspect and palpate the lips for symmetry, color, and edema. S Inspect

Mouth (Cont. ) S Inspect the palate and uvula. S Inspect the oropharyngeal characteristics

Ears and Hearing S External structures S Auricle S External auditory canal S External

Ears and Hearing (Cont. ) S Middle ear structures S Ossicles transmit sound from

Ears and Hearing (Cont. ) S Inner ear structures S Vestibule S Semicircular canals

Nose, Nasopharynx, and Sinuses S Function S Odor identification S Passage of inspired and

Nose, Nasopharynx, and Sinuses (Cont. ) S Structure S External nose S S Bone

Nose, Nasopharynx, and Sinuses (Cont. ) S Structure (Cont. ) S Sinuses S Maxillary

Mouth and Oropharynx S Function S Emission of air for vocalization and non-nasal expiration

Mouth and Oropharynx (Cont. ) S Structure S The bony arch of the hard

Infants and Children S External auditory canal in infants shorter than in adults S

Infants and Children (Cont. ) S Twenty deciduous teeth usually erupt between 6 and

Older Adults S Nearly a third of adults older than 65 years have hearing

Older Adults (Cont. ) S Deterioration of the sense of smell results from loss

History of Present Illness S Vertigo (a false sense of motion) S Time of

History of Present Illness (Cont. ) S Ear pain S Onset, duration, course S

History of Present Illness (Cont. ) S Hearing loss: one or both ears S

History of Present Illness (Cont. ) S Nasal discharge S Character S Associated symptoms

History of Present Illness (Cont. ) S Sinus pain S Fever, malaise, cough, headache,

History of Present Illness (Cont. ) S Dental problems S Pain S Swollen or

History of Present Illness (Cont. ) S Mouth lesions S Intermittent or constantly present,

History of Present Illness (Cont. ) S Difficulty swallowing S Solids, liquids, or both

Past Medical History S Systemic disease S Ear: frequent ear infections during childhood, surgery,

Family History S Hearing problems or hearing loss, Ménière disease S Allergies S Hereditary

Personal and Social History S Environmental hazards S Nutrition S Oral care patterns S

Infants and Children S Prenatal history S Prematurity S Breast-feeding, secondary tobacco smoke exposure,

Older Adults S Hearing loss causing any interference with daily life S Physical disability

Examination and Findings . an imprint of Elsevier Inc. Copyright © 2015 by Mosby,

Ears and Hearing S External ear S Inspect auricles S Size, shape, and symmetry

Ears and Hearing (Cont. ) S Palpate auricles and mastoid area S Tenderness or

Ears and Hearing (Cont. ) S Otoscopic examination S Used to inspect external auditory

Ears and Hearing (Cont. ) S Otoscopic examination (Cont. ) S Inspect tympanic membrane.

Ears and Hearing (Cont. ) S Hearing evaluation S Evaluate auditory function. S Response

Nose, Nasopharynx, and Sinuses S Nose S Inspect nose and nares. S Nose for

Nose, Nasopharynx, and Sinuses (Cont. ) S Nasal cavity S Inspect nasal mucosa. S

Nose, Nasopharynx, and Sinuses (Cont. ) S Sinuses S Inspect the frontal and maxillary

Mouth and Oropharynx S Oral cavity S Ask the patient to extend the tongue

Mouth and Oropharynx (Cont. ) S Oropharynx S Inspect palate and uvula. S Evaluate

Infants S Nose and sinuses S Paranasal sinuses are poorly developed during infancy, and

Infants (Cont. ) S Mouth S Observe for drooling. S Inspect gums, teeth, and

Children S Because the young child often resists otoscopic and oral examinations, it may

Children (Cont. ) S Mouth S Inspect teeth for grinding, decay, and brown spots.

