N 206
Physical Assessment
The Ears, Nose, Throat, & Neck
Dr. Maysa Al-momani
The Ear
•
-
The ear consists of:
external,
middle,
inner structures.
• The eardrum and the three
tiny bones conduct sound
from the eardrum to the
cochlea.
• The cochlea transmits the
waves to the brain.
External ear
Middle Ear
• Tympanic membrane
(ear drum) making the
Lateral limits of the middle
Ear.
• Middle ear is an airFilled cavity transmits
Sounds by three tiny bones,
The ossicles (malleus,
Incus, stapes).
• Connected by the eustachian
Tube to the nasopharynx
.
Pathway of Hearing
• Conductive phase: from the external ear through the
middle ear: ear canal → eardrum → three tiny bones
conduct sound from the eardrum → cochlea
disorder causes conductive hearing loss
• Sensorineural phase: involving the cochlea &
cochlear nerve. The cochlea transmits the waves →
cochlear nerve → brain.
disorder causes sensorineural hearing loss
Pattern of hearing loss, p. 271
Pathway of Hearing
• Vibration of sound pass through the air of external
ear & transmitted through the ear drum & the 3 tiny
bones (ossicles) of the middle ear to the cochlea.
• Cochlea senses & codes the vibration, nerve impulses
are sent to the brain through the cochlear nerve.
Health History
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•
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Hearing problems? How is your hearing?
If hearing loss, one or both ears?
Sudden or gradual loss?
Any associated symptoms?
– Earache (pain, fever, discharge, sore throat, URT
infection)
– Tinnitus (perceived sound that has no external
stimuli, rushing or roaring) it increases with age
– Dizziness; non specific term ( feeling unsteady,
light headed
Health History
-Vertigo: perception that the patient or the
environment is rotating or spinning
inner
ear problem, central or peripheral lesion of CN
V111 (acoustic).
Function of CN V111 (acoustic)
- hearing (cochlear division)
- balance (vestibular division)
Health History
• Difficulty understanding people talk?
– Sensorineural
• How does noise environment affect hearing?
– Noisy environment
• worse -- sensorineural
• better-- conductive
Ear Exam
• Inspect auricle and surrounding tissues
– Deformities
– Lumps
– Skin lesions
• If pain, discharge, inflammation
• palpate pinna and tragus for tenderness
• Tug test:
– Pain in acute otitis externa (swimmer’s ear)
inflammation of the ear canal.
– Palpate mastoid process for tenderness
-Tenderness behind ear in otitis media (inflammation of
the middle ear).
Ear Canal and Drum
• Using the otoscope: Use the largest ear
speculum that the canal will accommodate
.
• In adults: gently pulling the auricle upward
and backward & slightly away from the head..
In children, the auricle should be pulled
downward and backward. This process will
move the acoustic meatus in line with the
canal (Straighten ear canal
• Hold the otoscope like a pen/pencil and use
the little finger area as a fulcrum. This
prevents injury should the patient turn
suddenly.
• Direct it down and forward and through the
hair in the canal if present
Ear Canal and Drum
• Examine:
– External auditory canal
• Discharge, foreign bodies, redness, swelling, cerumen
• In acute otits externa (canal swollen, narrowed, moist,
pale, tender)
• In chronic otitis externa (skin of canal thickened, red &
itchy)
Ear Canal and Drum
• Inspect Tympanic membrane for
– color (Pinkish gray, red, white, yellow) and
translucency (transparent, opaque), and position
(retracted, neutral or bulging) of the drum
– Note a bright reflection of light .
– Identify the pars tensa with its cone of light.
– Note any middle ear structures visualized through
TMs
• position of: Handle of malleus, Short process of
malleus, Incus, and the anterior and posterior folds of
the pars flaccida (see p: 226).
Ear Canal and Drum
• Look for perforation, bulging, loss of shiny, no cone
of light, opaque, purulent drainage, fluid behind the ear
(serous effusion)
**Red bulging in A cute purulent otitis media
– Check mobility with
pneumatic otoscope
(rubber squeeze bulb)
Normal findings
• Auditory canal: some hair, often with yellow
to brown cerumen
• Ear drum (Tympanic membrane) :
-Pinkish gray in color, translucent
and in neutral position
-Malleus lies in oblique position behind the
upper part of the drum.
- Mobile with air inflation.
Ear Exam
• Auditory acuity
• Weber test (lateralization)
• Rinne test (to compare AC & BC)
Ear Exam
• Auditory Acuity: Assess hearing one ear at a
time with whisper test, tuning fork (512 Hz),
ticking watch, or others.
