ENT assessment

1. 13–1
Assessment
of
Ears, Nose, Mouth
and Throat
by
Hakim Shah
Updated on 09-12-2014

2. 13–2
Objectives
 Identify the structures of the ears, nose,
mouth, and throat.
 Discuss the system-specific history for the
ears, nose, mouth, and throat.
 Describe normal findings in the physical
assessment of the ears, nose, mouth, and
throat.
 Describe common abnormalities found in the
physical assessment of the ears, nose, mouth,
and throat.
 Perform the physical assessment of the ears,
nose, mouth, and throat.

3. 13–3
Anatomy and Physiology of the Ear
 Three sections
 External ear
 Middle ear
 Inner ear
External ear
 Auricle or pinna
 External auditory canal

4. 13–4

5. 13–5
Middle ear
 Ossicles

Malleus (hammer)

Incus (anvil)

Stapes (stirrup)
 Tympanic membrane
 Eustachian tube

6. 13–6
Inner ear
 Labyrinth
 Vestibule
 Semicircular canals
 Cochlea
 Frequency range of 20–20,000 Hz
 Decibel range 0–140

7. 13–7
Health History
 Ears
 Hearing loss
 Excessive cerumen
 Nose
 Decreased ability to smell (elderly)
 Mouth and throat
 Tooth loss
 Gum disease
 Decreased taste
 Tonsilitis
 Sore throat/infection

8. 13–8
Common Chief Complaints
 Ear
 Hearing loss
 Otorrhea
 Otalgia
 Tinnitus

9. 13–9
 Nose
 Pain
 Drainage
 Blockage or congestion
 Bleeding (Epistaxis)

10. 13–10
 Mouth and throat
 Halitosis
 Oral lesions
 Swelling
 Oral thrush
 Ulceration
 Pain
 Difficulty in swallowing
 Hoarseness of voice

11. 13–11
Evaluation of Chief Complaint
 Quality
 Associated manifestations
 Aggravating factors
 Alleviating factors
 Frequency
 Timing

12. 13–12
Past Health History
 Medical
 Otitis media or externa
 Nasal polyps, sinusitis, allergic rhinitis
 Tonsillitis, caries, upper respiratory infections
 Chronic diseases such as diabetes mellitus, renal
disease, hypertension, immuno-suppression
 Dental pathology
 Nutritional disturbances

13. 13–13
 Surgical
 Cosmetic surgery of head or neck
 Repair of deviated septum
 Oral surgery
 Tympanostomy tubes

14. 13–14
 Medications
 Antibiotics
 Antihistamines
 Decongestants
 Steroids
 Chemotherapy
 Immunosuppressive drugs

15. 13–15
 Allergies
 Signs and symptoms
 Pollen, insect stings, animal dander
 Injuries and accidents
 Foreign bodies
 Trauma
 Sports injuries
 Special needs
 Use of assistive devices (hearing aids)
 Speech disorders
 Childhood illnesses
 Frequent tonsillitis or ear infections

16. 13–16
Social History
 Alcohol use
 Drug use
 Tobacco use
 Sexual practices
 Work and home environment
 Hobbies and leisure activities
 Stress

17. 13–17
Health Maintenance Activities
 Sleep
 Diet
 Use of safety devices
 Health check-ups

18. 13–18
General Approach to
Assessment
 Greet patient
 Explain assessment techniques
 Quiet, well-lit environment
 Sitting position
 Compare right to left
 Systematic approach

19. 13–19
Equipment
 Otoscope
 Nasal speculum
 Penlight
 Tuning fork in 256 , 512 and 1024 Hz
 Tongue blade
 Watch
 Gauze square
 Cotton-tipped applicators

20. 13–20
Assessment of the Ear
Examination consists of three parts:
1. Auditory screening
2. Inspection and palpation of external
ear
3. Otoscopic assessment

21. 13–21
 Take history of:
_Ear aches
 Infections
 Discharge
 Hearing loss
 Environmental noise
 Tinnitus
 Vertigo
 Self care

