HENT

location of parotid gland

behind the mandible (superficial)

location of submandibular gland

deep to mandible

location of superficial temporal a

passes in front of the ear, easy to palpate

how are regions of head names?

named for underlying bone

steps to inspect the head

1. inspect


1. palpate

physical exam of head (face)

note facial expression/affect, asymmetry, invol movement, edema, masses

physical exam of head (skin)

color, pigment, texture, thickness, distrib hair

physical exam of head (hair)

quantity, distrib, texture, pattern of loss

physical exam of head (scalp)

flakes, dandruff, lumps, nevi

physical exam of head (skull)

general size and contour, deformities, depression, lump, tenderness

most common cause of headache

1. tension
2. migraines

ROS head

headache?

if yes- OPQRST

head trauma?

lightheadesness/dizziness?

myxedema is caused by

hypothyroidism

myxedema

form of cutaneous and dermal edema due to increased deposition of CT

acromegaly

due to over-production of growth hormone from a pituitary tumor (rare)

characteristic of acromegaly

* prominent orbital ridge


* enlargement of frontal sinus '
* long face
* enlargement of maxillary sinus
* large nose
* prominent mandible
* thickening of lips

Parkinsonism

caused by motor impairment due to parkinsons

characteristics of parkinsonism

* decreased facial expression
* decreased blinking
* characteristic stare

cushings syndrome

increased adrenal cortisol production

characteristic of cushing syndrome

* “moon face”
* rounded face due to increased fat
* red cheeks
* excessive hair growth

nephrotic syndrome

loss of proteins via kidney (proteinuria) leads to low protein in blood (hypoalbuminemia)

characteristic of nephrotic syndrome

* facial / periorbital edema
* pale skin

parotid gland enlargement

parotitis

* swelling anterior to earlobe
* swelling above angle of jaw
* usually unilateral

anatomy of external ear (3)

1. auricle / pinna
2. ear canal
3. mastoid process

auricle/pinna

made of cartilage, covered by skin, firm, and elastic consistency

* helix, antihelix, lobule, tragus

ear canal

* 24mm, open behind tragus


* curves inward, downward and anterior
* outer portion hairy with cerumen
* inner portion hairless
* end at tympanic membrane

mastoid process

palpable behind lobule, portion of temporal bone

anatomy of middle ear (3)

1. air filled cavity
2. eustachian tube
3. tympanic memrbane

air filled cavity

transmit sound by way of ossicles

* malleus, incud, stapes

airfilled caviity is connected by …. to nasopharynx

eustachian tube

Tympanic membrane

* thin opaque membrane held inward by malleus
* CN V (Trigeminal) – innervates Tensor tympani muscle
* Adjusts tension on TM (ear drum) to adjust for loud noises

middle ear landmarks

* Manubrium of malleus (handle)


* Short process of the malleus
* Umbo
* Cone of light
* Pars flaccida – above short process
* Pars tensa – below short process

most depressed portion of tympanic membrane

umbo

apex of the cone of light

umbo

anatomy of inner er (3)

* cochlea
* semicircular canals
* CN VIII

semicircular canal

help maintain equilib, send signal brain for balance

two parts of CN VIII (auditory nerve)

Cochlear division – sound

Vestibular division – balance

injury to external/middle ear is …

injury to internal ear…

conductive hearing loss

sensory neuro

ROS ears

Any changes in hearing?

Any skin changes on ears?

Any earaches?

Any discharge?

Tinnitus (ringing/noise)?

Vertigo? →Spinning sensation (feels like surroundings are moving)

Physical exam steps

1. inspect
2. palpate
3. otoscope exam
4. auditory acuity
5. assess hearing loss

How to assess hearing loss?

Conductive vs Neurosensory

if shown have hearing loss→

Weber

Rinne

inspection of ear

Auricle and surrounding area:

* Deformities, lumps, lesions, discharge, erythema, edema, tophi

palpation of ear

* Pinna/Auricle
* Tragus
* Mastoid process

Otoscope Exam Technique

* Visualize the ear canal/TM using the otoscope with largest speculum that fits


* Position head slightly away from you
* Grasp auricle and pull upward, back and slightly away from body
* Insert the speculum gently into the ear canal directing it down and forward

\

tophi

treat: normalize uric acid level

\

mastoditis

treat: IV antibiotic

otitis externa/ cellulitis

treat: oral antibiotic

Otoscope exam

* Inspection of Auditory Canal
* Ear canal
* Discharge, foreign bodies, erythema, edema, excess cerumen…
* Tympanic membrane
* Perforations, erythema, edema, effusions, movement, bulging, color, contour…
* Landmarks
* Cone of light
* Malleus – handle(manubrium) and short process

otitis media

* bulging
* erythema
* fluid

serous otitis media

\*not infection, but fluid present

otitis externa

Foreign body

Tympanostomy tube

TM perforation

Gross Auditory Acuity Testing

* Test one ear at a time
* Ask patient to occlude meatus of one ear
* Ask patient to close eyes
* Rub finger together and ask patient if they can hear that noise (near non-occluded ear)
* Slowly move fingers away from ear until patient can no longer hear the noise
* Compare distance bilaterally

basal cell carcinoma

Conductive Hearing Loss (CHL)

