Comprehensive Bullet-Point Notes – Ear, Nose, Mouth & Throat

Ear: Basic Anatomy & Function (Chap 16, p. 323)

• Sensory organ for:

  • Hearing: converts sound vibrations into electrical signals.

  • Equilibrium (balance): detects head position and motion.

• Three anatomic divisions:

  • External ear (pinna/auricle)

  • Composed of cartilage covered with skin; highly variable in shape.

  • Funnels sound waves from the environment → external auditory canal (EAC).

  • Visible landmarks: helix (outer rim), antihelix (inner rim), lobule (earlobe, fleshy), tragus (small, pointed cartilage anterior to the meatus), antitragus (opposite the tragus), concha (bowl-like depression leading to meatus), auditory meatus (opening of the ear canal).

  • Cerumen glands (produce earwax) and hair follicles line the EAC for protection.

  • Middle ear (air-filled cavity inside temporal bone)

  • Separated from the external ear by the tympanic membrane (TM).

  • Contains the smallest bones in the body (ossicles): malleus (hammer), incus (anvil), stapes (stirrup).

    • Malleus is attached to the TM; stapes fits into the oval window of the inner ear.

  • Eustachian tube (auditory tube): connects middle ear to nasopharynx; usually closed but opens with swallowing/yawning to equalise pressure across the tympanic membrane (TM) and drain secretions.

  • 3 key functions:

    • Conduct sound vibrations from the TM through the ossicles → oval window of the inner ear, amplifying sound along the way.

    • Protect inner ear by dampening loud sounds via the acoustic reflex (contraction of stapedius and tensor tympani muscles).

    • Pressure equalisation to prevent TM rupture or discomfort from barometric changes (e.g., during flying or diving).

  • Inner ear (labyrinth)

  • Complex structure encased within the temporal bone; contains fluid-filled chambers.

  • Cochlea: snail-shaped organ responsible for hearing. Contains the Organ of Corti, which houses hair cells.

  • Vestibule & semicircular canals: responsible for equilibrium and balance.

    • Vestibule detects linear acceleration and head position (utricle and saccule).

    • Semicircular canals detect angular acceleration and head rotation (anterior, posterior, lateral canals).

  • Transduces mechanical vibrations (from stapes in oval window) → fluid waves in the cochlea → movement of hair cells → electrical impulses (action potentials) that travel via the vestibulocochlear nerve (CN VIII) to the brain.

Physiology of Hearing

• Sound waves are initially collected by the pinna, travel through the external auditory canal, and vibrate the TM.

• These vibrations are transmitted and amplified by the ossicles in the middle ear.

• The stapes transmits these vibrations to the fluid within the cochlea of the inner ear, creating pressure waves.

• Fluid movement stimulates hair cells in the Organ of Corti, which convert mechanical energy into electrical signals.

• Three neural levels for processing these signals:

  • Peripheral (ear): Converts raw sound waves → mechanical vibrations → fluid waves → electrical action potentials via hair cells and CN VIII.

  • Brain-stem (binaural processing): CN VIII transmits signals to the brainstem.

  • Allows for localisation & identification of sound direction (e.g., distinguishing a book dropping behind you vs. in front).

  • Processes sound intensity (loudness) and frequency (pitch).

  • Integrates input from both ears for directional hearing and filtering background noise.

  • Cerebral cortex (temporal lobe): Interprets the complex patterns of electrical impulses as meaningful sound.

  • Allows for recognition, interpretation of meaning (e.g., doorbell sound → trigger appropriate response like going to answer it), and memory association with sounds.

  • Wernicke's area (language comprehension) and Broca's area (speech production) are involved in processing spoken language.

Categories of Hearing Loss

• Conductive (external/middle ear issue):

  • Occurs when sound waves are not properly conducted through the external or middle ear to the inner ear.

  • Mechanical blockage or dysfunction impedes sound transmission.