Older Adults S Ears and hearing S If hearing aid is worn, inspect auditory

Abnprmalities (Ear) S Acute otitis media S Inflammation in the middle ear, associated with

Abnormalities (Ear) S Hearing loss S Conductive hearing loss S Hearing loss resulting from

Abnormalitiles (Ear) S Hearing loss S Ménière disease S Disorder of progressive hearing loss

Abnormalities (Sinuses) S Sinusitis S Bacterial infection of one or more of the paranasal

Abnormalities (Mouth and Oropharynx) S Peritonsillar abscess S Deep infection in the space between

Abnormalities (Children) S Cleft lip and Palate Copyright © 2015 by Mosby, an imprint

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Ears, Nose, and Throat S Much can be learned about the function of the respiratory and digestive tracts from their accessible orifices—the ears, nose, mouth, and throat. S The special senses of smell, hearing, equilibrium, and taste are also located in the ears, nose, and mouth. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 3

Ears S Inspect the auricles and mastoid area for size, shape, symmetry, landmarks, color, position, and deformities or lesions. S Palpate the auricles and mastoid area for tenderness, swelling, and nodules. S Inspect the auditory canal with an otoscope, noting cerumen, color, lesions, discharge, or foreign bodies. S Inspect the tympanic membrane for landmarks, color, contour, perforations, and mobility. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 4

Ears (Cont. ) S Assess hearing through the following: S Response to questions during history S Response to a whispered voice S Response to tuning fork for air and bone conduction Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 5

Nose and Sinuses S Inspect the external nose for shape, size, color, and nares. S Palpate the ridge and soft tissues of the nose for tenderness, displacement of cartilage and bone, and masses. S Evaluate the patency of the nares. S Inspect the nasal mucosa and nasal septum for color, alignment, discharge, turbinates, and perforation. S Inspect the frontal and maxillary sinus area for swelling. S Palpate the frontal and maxillary sinuses for tenderness or pain, and swelling. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 6

Mouth S Inspect and palpate the lips for symmetry, color, and edema. S Inspect the teeth for occlusion, caries, loose or missing teeth, and surface abnormalities. S Inspect and palpate the gingivae for color, lesions, and tenderness. S Inspect the tongue and buccal mucosa for color, symmetry, swelling, and ulcerations. S Assess the function of cranial nerve XII (hypoglossal). S Palpate the tongue. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 7

Mouth (Cont. ) S Inspect the palate and uvula. S Inspect the oropharyngeal characteristics of the tonsils and posterior wall of the pharynx. S Elicit gag reflex (cranial nerves IX and X). Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 8

Ears and Hearing (Cont. ) S Middle ear structures S Ossicles transmit sound from tympanic membrane to inner ear. S Tympanic membrane separates middle from external ear. S Ossicles: malleolus, incus, stapes S Tympanic membrane Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 10

Ears and Hearing (Cont. ) S Inner ear structures S Vestibule S Semicircular canals S Cochlea S Inner ear functions S Cochlea transmits sound to CN VIII. S Semicircular canals are involved in vestibular function. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 11

Nose, Nasopharynx, and Sinuses S Function S Odor identification S Passage of inspired and expired air S Humidification, filtration, and warmth of inspired air S Resonance of laryngeal sounds Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 12

Nose, Nasopharynx, and Sinuses (Cont. ) S Structure S External nose S S Bone and cartilage Nares S Internal nose S Septum S Choanae S Turbinates S Cribriform plates S Kiesselbach plexus S Convergence of small fragile arteries and veins Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 13

Nose, Nasopharynx, and Sinuses (Cont. ) S Structure (Cont. ) S Sinuses S Maxillary S Frontal S Ethmoid S Sphenoid S Only the maxillary and frontal sinuses are accessible for physical examination. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 14

Mouth and Oropharynx S Function S Emission of air for vocalization and non-nasal expiration S Passage for food, liquids, saliva S Initiation of digestion by mastication and salivary secretion S Identify taste Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 15

Mouth and Oropharynx (Cont. ) S Structure S The bony arch of the hard palate and the fibrous soft palate form the roof of the mouth. S Loose, mobile tissue covering the mandibular bone forms the floor of the mouth. S The parotid, submandibular, and sublingual salivary glands are located in tissues surrounding the oral cavity. S The tonsils lie in the cavity between these pillars. S Swallowing is initiated when food is forced by the tongue toward the pharynx. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 16

