ENT Physical Examination Notes

Overview of ENT Physical Examination in Nursing 604

Course Introduction

• This course covers the physical examination of the ears, nose, and throat (ENT) and aims to empower students with the skills to:

  • Demonstrate the history and physical exam of the ears, nose, and throat.

  • Utilize the differential diagnosis process in evaluating common complaints associated with these systems.

Assessment of EENT

Key Structures

• Septum of Nose

• Lateral Wall of Nose

  • Emphasizes the importance of reviewing anatomy and physiology relevant to this area.

  • Discuss changes in these structures in older adults.

• Larynx

Anatomy and Physiology of the Nose

Functions of the Nose

• Main functions include:

  • Humidifying air

  • Warming air

  • Filtering particles

  • Sensing smell

• Anatomical Structure:

  • Upper 1/3: Bone

  • Lower 2/3: Cartilage and septum

  • Features inferior, middle, and superior turbinates (conchae)

Related Structures

• Sinuses: Function in warming and filtering air

  • Types: Sphenoid, Frontal, Ethmoid, Maxillary

• Mouth: Contains 3 pairs of salivary glands:

  • Submandibular: Openings visible under the tongue

  • Sublingual: Not visibly noticeable

  • Parotid: Located by the second molars

• Teeth: Typically 32 or 28 (depending on wisdom teeth)

• Oropharyngeal Structures: Includes uvula, anterior/posterior pillars, tonsils, and the posterior oropharynx.

• Ears: Responsible for hearing and balance/equilibrium.

Detailed Assessment

History Taking

• Chief Complaint (CC) / History of Present Illness (HPI):

  • For complaints in EENT areas, perform a complete symptom analysis covering:

  • Location

  • Quality

  • Quantity

  • Timing (onset, duration, progression, resolution, exacerbation)

  • Setting

  • Aggravating and alleviating factors

  • Associated symptoms

Psychosocial Factors Related to EENT

• Habits: Smoking, alcohol consumption, use of sunscreen/sunglasses, and drug use (specifically cocaine).

• Occupation-related Issues:

  • Consider potential hearing loss or exposures to harmful substances like sun or chemicals.

Medical and Family History

• Past Medical History (PMHx):

  • Includes: frequent sore throats, nosebleeds, allergies, sinusitis, dental issues, headaches, hypertension.

• Surgical History:

  • Notable surgical interventions involving nasal surgery, childhood illnesses, medications, allergies, and relevant screening/diagnostic tests (eye, dental, hearing exams).

• Family History:

  • Investigate incidences of cancers within the EENT systems (throat, head, neck), glaucoma, or relevant hereditary conditions.

Review of Systems (ROS) Related to EENT

Eyes

• Notable concerns may include:

  • Eye pain

  • Use of glasses/contacts

  • Cataracts, diplopia, photophobia

  • Previous eye exam.

Ears

• Assess for:

  • Changes in hearing, presence of tinnitus, pain, itching, discharge, balance problems, or vertigo.

Nose/Sinus

• Look for:

  • Abnormal smell perception, nasal discharge, epistaxis (nosebleed), sneezing, and sinus pain, as well as allergy symptoms.

Mouth/Throat

• Examine:

  • Dentures, sores, dental caries, lesions, abnormal taste, bleeding, sore throat, and difficulty swallowing (dysphagia).

  • Check for hoarseness and note the last dental examination.

Respiratory

• Gather information on:

  • Cough, sputum production, dyspnea, wheezing, cyanosis, night sweats, hemoptysis, and the date of last chest X-ray (CXR).

Physical Examination Techniques

Equipment Needed

• Essential tools include gloves, otoscope, ophthalmoscope, tongue blade, and gauze.

Examination of Eyes

• Reference an individual PowerPoint focusing on this area.

Examination of Ears

• Conduct the following steps:

  • Inspect external ear and surrounding tissues for size, shape, position, and color.

  • Palpate external ear structures: tragus, pinna, mastoid.

  • Using the otoscope, examine the ear canal and tympanic membrane (TM).

  • For adults, pull the pinna up and back.

