Ear Nose Throat

ASSESSMENT: EYES, EARS, NOSE, AND MOUTH

Objectives
  • The student will:   - Collect a health history of the eye.   - Describe the physical examination techniques performed to evaluate the eye and perform a complete eye exam.   - Document a complete eye assessment using both subjective (health history) and objective data (physical exam).
Assessing the Eyes
Focused History Questions
  • Have you noticed any changes in your vision?
  • Do you wear glasses or contact lenses?
  • Have you ever had an eye injury?
  • Have you ever had an eye infection?
  • Do you have any problems with excessive tearing or dry eyes?
  • Have you ever had eye surgery?
  • Have you ever experienced blurred vision, halos of light, spots, floaters, or flashes of light?
  • Do you have difficulty with nighttime vision?
  • Do you have a history of eye problems, such as glaucoma, or medical problems, such as diabetes or hypertension?
  • When was your last eye exam?
  • Do you have any prescriptions or over-the-counter eye medications?
  • Use OLDCART for all positive findings.
External Eye Anatomy
  • Upper eyelid
  • Sclera: covered by conjunctiva
  • Lateral canthus
  • Lower eyelid
  • Iris
  • Limbus
  • Pupil
  • Medial canthus
Lacrimal System
  • Lacrimal gland (within the bony orbit)
  • Lacrimal sac (within the bony orbit)
  • Canaliculi
  • Puncta
  • Nasolacrimal duct
Test Distance Vision
  • Snellen Eye Chart:   - Person stands 20 feet from the chart, places an opaque card over one eye at a time.   - Person leaves contact lenses or glasses on during the exam.   - Person reads through the chart to the smallest line of letters possible.
  • Snellen Record:   - Record result using the numeric fraction at the end of the last successful line read; indicate whether any letters missed or corrective lenses worn (e.g., 20/30—with glasses).   - Numerator indicates distance from the chart; denominator indicates distance at which a normal eye could read that line (e.g., 20/30 means you can read at 20 feet what a normal person can read from 30 feet away).   - Use the Snellen "E" chart for those who cannot read; symbols chart (cards) for children who cannot read (Allen test).
Distance Vision
Expected Findings
  • Normal: 20/20 in each eye and both eyes together.
  • Middle adults: the lens of the eye begins to lose ability to accommodate to near objects as age increases.
Abnormal Findings
  • A smaller fraction (e.g., 20/100) indicates diminished distant vision or myopia.
  • A larger fraction (e.g., 20/15) indicates diminished near vision (hyperopia).
Test Near Vision
  • Near vision tested in all individuals over age 40 and those reporting increasing difficulty reading.
  • Use a Jaeger card (handheld vision screener) with various sizes of print or newsprint, held 14 inches from the eye.
  • Test each eye separately with corrective lenses on.
  • Normal result: 14/14 in each eye without hesitancy in reading and without moving card closer or farther away.
  • Presbyopia: decrease in accommodation with aging.
Test Peripheral Vision
  • Confrontation Test:   - Peripheral vision of the patient is compared to that of the examiner.   - Examiner positioned at eye level with the person, about 2 feet away; person covers one eye with an opaque card; the other eye looks straight at the examiner.   - Use a pencil or flicking fingers as a target, move the target in from the periphery to the center of visual fields.
Expected Findings
  • No deficits in visual fields.
Abnormal Findings
  • Loss of peripheral vision; follow up with an ophthalmologist.
Assess Extraocular Movements
  • Inspect the eyes for parallel alignment.
  • Test the corneal light reflex by shining a penlight at the bridge of the nose, noting the light reflection on the cornea of each eye.
  • Instruct the patient to stare straight ahead as light is held about 12 inches away.
Expected Findings
  • Eyes are in parallel alignment; corneal light reflex appears in the same position in each eye.
Test the Six Cardinal Fields of Gaze
  • The examiner leads the person’s eyes through the six cardinal fields of gaze to elicit any muscle weakness during movement.
  • Person holds head steady and follows the movement of examiner’s finger, pen, or penlight only with the eyes.
Expected Findings
  • The eyes move through all six gaze positions without any weakness.
Perform the Cover Test
  • Cover Test:   - Detects small degrees of deviated alignment by interrupting the fusion reflex that normally keeps the two eyes parallel.   - Person stares straight ahead at the examiner's nose while covering one eye with an opaque card; note the uncovered eye as it is revealed.
