Ears, Nose,
Mouth, Throat
Ears
Summary of any symptom should
include PQRSTU
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P= provocative or palliative
Q= quality or quantity
R= region or radiation
S= severity scale
T= timing (onset, duration, frequency)
U= understand client’s perception
Anatomy
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The ear is responsible for hearing and
balance
Consists of 3 regions
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External ear
Middle ear
Inner ear
Structure and Function
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External Ear – auricle/pinna
movable cartilage and skin
Mastoid process= important Landmark
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External Auditory Canal – the opening in
the external ear; cul-de-sac 2.5 to 3 cm.
Long in adult and ends at the eardrum.
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Lined with glands that secrete cerumen
External Ear
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2 types of cerumen
Whites and blacks – wet, sticky, and honey
colored
 Asians and Native Americans – dry and flaky
Lubricates & protects
Moves to meatus with chewing & talking
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Outer 1/3 of canal is cartilage, inner 2/3
consists of bone covered with skin
External Ear
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Tympanic membrane (eardrum) separates
external and middle ear.
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Translucent membrane
Pearly, gray color
Cone of light reflection when using otoscope
Oval and slightly concave shape, pulled in at
center by malleus
External Ear
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Malleus (hammer) – one of the middle ear
ossicles
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3 parts
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Umbo, manubrium short process, may show
through the drum
Lymphatic drainage of the external ear flows
into
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Parotid, mastoid, superficial cervical nodes
Middle ear
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Tiny air–filled cavity in the temporal bone
contains:
Auditory ossicles (bones)
Malleus
Incus
Stapes
Openings to
Outer ear covered by tympanic membrane
Inner ear = oval and round windows
Eustachian tube connects middle ear to the nasopharnyx for
air passage (normally closed, opens with
swallowing/yawning)
Middle ear has 3 functions
1.
2.
3.
Conducts sound vibration from outer ear
to inner ear
Protects the inner ear by reducing the
amplitude of loud sounds
Eustachian tube allows equalization of
air pressure on each side of the ear
drum to avoid rupture ( high altitudes)
Inner Ear
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Contains the Bony Labyrinth which holds
the sensory organs for hearing and
equilibrium
1.
2.
3.
Vestibule
Semicircular canals
Cochlea (contains the central hearing
apparatus)
Function of hearing
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3 levels
1.
Peripheral – ear transmits sound and
converts its vibrations into electrical
impulses that can be analyzed by the brain.
The electrical impulses are conducted by
the auditory process of cranial nerve VIII
(Acoustic) to the brain stem
1.
2.
Amplitude=loudness
Frequency=pitch
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Sound waves cause the eardrum to vibrate
Vibrations travel via the ossicles thru the oval
window, the cochlea and are scattered against
the round window
The basilar membrane of the cochlea contain
the organ of Corti receptor hair cells that
translate the vibrations to electric impulses
The impulses go to the brainstem via Acoustic
nerve (VIII)
2.
Brain stem – function is binaural
interaction – permits identification of
sound and locating the direction of a
sound in space. The acoustic nerve
(Cranial nerve VIII) sends signals from
each ear to both sides of the brain stem.
Brainstem is sensitive to intensity &
timing from the ears depending on head
position
3.
Cerebral cortex – interprets the meaning
of the sound and begins the appropriate
response
Pathways of hearing
1.
2.
Air conduction (AC)– normal pathway of
hearing, the most efficient
Bone conduction (BC)– bones of the
skull vibrate and transmit vibrations to
the inner ear and acoustic nerve
Hearing loss
1.
Conductive – mechanical dysfunction of
the external or middle ear resulting in
partial hearing loss (if ↑ amplitude to
reach nerve elements in inner ear,
person can hear)
1.
Causes= impacted cerumen, FB, perforated
eardrum, pus/bld in the middle ear,
otosclerosis
Hearing loss
2.
Sensorineural ( perceptive) – pathology
of the inner ear, acoustic nerve or
auditory areas of the cerebral cortex. ↑
amplitude may not help
1.
3.
Causes= Presbycusis, a nerve degeneration
due to aging (50yrs) or ototoxic drugs
Equilibrium – labyrinth feeds info to the
brain about the body’s position in space,
inflammation causes vertigo.
Subjective data
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Earaches
Infections- otitis media
Discharge
Hearing loss
Environmental noise
Tinnitus- ototoxic: ASA, Aminoglycosides
(gentamicin) etc.
Vertigo
Self care behaviors
Objective data
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External ear = Inspect and Palpate
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Size and shape
Skin condition
Tenderness- pinna & tragus; mastoid process
External auditory meatus- cerumen
Inspect using Otoscope
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Pull pinna up & back for adult/older child
Pinna down for infant & ↓ 3yrs. Maintain
hold on pinna until exam is complete.
Avoid inner, bony section of canal=
sensitive to pain
Can angle otoscope towards nose
Inspect using Otoscope
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External canal
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Color
Swelling
Lesions
Discharge ; color and odor. Clean or change
speculum before examining other ear.
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Perform the otoscope exam prior to
hearing tests.