• If hearing is abnormal, perform the Weber
and Rinne tests to assess for sensorineural
and/or conductive hearing loss
Weber Test (lateralization)
• Vibrating fork (512 Hz)
• Place on top of patient head
or midforehead
• Ask patient in which ear
sound heard best (the sound
should be heard equally well
in both ears)
Weber Test (lateralization)
• If sound is heard asymmetrically, it means
one of two things:
– Conductive hearing loss on side with increased
sound. Unilateral conductive hearing loss as in
acute otitis media, perforation of eardrum,
obstruction of ear canal by cerumen (Sound
lateralized to the impaired ear*)
– Unilateral Sensorineural hearing loss on side with
decreased sound ( lateralized to good ear).
Rinne Test (To compare AC & BC)
• The vibrating tuning
fork is placed on the
mastoid process.
• When patient can no
longer hear sound, put
lateral to the ear.
• Ask if patient can still
hear sound.
Rinne Test (To compare AC & BC)
• A positive Rinne test is a normal test: air
conduction (AC) > bone conduction (BC).
• Conductive hearing loss produces a negative
Rinne test: BC ≥ AC.
• Sensorineural hearing loss produces a positive
Rinne test: AC>BC. If air conduction is more
than twice as long as bone conduction, then
suspect sensorineural loss.
Diseases Causing Hearing Loss
• Conductive Hearing loss: Lesion between the
receptors and environment (Ossicle lesion,
otitis media, otosclerosis, perforated eardrum,
impacted cerumen)
• Sensorineural hearing loss: Lesion of the
receptors or its pathway (Aging, drug toxicity,
noise damage, acoustic neuroma)
Anatomy of the Upper Airway
The Nose and Sinuses
Nose & paranasal sinuses
• Upper third of the nose is supported by bone
• Lower two thirds by cartilage
• Air enters nasal cavity by anterior naris
widened area (vestibule)
narrow nasal
passage to the nasopharynx
• Vestibule: lined with hair bearing skin
Nose & paranasal sinuses
Nasal septum:
• Formed the medial wall of each nasal cavity
• Supported by both bone &cartilage
• Covered by moucous membane
• Well supplied with blood
Turbinates aids the nasal cavities in their function:
-Cleansing
-Humidification
-Temperature control of inspired air
Nose & paranasal sinuses
• Nose latererally:
Middle meatus
(drain most of the
paranasal sinuses)
Inferior meatus
(drains the
nasolacrimal
duct)
Para Nasal Sinuses
Paranasal sinuses
• Are air filled cavities within the bones of the
skull
• Lined with mucous membrane
• Drains into the nasal cavities
The Nose
• Health history:
– Rhinorrhea—
• Nasal discharge or runny nose--Continuous, watery,
purulent, mucoid, bloody
• Nasal congestion---stuffy nose, sneezing, watery eyes,
throat discomfort, itching eyes, nose, throat.
– Frequent or severe colds
• Upper respiratory tract infection (URTI)
• How often?
• Remedies?
– Sinus pain
• Headache, tenderness, fever
• Post-nasal drip
The Nose
• Health history:
– Trauma
• Breath through nose? Any obstruction?
– Epistaxis– bleeding from nose
• How much? Teaspoon, does it pour out?
• From one or both nostrils?
• How do you treat them? Difficult to stop?
– Allergies
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•
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Pollen, dust?
How did you know?
Aggravating environment
Inhalers? Spray, drops
– Any change in sense of smell
The Nose
• Inspect external nose:
– asymmetry, deformity, lesions, inflammation, nasal
bone fracture.
– inspects the anterior & inferior surfaces of the nose
by gentle pressure on the tip of the nose using penlight or
otoscope light
• Palpation
– If injury, palpate gently
– Test for nasal obstruction/patency test:
Press on each ala nasi in turn and asking the patient to
breath in (sniff inward).
.
• Inspect using nasal speculum
• Inspect nasal mucosa (covers septum & turbinates),
nasal septum, any abnormalities
– Color and integrity of nasal mucosa—normal red
color, smooth moist surface
– Swelling, discharge, bleeding, foreign body,
exudatespolyps, ulcers
– Septum– deviation, perforation (cocaine), bleeding,
inflammation.
– Turbinates (middle and inferior turbinates)—light red color,
any exudates/pus, swelling/hypertrophy.
– polyps (smooth pale grey, a vascular, mobile, non-tender)
– Ulcers
The Nose
• Palpate sinus areas with thumbs
– Frontal sinus, below eyebrows: press up on the
frontal sinuses from under the boney brows.
– Maxillary sinus, below cheekbones
– Firm pressure, no pain
– Note tenderness (chronic allergy, acute infection
sinusitis)
– An inflamed sinus does not illuminate.
Transillumination of sinuses
Normal Findings
• The septum is in the middle and the turbinates
project into the nasal passages.
• There is sufficient room for the nasal passages.
• The nasal mucous membrane is redder than the
oral mucosa and compact over the turbinates.
• There may be a small amount of thin secretions.
• Viral rhinitis: mucosa is reddened and swollen.