Expected Findings
  • The gaze should steady when the eye is covered and uncovered.
Inspect the External Structures
  • General appearance: Check color and alignment of the eyes.
Expected Finding
  • Eyes should be clear, bright, and in parallel alignment.
Inspect the Eyelids
  • Note the presence of any lesions, edema, or lid lag.
Expected Findings
  • No lesions present; eyelids move freely. Upper eyelid covers half of the upper iris.
Inspect the Eyelashes
  • Note symmetry and distribution.
Expected Findings
  • Eyelashes are evenly distributed and curve outward. No crustations or infestations are present.
Inspect the Lacrimal Ducts and Glands
  • Inspect lacrimal duct for any redness or swelling.
  • Normally, the puncta drain tears into the lacrimal sac.
Expected Finding
  • Presence of excessive tearing may indicate blockage of the nasolacrimal duct.
  • Check by pressing the index finger against the sac, just inside the lower orbital rim.
Inspect the Conjunctivae
  • Note the color, moisture, and contour of the conjunctivae.
  • The palpebral conjunctivae cover the lids; to assess, have the patient look up while placing a cotton-tipped applicator on the upper lid, gently grasp the upper lid and lashes, and evert the lid over the cotton-tipped applicator.
  • The bulbar conjunctivae cover the eyeball; to assess, pull the lower lid down.
Expected Findings
  • The palpebral conjunctivae are smooth, glistening, and peach in color with minimal blood vessels.
  • The bulbar conjunctivae are clear with few blood vessels and white sclera visible.
Inspect the Sclera
  • Note the color of the sclera and check for any lesions.
Expected Findings
  • The sclera should be smooth, white, and glistening.
Inspect the Cornea, Lens, and Anterior Chamber
  • Shine a light from the side across the cornea to check for smoothness and clarity.
Expected Findings
  • The cornea and lens, and chamber are clear, smooth, and glistening.
Test the Corneal Reflex
  • Touch the cornea with a wisp of sterile cotton.
  • Not routinely performed on a conscious person.
Expected Findings
  • Blink reflex is prompt when cornea is stimulated.
Inspect the Iris and Pupils
  • Note the color, size, shape, and symmetry of the iris and pupils.
Expected Findings
  • The iris may be blue, green, brown, or a combination.
  • Its shape should be circular, and pupils should be round and equal in size.
  • Anisocoria: unequal pupils can be a normal variation if the difference is less than 0.5 mm.
Test Pupillary Reaction
  • Pupillary Light Reflex: Darken the room and have the person gaze into the distance.
  • Advance a light in from the side and note response.
Normal Response
  • Constriction of same-sided pupil (direct-light reflex) and simultaneous constriction of the other pupil (consensual light reflex).
Test Pupil Accommodation
  • Test the ability of pupils to adjust to various distances.
  • Ask the person to focus on a distant object, then have them shift gaze to a near object (e.g., examiner's finger about 3 inches from nose).
Expected Findings
  • Dilation of pupils for distance vision and pupil constriction, with the eyes crossing as the person attempts to focus on a near object.
  • Document findings as PERRLA (Pupils Equal, Round, React to Light and Accommodation).
Palpate the External Structures
  • Gently palpate the eyeball with fingertips on the upper lid over the sclera, noting consistency and tenderness.
  • Palpate the lacrimal glands and ducts by palpating below the eyebrow and below the inner canthus of the eye; note tenderness and excessive tearing/discharge.
Expected Finding
  • The eyeball is firm, non-tender, and lacrimal glands are non-palpable with no tenderness present.
Assess the Internal Structures via Ophthalmoscopy
  • Darken the room; stand about 1 foot from the patient at a 15-degree lateral angle.
  • Dial the lens wheel to zero; hold the ophthalmoscope to your brow.
  • Have the patient look straight ahead while you shine the light on one pupil to identify the red light reflex.
  • Move in closer (within a few inches) to observe internal structures of the eye; adjust lens to focus as needed.
Expected Findings
  • A positive red light reflex indicates healthy internal structures.
Inspection of Ocular Fundus
  • General Background of Fundus:   - Color: light red to dark brown-red
  • Optic Disc:   - Prominent landmark located on the nasal side of the retina
      - Color: creamy yellow-orange to pink
      - Shape: round or oval
      - Margins: distinct and sharply demarcated, though nasal edge may be slightly fuzzy.

