HEENT - HA

HEENT 10/28/24

– HEAD AND NECK ASSESSMENT WITH VISION AND HEARING BASICS –

THE HEAD - ANATOMY 

Skeletal structure: 

  • Cranium: frontal, parietal, occipital, and temporal 

  • Sutures joint the bones together 

  • Facial bones: maxilla, mandible, nasal, vomer, lacrimal 

Muscles: 

  • Facial muscles: frontalis, temporalis, zygomaticus, masseter, buccinators, orbicularis, oculi and oris function for chewing, speaking, smiling, frowning 



THE NECK - ANATOMY

  • Supported by cervical vertebrae C1-C7 

  • Major neck muscles: sternocleidomastoid and trapezius 

  • Trachea

  • Thyroid gland

  • Lymph nodes 

*** Major neck muscles may be used as accessory muscles of respiration when the patient has difficulty breathing 



COMMON PROBS WITH HEAD & NECK

Headache, neck pain, limited neck movement, facial pain, lumps or masses, hypothyroidism, hyperthyroidism



PRIORITY URGENT ASSESSMENT OF HEAD AND NECK

  • Acute head and neck injuries/pain

  • Neuro changes 

  • Acute changes in vision 

  • Acutely abnormal vital signs 

  • Signs of possible thyroid storm: 

    • Tachycardia 

    • Tachypnea

    • n/v/d

    • Abd pain 

    • Hyperkinesis (abnormally excessive muscular activity, impulsive, irritable) 

    • Fever

    • Weakness



SUBJECTIVE DATA COLLECTION - HEAD & NECK

  • headaches/aches/pains

  • Past injuries

  • Past surgeries

  • Medication reconciliation

  • Family history of thyroid disorders

NURSES PHYSICAL EXAM OF HEAD & NECK

Inspect and palpate the scalp 

  • Symmetry vs. deformities

  • Masses or lesions 

Inspect the eye

  • Redness, drainage, trama, asymmetries 

Inspect and palpate the external ear 

  • Redness, drainage, trauma

  • Lumps, masses, tenderness

Inspect neck 

  • Alignment, lesions, limited ROM 



ADVANCED PRACTICE PHYSICAL EXAM OF HEAD & NECK

Palpate and auscultate the thyroid

  • Assess for enlarged nodules

  • Listen for turbulent or decreased blood flow 

Palpate the lymph nodes

  • Assess for enlargement and tenderness

  • masses/lumps/possible cancer 



NORMAL FINDINGS OF HEAD & NECK
Head

  • Centered, proportional to body, erect, w/o tremors, tics, or unusual movements

  • Skull is round without obvious deformities

  • Neck muscles are symmetric 

  • Facial features symmetrical and proportional 

  • Hair is evenly distributed across scalp 

  • No tenderness on palpation 

Eyes

  • No edema, erythema, or bulging

  • Conjunctiva pink, lens clear, sclera white 

External ears

  • Symmetrical, equal in size, fully formed, without lumps 

  • Nontender to palpation 

Neck

  • Trachea is midline, cervical spine has straight alignment 



FUNCTIONAL HEARING & VISION TESTS

Distance vision 

  • Snellen (adults) or allen (children) chart 

  • Read ~20 ft from chart 

  • Covering one eye at a time, pt reads through to the smallest letters possible 

  • Glasses or contacts should remain on; reading glasses should be removed 

  • Ex; 20/60 - what the patient sees at 20 feet is what a person is about to see at 60 ft 

    • The larger the bottom number, the worse the visual acuity

Near vision

  • Usually affects patients >40 

  • Ask patients to read newsprint or a menu at a reading/close distance 

Hearing Acuity

  • Whisper Test: patient covers one ear at a time as clinician whispers three words 

  • If more than half of the words are incorrect the test is abnormal 

  • Repeat on other side 



CULTURAL CONSIDERATIONS FOR THYROID DISEASE

  • Thyroid disorders are more common in females assigned at birth than males 

  • Hypothyroidism is especially common in older females 

  • African Americans have a threefold higher risk of hyperthyroidism compared to Whites 

  • Thyroid cancer is highest amongst Asian/Pacific Islanders 



– EYE ASSESSMENT FOR ADVANCED SPECIALTY PRACTICE – 

THE EYE - ANATOMY

Internal (intraocular) structures that are directly involved in vision: 