Infants and Children S External auditory canal in infants shorter than in adults S Eustachian tube in infants wider, shorter, more horizontal than in adults S Salivation increased by 3 months Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 17

Infants and Children (Cont. ) S Twenty deciduous teeth usually erupt between 6 and 24 months of age. S Permanent teeth begin forming in the jaw by 6 months of age. S Eruption of the permanent teeth begins about 6 years of age and is completed around 14 or 15 years of age in most races. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 18

Older Adults S Nearly a third of adults older than 65 years have hearing loss S Age-related hearing loss is associated with: S Degeneration of hair cells in the organ of Corti S Loss of cortical and organ of Corti auditory neurons S Degeneration of the cochlear conductive membrane S Decreased vascularization of the cochlea Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 19

Older Adults (Cont. ) S Deterioration of the sense of smell results from loss of olfactory sensory neurons beginning at about 60 years of age. S 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. S eth are lost. S Difficulty chewing S Altered motor function of tongue S Difficulty swallowing Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 20

History of Present Illness S Vertigo (a false sense of motion) S Time of onset, duration of attacks S Description of attack S Associated symptoms S Unsteadiness, loss of balance, falling S Medications: ototoxic, salt retaining Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 21

History of Present Illness (Cont. ) S Ear pain S Onset, duration, course S Concurrent upper respiratory infection, frequent swimming, trauma to head S Associated symptoms S Method of ear canal cleaning S Medications: antibiotics, ear drops Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 22

History of Present Illness (Cont. ) S Hearing loss: one or both ears S Onset S Hears best S Speech S Associated symptoms S Management S Medications: ototoxic Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 23

History of Present Illness (Cont. ) S Nasal discharge S Character S Associated symptoms S Seasonality of symptoms S Tenderness over sinuses, face pain, headache Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 24

History of Present Illness (Cont. ) S Sinus pain S Fever, malaise, cough, headache, maxillary toothache, eye pain S Nasal congestion, colored nasal discharge S Tenderness or pressure over sinuses, pain increases when bending forward Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 25

History of Present Illness (Cont. ) S Dental problems S Pain S Swollen or bleeding gums, mouth ulcers or masses, tooth loss S Dentures or dental appliances S Malocclusion S Medications: phenytoin, cyclosporine, calcium channel blockers, mouth rinses Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 26

History of Present Illness (Cont. ) S Mouth lesions S Intermittent or constantly present, duration, painful or S S 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 Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 27

History of Present Illness (Cont. ) S Difficulty swallowing S Solids, liquids, or both S Feeling of food in throat, tightness, or substernal fullness S Drooling S Sore throat S Pain with swallowing S Exposure to dry heat, smoke, or fumes S Medications: antibiotics, nonprescription lozenges or sprays Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 28

Past Medical History S Systemic disease S Ear: frequent ear infections during childhood, surgery, labyrinthitis, antibiotic use; dosage and duration S Nose: trauma, surgery, chronic nosebleeds S Sinuses: chronic postnasal drip, recurrent or chronic sinusitis, allergies S Throat: frequent documented streptococcal infections, tonsillectomy, adenoidectomy Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 29

Infants and Children S Prenatal history S Prematurity S Breast-feeding, secondary tobacco smoke exposure, out-of- home child care S Congenital defect S Playing with small objects S Behaviors indicating hearing loss S Dental care Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 32

Older Adults S Hearing loss causing any interference with daily life S Physical disability S Deterioration of teeth, extractions, difficulty chewing S Dry mouth (xerostomia) S Medications that decrease salivation Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 33

Ears and Hearing S External ear S Inspect auricles S Size, shape, and symmetry S Landmarks and position on head S Color S Presence of deformities, lesions, or nodules S Inspect external auditory canal S Discharge and odor Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 35

Ears and Hearing (Cont. ) S Otoscopic examination S Used to inspect external auditory canal and middle ear S Inspect auditory canal from meatus to tympanic membrane S Discharge S Redness S Scaling S Lesions S Foreign bodies S Cerumen Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 37

Ears and Hearing (Cont. ) S Otoscopic examination (Cont. ) S Inspect tympanic membrane. S Landmarks S Color S Contour S Perforation S Use pneumatic attachment to evaluate mobility and compliance of tympanic membrane. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 38

