HA exam 3 - HEENT

Cranial Bones

• Occipital bone, Temporal bones, Parietal bone, Sphenoid bone, Ethmoid bone, Frontal bone

Fontanelle spots (soft spots)

• When a baby is born, the sutures where these spots are at are not closed

Parietal bone soft spot closure

• this bone closes within 1.5 months

Occipital bone soft spot closure

• this bone closes within 1.5 years

Ideal places to check facial features for symmetry?

• the opening between the eyelids

Cranial nerve (V) (trigeminal)

• This nerve is responsible for sensation in the face and motor functions

  • biting and chewing

Cranial nerve (VII) (facial nerve)

• this nerve is responsible for facial expressions

Parotid gland location

• located below and in front of each ear

• largest salivary gland

Sublingual gland location

• located under the tongue

Submandibular gland location

• located under the jaw

Stensen’s duct general

• a tube that is connected to parotid glands

• carries saliva to the mouth and releases it near upper molars

Sialolithiasis (calcified stones)

• formation of hardened mineral deposits within salivary glands or ducts

• causes pain and swelling while eating

Trigeminal neuralgia (tic douloureux)

• intermittent sharp shooting facial pain lasting several minutes over the divisions of the 5th trigeminal cranial nerve

Symptoms of a Typical Migraine

• Prodromal symptoms

  • visual disturbs

  • vertigo (dizziness)

  • tinnitus (ringing in ear)

  • numbness/tingling in fingers & toes

Migraine Headache General

• throbbing, severe pain on ONE side of the head

• ringing in the ears prior to headache

Headache due to mengingitis

• this type of headache moves into the neck

• causes neck pain w/ head flexion

Cluster headache

• this type of headache is localized in the eye and orbit

• moves to facial and temporal regions

Morning headaches

• this type of headache subsides after arising

  • sign of increased intracranial pressure

  • early sign of brain tumor

Why would a morning headache happen?

• when lying flat and sleeping, there is no gravity shift

• waking up, the brain CS fluid backs up because of a gravity shift

What type of headaches are worrisome?

• new onset headache (different type of pain)

• meningitis headache

• migraine headache

• morning headache

• cluster headache

• headaches in children (<5 yrs) or adults (>50 yrs)

• headaches w/ head injury

• headaches w/ head or neck surgery

• lumps or swelling in the neck

Normocephalic definition

• A normal sized head

Hydrocephalic definition

• when there is a lot of CSF collection

• results in a big head

Microcephalic definition

• neurological birth defect of a baby’s head

• results in a small head

Temporal artery location

• this artery is located between the eye and the top of the ear-pulse

Temporal arthritis

• this condition occurs when the temporal artery is hard, thick, and w/ inflammation

• can lead to blindness info treated

Physical exam of the HEENT

• Inspection, then palpation

• Head check: size, symmetry, lumps, bumps, pain

• Hair check: color, texture, distribution, hair loss

• face check: tenderness, symmetry

• sinus check: frontal and maxillary

• parotid gland check: tenderness and enlargement

Assessing Temporomandibular Joint (TMJ)

• to assess: place index finger over the front of each ear of the pt. and tell pt to open mouth

  • palpate for these signs:

  • swelling, tenderness, crepitation, pain, range of motion

Crepitation Definition

• a grinding, grating, or crackling sound in the jaw joint

  • caused by bone on bone friction

Viral infections causing facial abnormalities (mumps or flu)

• can cause swelling of parotid gland

• if a child has mumps, the chance of infertility increases in adulthood

Parotid gland enlargement definition

• this condition is asymmetry of the face, anterior to the earlobes

• can cause facial abnormalities

Bell’s palsy S/S

• Symptoms: twitching, weakness, paralysis, drooping eyelid or corner of the mouth, drooling, dry eye, dry mouth, decreased ability to taste, eye tearing, and facial distortion.

Bell’s palsy definition

• one sided facial paralysis

• this condition is temporary for most people

• begins suddenly and reaches a peak within 48 hours

Parkinson’s disease definition

• decreased dopamine secretion as the person gets older

• mask-like facial appearance (no expressions on their face)

• shuffling gait, rigid muscles, diminished reflexes

Examination of the neck

• examine these areas:

  • major neck muscles (COPD → enlarged neck muscle)

  • blood vessels

  • trachea

  • thyroid glands

  • lymph nodes

History to watch for in lymph nodes

• History: pain, lumps, discharge, rash, swelling, trauma, history of breast disease, surgery, self care behaviors

Axillary lymph nodes

• this lymph node is normally not palpable

• nodes enlarge with local infection of:

  • breast, arm, hand, breast cancer metastases

What do lymph nodes look like in acute infections?