  • Characterised by a person hearing better in noisy environments (background noise masks their own voice, so they speak more softly – Paracusis Willisiana).

  • They hear if amplitude is raised sufficiently (sound is louder but not clearer).

  • Common causes:

  • Impacted cerumen (wax) or foreign body in the EAC.

  • Perforated tympanic membrane (e.g., from infection, trauma, or pressure changes).

  • Middle-ear pus or fluid (otitis media with effusion, acute otitis media), which dampens ossicle movement.

  • Otosclerosis (abnormal bone growth in the middle ear, fixating the stapes).

  • Cholesteatoma (skin cyst in the middle ear).

• Sensorineural (perceptive):

  • Pathology or damage of the inner ear (cochlea, hair cells), vestibulocochlear nerve (CN VIII), or auditory cortex in the brain.

  • Increasing volume alone does not significantly improve word discrimination or clarity; sounds may be loud but distorted or unclear.

  • Often affects high frequencies first.

  • Causes:

  • Presbycusis: gradual, bilateral, age-related nerve degeneration, primarily affecting high-frequency hearing.

  • Ototoxic drugs (e.g., aminoglycosides such as gentamicin, loop diuretics, high-dose aspirin, some chemotherapeutics) that damage hair cells in the cochlea.

  • Excessive noise exposure (acoustic trauma).

  • Meniere's disease (disorder of inner ear fluid balance).

  • Viral infections (e.g., mumps, measles).

  • Congenital conditions.

  • Acoustic neuroma (tumour on CN VIII).

• Mixed:

  • Combination of both conductive and sensorineural deficits (e.g., an elderly patient with presbycusis who also has cerumen impaction).

Subjective Ear History (p. 327-329)

• Earache (otalgia):

  • Location: Superficial (pinna/EAC) vs. deep (middle ear, mastoid).

  • Character: Dull, sharp, throbbing, constant/intermittent, shooting pain (referred otalgia).

  • Precipitating/relieving factors: Aggravated by chewing, swallowing, touch? Relieved by heat/cold, pain medication?

  • Association with colds, sore throat, upper respiratory infection (URI), dental issues, TMJ dysfunction (referred pain).

  • Recent trauma or water exposure?

• Infections:

  • Frequency and type (e.g., otitis media, otitis externa).

  • Treatment history (antibiotics, ear drops, ear tubes).

  • Any recurrent infections, especially in children.

• Discharge (otorrhea):

  • Describe colour (clear, yellow, green, bloody), amount (scant, moderate, copious), consistency (watery, thick, purulent), odour (foul-smelling).

  • Suggests otitis externa (swimmer's ear, often clear or scanty, foul if bacterial) or TM perforation (often purulent or bloody if acute infection, clear if CSF leak).

  • Any associated pain, fever, or hearing change?

• Hearing loss:

  • Onset: Gradual vs. sudden (sudden onset is an emergency, especially if unilateral).

  • Unilateral/bilateral (one ear vs. both).

  • Quality: High-frequency sounds first? (common in presbycusis); Worse in noisy environments? (sensorineural); Better in noisy environments? (conductive - Paracusis Willisiana).

  • Occupational/recreational noise exposure (e.g., factory work, concerts, hunting), use of hearing protection (earplugs, earmuffs).

  • Family history of hearing loss.

  • Any history of ear surgery, head injury, or specific illnesses (e.g., meningitis, mumps).

• Tinnitus (perception of sound, such as ringing, buzzing, clicking, without external source):

  • Duration (constant, intermittent), laterality (one ear, both, in the head).

  • Character (high-pitched, low-pitched, pulsatile).

  • Medications (especially ototoxic drugs like aspirin, NSAIDs, quinine).

  • Worse in quiet rooms, at night? (when external masking sounds are absent).

  • Association with hearing loss, vertigo (Ménière's disease).

• Vertigo (distinct sensation of spinning or rotational movement, either of oneself or the surroundings):

  • Differentiate from dizziness or lightheadedness.

