Head, Eyes, Ears, Nose, and Throat (HEENT)

Hemorrhagic Stroke

• Thunderclap headache: feels like someone is clapping hands over the ears
• Worst headache ever
• Emergency: call the physician

Head Injury

• Questions to ask:
  • Did you wear a helmet?
  • What was the diagnosis (concussion)?
  • Hospital stay requirements

Dizziness

• Described as lightheadedness or a swimming sensation

Vertigo

• The room is spinning around you

Subjective Data - Neurologic Dysfunction due to Falls

• Family history (seizures)
• Surgeries (even benign tumor removals)

Neck Pain or Limited Range of Motion

• Common, self-limiting due to muscle pull
• Stiffness in the neck
• Possible history (fusion surgeries)

Nuchal Rigidity

• Stiff neck with no history of fusion surgeries
• Worrisome sign of meningitis
• Big sign and symptom of meningitis

Additional Neck Assessment

• Lumps or swelling
• Enlarged thyroid (baseline normal?)
• Swollen lymph nodes (possible infection)
• History of head and neck surgery (thyroid removal, thyroid cancer, brain cancer)

Headache Assessment

• Have the patient point to the location of the headache
• Example: Frontal headache vs. headache in the back of the neck (relevant in OB for preeclampsia symptoms)

Older Adults - Facial Changes

• Facial bones look more prominent (cheekbones, jaw)
• Due to subcutaneous fat loss and sagging skin

Tremors

• Typically abnormal, investigate. Can be expected (yellow flag)
• Possible degradation in spinal cord neurons

Mouth Changes

• Dry
• Smaller due to subcutaneous fat loss in lips (pursed lip look)
• Gums recede
• Teeth appear bigger (gum to teeth ratio change)

Tongue Changes

• Becomes smooth due to loss of taste buds
• May look like it's protruding

Kyphosis

• Humpback appearance/stooped over
• Due to dehydration of vertebral discs (made of water)
• Discs dehydrate and shrink, leading to stooped posture and height loss (bones aren't shrinking)

Thyroid Gland

• Atrophies/shrinks
• Palpation typically not possible; if palpable, refer due to concern for cancerous findings

Arteritis (Temporal Artery)

• Expected finding in older adults
• Temporal artery on forehead becomes twisted and hardened, sticks out
• Also described as torturous

Headache Comfort Measures

• Dim lights
• Minimize noise
• Silence phone
• Provide patient comfort

Eye Colors

• Differences due to melanin variations in the iris based on genetic origins

Sclera

• Should be white with fine veins
• Dark-skinned patients may have bluish-gray color or brown macules (normal variations)

Vision Loss

• Usually gradual and progressive
• Sudden loss of vision is an emergency; refer to physician

Aging Adult - Eye Changes

• Sunken in appearance due to subcutaneous fat loss; bones look more prominent
• Slower reflexes due to neuron loss and slower information processing
• Presbyopia: age-related vision loss; lens dehydrates and loses elasticity
• Floaters in vision due to dehydration
• Coarse eyebrow hair

Penguecula

• Yellow pigmented spots on the eye due to sun exposure, dust, and air pollution exposure

Arcus Senilis

• Cloudiness around the cornea
• Due to lipid buildup
• Does not affect vision

Xanthelasma

• Yellow plaques on the eyelids
• Age-related change; usually appears in patients >50 years old

Vision Screening

• Visual acuity screening needed
• Diabetic retinopathy: damage of microvasculature in eyes due to high blood sugars
  • Number one cause of blindness in the US (diabetes prevalence)
  • All diabetics have some variation of diabetic retinopathy

Safety Concerns

• Falls due to vision changes
• Do not rearrange the patient's room in the hospital (leave items where they are for safety)

Subjective Data - Eyes

• Vision difficulty
• Sudden loss of vision (emergency referral)
• Pain (burning, itching, pressure - glaucoma)
• Severe onset of eye pain (emergency referral)
• Eye strain
• Strabismus (crossed eyes):
  • Surgeries available
  • Patching the stronger eye in children

Red Eye Emergencies (Call the doctor right away)

• Sudden loss of vision.
• Any sort of trauma to the eye
• Corneal damage
• Distorted pupil (not round)
• Severe pain
• Herpes zoster (shingles) to the face

Watering and Discharge

• Purulent discharge (green, yellow)
• Red discharge
• Clear discharge with a head injury (cerebrospinal fluid leak)
• Watering excessive tears

Ocular Problems Subjective Questions

• Allergies (hay fever, foods)
• Surgeries, glaucoma, astigmatism
• Glasses or contacts
• LASIK, cataract surgeries
• What medications are you taking?