ASSESSING THE EARS AND HEARING

Objectives
  • The student will:   - Obtain a health history of the ear, nose, mouth, and throat.   - Describe the physical examination techniques to evaluate the structures listed above.   - Demonstrate how to use an otoscope.   - Document a complete assessment of the above structures using both subjective (health history) and objective data (physical exam).
Focused History Questions
  • Do you have any hearing problems?
  • Have you ever had ringing/buzzing in your ears?
  • Have you ever had any changes in your hearing?
  • Do you have any ear drainage?
  • Do you have any ear pain?
  • Do you have any balance problems, dizziness, or vertigo?
  • Do you have a history of head trauma?
  • Are you exposed to noise pollution at work or in your home environment?
  • Use OLDCART for all positive findings.
Inspection and Palpation of External Ear
  • Normal: Check the angle of attachment; normal angle = 10°.
  • Size & Shape: Equal size bilaterally, without swelling or thickening.
  • Skin Condition: Intact with no lumps or lesions.
  • Color: Consistent with skin tone.
  • Tenderness: Move pinna and push on tragus; they should feel firm, and movement shouldn't cause pain. Palpation of mastoid process should produce no pain.
Expected Findings
  • External Auditory Meatus: No swelling, redness, or discharge; cerumen usually present (color varies from gray-yellow to light brown and black; texture varies).
  • Ears: 4–10 cm in length, symmetrical in size and shape.
Perform an Otoscopic Exam
  • Have the patient tilt their head to the side not being examined.
  • For adults and older children: Pull pinna up and back.
  • For infants and children under 3 years of age: Pull pinna down.
Expected Findings
  • The ear canal is light in color and patent, with a small amount of yellow cerumen.
  • Normal eardrum is shiny and translucent, pearl-gray in color with a prominent cone-shaped light reflex at 5 o'clock in the right ear and 7 o'clock in the left.
  • Sections of malleus visible through the translucent eardrum: umbo, manubrium, and short process.
Test Gross Hearing - Whisper Test
  • Stand 1-2 feet behind the patient; have patient cover one ear while you whisper words in the other ear. Repeat for the other side.
Expected Findings
  • Patient able to hear the whisper on both sides.
Testing Hearing: Weber & Rinne Tests
  • Weber Test: Compares bone conduction to air conduction by placing a vibrating tuning fork on the skull.
  • Rinne Test: Compares air conduction to bone conduction by placing the tuning fork on mastoid process.
Pathways of Hearing
  • Understanding of the pathways includes; Bone conduction pathways vs Air conduction pathways.

ASSESSING THE NOSE AND SINUSES

The Nose and Paranasal Sinuses
Function
  • Inspiration and expiration of air.
  • Filtration, warmth, and moisturization of exchanged air.
  • Sensation of smell.
  • Resonance of speech.
Focused History Questions
  • Do you have any nasal congestion?
  • Do you have a history of nose or sinus problems?
  • Do you have any problems with seasonal or environmental allergies?
  • Do you have a history of sinus headaches?
  • Do you experience nosebleeds (epistaxis)?
  • Have you ever broken your nose?
  • Have you had any changes in your sense of smell?
  • Do you use any nasal sprays or allergy medications?
  • Use OLDCART for all positive findings.
Inspect and Palpate the External Nose
  • Inspect the nose for shape, size, color, discharge, nasal flaring or narrowing, lesions.
  • Palpate the ridge and soft tissues of the nose; note any displacement of bone & cartilage, tenderness, or masses.
  • Evaluate the nares for patency.
Inspect the Internal Structures
  • Use a nasal speculum while tilting the patient's head back.
  • Brace your finger against the nose while inserting the speculum about 1 cm into nares.
  • Normal Findings: Nasal mucosa should be pink and moist, septum intact & midline, no lesions noted.
Inspection and Palpation of Sinuses
  • Inspect frontal and maxillary sinuses for swelling.
  • Palpate frontal sinus (press up under the bony brow, using thumb on either side of nose).
  • Palpate maxillary sinus (press up under the zygomatic process, using thumb).
Expected Findings
  • No tenderness, lesions, or deformity; tenderness may indicate infectious or allergic sinusitis.

ASSESSING THE MOUTH AND THROAT

The Mouth
  • Gingival margin
  • Upper lip (everted)
  • Gingiva
  • Alveolar mucosa
  • Labial frenulum
  • Labial mucosa
  • Interdental papillae
Mouth & Throat History
  • Assess for:   - Hoarseness   - Dysphagia   - Altered taste   - Smoking/Ethanol (ETOH)   - Self-care behaviors
Assessment of the Mouth
  • Oral Mucosa: Color, moisture, lumps, ulcers, lips (cracking, scaliness).
  • Gums and Teeth: Color, swelling, ulcerations, alignment, caries, looseness, dentures.
The Mouth Components
  • Color: Examine the roof of the mouth (soft and hard palate).
  • Tongue and Floor of Mouth: Symmetry of CN XII, color, and texture.
Throat Inspection
  • Inspect tonsils for color, size, exudate.
  • Inspect the posterior wall of pharynx for color, exudate, or lesions.
  • Elicit gag reflex; touch posterior wall on each side to check for response.
  • Note any breath odor (halitosis).
Mouth and Pharynx Assessment
  • Tonsils Graded by Size:   - +1: visible   - +2: between tonsillar pillars and uvula   - +3: touching uvula   - +4: touching each other
Common Conditions Detected
  • Herpes Simplex 1: characterized by oral sores.
  • Candidiasis: oral thrush presenting as white patches.
  • Angioedema: localized swelling, often involving the tongue and lips.