  • Room-spinning sensation (e.g., Ménière’s disease, BPPV - Benign Paroxysmal Positional Vertigo, labyrinthitis).

  • Effect on Activities of Daily Living (ADLs): Does it cause falls, interfere with work or driving?

  • Triggers (head movements, positional changes, stress)? Associated symptoms (nausea, vomiting, nystagmus)?

• Ear hygiene:

  • Use of cotton swabs, ear candles, or other objects; depth of insertion (emphasise not putting anything smaller than an elbow in the ear).

  • Frequency of cleaning.

• Hearing aids:

  • Type (behind-the-ear, in-the-ear, in-the-canal, completely-in-canal), usage (how many hours/day), care (cleaning, battery changes), perceived benefit (clarity, comfort).

  • Modern aids are often invisible or very small → always ask, as patients may not offer this information spontaneously.

  • Cochlear implants? Bone-anchored hearing aids (BAHA)?

Objective Ear Assessment

• Inspect & palpate external ear:

  • Size, shape, symmetry of pinna.

  • Skin lesions (e.g., moles, cysts, basal cell carcinoma, squamous cell carcinoma), nodules (e.g., tophi in gout), piercings (any signs of infection).

  • Move pinna (tug test: pulling on helix or lobule) & press tragus → should be firm & non-tender. Tenderness suggests otitis externa.

  • Palpate mastoid process (bony prominence behind ear) → no pain. Tenderness here can indicate mastoiditis (inflammation of mastoid bone) or lymphadenitis.

• External auditory meatus:

  • Assess size of opening, presence of swelling, erythema (redness), exudate/discharge (colour, amount), cerumen (wax) amount (absent to impacted), foreign bodies.

  • Note any odour.

• Gross hearing screening:

  • If patient reports difficulty or you suspect a problem after history → refer for formal audiometry (gold standard for hearing assessment).

  • If no reported difficulty → perform Whisper Test as a quick screening tool (assesses high-frequency hearing).

  • Stand ~1 arm-length (0.6-0.9 meters) behind the patient to prevent lip reading.

  • Test one ear at a time (occlude the non-tested ear by having the patient gently press their tragus into the ear canal).

  • Shield your lips to prevent visual cues, whisper a set of two-syllable words or numbers (e.g., "baseball," "four-two," "light-bulb").

  • Patient is asked to repeat what they hear.

  • Normal: Patient correctly repeats ≥ 4/6 words/numbers (e.g., 3 pairs of 2-syllable words).

  • Abnormal: If < 4/6 correct repeats, suggests a need for further evaluation (audiometry).

• Otoscopy (advanced skill, requires practice and knowledge of landmarks):

  • Use an otoscope to visualise the ear canal and TM.

  • Adult: Pull pinna up & back (and slightly out) to straighten the S-shaped ear canal. The scope is held upside-down to brace the hand against the patient's face, preventing injury from sudden movement.

  • Insert speculum gently into the external auditory meatus, aiming slightly forward and downward.

  • Inspect the external auditory canal for swelling, redness, foreign bodies, discharge.

  • Tympanic membrane (eardrum):

  • Colour: Shiny, translucent, pearly-gray. Abnormal colours include red (acute otitis media), yellow/amber (effusion), white patches (scarring, tympanosclerosis), blue (hemotympanum).

  • Contour: Flat, slightly pulled in at the centre. Bulging suggests positive pressure (fluid/pus behind TM); retracted suggests negative pressure.

  • Mobility: Assessed with pneumatic otoscopy (puff of air should cause TM to move).

  • Perforations: Holes in the TM. Note size, location.

  • Landmarks: Identify annulus (fibrous ring), fibrous rim of TM, handle of malleus (umbo at the tip).

  • Cone-of-light (light reflex): A triangular reflection of light from the otoscope on the TM, indicating a healthy, intact eardrum.

    • Right ear: Cone-of-light points anteriorly and inferiorly at the 5{:}00 position.