• lymph nodes are enlarged, warm, tender, firm, and movable

What do lymph nodes look like in HIV?

• enlarged, firm, non-tender, mobile (occipital nodes are often involved)

What do lymph nodes look like in cancer?

• hard, size greater than 3cm, unilateral, non-tender, fixed, matted

What do lymph nodes look like in Hodgkin’s Lymphoma?

• rubbery, discrete, appear gradually

What does a Virchow’s sentinel node look like?

• hard and non-tender, left supraclavicular node

• highly suggestive of thoracic or abdominal cancer

In what percentage of the population is there a third lobe in the thyroid that extends upward from the isthmus or one of the two lobes?

about 33% or 1/3

Palpating the trachea

• To palpate, the nurse would first place a finger in the sternal notch, then feel each side of the notch and palpate tracheal rings

• inspect & palpate - tracheal shift

Inspecting & palpating the thyroid

• neck should be slightly extended w/o being turned to any side

• look for an enlarged and/or tender thyroid

• pt. should swallow water during inspection & palpitation

  • observe movement of the thyroid cartilage & gland

  • thyroid & cricoid cartilage move upwards as pt. swallows

• NOT palpable with aging

Auscultation of the thyroid

• look for soft, blowing, swishing sounds over the lobes

• detects bruits

  • heard in hyperthyroidism b/c of increased blood flow through thyroid arteries

• pt. should hold breath to prevent any breath sounds during auscultation

• ONLY auscultate if enlargement is identified during inspection & palpitation

Thyroiditis definition

• inflammation of the thyroid gland, often caused by autoimmune reactions (Hashimoto’s disease) or infections

• Enlarged, tender thyroid gland

What is rapid enlargement of a single nodule?

Malignancy in the thyroid gland

Hyperthyroidism (overactive thyroid)

• condition in which the thyroid gland produces too much of thyroxine (hormone)

• accelerates body metabolism

  • weight loss, rapid/irregular heartbeat, sweating, nervousness, irritability

• able to hear bruit with stethoscope

What is diffuse enlargement of the thyroid?

• this means that the entire thyroid enlarges

• this indicates hyperthyroidism

What if a single thyroid nodule enlarges?

• this suggests a malignancy and must be evaluated further

What should a normal thyroid look like?

• soft, smooth, symmetrical, and non-tender. it also slides upward slightly when swallowing

What does symmetrical enlargement of a soft, smooth thyroid look like?

• this indicated endemic hypothyroidism due to iodine deficiency

Thyroid gland symmetry

• thyroid Gand is symmetrical with small lobes, gland rises freely with swallowing

  • right lobe could be 25% larger than left

  • tissue is firm and pliable

Graves disease general

• this disease occurs when the thyroid overproduces thyroid hormones, causes hyperthyroidism

  • 50-80% of the cases in hyperthyroidism in US

Causes of Graves disease

• causes: multinodular goiter, toxic adenoma, inflammation of the thyroid, eating too much iodine, and too much synthetic thyroid hormone

Hashimoto’s thyroiditis disease

• disease caused by underachieve thyroid, does not produce enough thyroid hormones

  • leads to hypothyroidism

Causes of Hashimoto’s thyroiditis

• Immune-system cells lead to the death of the thyroid’s hormone-producing cells

Thyrotoxicosis

• condition that occurs due to excessive thyroid hormone of any cause

• therefore includes hyperthyroidism

Thyrotoxicosis S/S

• S/S: irritability, muscle weakness, insomnia, a fast heartbeat, heat intolerance, diarrhea, enlargement of the thyroid, hand tremor, and weight loss. Nervousness, increased perspiration, hand tremors, anxiety, trouble sleeping, bulging eyes (Grave’s disease), thinning of the skin, fine brittle hair, and muscular weakness (esp. Upper arms and thighs)

Manifestations of hypothyroidism/myxedema

• edema around the eyes, dry, coarse, and sparse hair, a puffy dull face, cold intolerance, muscle cramps, and constipation

  • lateral (thin) eyebrows, dry skin

What lab data indicates hyperthyroidism?

• elevated T3 and T4 hormones

• TOO much thyroxine is being secreted

What to ask pt. during nose, mouth, throat history?

