1. Ears, Nose, Mouth, Throat

2. Ears

3. Summary of any symptom should include PQRSTU
P= provocative or palliative
Q= quality or quantity
R= region or radiation
S= severity scale
T= timing (onset, duration, frequency)
U= understand client’s perception

4. Anatomy The ear is responsible for hearing and balance
Consists of 3 regions
External ear
Middle ear
Inner ear

5. Structure and Function
External Ear – auricle/pinna
movable cartilage and skin
Mastoid process= important Landmark
External Auditory Canal – the opening in the external ear; cul-de-sac 2.5 to 3 cm. Long in adult and ends at the eardrum.
Lined with glands that secrete cerumen

9. External Ear 2 types of cerumen
Whites and blacks – wet, sticky, and honey colored
Asians and Native Americans – dry and flaky
Lubricates & protects
Moves to meatus with chewing & talking
Outer 1/3 of canal is cartilage, inner 2/3 consists of bone covered with skin

11. External Ear
Tympanic membrane (eardrum) separates external and middle ear.
Translucent membrane
Pearly, gray color
Cone of light reflection when using otoscope
Oval and slightly concave shape, pulled in at center by malleus

13. External Ear Malleus (hammer) – one of the middle ear ossicles 3 parts
Umbo, manubrium short process, may show through the drum
Lymphatic drainage of the external ear flows into
Parotid, mastoid, superficial cervical nodes

14. Middle ear Tiny air–filled cavity in the temporal bone contains:
Auditory ossicles (bones)
Malleus
Incus
Stapes
Openings to
Outer ear covered by tympanic membrane
Inner ear = oval and round windows
Eustachian tube connects middle ear to the nasopharnyx for air passage (normally closed, opens with swallowing/yawning)

15. Middle ear has 3 functions
Conducts sound vibration from outer ear to inner ear
Protects the inner ear by reducing the amplitude of loud sounds
Eustachian tube allows equalization of air pressure on each side of the ear drum to avoid rupture ( high altitudes)

16. Inner Ear
Contains the Bony Labyrinth which holds the sensory organs for hearing and equilibrium
Vestibule
Semicircular canals
Cochlea (contains the central hearing apparatus)

17. Function of hearing 3 levels
Peripheral – ear transmits sound and converts its vibrations into electrical impulses that can be analyzed by the brain. The electrical impulses are conducted by the auditory process of cranial nerve VIII (Acoustic) to the brain stem
Amplitude=loudness
Frequency=pitch

18. Sound waves cause the eardrum to vibrate
Vibrations travel via the ossicles thru the oval window, the cochlea and are scattered against the round window
The basilar membrane of the cochlea contain the organ of Corti receptor hair cells that translate the vibrations to electric impulses
The impulses go to the brainstem via Acoustic nerve (VIII)

19. Brain stem – function is binaural interaction – permits identification of sound and locating the direction of a sound in space. The acoustic nerve (Cranial nerve VIII) sends signals from each ear to both sides of the brain stem. Brainstem is sensitive to intensity & timing from the ears depending on head position

20. Cerebral cortex – interprets the meaning of the sound and begins the appropriate response

21. Pathways of hearing
Air conduction (AC)– normal pathway of hearing, the most efficient
Bone conduction (BC)– bones of the skull vibrate and transmit vibrations to the inner ear and acoustic nerve

23. Hearing loss
Conductive – mechanical dysfunction of the external or middle ear resulting in partial hearing loss (if ↑ amplitude to reach nerve elements in inner ear, person can hear)
Causes= impacted cerumen, FB, perforated eardrum, pus/bld in the middle ear, otosclerosis

24. Hearing loss
Sensorineural ( perceptive) – pathology of the inner ear, acoustic nerve or auditory areas of the cerebral cortex. ↑ amplitude may not help
Causes= Presbycusis, a nerve degeneration due to aging (50yrs) or ototoxic drugs
Equilibrium – labyrinth feeds info to the brain about the body’s position in space, inflammation causes vertigo.

25. Subjective data Earaches Infections- otitis media Discharge
Hearing loss
Environmental noise
Tinnitus- ototoxic: ASA, Aminoglycosides (gentamicin) etc.
Vertigo
Self care behaviors

26. Objective data External ear = Inspect and Palpate Size and shape
Skin condition
Tenderness- pinna & tragus; mastoid process
External auditory meatus- cerumen

27. Inspect using Otoscope
Pull pinna up & back for adult/older child
Pinna down for infant & ↓ 3yrs. Maintain hold on pinna until exam is complete.
Avoid inner, bony section of canal= sensitive to pain
Can angle otoscope towards nose

28. Inspect using Otoscope
External canal
Color
Swelling
Lesions
Discharge ; color and odor. Clean or change speculum before examining other ear.

30. Perform the otoscope exam prior to hearing tests.

31. The following slide show a furuncle which is an infected hair follicle

33. Tympanic membrane Color – normal is shiny, translucent, pearl-grey
Characteristics – landmarks; umbro, manubrium, and short process
Position – flat, slightly pulled in at the center and flutters when person holds nose and swallows
Integrity of membrane – intact? Scarring = dense white patch

34. Hearing tests Begins with the history-Conversational tone
The following tests may indicate the presence of hearing loss but not the degree.