    • Left ear: Cone-of-light points anteriorly and inferiorly at the 7{:}00 position.

Age-Related Ear Changes

• Coarse, wiry cilia in the external auditory canal → contribute to cerumen impaction ↑.

• Dry cerumen (wax) and potential collapse of ear canals (due to loss of cartilage elasticity), especially upon insertion of an otoscope speculum.

• Presbycusis: most common type of sensorineural hearing loss in older adults.

  • Gradual, symmetric, bilateral high-frequency loss affecting nerve function in the cochlea.

  • Leads to difficulty hearing consonants (f, s, th, ch, sh) and distinguishing sounds in noisy environments or with rapid speech.

  • Impaired localisation of sound source.

• Pendulous ear lobes due to ↓ skin elasticity and loss of subcutaneous fat.

Nose & Sinus Anatomy (Chap 17, p. 351)

• External nose: Cartilaginous and bony framework covered by skin. Nares (nostrils) are openings.

• Nasal cavity: Extends posteriorly from nares to nasopharynx, divided sagittally by the nasal septum (composed of bone and cartilage).

• Turbinates (conchae): Three shelf-like projections (superior, middle, inferior) along the lateral walls of the nasal cavity.

  • Increase surface area of the nasal mucosa.

  • Function to warm, humidify, and filter inhaled air by trapping particles with mucus.

• Paranasal sinuses: Air-filled cavities within the skull bones, lined with mucous membrane, and connected to the nasal cavity.

  • Frontal sinuses: Located in the frontal bone, above the eyes. Accessible to exam (palpation).

  • Maxillary sinuses: Located in the maxillary bones, below the eyes. Accessible to exam (palpation).

  • Ethmoid sinuses: Deeper, located between the eyes and behind the nose (not directly palpable).

  • Sphenoid sinuses: Deepest, located behind the ethmoid sinuses (not directly palpable).

  • Functions: Lighten the skull, resonate sound, and produce mucus.

• Openings: Meatuses (channels) beneath corresponding turbinates, into which the paranasal sinuses and nasolacrimal ducts drain.

Mouth & Throat Anatomy

• Lips (labia): Red vermillion border, highly vascular, sensitive.

• Teeth & gums (gingiva): Adults typically have 32 permanent teeth. Gums cover the alveolar processes.

• Oral cavity: Space inside the dental arches.

• Palate: Forms the roof of the mouth.

  • Hard palate (anterior bony): Whitish, corrugated (rugae), separates oral and nasal cavities.

  • Soft palate (posterior muscular): Pinker, smooth, mobile; ends in the uvula.

• Uvula: Midline pendulous structure hanging from the soft palate; rises during swallowing and phonation to prevent food/liquid from entering the nasal cavity.

• Tongue: Muscular organ attached to the floor of the mouth.

  • Dorsal surface: Roughened by papillae (some containing taste buds).

  • Ventral surface: Smooth, rich with visible veins.

  • Functions: Speech articulation, taste, mastication (chewing), swallowing.

• Tonsils (palatine tonsils): Lymphoid tissue located in the oropharynx, on either side between the anterior and posterior tonsillar pillars.

  • Part of Waldeyer's ring, a lymphatic ring involved in immune surveillance.

  • Graded 1^+ ext{–} 4^+ based on size.

• Pharynx (throat): Divided into nasopharynx, oropharynx, and laryngopharynx.

Subjective Nose/Sinus History

• Rhinorrhea (nasal discharge/runny nose):

  • Describe colour (clear - allergies/viral; white/mucoid - viral/sinusitis; yellow/green/purulent - bacterial infection; bloody - trauma/epistaxis), consistency (watery, thick, stringy).

  • Unilateral vs. bilateral.

  • Association with sneezing, itching, congestion, facial pain.

• URI frequency: How often do colds or sinus infections occur?

  • Duration of symptoms, typical treatments, recurring patterns.