• ask about:

  • sinuses

  • nose

  • mouth/throat (hoarseness, dryness)

  • gum disease

  • tobacco use, heavy alcohol consumption

  • check oral hygiene

  • medications

Gingivitis definition

• Red, swollen gums that bleed easily occur in early gum disease 

Periodontitis definition

• estruction of the gum with tooth loss in more advanced gum disease

What is seen in the mouth with aphthous stomatitis (canker sore) and herpes simplex (cold sores)

• painful, recurrent ulcers in the mouth are seen

Warning signs of cancer in the mouth

• Mouth or tongue sores that do not heal

• red or white patches that persist

• a lump or thickening

• rough, crusty, or eroded areas

what does misuse of OTC nasal meds cause?

• it irritates nasal mucosa and can cause rebound

  • VERY common when using these meds

What is cheliosis of the lips?

• scaling painful fissures at the corner of the lips

What can cause tooth decay or gum disease

• recurrent sinus congestion, infection, and improper oral hygiene

What to tell patient during a nose bleed (epistaxis)?

• tell pt. to sit up, lean forward, and pinch their nose

  • compress nose for 15-20 minutes

What can cause the inability to breathe through both nostrils?

• sinus congestion, obstruction, and a deviated septum

What is rhinorrhea?

• excessive production of thin, clear mucus in the nasal cavity

• can indicate a chronic allergy or in a client with a past head injury

  • cerebrospinal fluid leak

Nasal mucosa definition

• highly vascularized, dark pink colored tissue lining the nasal cavity

• it should be moist, and free of exudate (mucus)

Nasal turbinates definition

• long curved bony structure covered by soft vascular tissue lining the sides of nasal passage

• should be dark pink, moist, and lesions free

What are causes of epistaxis (nosebleeds)?

• local causes (most common)

  • trauma, mucosal irritation, septal abnormality, inflammatory diseases, tumors

• systemic causes

• facial trauma

• foreign bodies

• nasal infection

• prolonged inhalation of dry air

Systemic causes of epistaxis

• causes: blood dyscrasias, arteriosclerosis, hereditary hemorrhagic telangiectasia, and idiopathic causes

What are the four pairs of sinuses?

• Frontal, maxillary

• Ethmoid, sphenoid

What to expect when palpating over the maxillary sinuses?

• a large amount of exudate crepitus

What would cause frontal and maxillary sinuses to be tender in palpitation?

• could be caused by allergies and acute bacterial rhinosinusitis

What signs are seen in acute sinusitis (infection of sinus)?

• pain, tenderness, swelling, and pressure around the eyes, cheeks, nose, or forehead

What happens in chronic sinusitis?

• the sinus become inflamed and swollen, but symptoms last 12 weeks or longer even with treatment

Palpating & percussing the sinuses

• palpate the maxillary sinuses by pressing the thumbs up on maxillary sinuses

• frontal and maxillary sinuses are tender upon percussion with pt. with allergies/sinus infection

Why would percussion not be performed for the sinuses?

• not performed in an effort to gauge particular sounds

Inspection of the mouth and throat

• inspection:

  • mouth & under tongue

  • lips & jaws

  • gums & cheeks

  • tongue

What to look for when inspecting the lips?

• lips are smooth and moist without lesions or swelling

What to look for when inspecting the jaw?

• Jaws are aligned with no deviation seen with biting down

What to look for when inspecting gums and cheeks?

• Gums are pink, moist, and firm with tight margins to the tooth. No lesions or masses

• Color and consistency of tissues along cheeks and gums should be even

What to look for when inspecting the tongue?

• use a square gauze pad to hold the patient’s tongue to each side

• Tongue should be pink, moist, a moderate size with papillae (little protuberances) present. No lesions or no red color present

• look for cancer lesions

What does smooth and glossy areas on the tongue indicate?

• atrophic glossitis

What is typically seen in tongue inspections?

• the dorsal surface of the tongue is normally roughened from papillae

• thin white coating may be seen

• ventral surface may show veins

Palpating the tongue

• palate any lesions, dryness, ulcers, or nodules

  • for induration

macroglossia definition

• enlarged tongue

microglossia definition

• very small tongue

What is seen in dehydrated tongues?

• deep tongue fissures

• MUST HYDRATE

What type of variation of tongue is seen in older adults?

• a fissured, topographic map-like tongue

Candida infection definition

• removable white plaque on tongue

Yeast infection on tongue definition

• Thick, white plaques on soft palate

  • requires treatment with medication

Leukoplakia definition

• White plaque on tongue that cannot be removed

• persistent lesions, ulcers, or nodules

• Indicates cancer

  • pt. should be referred

Induration of tongue

• hardening of tissue in the tongue

• increases likelihood of cancer

Smoker’s tongue

• smokers may have a yellow/brown coating on the tongue

• NOT leukoplakia