  • Insert the speculum gently while keeping your hand steady against the patient's face, directing it slightly downward and forward.

  • A healthy canal should appear pink without redness, with cerumen expected in normal situations.

  • Features of TM to note: color, landmarks, light cone, translucency, and any abnormalities (redness, bulging, bubbles, perforations).

Otoscopic View of the Middle Ear

• Landmarks visible with an otoscope include:

  • Light reflex

  • Umbo of the malleus

  • Long and lateral processes of the malleus

  • Incus

  • Parts of the tympanic membrane: pars flacida (above the malleus); pars tensa (remainder of the membrane).

Hearing Tests and Cranial Nerve (CN) Assessments

Whisper Test for Auditory Acuity

• Know how to perform this test effectively.

Rinne Test (Air to Bone Conduction Assessment)

• Normal findings: Air conduction (AC) > Bone conduction (BC) in a ratio of 2:1.

• Conductive hearing loss indicates issues with the outer or middle ear.

Weber Test for Lateralization

• Normally, sound is perceived midline in both ears.

• Implications:

  • Sensorineural loss: impaired organ of Corti, typically experienced with aging; sound is heard better in the unaffected ear.

  • In conductive loss: sound is louder in the affected (deaf) ear.

Additional Hearing Tests

• Other relevant tests could include tympanogram and audiogram for further evaluation of hearing.

Physical Exam: Nose and Sinuses

Inspection Techniques

• Check for: nostril patency, use an otoscope for direct inspection posteriorly upward.

  • Target the inferior and middle turbinates and septum; the superior turbinate cannot be evaluated.

• Assess for color, drainage, inflammation, bleeding, ulcers, polyps, and masses.

• Palpation of Sinuses: Check frontal and maxillary sinuses.

Physical Exam: Examination of the Mouth/Throat

Observational Assesment

• Inspect:

  • Lips and oral mucosa

  • Gums and teeth

  • Hard palate

  • Tongue and floor of mouth—move tongue side to side with gauze, check for leukoplakia, and observe salivary gland openings.

• Pharynx/Uvula:

  • Note the rise of the soft palate upon saying “ah” to test CN X.

• Tonsils: Evaluate the size and presence of exudates or lesions.

Clinical Predictor Rules for Sore Throat Assessment

Walsh Clinical Prediction Rules (Simplified)

• Establish points based on these factors:

  • Temperature > 38.3°C (100.9°F): +1 point

  • Pharyngeal or tonsillar exudates: +1 point

  • Enlarged or tender lymph nodes: +1 point

  • Recent cough: -1 point

Scoring and Management Recommendations

• For a total score of:

  • -1: 4.6% probability for positive culture for Group A Beta-Hemolytic Streptococcus (GABHS) – No culture, rapid test, or antibiotics

  • 0: 15.9% chance – Rapid streptococcal antigen test; treat if positive.

  • 1: 44.4%;

  • 2: 57.1% – No culture; consider empiric antibiotic therapy.

  • 3: 83.3% – No culture; empiric antibiotics recommended.

Age-Related Variants in EENT Examination

Eyes

• Common findings may include:

  • Ectropion, entropion, xanthomas, arcus senilis, pterygium, vision changes, glaucoma.

Ears

• Considerations:

  • Impaired hearing thresholds; deafness occurs at 85-90 decibels or below.

  • 25 decibels is the threshold for typical conversation.

  • Cerumen impaction and age-related high-frequency hearing loss due to reduced function of the organ of Corti.

Mouth

• Increased risks include cancer and periodontal disease, and reductions in taste bud functionality.

Documentation of Findings

Recommended Notation Styles

• EARS:

  • Canal without lesions or cerumen; tympanic membranes (TM's) bilaterally gray, intact with good landmarks, normal light reflex, no injection or retraction.

• NOSE:

  • Straight, patent; nasal mucosa pink, moist, no exudate or edema bilaterally.

• MOUTH:

  • Teeth in good condition (32), gums pink and moist, without bleeding.

• PHARYNX:

  • No signs of injection, lesions; assess tonsil size (reference Bates), check for exudates or concretions; uvula should be midline, assess for any unusual odors.