22. 13–22
Auditory Screening
 Voice-whisper test and Vestibular apparatus
 Normal finding: able to repeat words whispered at
a distance of 2 feet
 Tuning fork tests
 Weber test
 Rinne test
 Determine whether hearing loss is conductive or
sensorineural

23. 13–23
Voice whisper and balance test
 Test hearing acuity: Conversational speech note
behavioral response to conversational speech ( lip
reading, frowning, straining forward, turning to catch
sounds asks you to repeat, misunderstands your
questions)
 Voice test: Test one ear at time cover opposite ear ,
shied lips 1 to 2 feet whisper two syllable words have
patient repeat
 Romberg Test: (vestibule apparatus) test stand with
feet together and arms at sides, close eyes should hold
position for 20 seconds without loosing balance

24. 13–24
Tuning fork test
 Weber Test: Place vibrating tuning fork
midline on the skull ask if tone is equal
bilaterally or better in one ear.
 Rinne test: have patient signal when the
vibrating tuning fork can no longer be
heard place fork near the ear cannel
should still hear sound AC>BC

25. 13–25
Otoscopic Examination
 Otoscopic exam external canal- color ,
redness, swelling for cerumen, discharge,
foreign bodies, lesions,.
 Tympanic membrane- normal is shiny
translucent with pearl-gray color, flat
slightly pulled in at center flutters with
swelling membrane should be intact.

26. 13–26
Normal findings
 Weber test
 Normal finding: able to hear sound
equally in both ears
 Rinne test
 Normal finding: air conduction > bone
conduction

27. 13–27
External Ear
 Inspection
 Note position, size, color, and shape
color
 Palpation
 Auricle
 Tragus
 Mastoid bone
 TMJ

28. 13–28
 Normal findings
 Flesh color
 Positioned centrally and in proportion
to the head
 No foreign bodies, redness, drainage,
deformities, nodules, or lesions

29. 13–29
 Abnormal findings
 Pale, red, cyanotic
 Small-size or large-size ears
 Purulent drainage
 Clear or bloody drainage
 Hematoma behind ear over mastoid
 Pain or tenderness on palpation

30. 13–30
Otoscopic Assessment
Inspect both ears
 External ear canal:
 lesions, swelling, discharge, hairs,
foreign body, cerenum
 Tympanic memebrane
 Pull auricle upward and back ward to
straighten the auditory canal

31. 13–31
Ear Drum (light reflex)

32. 13–32
Light cone (Reflex) Tympanic membrane

33. 13–33

34. 13–34
 Normal findings
 Tympanic membrane is pearly gray with
well-defined landmarks
 Light reflex present at 5 o’clock in right
ear and 7 o’clock in left ear
 Tympanic membrane moves when patient
blows against resistance
 No redness, swelling, tenderness, lesions,
drainage, foreign bodies

35. 13–35
 Abnormal findings
 Chalky patches on tympanic membrane
 Severe pain
 Redness, swelling, narrowing, pain
 Drainage
 Hard, dry, very dark yellow cerumen
 Reddened tympanic membrane

36. 13–36
(continues)
Risk Factors for Otitis
Media
 Less than 2 years of age
 Frequent upper respiratory infections
 Cold weather
 Male gender
 Family history
 Smoky environment
 Bottle fed
 Down syndrome

37. 13–37
Tympanic membrane in OM

38. 13–38
Structure and function :
Nose, Mouth, and Throat
 Nose
 Function in the respiratory system
 External nose
 Nasal cavity
 Septum
 Turbinate
 Paranasal sinuses

Frontal

Maxillary

Ethmoid

Sphenoid

39. 13–39
Paranasal Sinuses

40. 13–40
 Mouth
 Function in the digestive and respiratory
system
 Hard and soft palates
 Uvula
 Tongue
 Salivary glands

Parotid

Submandibular

Sublingual
 Teeth

41. 13–41

42. 13–42
 Throat
 Oropharynx
 Tonsils
 Nasopharynx

43. 13–43
Equipment for examination of Nose,
Mouth and Throat
 Otoscope with short, wide-tipped nasal
speculum
 Pen light
 Two tongue blades
 Cotton gauze pad
 Gloves

