Ears, Nose, Mouth, and Throat Study Notes

Ears, Nose, Mouth, and Throat Study Notes

Learning Outcomes

  • 15.1 Describe the anatomy and physiology of the ears, nose, mouth, and throat.

  • 15.2 Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of the ears, nose, mouth, and throat.

  • 15.3 Determine which questions about the ears, nose, mouth, and throat to use for the focused interview.

  • 15.4 Outline the techniques for assessment of the ears, nose, mouth, and throat.

  • 15.5 Generate the appropriate documentation to describe the assessment of the ears, nose, mouth, and throat.

  • 15.6 Identify abnormal findings in the physical assessment of the ears, nose, mouth, and throat.

Introduction

  • The H E E N T (Head, Ears, Eyes, Nose, Throat) structures include features that enable the senses of hearing, smell, and taste.

  • The structures of the nose, mouth, and throat mark the beginning of both the respiratory and gastrointestinal systems.

Ears

Anatomy and Physiology Review: Ear

  • The ear is the sensory organ that functions in hearing and equilibrium.

  • It is divided into the external ear, middle ear, and inner ear.

  • Major functions of the ears include:

    • Collecting and transporting sound vibrations to the brain.

    • Maintaining the sense of equilibrium.

External Ear

  • Auricle Components:

    • Helix: External large rim

    • Tragus: Stiff projection that protects the anterior meatus of the auditory canal.

    • Lobule: Small flap of flesh at the inferior end of the auricle.

  • External Auditory Canal:

    • Approximately 1 inch (2.54 cm) in length, S-shaped, leading to the middle ear lined with glands.

    • Glands secrete cerumen (yellow-brown wax) to lubricate and protect the ear.

  • Mastoid Process:

    • Part of the temporal bone, adjacent to the middle ear cavity, containing air cells.

Middle Ear

  • Separation from External Ear:

    • Tympanic membrane (eardrum) separates the external ear from the middle ear.

  • Tympanic Membrane:

    • Translucent membrane, pearly gray in color, vibrates in response to sound waves.

  • Ossicles:

    • Comprises three small bones: malleus, incus, stapes.

  • Oval Window:

    • Connects to the inner ear, transmitting sound vibrations.

Inner Ear

  • Contains bony labyrinth holding sensory organs:

    • Vestibule: Part of the inner ear responsible for balance.

    • Three Semicircular Canals: Also involved in balance.

    • Cochlea: Involved in hearing.

    • Auditory Nerve (CN VIII): Transmits sound and equilibrium information to the brain.

  • Assessment Limitations:

    • Inner ear functions not assessable by direct examination but can be evaluated indirectly.

Special Considerations

  • Health assessment variations occur due to:

    • Age, developmental level, race, ethnicity, work history, living conditions, socioeconomics, emotional well-being.

  • Ethical and Environmental Considerations:

    • Cerumen type linked to ethnicity.

    • Occupational or hobbies' risk factors for hearing loss, especially in high noise environments.

Subjective Cues

  • Common symptoms to inquire about include:

    • Earache

    • Infections

    • Discharge

    • Hearing loss

    • Environmental noise exposure

    • Tinnitus- ringing in the ears

    • Vertigo - a sensation of spinning or dizziness that can accompany ear disorders.

    • Otitis media - an infection of the middle ear that can lead to pain and hearing issues.

    • Allergies - which can cause nasal congestion and affect overall ear and throat health.

    • Sinusitis - inflammation of the sinuses that can cause pressure and pain, often leading to ear discomfort.

    • Patient-centered care approaches.

Objective Data: Physical Assessment

  • Assessment Techniques:

    • Inspect and palpate external ear.

    • Inspect auditory canal and tympanic membrane.

    • Perform whisper test, Rinne test, Weber test, Romberg test.

Objective Findings: Ears

  • Ears must be symmetric in size, shape, color, and configuration.

  • External auditory canal should be patent and free of drainage.

  • External ear and mastoid process should be free of lesions.

  • Tympanic membrane should be flat, gray, translucent, showing no lesions, with visible malleolar process.

  • Normal hearing test results show air conduction (AC) is longer than bone conduction (BC).

  • Healthy subjects should maintain balance effectively.

Inspection and Palpation: Ears

  • Check size, shape, skin condition, and tenderness of external ear.

Otoscope Inspection Technique

  • Adult/Older Child: Pull pinna up and back to straighten the canal.