• Nasal trauma/obstruction: History of nasal fractures, deviated septum.

  • Unilateral/bilateral difficulty breathing through nose.

  • Intermittent/constant, worse at night or in certain positions.

  • Any history of polyps, foreign bodies, or hypertrophied turbinates.

• Epistaxis (nosebleed):

  • Amount (small, moderate, heavy), colour (bright red - anterior; dark red/clotted - posterior).

  • Unilateral/bilateral onset.

  • Ease of control: How long does it take to stop? Any recurrent episodes?

  • Precipitating factors: Picking, dry air, trauma, medications (anticoagulants, NSAIDs), underlying conditions (hypertension, clotting disorders).

  • Management teaching: Lean forward (to avoid swallowing blood), pinch soft part of nose (alae) against the septum for 10 ext{–}15 minutes (avoid tilting head back, which can cause aspiration or nausea from swallowed blood).

• Allergies: Specific triggers (pollen, dust, pets), seasonal patterns, type of reaction (sneezing, watery eyes, congestion).

  • Effectiveness of current medications (antihistamines, nasal sprays).

• Altered smell (anosmia - complete loss; hyposmia - diminished sense): Loss or change in ability to smell.

  • Onset (sudden, gradual), duration.

  • Causes: URI, head trauma, nasal polyps, neurological conditions, aging, COVID-19.

  • Impact on appetite or safety (inability to smell smoke/gas).

Subjective Mouth & Throat History

• Sores/lesions: Location (lips, tongue, buccal mucosa, gums).

  • Single vs multiple, duration (< 2 weeks → usually viral or traumatic; > 2 weeks → raises suspicion for malignancy, especially if non-healing).

  • Character (painful, non-painful, clear fluid, pus, bleeding).

  • Triggers (stress, particular foods, trauma, season, sun exposure - for cold sores).

  • History of oral thrush, candidiasis.

• Sore throat:

  • Onset, duration, severity.

  • Viral → often associated with rhinorrhea, cough; resolves 3 ext{–}5 days without antibiotics.

  • Bacterial (Strep throat - Streptococcus pyogenes): Suggestive symptoms include abrupt onset, severe sore throat, temperature > (100.4^ ext{ extdegree} ext{F}) (or 38^ ext{ extdegree} ext{C}), absence of cough, associated headache, abdominal pain in children, tonsillar exudates (pus), anterior cervical adenopathy (swollen lymph nodes).

  • Needs antibiotics (e.g., penicillin) to prevent serious complications like acute rheumatic fever (affecting heart valves) and post-streptococcal glomerulonephritis (kidney inflammation).

• Hoarseness (dysphonia): Change in voice quality (rough, breathy, strained).

  • Duration (acute vs. chronic).

  • Causes: Overuse (e.g., sport cheering, professional voice users), URIs (laryngitis), chronic irritation (GERD, smoking), vocal cord nodules/polyps, hypothyroidism, neurological conditions (e.g., Parkinson's), neoplasm (laryngeal cancer - persistent hoarseness > 2 weeks requires referral).

• Dysphagia (difficulty swallowing):

  • Difficulty initiating swallow (oropharyngeal) vs. sensation of food sticking (esophageal).

  • Causes: Pharyngitis, tonsillitis, GERD, neurological conditions (e.g., stroke, Parkinson's, ALS), oesophageal strictures, foreign body, cancer (oral, pharyngeal, oesophageal).

  • Liquids vs. solids; any associated pain (odynophagia).

• Dental status: Number of natural teeth, presence of dentures (full, partial, fixed).

  • Care routines (brushing, flossing, regular dental visits).

  • Last dental check-up.

  • Tooth pain, sensitivity, loose teeth, bleeding gums.

• Changes in taste/smell: Loss (ageusia/anosmia), diminished (hypogeusia/hyposmia), or distorted (dysgeusia/dysosmia).

  • Can significantly contribute to appetite decline and malnutrition, especially in older adults.