  1. Outer fibrous layer - contains the sclera and cornea 

  2. Vascular middle layer - composed of the iris, ciliary bodies, and choroids

  3. Inner neural layer - retina 

What happens when we see light: 

  1. The cornea allows the rays of light to eter the eye 

  2. The iris regulates the amount of light that enters the pupil by dilating and contracting 

  3. A normal pupil size range is from 3-5 mm






CRANIAL NERVES OF THE EYES 

Visual acuity & visual fields

  • CN II: optic nerve 

Cardinal fields of gaze

  • CN III: oculomotor nerve 

  • CN IV: trochlear nerve 

  • CN VI: abducens nerve



VISION PROBLEMS IN THE ELDERLY 

  • Loss of visual acuity of central vision may decrease especially after age 70

  • Leading causes of blindness and impaired vision in the US 

    • Macular degeneration (blurs central vision) 

    • Cataracts (clouding of the lens) 

    • Diabetic retinopathy (damaged blood vessels in the retina) 

    • Glaucoma (damage to the optic nerve) 



PRIORITY URGENT ASSESSMENT 

  1. Acute eye trauma or injury 

    1. Foreign body present; lacerations; hyphema 

    2. Determine the source of trauma (chemical, thermal, electrical, etc.) 

  2. Acute glaucoma 

    1. Caused by an acute blockage of fluid in the eye that can raise the pressure inside the eye and cause permanent vision loss 

    2. Patient will experience acute loss of vision 



COMMON EYE ABNORMALITIES

  • Ptosis in a patient following stroke 




CULTURAL VARIATIONS & HEALTH DISPARITIES 

  • Eye care services are underused by nondominant ethnic groups (particularly Latin Americans and recent immigrants) 

  • The Snellen E chart can be used for those who cannot read or speak English 

  • High risk groups for glaucoma 

    • African americans 

    • Family history of glaucoma 

    • People with diabetes

    • Severely near sighted 



TEACHING & HEALTH PROMOTION

  • Focus on preventing optical disease

  • Encourage routine  eye exams 

  • Wear protective eye wear to prevent injury trauma 

  • Wear sunglasses (prolong exposure increases risk for cataracts and other eye issues) 

  • Hydration and foods that promote eye health (deep water, fish, fruits, and vegetables) 

  • Tight control for diabetes management 

  • Tight control for blood pressure management 



– EAR ASSESSMENT FOR ADVANCED SPECIALTY PRACTICE –

THE EAR - ANATOMY


  • External ear canals channel sound waves through the TM → ossicles in the middle ear → cochlea 

  • Basal membrane within the cochlea vibrates the receptor hair cells of the organ of Corti, which transfer the signal into electrical impulses for the auditory nerve (CN VIII) 

  • The auditory nerve delivers impulses to the auditory cortex in the temporal lobe of the brain which interprets them as sound assigns meaning to them 

  • Cochlea interprets two components of sound: amplitude (volume) and frequency (pitch)

  • Decibels are the measurement units of amplitude and frequency is measured by Hertz 



CONDUCTIONS OF SOUND

Air conduction (AC) 

  • Most efficient method 

  • Normal pathway for sound to travel to the inner ear 

Bone conduction (BC) 

  • Sound bypasses the external ear

  • Delivers sound waves/vibrations directly to the inner ear 

*** compromise in either pathway causes hearing loss 



CONDUCTIONS OF SOUND




CN VIII: VESTIBULOCOCHLEAR NERVE 

CNVIII transmits sound and equilibrium information from the inner ear to the brain 





COMMON EAR COMPLAINTS

  • Hearing loss (acute or chronic) 

  • Vertigo 

  • Tinnitus 

  • Otalgia

  • Ear infections including otorrhea (air drainage) 



HEARING DIFFICULTIES 

Conductive hearing loss 

  • Sound waves disrupted by blockage 

  • Easily treatable 

  • Ex: cerumen impaction; fluid in the middle of the ear; cholesteatoma; otitis externa 

Sensorineural Hearing Loss (SNHL) 

  • Problem is beyond the middle ear 

  • Dysfunction of cochlea, organ of corti, auditory nerve, auditory cortex 

  • Ex: presbycusis (gradual degernarion of nerves and sensory hair cells of Organ of Corti; prenatal congenital SNHL can include inner ear malformations related to genetics and viral infections 

