Head, Eyes, Ears, Nose, Mouth, & Neck Health Assessment Head, Eyes, Ears, Nose, Mouth, & Neck

ROS: Head Recent head trauma? Loss of consciousness? Headaches? Sinus, migraine, neurological Use of helmet when appropriate? Occupation, contact sports or cycling, rollerblading, and skateboarding

Face Inspection Inspect the face for: Facial expressions Symmetry Note symmetry of eyebrows, palpebral fissures, nasolabial folds, and sides of mouth. Facial expressions appropriate to situation. Face symmetrical without drooping or involuntary movements.

Skull Inspection/Palpation Normocephalic-round, symmetric skull that is appropriately related to body size Cranial bones with normal protrusions: forehead, lateral angle of parietal bone, occipital bones, mastoid process Palpate for masses or nodules Assess infant sutures for bulging or depressed/sunken appearance Normocephalic without masses, lesions, or tenderness.

TMJ Palpate ROM Muscle Strength In groove in front of ears Open and close Protrusion and retraction Lateral side-to-side motion Muscle Strength Bite down while palpating the masseter muscles Clench teeth while placing downward pressure on the chin TMJ with full ROM and 5/5 muscle strength. No popping, clicking, or tenderness noted.

Anatomy

Basics of Vision Light reflected from image Light passess through pupil and cornea bends incoming light rays so they will be focus on the inner retina Retina with sensory neurons Nerve impulses sent through optic disc

ROS: Eyes Any visual or eye complaints? Pain, photophobia, burning, itching, excess tearing or crusting, diplopia, blurred vision, “curtain over eye,” floaters, flashing lights, or halos Any personal or family history of eye disease? Glaucoma, retinopathy, cataracts, macular degeneration (Box 33-13) Closed angle (acute) is ocular emergency sudden ocular pain, halos, red eye, very high pressure in eye, n/v, decreased vision, fixed mid-dilated pupil Any history of eye trauma, diabetes, hypertension, or eye surgery?

ROS: Eyes Wear glasses or contacts? When was last exam by ophthalmologist or optometrist? <40 y/o every 3-5 years >40 y/o every 2 years >65 y/o, presence of eye disorder, or at risk for eye disease annually or more often if indicated Use of eye protection when appropriate Use of chemicals, welding, sawing, fencing, motorcycling

RN Chart Symptoms Burning Discharge Discomfort Dryness Ecchymosis Edema Itching Pressure Redness Sclera hemorrhage Stye Tearing Visual field loss

Vision Exam CN II ………. Snellen Chart Abnormal vision: Normal 20/20 Abnormal 20/30 or above Legally blind 20/200 with correction Abnormal vision: Hyperopia: farsighted Myopia: nearsighted Presbiopia: inability to accommodate due to weak ciliary muscles, and inability to bulge with near vision (leads to hyperopia) Diplopia: double vision due to weakness of extraocular muscles Vision by Snellen chart: O.D. 20/20, O.S. 20/30, O.U. 20/20

Confrontation tests/Peripheral Visual Fields Gross measure of a patient’s peripheral vision compared to that of your own Have your patient look at you in the eyes 2 ft away Move your fingers into the vision field and have the patient state “now” when they can see your fingers. Normal=when you can see your own fingers at the same time that the patient does If you find a defect, test each eye separate and establish the boundaries. Enlarged blind spots occur in glaucoma, optic neuritis and papilledema Peripheral visual fields intact by confrontation test.

Extraocular Muscles Six muscles attaching eyeball to orbit Extraocular muscles are stimulated by three cranial nerves CN VI (abducens) innervates the lateral rectus muscle (abducts the eye) CN IV (trochlear) innervated the superior oblique muscles (moves eye down and in) CN III (oculomotor) innervates all the rest: superior, inferior, medial rectus and the inferior oblique muscles.