Objective Nose/Sinus Exam

• Inspect external nose: For symmetry, deformities, skin lesions, swelling, discharge, flaring of nostrils.

• Palpate frontal & maxillary sinuses for tenderness: Apply upward pressure under the brow for frontal sinuses; apply pressure over maxillary sinuses below the cheekbones.

  • Increased pain → suggests acute sinusitis (infection) or severe allergy exacerbation related to inflammation.

  • Percussion over sinuses can also elicit tenderness.

• Patency test (for nasal airflow): Ask patient to occlude one naris and sniff through the other.

  • Assess for airflow obstruction unilaterally or bilaterally.

• CN I (olfactory) test: Used to assess the sense of smell.

  • Ask the patient to close their eyes and identify a familiar non-irritating scent (e.g., coffee, vanilla, soap, chocolate).

  • Test each nostril separately while the other is occluded.

  • Document if smell is present, diminished, or absent.

Objective Mouth & Throat Exam

• Use a penlight (or otoscope head light), tongue blade, and gloves.

• Lips:

  • Inspect for colour, moisture, cracks (cheilosis, angular stomatitis at corners), lesions (herpes simplex, carcinoma), swelling.

  • Clinical colour findings:

  • Pallor → systemic conditions like shock or anemia.

  • Cyanosis → hypoxemia (low oxygen in blood) or extreme cold.

  • Cherry-red → carbon monoxide poisoning, ketoacidosis (diabetic coma), high fever.

• Teeth & gums:

  • Number of teeth, condition (decay, fillings, missing teeth), alignment (malocclusion).

  • Gingival colour (should be pink, moist), recession (gums pulling away from teeth), bleeding, swelling, inflammation (gingivitis).

  • Condition of teeth and gums can provide clues about overall nutrition and socioeconomic status.

• Tongue:

  • Dorsal surface: Inspect for typical rough papillae, pink colour, moisture. Note any coating, dryness.

  • Ventral surface (underside): Lift tongue to inspect for smooth, glistening surface, presence of visible veins, and adequate saliva.

  • Inspect entire U-shaped floor of mouth and sides of tongue: This area is a high-risk site for oral cancer. Look for white patches (leukoplakia), red patches (erythroplakia), nodules, ulcers, or induration (hardening).

  • Palpate the floor of the mouth if any suspicion of lesion.

• Buccal mucosa (inner lining of cheeks):

  • Inspect for colour (pink), smoothness, moisture. Look for leukoplakia (precancerous white patches, often from chronic irritation/smoking), canker sores (aphthous ulcers), candidiasis (thrush - white, non-scrapable patches).

  • Stensen's duct (salivary gland opening) opposite upper second molar.

• Palate:

  • Hard palate: Whitish, corrugated rugae anteriorly. Look for lesions, masses (e.g., torus palatinus - benign bony growth).

  • Soft palate: Pinker, smooth, mobile posteriorly. Assess for symmetry.

• Uvula & oropharynx:

  • Ask patient to say “ahh” to observe the soft palate and uvula.

  • Uvula should rise midline (this movement tests the integrity of CN X – vagus nerve).

  • Any deviation of the uvula may indicate a lesion or cranial nerve paralysis (e.g., stroke).

• Tonsil grading (if present; often removed or atrophied in adults):

  • 1^+: Visible, just behind the pillars.

  • 2^+: Halfway between tonsillar pillar and uvula.

  • 3^+: Touching the uvula.

  • 4^+: Touching each other (kissing tonsils), common in acute infection, can obstruct airway.

• Posterior pharyngeal wall: Inspect colour, presence of exudate (pus), lesions, post-nasal drip.

• Cranial nerves related to mouth/throat:

  • CN IX (glossopharyngeal): Assessed indirectly by gag reflex (afferent limb) and taste to posterior third of tongue.

  • CN X (vagus): Assessed by symmetrical palate rise (efferent limb of gag reflex), ability to swallow, and normal clear speech (no hoarseness or breathiness).

