Ears, Nose, Mouth, Throat

Ears

Summary of any symptom should include PQRSTU

• 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

• The ear is responsible for hearing and balance• Consists of 3 regions– External ear– Middle ear– Inner ear

Structure and Function

• External Ear – auricle/pinna movable cartilage and skin Mastoid process= important Landmark

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.Lined with glands that secrete cerumen

External Ear

• 2 types of cerumen– Whites and blacks – wet, sticky, and honey

colored– Asians and Native Americans – dry and flakyLubricates & protects Moves to meatus with chewing & talking

• Outer 1/3 of canal is cartilage, inner 2/3 consists of bone covered with skin

External Ear

• Tympanic membrane (eardrum) separates external and middle ear.– 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

• Malleus (hammer) – one of the middle ear ossicles – 3 parts • Umbo, manubrium short process, may show through

the drum

– Lymphatic drainage of the external ear flows into• Parotid, mastoid, superficial cervical nodes

Middle ear• Tiny air–filled cavity in the temporal bone contains:

Auditory ossicles (bones)MalleusIncusStapes

Openings to Outer ear covered by tympanic membraneInner ear = oval and round windowsEustachian tube connects middle ear to the nasopharnyx for air passage (normally closed, opens with swallowing/yawning)

Middle ear has 3 functions

1. Conducts sound vibration from outer ear to inner ear

2. Protects the inner ear by reducing the amplitude of loud sounds

3. Eustachian tube allows equalization of air pressure on each side of the ear drum to avoid rupture ( high altitudes)

Inner Ear

• Contains the Bony Labyrinth which holds the sensory organs for hearing and equilibrium

1. Vestibule2. Semicircular canals3. Cochlea (contains the central hearing apparatus)

Function of hearing

• 3 levels1. 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. Amplitude=loudness2. Frequency=pitch

• 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. Air conduction (AC)– normal pathway of hearing, the most efficient

2. 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. Causes= Presbycusis, a nerve degeneration due to aging (50yrs) or ototoxic drugs

3. Equilibrium – labyrinth feeds info to the brain about the body’s position in space, inflammation causes vertigo.

Subjective data• Earaches• Infections- otitis media• Discharge• Hearing loss• Environmental noise• Tinnitus- ototoxic: ASA, Aminoglycosides

(gentamicin) etc.• Vertigo• Self care behaviors

Objective data

• External ear = Inspect and Palpate– Size and shape– Skin condition– Tenderness- pinna & tragus; mastoid process– External auditory meatus- cerumen

Inspect using Otoscope

• 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

• External canal– Color– Swelling– Lesions– Discharge ; color and odor. Clean or change

speculum before examining other ear.

• Perform the otoscope exam prior to hearing tests.

• The following slide show a furuncle which is an infected hair follicle

Tympanic membrane

• 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

• Begins with the history-Conversational tone• The following tests may indicate the presence

of hearing loss but not the degree.

Hearing tests

• 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)

• Normal Response to Voice test– Correct identification of whispered words

bilaterally

• Tuning fork tests- measure hearing by AC and BC– To activate the tuning fork, hold it by the stem

and strike the tines softly on the back of the hand

1. Weber test – used when hearing is reported as better in one ear than other (bone conduction)

• Normal finding for the Weber test is– 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. Normally sound is heard 2X as long by air conduction as by bone conduction

2. 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

• First segment of the respiratory system• Warms, moistens and filters inhaled air• Sensory organ for smell

External parts

• 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

• 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

• 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

• 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– ↓ 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. Frontal sinuses2. Maxillary sinuses3. Ethnoid sinuses4. Sphenoid sinuses

Frontal & Maxillary sinuses are accessible to examination

Mouth

• First segment of the digestive system• Airway for the respiratory system• ORAL CAVITY– Lips– Palate

1. Hard2. Soft3. Uvula – hangs down from the soft palate

• Cheeks- side walls of cavity• Tongue

1. Papillae- rough, bumpy elevations on dorsal 2. Frenulum3. Taste buds

• Teeth – 32 permanent

• Salivary glands1. Parotid- largest of the glands, located in the

cheeks, front of the ear. Stenson’s duct opens in buccal mucosa

2. Submandibular- walnut size, beneath the mandible at the angle of the jaw. Wharton’s duct either side of the frenulum

3. Sublingual –smallest, almond shape, under tongue

Throat

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

• 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

• Discharge• Frequent colds• Sinus pain• Trauma• Epistaxis• Allergies• Altered smell

Subjective data Mouth and Nose

• Sores, lesions• Sore throat• Bleeding gums• Toothache• Hoarseness• Dysphagia• Altered taste

• Smoking• Alcohol intake• Self care behaviors

Objective behavior

• Nose – Inspect and palpate• INSPECT for:– Symmetry, deformity– Inflammation– Skin lesions– Color

• If injury – palpate gently

• Test for Patency• Test for Sense of Smell – Cranial nerve I

(olfactory)

• Inspect nasal cavity/ septum– Deviated septum?– Can see middle & inferior turbinates

• Inspect and palpate Paranasal Sinuses– Press thumbs over frontal & maxillary sinuses

• Transillumination for sinus inflammation– 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• Tonsils– 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 ????