Health Assessment – Ears, Nose, Mouth & Throat

Ear Anatomy and Physiology

The ear is divided into three anatomical regions—external, middle, and inner—each composed of specialized structures that work together to transmit sound waves and to maintain balance. The external ear begins with the pinna and the external auditory canal, a passageway supported by cartilage laterally and by the temporal bone medially. At the medial end of this canal lies the tympanic membrane, a thin, translucent barrier that converts air-borne vibrations into mechanical energy.

Immediately behind the tympanic membrane is the air-filled middle ear cavity, housing the three auditory ossicles: the malleus, incus, and stapes. The handle of the malleus is visibly attached to the tympanic membrane, the incus forms the bridge, and the footplate of the stapes rests in the oval window. An equalizing passage, the eustachian tube, connects the middle ear to the nasopharynx, regulating pressure on both sides of the tympanic membrane.

The inner ear, embedded in the bony labyrinth of the skull, contains the cochlea (responsible for hearing) and the vestibular apparatus (semicircular canals and vestibule), which collectively govern equilibrium. Neural impulses generated here travel via CN\ VIII—the vestibulocochlear nerve—to the brainstem and ultimately the auditory cortex of the temporal lobe.

Hearing operates on three hierarchical levels. At the peripheral level, sound waves are translated into electrical impulses by the organ of Corti. These signals ascend through the brainstem, where binaural interaction allows for sound localization, and finally reach the cerebral cortex, where conscious perception and interpretation occur.

Hearing loss is classified as conductive (mechanical blockage or dysfunction of the external or middle ear), sensorineural (pathology of the inner ear or CN\ VIII), or mixed, when both components coexist. Any interference with vestibular input may produce vertigo and imbalance.

Subjective Assessment of the Ear (PQRSTU Framework)

During history taking, explore Pain/Provocation (otalgia), Quality/Quantity of symptoms, Region/Radiation, Severity, Timing, and Understanding of the patient. Ask specifically about environmental noise exposure, recurrent infections, tinnitus, otorrhea (discharge), vertigo, self-perceived hearing loss, and general ear-care practices. Subtle behavioural clues signal occult hearing deficits: the patient may watch your lips rather than your eyes, lean forward or turn an ear to you, repeatedly request clarification, or speak in a monotone, loudly, or with garbled articulation.

Objective Ear Examination

Begin by inspecting and palpating the external ear for symmetry, skin integrity, tenderness, and nodules. Proceed to functional testing. A single screening question—“Do you have difficulty hearing now?”—has moderate sensitivity; an affirmative answer warrants formal audiometry. If the response is negative, employ the whispered-voice test: stand 30–60 cm (1–2 ft) behind the seated patient, occlude and gently massage the tragus of the non-test ear, shield your lips, and whisper a series of random numbers and letters. Correct repetition of three out of six total syllables constitutes a normal result.

Otoscopy follows. Straighten the adult canal by drawing the pinna up and back; this aligns the cartilaginous and bony portions to minimize discomfort and to prevent injury. Hold the otoscope upside-down, bracing the dorsum of your hand against the patient’s cheek for stabil­ity and safety. A healthy tympanic membrane appears pearly gray and translucent, with a prominent cone of reflected light: at the 5 o’clock position in the right ear and 7 o’clock in the left. Identify the handle of the malleus, the umbo, and the annulus.

Age-Related Ear Changes

In older adults, coarse wiry hairs populate the canal, cerumen becomes drier and more adherent, and elasticity of auricular cartilage diminishes, producing elongated—often pendulous—lobes. Presbycusis, a bilateral sensorineural loss, preferentially impairs perception of higher-pitched consonants; consequently, words seem garbled, and sound localization deteriorates.

Common Abnormalities of the Ear

External ear disorders include otitis externa ("swimmer’s ear" presenting with painful tragal palpation), traumatic cauliflower ear due to perichondral hematoma, and keloids at pierced-ear sites. Within the canal or on the drum you may observe excessive cerumen, acute otitis media with bulging erythematous membrane, or perforations that appear as round or oval darkened sections.

Nasal, Oral, and Pharyngeal Anatomy

The nose comprises an external cartilaginous framework and an internal cavity partitioned by the septum. The turbinates (superior, middle, inferior) increase surface area, while the paranasal sinuses—frontal and maxillary being accessible—lighten the skull and condition inspired air.