  • Infants/Children Under 3: Pull pinna down.

  • Insert otoscope slowly along the canal's axis.

Preparation for Data Collection

  • Position sitting upright with head at eye level.

  • Note potential cerumen obstructions.

  • Special examination instruments: otoscope, tuning fork, nasal speculum.

  • Assess binaural hearing capabilities.

External Canal Inspection

  • Look for redness, swelling, lesions, foreign bodies, or discharge; note color and odor if present.

Tympanic Membrane Inspection

  • Check for normal color, characteristics, and landmarks.

  • The normal TM should appear shiny, translucent, with a pearl-gray color.

  • Assess for the cone of light reflex in the anteroinferior quadrant.

  • Evaluate for perforations.

Whispered Voice Test Procedure

  • Test one ear at a time while occluding the opposite ear; whisper a phrase from 30-60 cm (1-2 ft) away.

  • Observe for correct repetition of words.

Tuning Fork Tests

  • Hearing Measurement:

    • Assess air conduction (AC) through ear canal vs. bone conduction (BC) via cranial bones.

    • Normally, AC is more sensitive; use tuning fork to perform Weber and Rinne tests.

  • Weber Test:

    • Normal: Sound equally heard in both ears.

    • Abnormal: Sound lateralizes to one ear (conductive loss to poorer ear, sensorineural loss to better ear).

  • Rinne Test:

    • Normal: AC > BC (positive finding).

    • Abnormal results indicate conductive loss (AC = BC or AC < BC, indicating longer BC).

Vestibular Apparatus Testing (Romberg Sign)

  • Assesses vestibular functions related to balance maintenance while standing.

Abnormal Findings: External Ear

  • Common issues include:

    • Frostbite

    • Brachial remnant and ear deformity

    • Otitis externa (Swimmer’s ear)

    • Cellulitis may occur as a complication, leading to redness, swelling, and pain that can affect hearing.

Abnormal Findings: Lumps and Lesions on External Ear

  • Identify:

    • Sebaceous cyst

    • Tophi

    • Chondrodermatitis nodularis helicis

    • Battle sign

    • Carcinoma.

Abnormal Findings: Ear Canal

  • Common abnormalities include:

    • Excessive cerumen

    • Otitis externa

    • Osteoma

    • Exostosis

    • Furuncle

    • Polyp.

Abnormal Findings: Tympanic Membrane

  • Evaluation findings may suggest:

    • Retracted drum

    • Otitis media with effusion (OME)

    • Acute otitis media

    • Perforation

    • Scarring of ear drum

    • Presence of tympanostomy tubes

    • Scarred drum.

Nose, Mouth, & Throat

Anatomy and Physiology Review: Nose and Sinuses

  • Structure:

    • The nose is a triangular organ of bone and cartilage, the only externally visible part of the respiratory system.

  • Function:

    • Air enters the nasal cavity during inspiration, where it is filtered, warmed, and moistened before reaching the lungs.

  • Nasal Structure:

    • The bridge of the nose is on the superior aspect, medial to the orbits; the nares are oval openings at the base.

  • Nasal Cavity:

    • Divided by the nasal septum; contains rich blood supply to filter air.

    • Turbinates: three projections (superior, middle, inferior) aiding in airflow.

    • Olfactory cells located at the roof are responsible for the sense of smell (connected to CN I).

Function of the Nose and Sinuses

  • The paranasal sinuses are mucus-lined air-filled spaces that surround the nasal cavity.

  • Types of Sinuses:

    • Sphenoid

    • Frontal

    • Ethmoid

    • Maxillary

  • Functions:

    • Provide a respiratory airway

    • Filter, warm, and humidify the air

    • Provide voice resonance

    • House olfaction receptors.

Anatomy and Physiology Review: Mouth

  • The oral cavity is oval-shaped, marking the start of the alimentary canal and digestive system, divided into:

    • Vestibule: the smaller anterior portion with lips, buccal mucosa, gums, and cheeks.

    • Oral Cavity Proper: contains teeth, tongue, hard and soft palate, uvula, mandibular, and maxillary arches.

  • Teeth:

    • 32 permanent teeth for adults, 20 deciduous for children; held in alveoli of mandible and maxilla.

    • Enamel-covered crown is visible; the root is embedded in jawbone.

Mouth Structures

  • Tongue:

    • Organ for taste sitting on the floor, base resting on hyoid bone; connected by frenulum.

