Head, Ears, Nose, & Oropharynx

Examination techniques for the head

Primarily inspection, palpation, limited ausculation

What should you look for while inspecting the head?

-Size, shape, and positioning(posturing)
-Symmetry (bilaterally)
-Scalp (hair distribution, color, texture, moisture & dandruff, fungal Infections, or infestations)
-Face (presence of pathological facies)

Acromegaly

enlargment of facial features
-associated with an overproduction of Human growth hormone
-increased frontal fossa (forehead), brow furrow, enlargement of the base of the nose, thickening of lips, parotid hypertrophy (puffy cheeks), and loss of oval facial features

Myxedema

-dry, coarse, sparse hair, lateral eyebrow thinning, periorbital edema, & puffy dull face with dry skin
-hypothyroidism

Cushing's Syndrome

round face ("moon face"), Hirsutism (increased hair growth), hump in upper back

Parotid Gland Enlargement

puffy cheeks, rapid, painful inflammation

Facial signs of Parkinson's Disease

-decreased facial mobility (mask like appearance), stare from decreased blinking, upper trunk tends to flex forward

Nephrotic syndrome (facial signs)

-face become edematous & pale
-periorbital edema (swelling around the eye)- eyes become slit-like
-swollen lips (specifically with glomerular disease)

examination techniques of external ear

inspection, palpation, movement

keloid

-Firm, nodular, hypertrophic mass of scar
tissue
-Can develop from an ear piercing

Chondrodermatitis Nodularis Helicus (CNH)

-painful and tender papule on the helix or antihelix
-reddening, crusting, & ulceration may be present

Tophi

hard nodules on the helix that may discharge chalky white discharge
-can also develop on hands, joints, feet, and other areas (from chronic high levels of uric acid)

Rheumatoid nodules

small lumps on the helix in people who suffer from rheumatoid arthritis
-may be present on hands, ulnar surfaces, knees, heels, etc.

Otoscopic examination is used for

auditory canal and tympanic membrane visualization

Normal eardrum appearance

-Pinkish gray and clear, not retracted or bulging
-Malleus visible behind upper part of eardrum
-Cone of light at 4-5 o'clock position
-Pars flaccida and pars tensa
-Part of incus visible posteriorly to malleus
-Small blood vessels along handle of malleus

Otitis Externa

infection of the ear canal, "swimmer's ear"
-signs: exudates and crusting of exudates, pulling and pushing (tug test) is painful, erythema and edema of ear canal

Acute Otitis Media w/ purulent effusion

middle ear infection, common in children
-bulging tympanic membrane (causes cone of light displacement), erythema (can't see bony landmarks bc of redness), patient complaining of pain behind ear, conductive hearing loss (from blockage with pus)

Serous Effusion/Serous Otitis Media

amber fluid behind the tympanic membrane
-patient reports fullness, crackling, or popping
-membrane is clear to pink in color
-can see bubbles of fluid

Bullous Myringitis

painful hemorrhagic vesicles appear on TM, ear canal, or both
-sx: earache, blood tinged discharge, conductive hearing loss

Tympanic Membrane perforation

Tear/trauma to the tympanic membrane
-two types: central and marginal
-patient likely to report decreased hearing, history of trauma, and headaches

Tympanosclerosis

Large chalky white patch with irregular margins in the eardrum
-scarring of TM from severe otitis media, usually doesn't impair hearing

What are the two pathways of hearing?

air conduction and bone conduction

Air conduction

air vibrations move through ear canal, hits TM, ossicles, cochlea, brain

Bone conduction

vibrations hit the skull and move straight to cochlea then brain

Air conduction is normally ____ than bone conduction

longer

Auditory Acuity test

-assesses the clarity or sensitivity of hearing
-ex. testing each ear by occluding the other and rubbing fingers/whispering/ticking watch close then away from ear

Weber test

Test done by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate in which ear the tone can be heard
-lateralization (hearing better in one ear) is a sign to do other testing

Rinne Test

hearing acuity test performed with a vibrating tuning fork that is first placed on the mastoid process and then in front of the external auditory canal to test bone and air conduction

Problems with conduction are caused by issues in the...

external ear and middle ear that impair sound conduction to inner ear

Sensorineural problems are caused by issues in the...

inner ear (ex. cochlea), eighth cranial nerve, and CNS

Conductive hearing loss- age on onset

childhood to young adulthood (up to 40 years old)

Sensorineural hearing loss- age of onset

middle or late years

Conductive hearing loss- effects

little effect on sound
hearing seems to improve in noisy environment
voice remains soft b/c inner ear and cochlear nerve is intact

Sensorineural hearing loss- effects

higher registers are lost
hearing worsens in noisy environment
voice is loud

Conduction hearing loss (Weber and Rinne results)

Rinne: Bone > air
Weber: lateralized to the "bad"/affected ear

Sensorineural hearing loss (Weber and Rinne results)

Rinne: Air > Bone
Weber: lateralized to the "good"/unaffected ear

Examination techniques for the nose

external inspection, palpation, internal examination (inspect turbinates, mucosa, septum)

epistaxis

bleeding from the nose
-most commonly caused by "digital trauma" or picking of nose
-spontaneous is caused by dryness

Anosmia

absence of the sense of smell/complete loss
-rare

Acute bacterial sinusitis

serious bacterial infection following an URI
-fever, malaise, severe frontal or paranasal sinus pain, purulent nasal discharge, pain aggravated by head positioning, red, swollen, tender, and warm to touch