• Allergic rhinitis: pale, bluish, or red
**(normal: presence of red color at the hard palate through the
mouth).
Mouth & Pharynx anatomy
Mouth and Throat
• Health history:
– Sore throat
• How frequent? Since when?
• Cough, fever, fatigue, headache, hoarseness, postnasal
drip
• Worse when arising? Humidity, dryness?
– Sores or lesions in mouth or tongue
• For how long? Single or multiple?
• Stress, food, season change?
– Altered taste
– Bleeding gums--gingivitis
– Toothache, self care behaviors (oral health)
Mouth and Throat
• Health history:
– Hoarseness—Acute or chronic
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Overuse of voice
Allergy, smoking, other inhaled irritants, acute infection
Hypothyroidism
Tumors
– Dysphagia—difficulty swallowing
• Gastroesophageal reflux disease, neurological,
esophageal cancer
– Pharyngitis-- Swollen glands or lumps in neck
The Mouth and Throat
• Health history:
– Enlarged thyroid gland—goiter
– Thyroid function—
• Temperature intolerance
– Do you prefer hot or cold weather
– Do you dress more warmly or less warmly than other people?
• Palpitations?
• Change in weight?
Mouth and Throat Exam
• Inspect the followings:
– The Lips
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•
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Color, moisture, cracking, Scaliness, lesions, lumps
Pallor—shock and anemia
Cyanosis– hypoxemia and chilling
Cherry red lips– carbon monoxide poisoning, acidosis,
ketoacidosis
• herpes simplex (cold sore, fever blister); HSV produces
recurrent & painful vesicular eruptions of the lips &
surrounding skin.
• Angular Cheilities (an ulceration of the corner of the
mouth) as in nutritional deficiency or over closure of
the mouth as in people with no teeth
• Edema
• Cleft lip
The Teeth and Gums
• Condition of teeth, diseased, Missing teeth or
absent, mobility (loose), caries;; abnormal
position; misshape; discolored
• Dentures : instruct the patient to remove dentures
if he /she wears them
• Discolored—brown from excessive flouride use,
Yellow—smoking
• Plaque, Carries—tooth decay
Put glove on to palpate any detected suspicious ulcers, nodules,
lesions. Check for looseness with your gloved thumb & index
finger.
Inspects the Gum
• Color of gums (normally pink, patchy brownness may
be present especially in black people).
• swelling or ulceration of gum margins & interdental
papillae
• Gingivitis: red swollen bleeding gums, Hypertrophy of
gums
• Dark line on gingival margins—lead poisoning
Mucosa: using good light & tongue blade inspect the oral mucosa for:
– color: pallor anemia, cyanosis (central or peripheral)
– if structures are intact, any lesions, ulcer (aphthous
ulcer), white patches & nodules, irritation
The Tongue (Inspect)
• Color— normally pink and even
• surface texture & characteristics: normally rough
with papillae
– Smooth tongue:
vitamin or iron deficiency
– Fissures
• Coating—Thick white patch (leukoplakia),
resulted from frequent chewing of tobacco,
local irritant that may lead
to cancer.
The Tongue (Inspect)
• Moisture
– Dry mouth with dehydration, fever, deep vertical fissures,
Decreased/ excess saliva
• Persistent ulcer or nodule
• Enlarged with indentation —mental retardation,
hypothyroidism, acromegaly
• Symmetry: hypoglossal nerve (CN XII) with tongue
protruding, deviation toward paralyzed side, lesion
• Tremor (fine tremor with hyperthyroidism, cerebral
palsy),
• loss of movement
Under the Tongue
• Inspect the U-shape under the tongue
• Note white patches, redness, nodules, ulcerations
• Any lesion or ulcer persisting more than 2 weeks
should be followed
• Use gloved hand to palpate any lesions
• Place other hand under jaw while palpating to locate
any abnormality
• Note any thickening/hardening or infiltration
(induration) of tissues
See table 7-25 p. 279 fissured tongue
Pharynx
• Pharyngeal wall– note color, any exudate, lesions
– Redness, swelling, pus : (Pharyngitis: Viral, Strep)
– Grayish exudate (Diphtheria)
• Inspect soft palate, anterior and posterior pillars,
uvula, tonsils, and pharynx — color, symmetry,
exudates, swelling, ulceration, tonsillar
enlargement
• Enlarged Tonsils (Normal, Tonsillitis, Lymphoma)
• Unilateral red bulge and painful: (Peritonsillar
abscess)
• Tonsil exudates: streptococcal pharyngitis and
acute tonsillitis; bright red pharynex with
red,swollen tonsils, pillar & uvula.