    • Types of Surfaces:

    • Ventral (underside): smooth with visible vessels;

    • Dorsal (top): rough, contains papillae with taste buds innervated by CN VII and IX; involved in speech and swallowing (CN XII).

Palate and Salivary Glands

  • Hard Palate: anterior roof, formed by bone.

  • Soft Palate: posterior, formed by muscle; uvula hangs from its free edge.

  • Salivary Glands:

    • Parotid Glands: located anterior to the ear; saliva enters the mouth via Stensen duct.

    • Submandibular Glands: beneath the mandible, saliva via Wharton’s duct.

    • Sublingual Glands: located under the tongue.

Anatomy and Physiology: Throat

  • Pharynx:

    • Connects nose, mouth, larynx, and esophagus.

    • Sections:

    • Nasopharynx: behind the nose, above the soft palate, contains adenoids and eustachian tube openings.

  • Oropharynx:

    • Lies between the soft palate and hyoid bone.

    • Laryngopharynx:

    • Connects to the esophagus.

Subjective Data: Nose and Sinuses

  • Inquire about:

    • Discharge

    • Frequent colds (upper respiratory infections)

    • Sinus pain

    • Trauma

    • Epistaxis (nosebleeds)

    • Allergies

    • Altered smell.

Subjective Data: Mouth and Throat

  • Common symptoms include:

    • Sores or lesions

    • Sore throat

    • Bleeding gums

    • Toothache

    • Hoarseness

    • Dysphagia

    • Altered taste

    • History of smoking or alcohol consumption

    • Dental care patterns

    • Dentures or appliances.

Objective Data Preparation

  • Positioning:

    • Patient sitting upright at eye level.

    • Provide a towel for denture removal if needed.

  • Equipment Needed:

    • Otoscope with short, nasal speculum

    • Penlight

    • Tongue blades

    • Cotton gauze pad (4" x 4")

    • Gloves.

Objective Data: Nose Inspection and Palpation

  • External Nose:

    • Check for symmetry and deformities.

    • Test patency of nostrils; sense of smell (CN I) not routinely tested.

Objective Data: Nasal Cavity Inspection and Palpation

  • Inspect nasal turbinates and septum for any abnormalities.

Objective Data: Palpation of Sinus Areas

  • Use thumbs to press over frontal sinuses and maxillary sinuses to assess for tenderness.

  • Transillumination:

    • A technique used to illuminate the sinuses.

Objective Data: Mouth Inspection

  • Inspect lips first, followed by anterior to posterior structures, using a tongue blade and bright light for clarity.

Objective Data: Teeth and Gums Inspection

  • Assess overall condition of teeth; normal occlusion is important.

  • Examine gum margins for swelling, retraction, bleeding, or discoloration.

Objective Data: Tongue Inspection

  • Check for color, surface characteristics, and moisture content.

Objective Data: Throat Inspection

  • Assess both hard and soft palate.

  • Observe uvula movement and tonsils (graded from 1+ to 4+):

    • 1+: Visible

    • 2+: Halfway between tonsillar pillars and uvula

    • 3+: Touching uvula

    • 4+: Touching each other.

Nose Abnormalities

  • Common issues include:

    • Choanal atresia

    • Epistaxis

    • Sinusitis

    • Allergic rhinitis (hay fever)

    • Furuncle

    • Acute rhinitis (nonallergic)

    • Foreign body

    • Perforated septum

    • Nasal polyps.

Lip Abnormalities

  • Identify conditions such as:

    • Cleft Lip

    • Herpes Simplex

    • Angular Cheilitis

    • Retention cyst

    • Carcinoma (mucocele).

Teeth and Gum Abnormalities

  • Common findings include:

    • Tooth avulsion

    • Dental caries

    • Gingivitis

    • Baby bottle tooth decay.

Mouth Abnormalities

  • Possible conditions:

    • Aphthous ulcers

    • Candidiasis

    • Leukoplakia.

Tongue Abnormalities

  • Assessment may reveal:

    • Black hairy tongue

    • Ankyloglossia

    • Atrophic glossitis

    • Carcinoma

    • Migratory glossitis.

Oropharynx Abnormalities

  • Common issues include:

    • Bifid uvula

    • Oral Kaposi’s sarcoma

    • Peritonsillar abscess

    • Acute tonsillitis and tonsil stones.