Extraocular Muscles Extraocular Muscle function: test function of each muscle by asking the patient to move eyes (keep head still) through six cardinal positions of gaze. Normal: Eyes parallel without nystagmus. EOMs intact without nystagmus or lid lag.

Inspection Position and alignment of the eyes Abnormal protrusion in Graves’ disease, orbital tumors or inflammation Crossing of eyes (strabismus) with neuromuscular injury or inherited abnormalities Eyes without protrusion or sunken appearance. Eyebrows: quantity and distribution and scaliness of underlying skin Sparseness noted in hypothyroidism or elderly Eyebrows present bilaterally and move symmetrically. No scaling or lesions. Eyelids: Inspect Width of palpebral fissures, ptosis, edema of the lids, color of the lids, lesions, condition and direction of eyelashes, adequacy of eye closure Eyelids intact without redness, swelling, dc, or lesions.Eyelashes evenly distributed and curve outward.

Inspection Lacrimal apparatus: Inspect lacrimal gland and sac for redness & swelling Assess for excessive tearing or dryness No swelling of lacrimal apparateus noted. Puncta patent, without erythema, or tenderness. Conjunctiva and sclera: depress both lower lids with your thumbs, exposing the sclera and conjunctiva, ask the patient to look up/down and side/side to get a good view Assess color, vascular patterns, nodules or swelling. Conjunctiva clear, sclera white. No lesions or foreign bodies noted.

Inspection Pupils Size, shape and symmetry Pupillary reaction to light If pupils are large, small or unequal, measure them Pupillary reaction to light In a darkened room, have a patient look into the distance Shine a bright light obliquely into each pupil Direct reaction: pupillary constriction in the same eye Consensual reaction: pupillary constriction of the opposite eye PERRLA (only if perform accommodation). Pupils R 4/2 = L 4/2.

Pupils Accommodation: convergence of eyes, constriction of pupil as patient shifts gaze from a distance to a near object Documentation: PERRLA (Pupils Equal Round, Reactive to Light & Accommodating)

Inspection Cornea and lens Inspect for opacities (cataracts) with oblique lighting Smooth without opacities.

Ophthalmoscopic Exam Getting Started Start at the “0” diopters Use large, round beam of light Use your right hand and right eye for patient’s right eye, and your left eye for patient’s left eye Get close Darken room Have patient gaze at a distant object

Light Reflex Stand 15 inches away from the patient and off to the side of the patient, shine the light beam on the pupil and look for the orange glow in the pupil. Normally: light reflex. Abnormal: absent light reflex (may be due to opacity of the lens, i.e. cataract) Red reflex present bilaterally.

Examining the Optic Disc and Retina First, locate the optic disc (you can follow a blood vessel centrally to find it) Focus by adjusting the lens of your ophthalmoscope If the patient is nearsighted (myopic), rotate the lens disc counterclockwise to the minus diopters If the patient is farsighted (hyperopic), move the disc clockwise to the plus diopters You can correct your own refractive error in the same way

Ophthalmoscopic Exam Inspect for: General background of fundus Color, lesions Fundus red without lesions Optic Disc Sharpness or clarity of the disc outline Color of the disc, normally yellowish orange to creamy pink Size of the central physiologic cup (if present), usually yellowish white. The horizontal diameter is usually less than half the horizontal diameter of the disc. Normal Optic disc findings 1.5mm in size, round Margins sharp Demarcated from retina Optic disc creamy yellow, round, with sharply demarcated margins.

Abnormal Optic Disc Papilledema: swelling of the optic disc and anterior bulging of the physiologic cup. Related from increased intracranial pressure May be related to meningitis, trauma, mass, lesions

Ophthalmoscopic Exam Vessels Macula Arterioles brighter than veins, 25% smaller A:V ratio 2:3 Arterioles and veins cross each other without changing in diameter Observed vessels were without nicking. AV ratio 2:3 Macula Located 2 DD temporal to disc Color even and darker than rest of fundus May see fovea light reflex Macular dark red, even, and homogenous.

