Head, Neck, Neuro

What parts of eye are accessible to examination?

The sclera (anteriorly), and the retina (through and opthalmoscope)

Sclera

Tough protective white covering, white to gray-blue due to cultural variation

Cornea

Very sensitive to touch; contact with wisp of cotton stimulates a blink in both eyes called CORNEAL REFLEX

Iris

Contract in bright light and accommodate for near vision; dilate pupil when light is dim and for far vision

Conjunctiva

We can look at this to indicate health status; if unhealthy could have pallor or jaundice

Retina

Light sensitive area at back of the eye; only portion of CNS visible from exterior. *Many systemic diseases that affect vascular system show signs in retinal vessels

Pupil

size reacts to amount of light and accommodation or focusing object on retina

Direct and consensual eye movements

Direct - eye u shine the light in, pupil constricts. Consensual - not the eye you're shining the light in but it should still constrict

Coloboma

Irregular shape of the pupil

Aniscoria

Different pupil size in each eye

PERRLA

Pupils Equal, Round, React to Light, Accommodate

Constriction:

Pupils Constrict when focusing on Close object

Dilation:

Pupils Dilate when focusing on Distant object

Pinpoint:

If someone is on opioids

Dilated could occur if:

someone has neurological damage

Strabismus

Misaligned eyes. Esotropia - eyes aligned toward midline; Exotropia - eyes deviate more toward the outside

Diplopia

Double vision (u see two images of the same thing)

Testing extra ocular movements

Hold target back 12inches and move to the 6 positions then back to center. Normal response is parallel tracking of object with both eyes.
TESTS cranial nerves: III Oculomotor, IV trochlear, and VI abducens.

Corneal Light Reflex/Hirschbebrg test

Assesses parallel alignment of eye axes by shining a light toward person's eyes. Tell patient to stare ahead of u as u shine light from 12inches away. Note reflection of light on corneas; should be in exact ame spot on each eye.

Visual Acuity Test: Snellen Eye Chart

Position patient 20ft away. Normal visual acuity = 20/20.
Top # = distance person stands from chart; denominator gives the distance a normal eye could have read that particular line. Ask them to read smallest line. I.e. 20/30 means "you can read at 20 ft what the normal eye can see at 30ft."

Visual acuity test: Near vision

Test near vision with handheld vision screener with various sizes of print

Macula -

It's the area of keenest vision. Absent at birth but matures by 8 months in an infant.

Vision/eyes in infants

By 3-4 months infant ests. binocularity and can fixate on a single image w both eyes simultaneously. Lens is nearly spherical at birth and grows flatter throughout life. Consistency changes from that of soft plastic at birth to rigid glass in old age.

Testing light perception in infants

BLINK REFLEX - neonate blinks in response to bright light

Aging and vision

Pupil size decreases, lens loses elasticity which decreases ability to change shape to accommodate for near vision = PRESBYOPIA. Visual acuity may diminish gradually after age 50 and even more so after age 70.

The beginning of cataracts:

By age 70, normally transparent fibers of lens begin to thicken and yellow

Ocular structures and aging:

Eyebrows - may show loss of outer 1/3-1/5 of hair because of decrease in hair follicles and remaining hair is course.
As result of atrophy of elastic tissues, skin around eyes may show wrinkles or crow's feet; upper lip may be so elongated as to rest on lashes, resulting in pseudoptosis (type of drooping).

Most common causes of decreased visual functioning in older adults

Cataract formation, Glaucoma, Macular degeneration, Loss of central vision

Cataract Formation:

Lens opacity resulting from a clumping of proteins in lens

Glaucoma

increased intraocular pressure. Chronic open-angle glaucoma is the most common type

Macular degeneration

breakdown of cells in macula of retina

Loss of central vision

Most common cause of blindness, person is unable to read fine print, sew etc; may cause great distress for patient

Papilledema

Optic disc swelling that is secondary to elevated intracranial pressure (i.e. they fell and hit a certain part of their head and the brain starts to swell)

Brushfield's Spots

White specks around the edge of the iris, may be associated with DS.

RED REFLEX

CHECKED FIRST IN NEWBORN NURSERY. Reddish orange reflection of light from the retina, many eye problems can be detected by this test such as:
1. Cataracts - presents as leukocoria (leuk = white, so leukocoria means it looks white instead of red when u check for red reflex)
2. Retinoblastoma (A tumor in the eye)- presents as leukocoria
3. Retinal detachment.