Impairment of sound conduction in the middle or external ear

ex: otitis media, serous otitis media

AIR CONDUCTION

Sensorineural Hearing Loss (SNHL)

Cochlear nerve function impaired

BONE CONDUCTION

examples of causes of sensorineural hearing loss (SNHL)

can be from drugs, age, genetic, head injury, trauma

Weber test

* Tests for both CHL and SNHL
* Set fork in motion Place firmly on top midline of patient’s head
* Ask patient where they can hear the sound – one side or both sides
* test lateralization - which side hear best?
* if L, lateralized to L

if hearing deficit R side…

unilateral sensory hearing loss (inner ear cochlea), the sound will be heard best in good ear (L side)

* indicate sensory neural problem
* but if hear best R side = conductive hearing problem

Rinne Test

* Compares AC and BC
* Set fork in motion
* Place on mastoid process – level with canal
* Verify the patient can hear it & ask patient to tell you when they can no longer hear the noise
* Place tuning fork close to the ear canal with U facing forward at that time
* Ask if patient can hear the sound
* Test bilaterally

what does rinne test for?

compare air conduction vs bone conduction

nose anatomy upper 1/3 is …

lower 2/3 is …

bone

cartilage

pathway of air

air enter through anterior nares then passes into vestibule then passes to nasopharynx

medial wall contains …

lateral wall contains …

nasal septum

turbinates (curving bony structure)

function of turbinates

cleanse, moisten, warm air

paranasal sinuses (4)

air filled cavities within bone of skull


1. frontal
2. ethmoid
3. sphenoid
4. maxillary

lines with mucous membrane and secrete fluid

what paranasal sinus can you palpate

frontal and maxillary

ROS nose and sinuses

* Any rhinorrhea?
* Nasal congestion?
* Sinus pressure?
* Epistaxis?
* Sneezing?
* Throat discomfort?
* Facial pain?
* Any injury or trauma to the face?

physical exam of nose steps

1. inspect
2. palpate: tenderness
3. check patency : bilaterally
4. physical exam

inspection of nose

Gross deformity

Asymmetry

Swelling

Lesions

Erythema

Bleeding

physical exam of nose

* Internal exam technique
* Use otoscope with largest speculum that fits
* Tilt head back
* Direct speculum posterior and then upward in small increments
* Identify landmarks

internal exam of nose looks at

* mucosa
* septum
* turbinates

sinus physical exam steps

1. inspect
2. palpate

inspection of sinus

Erythema

Edema

palpate of sinus

Temperature

Tenderness

Press firmly over sinuses

Frontal

Maxillary

Compare bilaterally

allergic rhinitis

Nasal mucosa may be pale, bluish or red, and boggy

Sinusitis

Local sinus tenderness with pain, fever, and nasal discharge

Upper respiratory (URI)

Nasal mucosa will be reddened and swollen

Mouth and throat anatomy

1. Lips


1. Muscular folds that surround entrance to the mouth
2. Gingiva


1. Firmly attached to teeth and maxilla on mandible
3. Labial frenulum


1. Connects lips with gingiva
4. Tooth


1. Composed mostly of dentin with enamel and crown

tongue and pharynx anatomy

1. Tongue


1. Covered with papilla
2. Lingual frenulum


1. Attaches tongue to floor of mouth
3. Anterior and posterior tonsillar pillars
4. Tonsils
5. Soft palate
6. Uvula
7. Hard palate
8. Pharynx
9. Buccal mucosa

function of uvula

prevent food enter nasal cavity

ROS of mouth and throat

Condition of teeth

Bleeding gums?

Dentures?

Sore tongue?

Dry mouth?

Hoarseness?

Sore throat?

Lesions on oral mucosa?

Dysphagia

mouth and throat physical exam steps

1. tongue exam
2. gag reflex

general tips for mouth and throat physical exam

* Remove dentures (if patient has them)


* Wear gloves when palpating lesions in the mouth
* Use light source – pen light or otoscope

tongue exam

1. Wrap gauze around tip of tongue


2. Move tongue from one side to the other
3. Palpate length of tongue with gloved hand

gag reflex exam

lightly stimulate back of throat bilaterally

leukopathia

hairy leukoplakia

oral candidiasis

Herpes simplex

angioedema

basal cell

strep

viral pharyngitis

ulcer

grade 0 tonsils

surgically removed

grade 1 tonsils

tonsils hidden within tonsils pillars

grade 2 tonsils

tonsils extending to the pillars