Ear Anatomy

Anatomy

Physiology Sound waves strike the tympanic membrane Vibrations transmit through the auditory ossicles (malleus, incus, stapes) to oval window Vibrations travel to cochlea and then to the round window CN VIII (acoustic) Nerve sends message to brain

The Aging Adult Decreased hearing because: Presbycusis Gradual sensorineural hearing loss caused by nerve degeneration in inner ear or auditory nerve Onset around 50 years old First notices a high-frequency tone loss Harder to hear consonants than vowels Words sound garbled Accentuated by background noise Music, dishes clattering, large party noise

The Aging Adult Auditory reaction time increases after age 70. Cilia lining the ear canal becomes coarse and stiff Decreased hearing as impedes sound waves Causes cerumen to accumulate and oxidize Cerumen drier due to atrophy of apocrine gland Auditory reaction time increases after age 70. Takes longer for the older adult to process sensory input and respond to it.

ROS: Ear How is your hearing? Use of hearing aid? Taking ototoxic drugs? Have you had any trouble with your ears or balance? Are you having any vertigo? (feeling as if the room is spinning, different from dizzy) Are you having any tinnitus? (musical ringing in the ear) Does anyone smoke in your household? Increased risk of otitis media in children

Inspection and Palpation Outer Ear: Auricles (pinna) Helix should be in a line extending from the eye the occipital area Symmetrical No masses, lesions, or tenderness Manipulate the pinna & tragus to assess for external otitis Ears equal bilaterally. No Swelling or thickening of cartilage. Skin intact without massess or lesions. No tenderness noted.

Examining the Ear Canal and Drum Use an otoscope with the largest ear speculum that the canal will accommodate Position the patient’s head so that you can see through the scope Straighten the ear canal be grasping the auricle firmly and pull it upward, backward and slightly away from the head Brace your hand against the patient’s face Insert the speculum gently into the ear canal, directing it somewhat down and forward

Examining the Ear Canal and Drum Inspect the ear canal Discharge, foreign bodies, redness of the skin and swelling Cerumen (wax) can be yellow to brown, soft or hard, may obscure your view External canal without erythema, edema, foreign bodies, lesions, or dc.

Inspect the Eardrum Identify the handle of the malleus Identify the short process of the malleus Inspect the pars flaccida and Pars tensa Normal Shiny, transparent, pearly gray, slight concave, non-bulging, no perforation TM gray and intact bilaterally without erythema, bulging, or retraction.

Abnormal TM

Auditory Acuity Estimating Hearing Occlude one ear of your patient Stand 1-2 feet behind patient Whisper a word (i.e. 88) Repeat with other ear Gross hearing intact by whisper test.

Auditory Acuity Weber Test Tap against palm and place midline vertex of head Normal: Hears equally in both ears Conductive hearing loss- best in impaired ear Sensorineural hearing loss- only in normal ear

Auditory Acuity Rinne Test Tap against palm and place on mastoid process. When no longer hears place 1-2 cm from ear until no longer hears Normal: AC>BC (2:1 ratio) Conductive hearing loss- BC=AC or BC>AC Sensorineural hearing loss- heard longer thru air, but less than 2:1 ratio

Nose and Paranasal Sinuses ROS Nasal congestion or runny nose (rhinorrhea)? Sneezing? Medications that may cause stuffiness? Pain, tenderness in the face over the sinuses? Is the pain limited to one side? Trauma or bleeding from the nose (epistaxis)?

Nose and Paranasal Sinuses Allergic Rhinitis Itching Swelling Rhinorrhea Sneezing Tearing eyes Later- stuffy nose, coughing, decreased smell, sore throat, dark circles under eyes

Nose and Sinuses Inspect the anterior and inferior surfaces of the nose Note any asymmetry or deformity Inspect for discharge Test patency Press on each nostril one at a time and have the patient breath in Palpate for any masses, lesions or tenderness Nose symmetrical midline. No deformities or skin lesions. Nares patent bilaterally.