Periorbital edema

Lids are swollen and puffy. I.e. infections, crying, allergies, heart failure or renal failure.

Arcus senilis

(think senile, so happens older people) Gray arc sometimes visible around the cornea in older adults, benign.

Exophthalmos

Protrusion of the eyeballs, wide-eyed stare, retracted lids and lid-lag

Entropian

Inward turning of the lid margin, common in the elderly

Ectropian

Margin of lower eyelid turned outward

Ptosis

Drooping of the eye (check for eye symmetry)

Hordeolum

STYE. Localized staph infection of lid or hair follicle

Cataract

Opacity of the crystalline lens.
Causes: Can be due to aging, could be congenital, could emerge from trauma
Cloudy or blurred vision, glare from headlights, diplopia (double vision), absence of red reflex

Glaucoma

Increased intraocular pressure, Open angle = 90% of cases, develops slowly, lifelong. Closed angle = develops quickly and demands immediate medical attention.

Age-related macular degeneration

The leading cause of blindness, breakdown of cells in the macula of the retina, loss of central vision occurs, no cure.
Risk factors: genetics, caucasian race, smoking

diabetic retinopathy

among leading cause of blindness in adults, excessive glucose damages blood vessels (very important that diabetics monitor their sugar, this is just one of the reasons why!). There's all these extra blood vessels and they're hemorrhaging, and eye aneurysms can even occur. Spotty vision ("olives" as mom says).

Conjunctivitis

infection of the eye, very contagious

Subconjunctival hemorrhage

bleeding right into the eye

Corneal abrasion

Most common result of blunt eye injury i.e. scratches, poorly fitting or overly worn contact lenses. Presents with: Intense pain, foreign body sensation (u feel like there's something in your eye), lacrimation (tears), redness, and photophobia (light sensitivity, causing burning sensation in response to light). ** Also eye dryness and eyes being opened for a long time can cause corneal abrasion in patient, close patient's eyes in OR. Can also lead to corneal ulcer

Floaters

Undissolved vitreous gel, casts shadows on the retina when light enters the eye. Appears as spots or squiggly lines. Not a danger unless there's a sudden increase and/or associated with other symptoms.

Inner Ear:

For balance and equilibrium, and hearing. Auditory nerve is cranial nerve VIII. Romberg test tests equilibrium.

Hearing: Amplitude and frequency

Amp: loudness
Freq: Pitch or number of cycles per second

Conductive hearing loss

Mechanical dysfunction of external or middle ear. Can be caused by foreign bodies, ruptured tympanic membrane, cerumen (wax), otosclerosis.

Otosclerosis:

Gradual hardening of earwax that causes the footplate of the stapes to become fixed to oval window, impeding transmission of sound and causing progressive deafness. Common cause of hearing loss in young adults between ages 20-40.

Prebyscusis:

Hearing loss that occurs with aging, even ppl in quiet environment. It is a gradual SENSORINEURAL loss caused by nerve degeneration in inner ear or auditory nerve. Onset usually occurs in 50s and slowly progresses.

Sensorineural hearing loss

(aka perceptive hearing loss) hearing loss signifies pathology of inner ear, cranial nerve VII, or auditory areas of cerebral cortex. Some causes include ototoxic drugs (drugs that result in hearing loss), heredity, infections (rubella or CMV in utero), loud noise/explosion.

In aging people, cilia lining inner ear canal become coarse and stiff.

-May cause cerumen to accumulate and oxidize, which greatly reduces hearing.
-Cerumen is drier because of atrophy of apocrine glands
-Impacted cerumen common but reversible cause of hearing loss

Ear position

Important part of newborn assessment: top of pinna should match an imaginary line extending from corner of eye to occiput. Ear should be positioned within 10 degrees of vertical. Low-set ears are found with trisomy 21, 13, and 18 (rare)

Universal newborn hearing screening

Done before infant is dicharged home - Used to detect hearing at an early age; ABR = auditory brainstem response

To examine ear

Otoscope - auricle up and back in adult; down in child

Cerumen

Genetically determined:
-Dry cerumen: gray and flaky, frequently forms thin mass in ear canal. More common in Asian and American Indian populations
-Wet cerumen: honey-brown to dark brown and moist.

