Ears, Nose, and Throat

Otoscope with pneumatic attachment


image Tuning fork (512-1024 Hz)

image Nasal speculum

image Tongue blades

image Gloves

image Gauze

image Penlight, sinus transilluminator, or light from otoscope




EXAMINATION


Have patient sit.











































































































TECHNIQUE FINDINGS
EARS
Inspect auricles and mastoid area
Examine lateral and medial surfaces and surrounding tissue.  

image
 
imageSize/shape/symmetry EXPECTED:Familial variations. Auricles of equal size and similar appearance. Darwin tubercle.
UNEXPECTED:Unequal size or configuration. Cauliflower ear and other deformities.
imageLesions UNEXPECTED:Moles, cysts or other lesions, nodules, or tophi.
imageColor EXPECTED:Same color as facial skin.
UNEXPECTED:Blueness, pallor, or excessive redness.

imagePosition

Draw imaginary line between inner canthus and most prominent protuberance of occiput. Draw imaginary line perpendicular to first line and anterior to auricle.

 EXPECTED:Top of auricle touching or above horizontal line. Vertical position.
UNEXPECTED:Auricle positioned below line (low-set); unequal alignment. Lateral posterior angle greater than 10 degrees.
imagePreauricular area EXPECTED:Preauricular pits, skin tags, or smooth skin.
UNEXPECTED:Openings in preauricular area, discharge.
imageExternal auditory canal EXPECTED:No discharge, no odor; canal walls pink.
UNEXPECTED:Serous, bloody, or purulent discharge; foul smell.
Palpate auricles and mastoid area
  EXPECTED:Firm and mobile, readily recoils from folded position; no tenderness in postauricular or mastoid area.
UNEXPECTED:Tenderness, swelling, nodules. Pain when pulling on lobule.
Inspect auditory canal with otoscope
  EXPECTED:Minimal cerumen in varying color and texture. Uniformly pink canal. Hairs in outer third of canal.
UNEXPECTED:Cerumen obscures tympanic membrane, odor, lesions, discharge, scaling, excessive redness, foreign body.
Inspect tympanic membrane

imageLandmarks

Vary light direction to observe entire membrane and annulus.

 EXPECTED:Visible landmarks (umbo, handle of malleus, light reflex).
UNEXPECTED:Perforations, landmarks not visible.
imageColor EXPECTED:Translucent, pearly gray.
UNEXPECTED:Amber, yellow, blue, deep red, chalky white, dull, white flecks, or dense white plaques; air bubbles or fluid level.


Tympanic membrane. From Barkauskas et al, 2001.

image
 
Contour EXPECTED:Slightly conical with concavity at umbo.
UNEXPECTED:Bulging (more conical, usually with loss of bony landmarks and distorted light reflex) or retracted (more concave, usually with
  accentuated bony landmarks and distorted light reflex).

Mobility

Seal canal with speculum, and gently apply positive (squeeze) and negative (release) pressure with pneumatic attachment.

 EXPECTED:Movement in and out.
UNEXPECTED:No movement.
Assess hearing
imageQuestions during history EXPECTED:Responds to questions appropriately.
UNEXPECTED:Excessive requests for repetition. Speech with monotonous tone and erratic volume.

imageWhispered voice

Have patient mask hearing in one ear by inserting a finger in ear canal. Stand 1 to 2 feet from other ear and softly whisper three letter and number combinations (e.g., 3, T, 9 or 5, M, 2). Use a different letter number combination in other ear.

 EXPECTED:Patient repeats numbers and letters correctly more than 50% of time.
UNEXPECTED:Patient unable to repeat whispered words.

imageWeber test

Place base of vibrating tuning fork on midline vertex of head. Repeat with one ear occluded.

 EXPECTED:Sound heard equally in both ears (unoccluded). Sound heard better in occluded ear.
UNEXPECTED:See table on p. 84.


Weber test.

image
 




















Interpretation of Tuning Fork Tests
  Weber Test Rinne Test
Expected findings No lateralization but will lateralize to ear occluded by patient Air conduction heard longer than bone conduction by 2 : 1 ratio (Rinne positive)
Conductive hearing loss Lateralization to deaf ear unless sensorineural loss Bone conduction heard longer than air conduction in affected ear (Rinne negative)
Sensorineural hearing loss Lateralization to better-hearing ear unless conductive loss Air conduction heard longer than bone conduction in affected ear, but less than 2 : 1 ratio











imageRinne test

Place base of vibrating tuning fork against mastoid bone, note seconds until sound is no longer heard; then quickly move fork 1 to 2 cm (image to 1 inch) from auditory canal and note seconds until sound is no longer heard. Repeat with other ear.

 EXPECTED:Measurement of air-conducted sound twice as long as measurement of bone- conducted sound.
UNEXPECTED:See table below.


Rinne test. A, Tuning fork against mastoid bone. B, Tuning fork near ear.

image image
 







































































TECHNIQUE FINDINGS
NOSE AND SINUSES
Inspect external nose
imageShape/size EXPECTED:Smooth. Columella directly midline, width is not greater than diameter of naris.
UNEXPECTED:Swelling or depression of nasal bridge. Transverse crease at junction of nose cartilage and bone.
imageColor EXPECTED:Conforms to face color.
imageNares EXPECTED:Oval. Symmetrically positioned
UNEXPECTED:Asymmetry, narrowing, discharge, nasal flaring on inspiration.
Palpate ridge and soft tissues of nose
Place one finger on each side of nasal arch and gently palpate from nasal bridge to tip. EXPECTED:Firm and stable structures.
UNEXPECTED:Displacement of bone and cartilage, tenderness, or masses.
Evaluate patency of nares
Occlude one naris with finger on side of nose, ask patient to breathe through nose. Repeat with other naris. EXPECTED:Noiseless, easy breathing.
UNEXPECTED:Noisy breathing; occlusion.
Inspect nasal mucosa and nasal septum
Tilt patient’s head toward opposite shoulder. Gently insert speculum without overdilating naris.  
imageColor EXPECTED:Mucosa and turbinates deep pink and glistening.
  UNEXPECTED:Increased redness of mucosa or localized redness and swelling in vestibule. Turbinates bluish gray or pale pink.
imageShape EXPECTED:Septum close to midline and fairly straight, thicker anteriorly than posteriorly. Inferior and middle turbinates visible.
UNEXPECTED:Asymmetry of posterior nasal cavities, septal deviation.
imageCondition EXPECTED:Possibly film of clear discharge on septum. Possibly hairs in vestibule. Turbinates firm consistency.
UNEXPECTED:Discharge, bleeding, crusting, masses, or lesions. Swollen, boggy turbinates. Perforated septum. Polyps.
SENSE OF SMELL
See Chapter 18.  
Inspect frontal and maxillary sinus area
  UNEXPECTED:Swelling.


Sinuses.

image

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Mar 25, 2017 | Posted by in PHYSIOLOGY | Comments Off on Ears, Nose, and Throat

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