Nose and Sinuses ……… Inspect the inside of the nose Inspect vestibule, septum and turbinates Color of nasal mucosa Foreign body Discharge (note color: clear, yellow, green, bloody) Masses, lesions, polyps Septum: deviation, perforation, bleeding Turbinates: color, swelling, exudate, polyps Normally no swelling, mucoid drainage; redder than oral mucosa Septum without deviation, perforation, or bleeding. Turbinates pink, without dc, edema, exudate, or polyp.

Nose and Sinuses Palpate for sinus tenderness Press up on the frontal sinuses from under the bony brows (avoid pressure on the eyes) Press up on the maxillary sinuses Normal: pt will feel pressure but no pain with palpation Frontal and maxillary sinuses nontender to palpation

Mouth and Pharynx ROS Sore throat Sore tongue Bleeding from the gums Tooth pain Hoarseness

Mouth and Pharynx Inspect lips Inspect oral mucosa (inside of mouth) Color Moisture Lumps Ulcers Cracking Symmetry Swelling (edema) Inspect oral mucosa (inside of mouth) With good light and a tongue blade, inspect for color, ulcers, white patches, and nodules. Lips pink and moist without cracking or lesions. Buccal mucosa pink without nodules or lesions.

Mouth and Pharynx Teeth/Gums Inspect for missing teeth, caries, conditions, discoloration Note the color of the gums Normal Pink Margins without swelling No bleeding Teeth white, straight, evenly spaced, clean and free of decay. Gums pink without swelling or bleeding.

Mouth and Pharynx Tongue Ask the patient to stick out his tongue Inspect for symmetry (CN XII) Note the color and texture of the dorsum of the tongue Deep fissures with dry mucosa could indicate dehydration Inspect the sides and undersurface of the tongue Inspect the floor of the mouth (these are the areas where cancer most often develops) Note any white or reddened areas, nodules, or ulcerations. Tongue pink, moist, without lesions.

Mouth and Pharynx … Pharynx With the patient’s mouth open, have the patient say “ah” As the patient says “ah” check the rise of the soft palate (CN X) Gag reflex (CN IX , X) If needed press a tongue blade firmly down upon the midpoint of the arched tongue Inspect the soft palate, anterior and posterior pillars, uvula, tonsils and pharynx Note color, swelling, ulceration Tonsillar enlargement Exudate Breath odor (halitosis) Soft palpate pink, rises midline. Tonsils pink without enlargement or exudate. Pharyngeal wall pink without exudate or lesions. No halitosis noted.

Neck ROS Neck pain? Lumps or swelling? History of neck surgery? History of neck trauma?

Neck Inspection & Palpation Inspect for: Head position Neck muscle symmetry Masses or scars Abnormal pulsations Neck supple & symmetrical Without masses, scars, or abnormal pulsations

Trachea Inspect Palpate Should be midline For tracheal shift Place finger in sternal notch and slip to each side. Trachea midline.

Cervical Lymph Nodes Palpate the lymph nodes Preauricular Use the pads of your index and middle fingers with a gentle rotary motion. Preauricular Posterior auricular Occipital Tonsilar Submandibular Submental Superficial cervical Posterior cervical Deep cervical chain supraclavicular

Cervical Lymph Nodes Note location, size, shape, delimitation, mobility, consistency and tenderness. Lymph nodes normally nonpalpable in healthy adults Small, soft, mobile, discrete, non-tender nodes (shotty) may be found in normal persons. Enlarged (>1cm) firm, tender, and freely moveable often indicates infection. Hard, non-tender, and fixed often indicates malignancy. Enlarged supraclavicular node, especially on left, suggests possible metastasis from thorax or abdomen No lymphadenopathy noted or lymph nodes nonpalpable.

Thyroid Gland Inspect first then palpate Assess for: Enlargement Goiter Consistency Symmetry Nodules Movement Thyroid nonpalpable