Copyright © 2015 by Mosby, an imprint of Elsevier Inc. . Chapter 12 Ears, Nose, and Throat

Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  It is the supreme art of the teacher to awaken joy in creative expression and knowledge." --Albert Einstein

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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. 3

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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. 4

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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 5

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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. 6

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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. 7

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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). 8

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Ears and Hearing  External structures  Auricle  External auditory canal  External functions  Protective  Helps gather and channel sound 9

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

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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. 11

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

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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 13

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

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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 15

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Mouth and Oropharynx (Cont.)  Structure  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.  The parotid, submandibular, and sublingual salivary glands are located in tissues surrounding the oral cavity.  The tonsils lie in the cavity between these pillars.  Swallowing is initiated when food is forced by the tongue toward the pharynx. 16

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Infants and Children  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 17

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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. 18

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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 19

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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.  eth are lost.  Difficulty chewing  Altered motor function of tongue  Difficulty swallowing 20

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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 21

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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 22

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

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

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. History of Present Illness (Cont.)  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 25

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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 26

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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 27

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

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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 29

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Family History  Hearing problems or hearing loss, Ménière disease  Allergies  Hereditary renal disease 30

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Personal and Social History  Environmental hazards  Nutrition  Oral care patterns  Tobacco use  Alcohol use  Intranasal use of cocaine 31

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

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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 33

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. . Examination and Findings 34

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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 35

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Ears and Hearing (Cont.)  Palpate auricles and mastoid area  Tenderness or pain  Swelling  Nodules 36

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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 37

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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. 38

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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 39

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Nose, Nasopharynx, and Sinuses  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. 40

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

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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. 42

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

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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) 44

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Infants  Nose and sinuses  Paranasal sinuses are poorly developed during infancy, and examination is generally unnecessary.  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. 45

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Infants (Cont.)  Mouth  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. 46

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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. 47

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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.  Nose and sinuses  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). 48

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 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. 49

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Abnprmalities (Ear)  Acute otitis media  Inflammation in the middle ear, associated with a middle ear effusion that becomes infected by bacterial organisms  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 50

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Abnormalities (Ear)  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 51

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Abnormalitiles (Ear)  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 52

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Abnormalities (Sinuses)  Sinusitis  Bacterial infection of one or more of the paranasal sinuses 53

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Abnormalities (Mouth and Oropharynx)  Peritonsillar abscess  Deep infection in the space between the soft palate and tonsil  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 54

Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Abnormalities (Children)  Cleft lip and Palate 55