The mouth includes the lips, teeth, gingivae, hard and soft palates, dorsum and ventrum of the tongue, and the oropharynx. The uvula hangs midline at the posterior margin of the soft palate, and paired palatine tonsils reside in the tonsillar fossae.

Subjective Assessment of Nose, Mouth, and Throat (PQRSTU)

For the nose, inquire about allergies, rhinorrhea, episodic or chronic colds, pain or trauma, epistaxis, and altered smell. For the mouth/throat, cover sores, lesions, sore throats, bleeding gums, toothaches, hoarseness, dysphagia, changes in taste, tobacco or alcohol use, and daily oral-hygiene routines.

Objective Examination of Nose and Sinuses

Inspect the external nose for alignment and deformity; evaluate each naris for patency by occluding the opposite side. Using a penlight, inspect the mucosa, noting color, edema, discharge, septal deviation, or perforation. Palpate the frontal sinuses (under the brow) and maxillary sinuses (below the zygomatic arch) for tenderness. Olfactory function is screened by testing CN\ I—have the patient identify familiar scents with eyes closed, occluding one naris at a time.

Objective Examination of Mouth

Proper illumination is essential. Inspect the lips for color and moisture, the gums for margin recession or hyperplasia, and all tooth surfaces for caries, cracks, and alignment. The buccal mucosa should appear pink and smooth; Stensen’s ducts are opposite the upper second molars. Examine the tongue’s dorsal surface for papillae and lesions, then grasp the tip with gauze to inspect the ventral surface and floor of mouth; palpation here is critical because malignancies commonly originate in the horseshoe area under the tongue. The hard palate is whitish and corrugated, whereas the soft palate is pink, smooth, and mobile.

Objective Examination of Throat

Ask the patient to phonate—"ahh"—observing soft-palate rise and midline uvular elevation, a test of CN\ IX and CN\ X. Grade tonsillar enlargement from 0 (absent/removed) to 4 ("kissing" the uvula); 1+ is normal in healthy adults. Using a tongue blade, inspect the posterior pharyngeal wall for color, exudate, or cobblestoning. Finally, assess CN\ XII by asking the patient to protrude the tongue and push it against your resisting finger—deviation or weakness suggests hypoglossal pathology.

Age-Related Craniofacial Changes

With aging, subcutaneous fat diminishes, rendering the nose more prominent. Tooth loss and drifting cause malocclusion, affecting mastication and nutrition. Salivary secretion wanes, and taste as well as smell diminish, reducing appetite and dietary variety. On inspection, expect uniform yellow tooth enamel, receding gums, and a smoother, shiny tongue due to papillary atrophy.

Common Abnormalities of Nose, Mouth, and Throat

Nasal disorders include epistaxis, acute viral rhinitis (erythematous turbinates, watery discharge), allergic rhinitis (pale boggy mucosa, clear discharge), and bacterial sinusitis (purulent drainage, tenderness). Dental and gingival problems encompass malocclusion, dental caries, "meth mouth" (rampant decay from methamphetamine use), and gingivitis with erythematous bleeding gums. Tongue pathology may reveal candidiasis—a white, curd-like coat that scrapes off—and migratory glossitis, characterized by erythematous depapillated patches with white borders. Throat infections vary from tonsillitis with exudative crypts to diffuse pharyngitis.

Practical, Safety, and Patient-Centred Considerations

Ensuring patient safety underpins each technical maneuver: stabilizing your otoscope hand prevents canal injury; manipulating the pinna appropriately aligns the canal; and employing a quiet, private environment improves validity of whispered-voice testing. A patient-centred approach respects the person’s communication needs—face the individual, speak clearly, and confirm comprehension, particularly in those with presbycusis. Ethically, early detection of hearing or oral disease preserves quality of life, supports autonomy, and prevents downstream complications such as social isolation, malnutrition, or systemic infection.

Integrative and Inter-Lecture Connections

Assessment skills for the ear, nose, and throat build on foundational head and neck anatomy and reinforce broader principles of inspection, palpation, percussion, and auscultation learned earlier in the course. Understanding sensorineural versus conductive pathways parallels cardiovascular and respiratory concepts of central versus peripheral mechanisms. Finally, accurate cranial-nerve testing integrates neurological content, emphasizing holistic, system-wide evaluation.