Ears and Hearing (Cont. ) S Hearing evaluation S Evaluate auditory function. S Response to questions and directions S Whispered voice test S Compare air to bone conduction. S Weber test S Rinne test Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 39

Nose, Nasopharynx, and Sinuses S Nose S Inspect nose and nares. S Nose for shape, size, and color S Nares for flaring, narrowing, or discharge S Palpate nose. S Displacement of bone or cartilage S Tenderness S Masses S Evaluate patency of nares. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 40

Nose, Nasopharynx, and Sinuses (Cont. ) S Nasal cavity S Inspect nasal mucosa. S Color S Discharge S Masses or lesions S Swelling of turbinates Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 41

Nose, Nasopharynx, and Sinuses (Cont. ) S Sinuses S Inspect the frontal and maxillary sinus areas for swelling. S Palpate frontal and maxillary sinuses for tenderness. S Transillumination of the frontal and maxillary sinuses may be performed if sinus tenderness is present or infection is suspected. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 42

Mouth and Oropharynx S Oral cavity S Ask the patient to extend the tongue while you inspect for: S Deviation S Tremor S Limitation of movement S Lips S Inspect and palpate lips. S Symmetry S Color S Edema S Surface abnormalities Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 43

Mouth and Oropharynx (Cont. ) S Oropharynx S Inspect palate and uvula. S Evaluate movement of soft palate. S Inspect oropharynx with tongue blade. S Observe tonsillar pillars; note size of tonsils if present. S Note integrity of retropharyngeal wall. S Elicit gag reflex. S Tests the glossopharyngeal and vagus nerves (cranial nerves IX and X) Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 44

Infants S Nose and sinuses S Paranasal sinuses are poorly developed during infancy, and examination is generally unnecessary. S Ears S Inspect auricle for full formation and flexibility. S Auditory canals should be examined in first few weeks of life. S Tympanic membrane becomes conical after first few months of life. S Evaluate infant hearing using sound stimuli. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 45

Infants (Cont. ) S Mouth S Observe for drooling. S Inspect gums, teeth, and tongue. S Inspect palatal arch and soft palate. S Evaluate suck reflex. S Avoid depressing the tongue because this stimulates a strong reflex protrusion or the tongue, making visualization of the mouth difficult. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 46

Children S Because the young child often resists otoscopic and oral examinations, it may be wise to postpone these procedures until the end. S Be prepared to immobilize if encouraging the child to cooperate fails. S Another person, usually the parent, may be needed to effectively hold the child. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 47

Children (Cont. ) S Mouth S Inspect teeth for grinding, decay, and brown spots. S Check gag reflex, enabling brief view of mouth and oropharynx. S Inspect buccal mucosa. S Inspect tonsils and epiglottis. S Nose and sinuses S 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). Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 48

Older Adults S Ears and hearing S If hearing aid is worn, inspect auditory canal S S 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. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 49

Abnprmalities (Ear) S Acute otitis media S Inflammation in the middle ear, associated with a middle ear effusion that becomes infected by bacterial organisms S Otitis media with effusion S Inflammation of the middle ear resulting in the collection of serous, mucoid, or purulent fluid (effusion) when the tympanic membrane is intact Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 50

Abnormalities (Ear) S Hearing loss S Conductive hearing loss S Hearing loss resulting from reduced transmission of sound to the middle ear S Sensorineural hearing loss S 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 Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 51

Abnormalitiles (Ear) S Hearing loss S Ménière disease S Disorder of progressive hearing loss that in some cases has a genetic mode of transmission S Vertigo S Illusion of rotational movement by a patient, often due to a disorder of the inner ear S Ménière disease Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 52

Abnormalities (Mouth and Oropharynx) S Peritonsillar abscess S Deep infection in the space between the soft palate and tonsil S Acute pharyngitis S Infection of tonsils or posterior pharynx by microorganisms such as group A β-hemolytic streptococci or other streptococcal species, Neisseria gonorrhea, Mycoplasma pneumoniae Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 54