1. Eye, Ear & Maxillofacial Pathologies
Kimberly Lakhan, PA-C
SMDC ENT

2. Eye Anatomy

3. How to Use a Ophthalmoscope

4. Preparing your Equipment
Check the battery
Cover off
Familiarize self with dials & levers, set all to “0”
Light should be bright, round, white
Turn light down, dim

5. Preparing your patient
Warn then about the light
Position – sitting, looking on fixed spot over your shoulder - slightly out (Be Specific)

6. Your Position Eye to Eye (Left to left, Right to Right)
Try and keep your other eye open
Begin at arm’s length by shining light into the patient’s pupil.
Continue to move forward until your forehead rests on your thumb. The closer you are the wider your field of view.
Turn dial to focus on disc

7. What am I looking for?
Red reflex
Optic disc
Vessels
Macula

8. Eye Pathology Conjunctivitis Hyphema Lacerated Eye Lid
Corneal Abrasion
Orbital Fx
Ruptured Globe
Detached Retina
Strabismus
Aniscoria
Stye
Raccoon Eyes

9. Conjunctivitis

10. Hyphema

11. Lacerated Eyelid

12. Corneal Abrasion

13. Orbital Fracture (“Blow-Out”)

14. Rupture of Globe

15. Retinal Detachment

16. Strabismus

17. Anisocoria

18. Stye

19. Raccoon Eyes Bilateral Temporal Bone Fractures
Also look for bleeding from the ear canals and/or a hemotympanum (blood behind the ear drum)

20. Eye Referral Embedded object Decreased or partial vision Hyphema
Diplopia
Laceration of eyelid
Strabismus
Nystagmus
Inverted or everted eye
Eye swollen shut
Abnormal pupil size

21. Nasal Anatomy

22. Nasal Anatomy

23. Nasal Pathology Epistaxis Nasal Fracture Deviated septum
Perforated septum
Polyps

24. Epistaxis
Control the bleeding

25. Nasal Fracture

26. Deviated Septum

27. Perforated Septum

28. Nasal Polyps

29. Nasal Referral Unable to breath out of one or both nostrils
CSF coming from nose/Halo Sign Fx
Uncontrollable epistaxis

30. Ear Anatomy

31. Tympanic Membrane

32. Use of the Otoscope in Athletic Training

33. Objectives Briefly discuss the types and features of the otoscope
Provide an overview of otoscopic assessment procedures
Present a clinical teaching model for teaching your students to properly use the otoscope
Provide educational resources for teaching otoscopy

34. Types & Features of the Otoscope

35. Types of Otoscopes Clinical model $200 - $400+ Pocket style < $50

36. Features of the Otoscope
Power source
Battery (most common in athletic training clinical setting)
Electric
Light source
Incandescent bulb (produces a yellow light)
Hallogen bulb (best – produces a white light)

37. Features of the Otoscope
Magnifier
Not available on all models
Provides better view of tympanic membrane, particularly for beginners

38. Features of the Otoscope
Speculum
Variety of sizes
Reusable or disposable

39. Overview of Otoscopic Assessment

40. Examination of the Ear Special tests Otoscopic assessment History
Observation
Palpation
Special tests
Otoscopic assessment

41. Examination of the Ear History Trauma Allergies, colds, sinus drainage
Changes in pressure (flying, diving)
Dizziness
Changes in hearing
Duration of symptoms

42. Examination of the Ear Observation Redness Swelling Drainage
Foreign object
Cuts, scrapes, bruises

43. Examination of the Ear
Palpation
Gentle pressure on tragus

44. Examination of the Ear
Palpation
Traction on ear lobe & pinna

45. Otoscopic Assessment Evaluate the noninvolved ear first
This practice provides a basis for comparison AND prevents cross-contamination

46. Otoscopic Assessment Step 1:
Place your patient in a seated position with his/her head turned slightly downward and away from the ear to be examined

47. Otoscopic Assessment Step 1 (cont.):
the “puppy position” (puppies always cock their heads to the side when you talk to them)

48. Otoscopic Assessment Step 2:
Select the largest possible speculum that can be comfortably inserted into the ear

49. Otoscopic Assessment Step 2 (cont.):
When inserted, the speculum should fit snugly in the outer third of the canal and rest against the tragus and anterior wall of the canal
Modified from Middle Ear Conditions. Anatomical Chart Co. Skokie, IL, 1999.

50. Otoscopic Assessment Step 2 (cont.):
Choosing a speculum that is too small will cause movement within the canal
Excessive movement can cause discomfort for your patient
Modified from Middle Ear Conditions. Anatomical Chart Co. Skokie, IL, 1999.

51. Otoscopic Assessment Step 3:
Choosing a speculum that is too small will cause movement within the canal
Excessive movement can cause discomfort for your patient

52. Otoscopic Assessment Step 3 (cont.):
The otoscope should be stabilized by placing the ring and little finger resting on the patient’s cheek or temple

53. Otoscopic Assessment
Pencil Grip
Hammer Grip

54. Otoscopic Assessment Step 4:
Pull the pinna upward and backward to straighten the canal
Modified from Middle Ear Conditions. Anatomical Chart Co. Skokie, IL, 1999.