Examination techniques of the mouth

Inspection with selective palpation

Angular chellitis

erythema and edema at the angles of the mouth, then fissures

Actinic chellitis

lip (mainly lower lip) becomes scaly, somewhat thickened, and slightly everted
-predisposition to SCC

Herpes simplex of lip (cold sore, fever blister)

recurrent and painful vesicular eruptions
-first a small cluster of vesicles then rupture and yellow/brown crust forms
-healing takes 10-14 days

Angioedema

erythema and edema of the lip mucosa (localized swelling)
-can be life threatening (think anaphylaxis)

Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)

multiple small red spots on lips (telangiectasia on oral mucosa)

Peutz-Jeghers syndrome

small brown pigmented spots in the dermal layer of the lips, buccal mucosa, & perioral area
-increased risk for GI and other cancers

Chancre of primary syphilis

ulcerated papule with an indurated edge
-appears 3-6 weeks after initial infection

Carcinoma of the lip (SCC)

scaly plaque, ulcer w/ or w/o crust, nodular lesion that does not heal
-usually on the lower lip

Marginal gingivitis

Gingival margins are reddened and swollen & interdental papillae are blunted, swollen, & red
-common in adolescents, early adulthood, pregnancy

Acute necrotizing ulcerative gingivitis

ulcers in interdental papillae, necrotizing process spreads along gum lines, gums are red & painful, bleed easily, foul breath, fever and malaise, enlarged lymph nodes

Gingival hyperplasia

gums are red, enlarged, & swollen; so much that they may cover the teeth

Pregnancy Epulis or Pyogenic Granuloma (Pregnancy Tumor)

red purple papules of granulation tissue that form in the gingival interdental papillae, nasal cavity, & sometimes on fingers

Attrition of teeth

chewing surfaces of teeth are worn down by repetitive use → yellow-brown dentin becomes exposed

Recession of gums

"long tooth" appearance
-occurs commonly in elderly people

Abrasion of teeth with notching

The biting surface of the teeth may become abraded or notched by recurrent trauma
-holding nails or opening bobby pins between the teeth

Hutchinson teeth in congenital syphilis

teeth are smaller & more widely spaced than normal & are notched on biting surfaces
-sides of teeth taper to biting edge

Geographic tongue (benign migratory glossitis)

scattered smooth red areas denuded of papillae with normal rough and coated areas
-map like patterns

Fissured tongue

benign condition characterized by deep grooves (fissures) in the top surface of the tongue
-"furrowed tongue"; common with increased age

Candidasis (Thrush)

thick white coating from candida infection that CAN be scraped off
-immunosupression from chemo and prednisone treatment

Black hairy tongue

"hairy" yellowish to brown and black hypertrophied and elongated papillae on the tongue's dorsum
-benign condition associated with Candida and bacterial overgrowth, antibiotic therapy, and poor dental hygiene

Smooth Tongue (Atrophic Glossitis)

smooth and often sore tongue without papillae
-assoc w/ deficiencies in riboflavin, niacin, folic acid, vit B12, pyridoxine, iron, or tx w/ chemotherapy

Oral hairy leukoplakia

White raised asymptomatic plaques with a feather pattern on sides of tongue that CANNOT be scraped off
-assoc w/ EBV, HIV, AIDS

Varicose veins of the tongue

small purplish or blue black round swellings under the tongue
-appear with age

Apthous ulcer (canker sore)

painful, shallow whiteish-gray oval ulceration surrounded by halo of reddened mucosa
-assoc w/ Bechet disease

Mucous Patch of Syphilis

slightly raised, oval lesion, covered by a grayish membrane
-painless lesion of secondary syphilis

Tori mandibulares

rounded bony growths on inner surface of the mandible
-typically bilateral, asymptomatic, and harmless

Carcinoma, floor of mouth

ulcerated lesion, reddened area of mucosa (erythroplakia)

Large normal tonsils

tonsils may protrude medially behind pillars & to midline, pink color, with no exudates
-no infection

Exudative tonsils

red throat w/ white exudate on tonsils.
-assoc sx: fever, enlarged cervical lymph nodes
-indicate strep throat or mono infection

Pharyngitis

Reddened throat w/o exudate.
-can be viral or bacterial
-sore throat, erythema, edema, scratchy throat

Diphtheria

throat is dull, red, and a grey exudate (pseudomembrane) is present on uvula, pharynx, and tongue
-life threatening b/c airway may become obstructed

Thrush on the Palate (Candidiasis)

thick, white, plaques adhering to underlying mucosa
-yeast infection (candida overgrowth); prolong antibiotic treatment, corticosteroid use, AIDS

Kaposi sarcoma

deep purple lesions; low grade vascular tumor assoc w/ herpesvirus 8
-seen in AIDs

Torus palatinus

a midline bony growth in the hard palate

Fordyce spots

normal sebaceous glands that appear as small yellowish spots in the buccal mucosa or lips

Koplik spots

small white specks resembling "grains of salt on a red background"
-early sign of the measles

Petechiae

small red spots caused by blood that escapes from capillaries into tissues
-caused by biting cheek, infection, low platelets

Leukoplakia

thickened white leathery patch that can appear anywhere in the oral mucosa
-risk factors: HPV, chewing tobacco, heavy smoking, alcohol