Environmental Concerns and Subjective Questions

• Eye protection with chemical fumes
• Using personal protective equipment for caustic substances
• Welders wearing protective hoods
• Secondhand smoke exposure
• Medications causing dry eye

Tympanic Membrane

• Healthy eardrum is pearly gray and translucent with a cone-shaped light reflex

Earwax (Cerumen)

• Not attributed to poor hygiene
• Catches bacteria, pathogens, dirt and dust
• Antibacterial properties
• Different variations in color and consistency (flaky white, dry yellow, moist honey-colored)

Earaches

• PQRST assessment
• History of ear infections (can cause hearing loss and scarring)
• Cold symptoms prior to earache (eustachian tube blockage)

Ear Discharges

• Purulent discharge
• Bloody
• Clear discharge with a head injury (cerebrospinal fluid leak)

Hearing Loss

• Have you had any hearing loss?
• How would patients describe hearing loss: Wife says that I have to turn the TV up louder, difficulty hearing in noisy environments, difficulty hearing people when they whisper.
• High-pitched/high-frequency sounds typically lost first

Environmental Noise

• Construction
• Factory work
• Hobbies: raves, concerts (wearing protection?)

Tinnitus

• Ringing in the ears
• Worse when it's quiet
• Presence of sound with an absence of stimuli

Vertigo

• The realness is spinning around you.
• Not to be confused with dizziness

Patient Centered Care - Ears

• Ear protection
• Regular audiology appointments
• Hearing aid checks and cleaning
• Appropriate ear cleaning methods (avoid Q-tips)

Otosclerosis

• Hardening of the bones of the ears (bones stick together)
• The ossicles are the vibrating bits.
• If ossicles are small, roast and firm and not vibrate, don't transmit sound.
• Contributes to presbycusis (age-related hearing loss)
• Conductive

Cerumen Production due to dehydration

• Dehydrates; becomes flaky and thick, dries out and clumps together
• Can contribute to hearing loss in older adults
• Remove cerumen before hearing test

Presbycusis

• Age-related changes in hearing
• Sensorineural

Nose, Mouth, and Throat Assessments

• Five kids UDL split
• Cleft lip/palate (typically fixed in childhood)
• Torus pallatinus (bony ridge on hard palate)
• Just a Thing buccal mucosa
• Genetic predispositions for periodontal disease/tooth decay
• HPV/HSV of the mouth from lifestyle

Obstructive Sleep Apnea

• Collapse of upper airway
• Apneic episodes
• Typically in obese patients

Frequent Colds

• Further investigation needed
• Possible autoimmune condition or underlying respiratory problem

Discharge from the Nose Subjective Data

• Rhinorrhea (excessive discharge)
• Watery, red, yellow, or green depending on cause

Nosebleeds

• Epistaxis (nosebleeds)

Sinus Pain Subjective Data

• Tenderness upon palpation (sinus infection)
• Excess pressure when leaning over

Altered Smell

• COVID
• Smoking
• Cocaine
• Pregnancy (increased sense of smell)

Trauma

• Have you had a broken nose?
• Did you get it reset?
• Have you had surgery on your nose (Sinus surgery?)

Subjective Questions

• Have you had allergies to medications?
• Hay fever?
• Just general allergies as well?( What may be causing those symptoms)

Mouth and Throat Sore/ Lesions

• History of HSV (herpes)

If you have a Sore Throat Subjective Data

• Recurrent bouts of strep throat (can cause kidney damage)

Bleeding Gums Subjective Data

• Gingivitis
• Poor hygiene
• Medications
• Antiplatelet medications/clotting factor abnormalities

Subjective Question About Toothaches

• Voice Hoarseness Subjective Question
• Smoky.
• Drainage.
• Inflammation. Post nasal drip.
• Tumors
• Strain on the voice

Difficulty Swallowing

• Dysphagia
• Do you complain of difficulty swallowing
• due to a stroke. A cancerous tumor pushing on that tube.
• Sensation of dysphasia can be caused by GERD or acid reflux

Subjective History Questions

• Obstructive sleep apnea
• Smoking and alcohol consumption effects our health
• Patient centered care if the patient is wearing dentures