55. Otoscopic Assessment Step 5:
While maintaining traction on the pinna, place the speculum of the otoscope at, but not in the ear canal

56. Otoscopic Assessment Caution: Never insert the otoscope blindly
Always “Watch your way in”

57. Otoscopic Assessment Tip:
If the patient experiences pain, reposition the canal by adjusting the angle and degree of traction on the pinna

58. Otoscopic Assessment Caution:
If the patient’s discomfort persists even after readjustment of the canal, halt the examination and refer the patient to a physician.

59. Otoscopic Assessment Step 6:
Once the tympanic membrane comes into view, rotate the speculum to view as much of the membrane as possible
Marty DR. The Ear Book. Jefferson City, MO: Lang ENT Publishing. 1987;Color plate 1.

60. Otoscopic Assessment Tip
Like trying to view the corners of a room through a key hole
Marty DR. The Ear Book. Jefferson City, MO: Lang ENT Publishing. 1987;Color plate 1.
Modified from Middle Ear Conditions. Anatomical Chart Co. Skokie, IL, 1999.

61. Otoscopic Assessment Tip
The posterior inferior portion of the membrane is often difficult to see
Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53,54.
This is due to the angle of the membrane within the canal
Modified from Middle Ear Conditions. Anatomical Chart Co. Skokie, IL, 1999.

62. Otoscopic Assessment Step 7:
Inspect the membrane for color, clarity, & position
Pearly gray
Semitransparent
Not bulging or retracted L R
Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53,54.

63. Otoscopic Assessment Step 8: Identify key landmarks Malleus
Short process
Malleus
Manubrium
Short process
Umbo
Umbo L R
Light reflex
Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53,54.

64. Otoscopic Assessment Step 8 (cont.): Identify key landmarks
Note that manubrium angles toward the 10 o’clock position in the left ear and the 2 o’clock position in the right ear L R
Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53,54.

65. Otoscopic Assessment Step 8 (cont.): Identify key landmarks
Pars flaccida
Step 8 (cont.):
Identify key landmarks
Pars flaccida
Pars tensa L
Annulus R
Pars tensa
Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53,54.

66. Otoscopic Assessment Step 8 (cont.): Identify key landmarks Stapes
Look beyond the membrane
Stapes
Incus
Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53.

67. Otoscopic Assessment Step 9: Look for abnormalities Fluid Perforations
Fluid & Air Bubbles
Perforation
Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994; 29:54.
Marty DR. The Ear Book. Jefferson City, MO: Lang ENT Publishing. 1987;Color plate 8.

68. Otoscopic Assessment Step 10:
Work with your team physician to develop your confidence and skill
PRACTICE, PRACTICE, PRACTICE !!!
You must look at many ears to develop to become comfortable with “normal”

69. Ear Pathology Hematoma Auris Otitis Externa Otitis Media
Perforated/ruptured tympanic membrane

70. Hematoma Auris

71. Otitis Externa

72. Otitis Media

73. Perforated membrane

74. Ear Referral Blood or CSF coming from ear Battle’s sign
Hearing loss or diminished in one or both ears

75. Guided, Self-Directed Activities
Content
Recognition of pathology – visual images
Perforation
Middle ear fluid
Marty DR. The Ear Book. Jefferson City, MO: Lang ENT Publishing. 1987;Color plate 8.
Marty DR. The Ear Book. Jefferson City, MO: Lang ENT Publishing. 1987;Color plate 3.

76. Guided, Self-Directed Activities – Post Lab
Content
Recognition of pathology – visual images
Perforation
Otitis Media
Modified from Middle Ear Conditions. Anatomical Chart Co., Skokie, IL
Modified from Middle Ear Conditions. Anatomical Chart Co., Skokie, IL

77. Facial/Tooth Anatomy

78. Tooth Pathology Tooth Fx Jaw Fx Tooth Intrusion Tooth Luxation
Tooth Extrusion

79. Tooth Injuries - Fx

80. Jaw Fx

81. Tooth Intrusion

82. Tooth Luxation
Lingual Displacement
Facial Displacement/Luxation

83. Tooth Extrusion

84. Facial Lacerations/Stitches

85. Tooth/Facial referral
Suspected Fx
Lacerations that need stitches
Fx Tooth
Avulsed tooth
Malocclusion
P c breathing
TMJ dislocation
When accompanied by closed head injury

86. Tonsil Anatomy
Uvula
Tonsil

87. Tonsil Grade Slide 25 — Tonsil Grade
The grade of the tonsils increases with tonsillar size. Grade 4 is often referred to as “kissing” tonsils.

88. Other ENT Pathologies
Rhinitis
Tonsillitis
Strep Throat

89. Other ENT Pathologies
Laryngitis
Pharyngitis
Sinusitis

90. Antibiotics and URIs Difficult to determine if Viral or Bacteria cause
Many physicians treat with antibiotics regardless

91. Summary
A directed history and thorough physical exam are key.