Hard and Soft Palate
• Inspect color and shape of hard palate (roof of
mouth)
– Cleft palate
– Midline lobulated bony growth
• Ask patient to say “Ah” while depressing tongue to
check pharynx—note integrity and mobility as
person phonates
– Failure of soft palate to raise with "aah" and deviation to
opposite side: (Paralysis of Vagus CN X)
– Check gag reflex (Glossopharangeal CN IX, and Vagus CN X)
The Neck
• Anatomy of neck— Knowledge of grouping and location of
cervical lymph nodes is necessary.
• Preauricular
• Posterior auricular
• Occipital
• Posterior cervical
• Submandibular , may be palpable
• Sub mental
• Superficial cervical
• Deep cervical
• Tonsillar: At the angle of Mandible , may be palpable
• Supraclavicular
.
.
Systematically palpate with the pads of your index and middle fingers for the
various lymph node groups, feel in sequence.
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Preauricular - In front of the ear
Posterior auricular – superficial to the mastoid process
Occipital - At the base of the skull
Tonsillar - At the angle of the mandible
Submandibular – midway between the angle & the tip of the
mandible
Submental - Under the jaw in the midline
Superficial (Anterior) Cervical - Over and in front of the
sternomastoid muscle
Posterior cervical: along the anterior edge of the trapezius
Deep cervical chain: deep to the sternomastoid
Supraclavicular - In the angle of the sternomastoid and clavicle
Technique of examination
• Inspect the neck for:
-symmetry
-Masses or scars
• Enlargement of the parotid or submandibular glands
• Note any visible lymph nodes
The lymph nodes:
-Palpate the lymph nodes by using the pads of your
index & middle fingers, move the skin over the
underlying tissues in each area.
-patient relaxed, the neck flexed slightly forward slightly
toward the side being examined.
-examine both sides at once. Except for submental feel
with one hand.
Normal& Abnormal Finding
• When the nodes are palpable describe the location,
size, shape, delimitation, mobility, consistency, and
tenderness.
• Normal: Small, mobile, discrete, soft (smooth), and
non tender.
• Drainage sites for each group of nodes
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Anterior cervical: (Tonsillitis, Pharyngitis)
Acute posterior: ( Acute otitis externa, scalp infections)
Pre-auricular: (Acute otitis externa)
Deep/posterior Cervical: (Thyroid, Laryngeal CA)
Supraclavicular: (Lung CA)
Generalized: (Lymphoma, HIV)
Internal Anatomy of the Upper Airway
The trachea & the thyroid Gland
• Inspect the trachea for any deviation. Then feel for any
deviation. Place your finger along one side of the trachea and
note the space between it and the sternomastoid (space
should be symmetrical)
• Inspect the neck for fullness over the thyroid region
• Inspect the neck for the Thyroid gland: head back, using
tangential light downward from the tip of the patient’s chin,
inspect the region below the cricoid cartilage for the gland
for consistency, shape, size and approximate weight.
• It is soft and approximately weighs no more than 20 grams.
Thyroid Gland
• Ask the patient to swallow water, extend the neck gently and
observe the mobility of the thyroid gland while swallowing,
noting its contour & symmetry.
• The thyroid cartilage, the cricoid cartilage and the thyroid
gland all rise with swallowing and then fall to their resting
position.
• Palpate the thyroid gland while swallowing, separately
examining each lateral lobe and the isthmus.
• Some prefer to examine the thyroid from the front.
The thyroid gland: is usually
palpable in the midline below the
thyroid cartilage.
thyroid isthmus may not be
palpable
The parotid glands : are
located in the preauricular area
on each side in the lateral neck.
The tail of each parotid gland
extends below the angle of the
mandible, inferior to the
earlobe.
. is visible and
Note whether thyroid gland
symmetrical. A visibly enlarged thyroid gland is
called a goiter.
• Move to a position behind the patient.
• Identify the cricoid cartilage with the fingers of
both hands.
• Move downward two or three tracheal rings while
palpating for the isthmus.
• Move laterally from the midline while palpating for
the lobes of the thyroid.
• Note the size, shape, symmetry, consistency
and position of the lobes, as well as the presence of
any nodules and tenderness. The normal gland is
often not palpable.
See steps for palpating the thyroid gland p. 242.
•
Thyroid Abnormal Finding
• Describe whether it is diffuse or localized
enlargement.
• Size, shape, consistency, tenderness and
mobility
• Lower edge is palpable?– An enlarged thyroid
may extend into the anterior mediastinum
below the sternal notch.
• If enlarged, listen over lateral lobes to detect a
bruit
.
Common Thyroid Lesions: table 7-26
• Hyperthyroidism: Diffuse enlargement.
• Hypothyrodism
• Multinodular goiter: Multiple nodules may extend into
the anterior mediastinum below the sternal notch.
• Cancer: Hard, rapid growth, fixed, regional. nodes.
• Thyroiditis: Diffuse, firm and tender.
• Thyroglossal cyst: Localized, in midline, firm, moves
with tongue protrusion