Tinnitus

  • Perceptions of buzzing/ringing in one or both ears that does not correspond with an external sound 

  • Can be mild to severe

  • Little is known about cause 



VESTIBULAR DYSFUNCTION

  • Semicircular canals and vestibules provide the body with proprioception and equilibrium 

  • Disease can cause inflammation and loss of equilibrium, leading to a sense of vertigo (room spinning sensation) 

  • Can lead to meniere disease



PRIORITY URGENT ASSESSMENT 

  • Foreign body stuck in the ear - needs prompt removal 

  • Foul-smelling drainage from the ear

  • Ear trauma 



Hearing Problems in the Elderly 

  • Extra cartilage growth 

  • Coarse and stiffer hairs lining the ear canal 

  • Cerumen accumulation 

  • Delayed electrical response in the brain (>70 y/o)

  • Meniere disease

  • Ototoxic medications (high dose aspirin; chemo; strong diuretics) 

  • Autoimmune inner ear disease

  • Noise exposure 



PSYCHOSOCIAL CONSIDERATIONS

Hearing loss can lead to: 

  • Increased risk for depression

  • Dissatisfaction with life 

  • Reduced functional health 

  • Withdrawal from social activities



– NOSE, SINUSES, MOUTH, AND THROAT –

THE NOSE - ANATOMY

  • Primary organ for smell 

  • Stimulates the olfactory receptors of CN I (olfactory) 

  • Nerve and blood supply: 

    • CN V, VII, IX, X all play a role 

    • Rich blood supply to the nose (Kiesslbach plexus) 

  • Lymphatic drainage



THE SINUSES - ANATOMY

  • Holly, bony, air-filled cavities within the forehead and facial cavities

  • Lighten the weight of cranium 

  • Sinuses produce mucus that empties into the nasal cavity 



THE MOUTH - ANATOMY

  • Taste, chewing (mastication), speech articulation 

  • High vascular, especially the floor of the mouth (sublingual medications) 

  • 3 major salivary glands 

  1. Parotid gland (largest) 

  2. Submandibular gland

  3. Sublingual gland 

  • Tongue is innervated by CN 

  1. V: trigeminal 

  2. VII: facial 

  3. IX: glossopharyngeal 

  4. X: vagus

  5. XII: hypoglossal 



THROAT, TONSILS, ADENOIDS

  • Throat (oropharynx) is the common channel for respiratory and digestive systems

  • Lymphatic tissue of the tonsils and adenoids contribute to immunological defense 



COMMON ISSUES 

  • Facial pressure/pain/headache

  • snoring/sleep apnea

  • Obstructive breathing

  • Nasal congestion 

  • Nosebleeds

  • Halitosis (bad breath) 

  • Anosmia (decreased smell) 

  • Cough

  • pharyngitis/sore throat

  • Dysphagia (difficulty swallowing) 

  • Dental pain 

  • Voice changes

  • Oral lesions 



PRIORITY URGENT ASSESSMENT

Nosebleeds epistaxis

  • Kiesselbach plexus: common site of nosebleeds

  • Apply pressure by pinching the nostrils and encourage mouth breathing 

Aspiration 

Abrupt loss of sense of smell (anosmia) 

  • Concern for brain tumor 

  • Concern for COVID-19 infection 

Epiglottitis 



ASSESSMENT OF RISK FACTORS 

Consider irritants/allergens 

  • Smoke exposure 

  • Dust mites

  • Pets

  • Pollen

  • Mold spores



NURSE’S PHYSICAL EXAM OF NOSE, SINUSES, MOUTH AND THROAT 

  • Inspection of the nose, mouth, throat 

  • inspect/evaluate swallowing 

  • Assess for aspiration 



NORMAL EXAM FINDINGS

Nose (internal and external) 

  • Appears symmetrical, midline, no lesions, coloration is consistent with other facial complexion, septum midline, mucosa pink and moist, no prominent blood vessels or crusts

  • Small amounts of clear drainage present 

Sinuses (external) 

  • Symmetrical with no redness or swelling 

Mouth (internal & external) 

  • Lips are pink, moist, without lesions

  • Buccal mucosa and soft hard palates are pink with no inflammation, ulceration, swelling, or lesions

  • Uvula raises symmetrical

Throat (internal) 

  • Tissue is pink and moist with symmetrical margins 

  • No enlargement or lesions are noted 

  • Tonsils are absent or 1+