35. Hearing tests
Voice– place a finger on the tragus of one ear and while rapidly pushing it in and out of the meatus, place your head 1 –2 feet from your client’s other ear, shield your lips and whisper a 2 syllable word. Repeat on the opposite ear using another word, have the client identify the words (Used to detect high-tone loss)

36. Normal Response to Voice test
Correct identification of whispered words bilaterally

37. Tuning fork tests- measure hearing by AC and BC
To activate the tuning fork, hold it by the stem and strike the tines softly on the back of the hand
Weber test – used when hearing is reported as better in one ear than other (bone conduction)

38. Normal finding for the Weber test is
Tone heard = loud bilaterally
If sound lateralizes to one ear it indicates conductive or sensorineural loss.

39. Rinne test – compares bone conduction and air conduction
Normally sound is heard 2X as long by air conduction as by bone conduction
Normal response ; positive Rinne Test = AC>BC Bilaterally
Sound is heard longer by BC with a conductive loss.

40. Weber test
Rinne test

41. Nose, Throat and Mouth

42. Nose First segment of the respiratory system
Warms, moistens and filters inhaled air
Sensory organ for smell

43. External parts Bridge Tip Nares Vestibule -nares widen in to vestibule
Columella divides the nares
Ala –lateral outside wing of the nose bilaterally
Upper 1/3 nose is bone; rest is cartilage

44. Internal Nasal cavity, extends back over the roof of the mouth
Nasal hair, ciliated mucous membrane – red due to ↑ bld supply
Septum-divides cavity into 2 passages

45. Internal
Superior, middle, inferior turbinates- 3 parallel bony projections on lateral walls of each cavity
Meatus- cleft underlying each turbinate. The sinuses drain into the middle, tears from the nasolacrimal duct drain into the inferior

47. Internal
Olfactory receptors- in roof of the nasal cavity & upper part of septum. Merge into the olfactory nerve (I) goes to the temporal lobe of the brain

49. Foreign Body

51. Paranasal sinuses- air- filled pockets in the cranium Purpose
↓ wt. of the skull
Serve as resonators for sound
Provide mucous for the nasal cavity
Sinus openings are narrow = susceptible to occlusion resulting in inflammation/sinusitis

52. Frontal sinuses
Maxillary sinuses
Ethnoid sinuses
Sphenoid sinuses
Frontal & Maxillary sinuses are accessible to examination

55. Mouth First segment of the digestive system
Airway for the respiratory system
ORAL CAVITY
Lips
Palate
Hard
Soft
Uvula – hangs down from the soft palate

56. Cheeks- side walls of cavity Tongue
Papillae- rough, bumpy elevations on dorsal
Frenulum
Taste buds
Teeth – 32 permanent

58. Salivary glands
Parotid- largest of the glands, located in the cheeks, front of the ear. Stenson’s duct opens in buccal mucosa
Submandibular- walnut size, beneath the mandible at the angle of the jaw. Wharton’s duct either side of the frenulum
Sublingual –smallest, almond shape, under tongue

60. Throat Area behind the mouth & nose
Oropharynx – separated from the mouth by a fold of tissue on each side called anterior tonsillar pillars
Tonsils – lymphoid tissue behind pillars

61. Posterior pharyngeal wall located behind the tonsils
Nasopharynx continues from the oropharynx but it is above it and behind the nasal cavity. It holds the adenoids and the eustachian tube openings.

62. Subjective data Nose Discharge Frequent colds Sinus pain Trauma
Epistaxis
Allergies
Altered smell

63. Subjective data Mouth and Nose
Sores, lesions
Sore throat
Bleeding gums
Toothache
Hoarseness
Dysphagia
Altered taste

64. Smoking
Alcohol intake
Self care behaviors

65. Objective behavior Nose – Inspect and palpate INSPECT for:
Symmetry, deformity
Inflammation
Skin lesions
Color
If injury – palpate gently

66. Test for Patency
Test for Sense of Smell – Cranial nerve I (olfactory)

67. Inspect nasal cavity/ septum
Deviated septum?
Can see middle & inferior turbinates

68. Inspect and palpate Paranasal Sinuses
Press thumbs over frontal & maxillary sinuses
Transillumination for sinus inflammation
Frontal & Maxillary sinuses
Darken room

71. Mouth - Inspect Use gloves, tongue depressor, light Lips Teeth Gums
Buccal mucosa –Stenson’s duct (parotid)
Palate

74. Throat - Inspect Tonsils Posterior pharyngeal wall
Grade size 1+ visible
…………….2+ ½ way b/t tonsillar pillars and uvula
…………… touching the uvula
…………… touching each other
Posterior pharyngeal wall
Gag reflex cranial nerves IX = glossopharyngeal and X = Vagus
Cranial nerve XII = hypoglossal- stick out tongue
Halitosis – Due to ????