44. 13–44
Assessment of the Nose
 Take history of:
 Discharge
 Frequent colds
 Sinus pain
 Trauma
 Epistaxis
 Allergies
 Altered smell

45. 13–45
Inspection and palpation of nose
 External nose
 Tenderness, discharge ,trauma, bleeding, lesions,
masses, swelling, asymmetry
 Test patency of nostril
 Inspection of internal nose
 Speculum or otoscope with nasal speculum
 Nasal cavity
Nasal septum
Turbinates
 Sinus Areas- Palpate
Frontal and maxillary sinuses
Transillumination

46. 13–46
 Normal findings
 Located in midline of face
 No swelling, bleeding, lesions, or masses
 Both nostrils patent
 Septum midline
 Nasal mucosa is pink or dull red

47. 13–47
 Abnormal findings
 Broken, misshapen, swollen nose
 Occluded nasal passages
 Septum is deviated
 Nasal mucosa is red and swollen
 Purulent drainage

48. 13–48
Assessment of the Sinuses
 Inspection (Sinus Transillumination)
 Palpation and percussion
 Normal findings
 No discomfort during palpation or
percussion
 Resonance heard on percussion

49. 13–49
(continues)
Assessment of the Mouth
Inspect Mouth
 Lips
 Teeth and gums
 Tongue
 U-shaped areas under the tongue
 Buccal mucosa
 Uvula
 Hard and soft palate

50. 13–50
Mouth inspection and palpation
 LIPS inspect for color, moisture, cracking,
or lesions. Palpate lips, and face for mass
and tenderness
 TEETH/gums note any diseased absent,
loose teeth gums should be pink or coral,
check for swelling, retraction of gum
margins spongy, bleeding discolored gums.
 TONGUE color pink and even dorsal side
roughened, ventral smooth, glistening,
shows veins Inspect under tongue for
nodules, lesions, ulcerations

51. 13–51
Cont…
 Buccal mucosa looks pink, smooth,
moist, dark skinned people may have
patchy hyperpigmentation
 Uvula fleshy pendant midline uvula and
soft palate rise with “ahhh” sound.
anterior hard palate is white with
irregular transverse rugae the posterior
soft palate is pinker smooth, and
upwardly movable.

52. 13–52
 Normal findings of Mouth
 Breath is fresh
 Pink, moist lips
 Tongue midline, symmetrical, with adequate
movement
 No pockets between gums and teeth
 No bleeding
 Smooth, white teeth; proper alignment, no
dental caries

53. 13–53
 Abnormal findings of Mouth
 Lesions, growths
 Dry, cracked lips
 Vesicles or blisters
 Red, tender, inflamed tongue, gums, buccal mucosa
 Thrush
 Coating on tongue
 Red, tender, swollen gingiva
 Bleeding gums

54. 13–54
(continues)
Inspection of the Throat
 Position, size, color,and general
appearance of tonsils and uvula
 Gag reflex
 Color of oropharynx
 Presence of swelling, exudate,
lesions

55. 13–55
Assessment of tonsils
 Enlarged tonsils are graded

Grade 1 – wnl

Grade 2 – tonsils b/w pillars
and uvula

Grade 3 – tonsils touching
uvula

Grade 4 – tonsils touching
each other (kissing tonsils)

56. 13–56

57. 13–57
Neck assessment usually done with
Thorax

58. 13–58
 Normal findings
 Soft palate and uvula rise when patient
says “ah”
 Uvula is midline
 Throat is pink and vascular
 No swelling, exudate, or lesions
 Gag reflex is present

59. 13–59
 Abnormal findings
 Posterior pharynx is red with white
patches
 Tonsils and uvula are red and swollen
 Hoarse voice
 Grayish membrane covering tonsils,
uvula, soft palate

60. 13–60
Gerontological
Variations
 Presbycusis
 Diminished sense of smell and taste
 Lesions
 Periodontal disease
 Oral alterations due to disease or
side effects of medications
 Tooth loss

61. 13–61
Thank You

62. 13–62
Reference
 Bickly L.S, B.(2011) Bates guide to
physical examination and history
taking (10th ed).Philadelphia:
J.B.Lippincott