HA: EYES, EARS, NOSE, MOUTH

External structure of the eye

•Eyelids (Upper and Lower)
•Lateral (outer) and medial (inner) canthus
•Eyelashes, conjunctiva
•Lacrimal apparatus
•Extraocular muscles

- sclera
- iris
- pupil

bulbar conjunctiva

membrane that covers white of eyes (not cornea)
Small blood vessels found in this membrane

Lacrimal gland

gland located in the upper outer region above the eyeball that secretes tears

Extraocular muscles

Rectus
- Superior (CN III)
- Inferior (CN III)
- Medial (CN III)
- Lateral (CN VI)

Oblique
- Superior (CN IV)
- Inferior (CN III)

Snellen chart

chart containing symbols that is used in the testing of visual acuity

Snellen E chart

When performing a distance vision exam on a patient that does not speak English, which chart should be used?

Eyeballs Normal findings

Symmetrically aligned in sockets without protruding or sinking

Exophthalmos

- bulging eyes
- can be sign of thyroid gland problems
- must be checked quickly

Sunken Eyeballs

"eyebags"
- enophthalmos
- sunk in face
- family history, dehydration, lack of sleep, malnutrition

Eyebrows Normal findings

Same with hair color; symmetric; evenly distributed

Eyelids normal findings

- let patient blink

- lashes short, evenly spaced, and curled outward; lower lid margins at bottom edge of iris; upper lid margins cover approx. 2mm of iris; lid margins pink and moist without swelling or lesions; upper and lower lids close easily and meet when closed

Ectropion

where the lower eyelids droops away from the eye and turns outwards

- "everted"

Entropion

inward turning of the rim of the eyelid such as the pilosebaceious unit and mucocutaneous junction are directed posteriorly toward the cornea and ocular surface

- "inverted"

Chalazion

Red bump on eyelid

hordeolum

sty; an acute infection of a sebaceous gland of the eyelid

Blepharitis

inflammation of the eyelid
- red, swollen, irritated, itchy

Ptosis

drooping eyelid

Lagophthalmos

incomplete eyelid closure

Bulbar conjunctivae and sclerae Normal findings

- let patient look up

- Clear, moist, smooth and with tiny vessels visible; sclerae are white

- Clarity, color, and texture

Eye trauma

bruises, punctures, and scratches, result from accidents, exposure to chemicals, or foreign materials

conjunctivitis

pink eye or piskat

- welding, no eye protection
- redness of the sclera

Pinguecula

- conjunctival stromal degeneration of the eye.
- elevated yellow-white plaque at bulbar conjunctivae

subconjunctival hemorrhage

bleeding between the conjunctiva and the sclera
- breaking of blood vessel
- HPN

Episcleritis

- red eye, due to inflamation of sclera
- benign, self-limiting (it will go away)

Lower Palpebral conjunctivae assessment

Must pull lower eyelid down to see. Should be pink, moist.

Upper Palpebral conjunctivae assessment

- close patient eye
- use cotton bud to turn over the eye

Palpebral conjunctiva Normal findings

pink, moist, and free of swelling, lesions, foreign bodies, trauma or abnormal discharges

Pallor (pale palpebral conjunctiva)

- signifies anemia, low blood count, low blood circulation

Lacrimal apparatus assessment

swelling, redness, drainage, and tenderness

Palpating lacrimal glands

- massage top parts of eyes, next to eyebrows
- check for swelling, tenderness, discharge

Palpating nasolacrimal duct

- palpate next to nose bridge
- check for swelling, tenderness, discharge

Lacrimal apparatus normal findings

puncta visible without swelling or redness; no tenderness of drainage noted; minimal lacrimation

puncta

visible on the upper and lower lids at the inner canthus; where tears drain

Darcryocystitis

- inflammation of the lacrimal sac
- redness, swelling, different from eye trauma

Cornea and Lens Normal finding

Transparent, moist, without opacities; lens are clear

Arcus senilis

whitish ring surrounding the cornea around the iris
- normal in aging
- young high cholesterol level or lipids

Corneal scar

opacity of the cornea
- needs surgical removal or drugs

pterygium

winglike growth of conjunctival tissue extending to the cornea

cataract

- opacity of the lens, blurring of vision

Iris normal findings

Round; uniform color

- can be brown, blue, green
- red is abnormal
- look for shape and color

Hyphema

collection of blood inside anterior chamber of eye
(between cornea and the iris)
- signifies trauma

Hypopyon

accumulation of white blood cells that form whitish layer of fluid in the lower portion of the eye's anterior chamber

- infection of internal eye

Pupil Normal findings

Equally round about 3 mm in size; illuminated pupil constricts & pupil opposite the one illuminated constricts simultaneously; pupils converge & constrict as object moves in toward nose; pupil responses uniform

Pupillary gauge for measuring pupil size

size chart for checking dilation and constriction

Testing pupillary reaction to light (direct and consensual)

- shine light on eye
- do not keep steady for long time

Direct pupillary reaction

A reflexive reaction occurring when a light is directed into one pupil; the normal response is pupillary constriction.