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The following slide show a furuncle which
is an infected hair follicle
Tympanic membrane
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Color – normal is shiny, translucent, pearl-grey
Characteristics – landmarks; umbro,
manubrium, and short process
Position – flat, slightly pulled in at the center and
flutters when person holds nose and swallows
Integrity of membrane – intact? Scarring =
dense white patch
Hearing tests
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Begins with the history-Conversational
tone
The following tests may indicate the
presence of hearing loss but not the
degree.
Hearing tests
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Voice– place a finger on the tragus of one
ear and while rapidly pushing it in and out
of the meatus, place your head 1 –2 feet
from your client’s other ear, shield your
lips and whisper a 2 syllable word. Repeat
on the opposite ear using another word,
have the client identify the words (Used to
detect high-tone loss)
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Normal Response to Voice test
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Correct identification of whispered words
bilaterally
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Tuning fork tests- measure hearing by
AC and BC
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1.
To activate the tuning fork, hold it by the
stem and strike the tines softly on the back
of the hand
Weber test – used when hearing is
reported as better in one ear than other
(bone conduction)
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Normal finding for the Weber test is
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Tone heard = loud bilaterally
If sound lateralizes to one ear it indicates
conductive or sensorineural loss.
2.
Rinne test – compares bone conduction
and air conduction
1.
2.
Normally sound is heard 2X as long by air
conduction as by bone conduction
Normal response ; positive Rinne Test =
AC>BC Bilaterally
Sound is heard longer by BC with a conductive
loss.
Weber test
Rinne test
Nose, Throat and Mouth
Nose
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First segment of the respiratory system
Warms, moistens and filters inhaled air
Sensory organ for smell
External parts
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Bridge
Tip
Nares
Vestibule -nares widen in to vestibule
Columella divides the nares
Ala –lateral outside wing of the nose bilaterally
Upper 1/3 nose is bone; rest is cartilage
Internal
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Nasal cavity, extends back over the roof of
the mouth
Nasal hair, ciliated mucous membrane –
red due to ↑ bld supply
Septum-divides cavity into 2 passages
Internal
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Superior, middle, inferior turbinates- 3
parallel bony projections on lateral walls of
each cavity
Meatus- cleft underlying each turbinate.
The sinuses drain into the middle, tears
from the nasolacrimal duct drain into the
inferior
Internal
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Olfactory receptors- in roof of the nasal
cavity & upper part of septum. Merge into
the olfactory nerve (I) goes to the temporal
lobe of the brain
Foreign Body
Paranasal sinuses- air- filled pockets in the
cranium
Purpose
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↓ wt. of the skull
Serve as resonators for sound
Provide mucous for the nasal cavity
Sinus openings are narrow = susceptible to
occlusion resulting in inflammation/sinusitis
1.
2.
3.
4.
Frontal sinuses
Maxillary sinuses
Ethnoid sinuses
Sphenoid sinuses
Frontal & Maxillary sinuses are accessible to
examination
Mouth
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First segment of the digestive system
Airway for the respiratory system
ORAL CAVITY
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Lips
Palate
1.
2.
3.
Hard
Soft
Uvula – hangs down from the soft palate
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Cheeks- side walls of cavity
Tongue
1.
2.
3.
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Papillae- rough, bumpy elevations on dorsal
Frenulum
Taste buds
Teeth – 32 permanent
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Salivary glands
1.
2.
3.
Parotid- largest of the glands, located in the
cheeks, front of the ear. Stenson’s duct
opens in buccal mucosa
Submandibular- walnut size, beneath the
mandible at the angle of the jaw. Wharton’s
duct either side of the frenulum
Sublingual –smallest, almond shape, under
tongue
Throat
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Area behind the mouth & nose
Oropharynx – separated from the mouth
by a fold of tissue on each side called
anterior tonsillar pillars
Tonsils – lymphoid tissue behind pillars
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Posterior pharyngeal wall located behind
the tonsils
Nasopharynx continues from the
oropharynx but it is above it and behind
the nasal cavity. It holds the adenoids and
the eustachian tube openings.
Subjective data Nose
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Discharge
Frequent colds
Sinus pain
Trauma
Epistaxis
Allergies
Altered smell
Subjective data Mouth and Nose
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Sores, lesions
Sore throat
Bleeding gums
Toothache
Hoarseness
Dysphagia
Altered taste
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Smoking
Alcohol intake
Self care behaviors
Objective behavior
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Nose – Inspect and palpate
INSPECT for:
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Symmetry, deformity
Inflammation
Skin lesions
Color
If injury – palpate gently
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Test for Patency
Test for Sense of Smell – Cranial nerve I
(olfactory)
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Inspect nasal cavity/ septum
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Deviated septum?
Can see middle & inferior turbinates
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Inspect and palpate Paranasal Sinuses
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Press thumbs over frontal & maxillary
sinuses
Transillumination for sinus inflammation
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Frontal & Maxillary sinuses
Darken room
Mouth - Inspect
Use gloves, tongue depressor, light
 Lips
 Teeth
 Gums
 Tongue
 Buccal mucosa –Stenson’s duct (parotid)
 Palate
Throat - Inspect
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Tonsils
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Grade size 1+ visible
…………….2+ ½ way b/t tonsillar pillars and uvula
…………….3+ touching the uvula
…………….4+ touching each other
Posterior pharyngeal wall
Gag reflex cranial nerves IX = glossopharyngeal
and X = Vagus
Cranial nerve XII = hypoglossal- stick out tongue
Halitosis – Due to ????