Tympanic Membrane (TM)

separates inner and middle ear blah blah blah

Otitis externa

An inflammation or infection of the external auditory canal (EAC), the auricle, or both. Presents with: Otalgia; ear fullness or pressure; erythema, edema, and narrowing of EAC, tinnitus; Can occur from exposure to activities with water (swimmer's ear)

Otalgia:

Ear pain

Tinnitus:

Ringing of the ear

Otitis media

Obstruction of Eustachian tube or passage of nasopharyngeal secretions into middle ear. More common in children because it's shorter and wider than in adult ears so it's easier for pathogens to migrate from the nasopharynx to migrate thru middle ear. Feed child upright and do not prop up a bottle. Fluid in middle ear may lead to hearing loss and delayed development.

Vertigo:

Sensation of mvmt, usually rotational motion like whirling/spinning.
-> Subjective vertigo: sensation one's body is rotating in space
-> Objective vertigo: sensation that objects are spinning around the body
VERTIGO = CARDINAL SYMPTOM of vestibular dysfunction

Nystagmus (eyes)

Involuntary movement of eye. May be congenital or acquired from multiple causes

If labyrinth of ear becomes inflamed:

Staggering gait when person walks, vertigo

If mom has rubella during pregnancy:

can damage child's organ of corti and impair hearing

Infant's Eustachian tube is:

shorter wider and more horizontal than adults' (thus..........)

Infants and young children: Hearing acuity test

Room should be silent and baby contented. Make a loud sudden noise; you should note the following responses:

Moro Reflex

For newborns. A startle reflex present at birth that disappears by 1-4 months

Acoustic blink reflex

3-4 months old. Infant stops movement and appears to listen, halts sucking, quiets if crying, cries if quiet

6-8 month hearing reflex:

Infant turns head to localize sound; responds to won name

Preschool and school age child hearing screening:

screened with audiometry

Why should you test hearing early

To catch early problem like delayed speech, social development, and learning deficit

Air conduction greater than bone conduction =

Normal. But bone conduction greater than air conduction indicates hearing loss.

Nares

Nostrils

what's the most common site of nosebleeds?

Kiesselbach's plexus (part of anterior part of nasal septum)

What could cause sinusitis

Paranasal sinus openings are narrow and easily occluded

when do maxillary sinuses reach full size?

after permanent teeth have erupted.

Ethmoid sinuses grow....

...rapidly between 6-8 years of age and after puberty

Frontal sinuses develop...

...between ages 7 and 8, reach full size after puberty

Sphenoid sinuses develop...

...after puberty

Two pairs of sinuses are accessible to examine:

-Frontal: in frontal bone, medial to orbits
-Maxillary: in maxilla (cheekbone) alone side walls of nasal cavities

Palpate for sinus tenderness:

Maxillary - Palpate below cheekbones
Frontal - Palpate up and under the eyebrows

3 pairs of salivary glands:

Parotid (cheeks), submandibular (beneath mandible), sublingual (floor of mouth under tongue)

How many teeth should adult have?

32.

What does saliva do:

moistens and lubricates food bolus, starts digestion, cleans and protects mucosa.

Mumps

Swollen parotid gland (one o the salivary glands)

Gingivitis:

Swelling of the gums

When does salivation start?

3 months old

Child teeth development

Both sets begin developing in utero. 20 deciduous that begin to erupt between 6 and 24 months, all should be there by 2 & 1/2 years. Deciduous teeth lost beginning at age 6 through age 12, replaced by permanent starting with central incisors.

Pregnant women and vascularity of upper respiratory tract:

During pregnancy, there is an increased vascularity in the upper respiratory tract, which can cause nasal stuffiness and epistaxis (nosebleed). Additionally gums may be hyperemic (extra blood in gums) and softened and may bleed with normal toothbrushing.

edentulous

lacking teeth

What is a major cause of decreased saliva flow?

Use of medications with anticholinergic effects (more than 250 meds have dry mouth side fx)

aging adult and smell and taste

Diminished sense of taste and
smell decreases aging person’s
interest in food and may
contribute to malnutrition

bruxism

grinding teeth

Whiteness of tongue

Thrush due to yeast overgrowth