Consensual pupillary reaction

When light is shone in one eye, the pupillary reaction seen in the other eye, It is a normal reflex

pupil dilation

When the pupils in the eyes expand to look large
(sympathetic)

Testing Accomodation of pupils

- let patient focus on object in midline of face
- equal movement

- moving object towards nose \= constriction and inward movement

PERRLA

pupils equal, round, reactive to light and accommodation
- DO NOT USE AS A NURSE

Miosis

small, abnormal contraction of the pupil
- drug addicts

anisocoria

unequal pupil size
- brain lesions

mydriasis

dilation of the pupil
- high on drugs, coffee or stimulants

Extraocular muscle function tests

corneal light reflex test
Cover test

corneal light reflex test

- shine light at bridge of nose 12 in away.
- reflection of light on corneas should be in the exact same spot on each eye
- asymmetric position of light reflex indicates deviated alignment due to muscle weakness or paralysis

corneal light reflex test normal finding

reflections of light noted at same location on both eyes

Cover test

an examination of how the two eyes work together and is used to assess binocular vision. one eye at a time is covered while the patient focuses on an object across the room.

- if one eye moves \= extraocular muscle weakness

Cover test normal finding

uncovered eye remains fixed; covered eye does not move as cover is removed

Cardinal gaze (Position test)

six positions
- let patient look upper left, up, upper right, left, forward, then right
- can assess for down left, down, and down right by raising eyelids

- can use pencil to guide eyes

Cardinal gaze Normal findings

Both eyes move in a smooth, coordinated manner in all 6 directions

strabismus (tropia)

constant malalignment of the eye axis

Esotropia
Exotropia

Esotropia

inward turning of the eye

Exotropia

outward turning of the eye

hypotropia

downward deviation of one eye

hypertropia

upward deviation of one eye

Nystagmus

involuntary, jerking movements of the eyes

- inner ear problem

Pseudostrabismus

has the appearance of strabismus because of epicanthic fold but is normal for a young child.

- NORMAL PEDIATRIC VARIATION
- will adjust in adulthood

color vision

- ability to distinguish colors
- use Ishihara plates and ask patient to name the color of something in the exam room

Ishihara plates

used to test for color deficiency
- six plates in total
- Tell patient to read the number on the plate
- jot down findings and interpret
- indicate "spots" if no number can be seen

Ishihara test interpretation example

Quick Ishihara Color Vision screening

One plate used to assess color blindness

If normal vision \= 5
If red-green color blindness \= 2

Color vision Normal findings

Able to identify primary colors in exam room ; identifies all six screening Ishihara plates correctly

Visual acuity: Distant vision Normal finding

20/20 OD and OS without hesitation, frowning or squinting

Astigmatism

- happens when the cornea or lens has a different shape than normal
- irregular cornea

Using the Snellen chart

Point at a line, ask patient to read
- if they cannot read or if they miss 2 letters, ask them to read the next line up
- both eyes, then cover one eye, then the other
- pay attention to squinting or leaning closer to read better

Line 8 is normal vision (20/20)

Myopia

nearsightedness; difficulty seeing distant objects when light rays are focused on a point in front of the retina

- lens are too powerful

Amblyopia

lazy eye
- poor vision that happens in 1 eye
- legally blind

Visual acuity: Near vision Normal findings

Reads print at 14 inches without difficulty

Rosenbaum card

used to test for near vision

Using rosenbaum card

14 in from eye
- check myopes (nearsighted) with glasses only
- both eyes, one eye, then other

Jaeger test card

- used to test near vision
- sentences instead of letters or words

presbyopia

farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age.
- needs reading glasses

Peripheral vision (Confrontation test) Normal findings

Client sees examiner's finger at the same time the examiner sees

Peripheral vision (Confrontation test)

1. stand opposite the patient at eye level at a distance of 1 meter
2. each cover an eye directly opposite from each other
3. extend arm and move centrally until patient can see

Normal visual field degrees to assess during confrontation test

Inferior
Superior
Temporal
Nasal

Inferior visual field degree

70 degrees

Superior visual field degree

50 degrees

Temporal visual field degree

90 degrees

Nasal visual field degree

60 degrees

Equipment in ear assessment

- tuning fork
- otoscope
- pneumatic otoscope
- tympanometry
- reflectometry
- audiometry

Symmetry and size of Ears

Inspection only
- check if they are same size, same position, same configuration

Auricle position normal finding

alignment of pinna with lateral canthus of eyes

Normal variation in configuration of ear lobe

1. Free
2. Partially attached
3. Attached (Curve)
4. Soldered (looks like no ear lobe)

Low set ears

lower pinna than lateral canthus
- Down syndrome

External ear

- look for lesions, discolorations, discharge, tenderness

Darwin's tubercle

small, painless nodule at the helix
- abnormal finding

External canal

presence of foreign body or discharge; tenderness; amount, color, consistency, and odor of cerumen, color and consistency of ear canal walls and tympanic membrane

- 3\> \= pull ear down and back
- 3< \= pull ear up and back

Abnormal findings in External Canal

▪ Auricular tophi
▪ Postauricular cyst
▪ Malignant lesions
▪ External Otitis (Otitis Externa)
▪ Foreign Bodies Occlusion
▪ Cerumen Impaction.
▪ Exostoses
▪ CONGENITAL MALFORMATIONS
o Microtia
o Aural Atresia
▪ Acute Otitis Media (AOM)
▪ Serous Otitis Media (SOM)
▪ Chronic Otitis Media (COM)
▪ Tympanic membrane perforation

Auricular tophi

firm deposits of monodosium urate in crystal form, which may slowly develop in subcutaneous tissue of the ear.

- Ear is not usual locations for gout tophi, but when it does, helix and antihelix are common sites

Postauricular cyst

rare, unilateral asymptomatic, extracranial swellings
- delay in seeking medical intervention due to blocked sebaceous gland behind the ear.