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Assessment of

Ears, Nose, Mouth and Throat

by

Hakim Shah

Updated on 09-12-2014

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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.

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Anatomy and Physiology of the Ear

Three sections External ear Middle ear Inner ear

External ear Auricle or pinna External auditory canal

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Middle ear Ossicles

Malleus (hammer) Incus (anvil) Stapes (stirrup)

Tympanic membrane Eustachian tube

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Inner ear Labyrinth Vestibule Semicircular canals Cochlea

Frequency range of 20–20,000 Hz Decibel range 0–140

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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

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Common Chief Complaints

Ear Hearing loss Otorrhea Otalgia Tinnitus

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Nose Pain Drainage Blockage or congestion Bleeding (Epistaxis)

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Mouth and throat Halitosis Oral lesions Swelling Oral thrush Ulceration Pain Difficulty in swallowing Hoarseness of voice

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Evaluation of Chief Complaint Quality Associated manifestations Aggravating factors Alleviating factors Frequency Timing

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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

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Surgical Cosmetic surgery of head or neck Repair of deviated septum Oral surgery Tympanostomy tubes

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Medications Antibiotics Antihistamines Decongestants Steroids Chemotherapy Immunosuppressive drugs

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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

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Social History Alcohol use Drug use Tobacco use Sexual practices Work and home environment Hobbies and leisure activities Stress

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Health Maintenance Activities

Sleep Diet Use of safety devices Health check-ups

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General Approach to Assessment

Greet patient Explain assessment techniques Quiet, well-lit environment Sitting position Compare right to left Systematic approach

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

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Assessment of the Ear

Examination consists of three parts:1. Auditory screening

2. Inspection and palpation of external ear

3. Otoscopic assessment

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Take history of:

_Ear aches Infections Discharge Hearing loss Environmental noise Tinnitus Vertigo Self care

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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

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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

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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

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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.

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Normal findings

Weber test Normal finding: able to hear sound

equally in both ears Rinne test

Normal finding: air conduction > bone conduction

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External Ear

Inspection Note position, size, color, and shape

color Palpation

Auricle Tragus Mastoid bone TMJ

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Normal findings Flesh color Positioned centrally and in proportion

to the head No foreign bodies, redness, drainage,

deformities, nodules, or lesions

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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

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Otoscopic AssessmentInspect 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

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Ear Drum (light reflex)

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Light cone (Reflex) Tympanic membrane

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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

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Abnormal findings Chalky patches on tympanic membrane Severe pain Redness, swelling, narrowing, pain Drainage Hard, dry, very dark yellow cerumen Reddened tympanic membrane

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(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

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Tympanic membrane in OM

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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

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Paranasal Sinuses

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Mouth Function in the digestive and respiratory

system Hard and soft palates Uvula Tongue Salivary glands

Parotid Submandibular Sublingual

Teeth

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Throat Oropharynx Tonsils Nasopharynx

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Equipment for examination of Nose, Mouth and Throat Otoscope with short, wide-tipped nasal

speculum Pen light Two tongue blades Cotton gauze pad Gloves

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Assessment of the Nose Take history of:

Discharge Frequent colds Sinus pain Trauma Epistaxis Allergies Altered smell

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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 septumTurbinates

Sinus Areas- PalpateFrontal and maxillary sinusesTransillumination

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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

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Abnormal findings Broken, misshapen, swollen nose Occluded nasal passages Septum is deviated Nasal mucosa is red and swollen Purulent drainage

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Assessment of the Sinuses Inspection (Sinus Transillumination) Palpation and percussion Normal findings

No discomfort during palpation or percussion

Resonance heard on percussion

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(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

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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

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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.

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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

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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

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(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

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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)

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Neck assessment usually done with Thorax

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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

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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

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Gerontological Variations Presbycusis Diminished sense of smell and taste Lesions Periodontal disease Oral alterations due to disease or

side effects of medications Tooth loss

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Thank You

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Reference Bickly L.S, B.(2011) Bates guide to

physical examination and history taking  (10th ed).Philadelphia: J.B.Lippincott