  • CN XII (hypoglossal): Assessed by tongue movement (protrude tongue midline, move side-to-side, press against cheek strength).

  • Deviations or fasciculations (tremors) can indicate nerve damage.

  • Speech clarity (articulation) also depends on CN XII function.

Age-Related Changes (Nose, Mouth, Throat)

• Nose appears more prominent due to loss of subcutaneous fat and cartilage changes.

• Xerostomia (↓ saliva production): Due to medications (common), systemic diseases (e.g., Sjögren's syndrome), or gland atrophy. Leads to dry mouth, increased risk of dental caries, difficulty chewing/swallowing.

• Tooth loss: Common due to decay, gum disease, or trauma. Can lead to malocclusion (improper bite) → chewing problems → potential nutrition risk (difficulty eating solid foods).

• Uniform yellowing of dentin (inner tooth layer) visible through thinning enamel; gum recession (gums pull back from teeth, exposing roots).

• Tongue smoother (papillary atrophy) → diminished taste sensation, contributing to reduced appetite.

• Reduced smell (anosmia/hyposmia) and taste perception contribute significantly to appetite decline and potential weight loss, and reduced enjoyment of food.

• Adaptations: Dentures (may be ill-fitting or poorly maintained), altered speech (due to ill-fitting dentures or missing teeth), pocketing food in buccal sulcus (due to decreased sensation or motor control), example: father storing lower denture in shirt pocket.

Practical / Real-World & Ethical Points

• Encourage hearing protection: Essential in noisy occupational settings (construction, manufacturing), recreational activities (concerts, hunting), and responsible headphone usage (especially for teenagers, stressing volume limits and duration) to prevent noise-induced hearing loss.

• Ototoxic medication monitoring: Balance therapeutic need (e.g., life-saving antibiotics like gentamicin) vs. auditory risk (irreversible hearing loss). Regular audiometry may be indicated.

• Antibiotic stewardship: Educate patients that antibiotics are ineffective for viral sore throats (the vast majority); only treat confirmed strep throat to prevent rheumatic sequelae (e.g., rheumatic fever, which can cause severe heart valve damage) and resistant bacteria.

• Safe ear hygiene: Emphasise not putting any objects (e.g., cotton swabs, hairpins) inside the ear canal, as this can push cerumen deeper, cause impaction, or perforate the TM. Professional cerumen removal by a healthcare provider (irrigation, manual removal) if needed.

• Empathic communication with hearing-impaired patients: Always face the patient directly, maintain eye contact, speak clearly and slightly slower (but do not shout), use visual cues (gestures, facial expressions), provide written information, and ensure good lighting for lip-reading.

• Education on correct nose-bleed first aid: Reinforce leaning forward and pinching the soft part of the nose for 10 ext{–}15 minutes. Counter common myths like tilting the head back.

Quick Reference Values & Terms

• Fever threshold for possible strep throat → > (100.4^ ext{ extdegree} ext{F}) (=38^ ext{ extdegree} ext{C})

• Cone of light positions: Right ear 5{:}00, Left ear 7{:}00

• Whisper test pass criteria: ext{Greater than or equal to } 4/6 correct responses

• Tonsil scale: 1^+–4^+ (Visible to touching each other)

• Tinnitus definition: Perception of sound without external auditory stimulus (e.g., ringing, buzzing, clicking).

• Epistaxis = medical term for nosebleed.

• Presbycusis = age-related sensorineural hearing loss, typically bilateral high-frequency loss.

• Otalgia = medical term for earache.

• Otorrhea = medical term for ear discharge.

• Rhinorrhea = medical term for nasal discharge/runny nose.

• Dysphagia = medical term for difficulty swallowing.

• Xerostomia = medical term for dry mouth due to reduced saliva production.

• Anosmia = complete loss of the sense of smell.

• Vertigo = sensation of spinning motion (either of oneself or the surroundings).