ENT Examination

3rd year B.Sc Nursing
Medical Surgical Nursing-II
Unit-1 Nursing Management of Patients with Ear,Nose and Throat problems

1. EXAMINATION OF EAR NOSE &THROAT BY, VEDANTHA VINOD ASSISTANT LECTURER CCON-MYSORE

2. CONTENTS TO BE DISCUSSED: BASIC ANATOMY & PHYSIOLOGY OF EAR,NOSE AND THROAT. HISTORY OTOSCOPIC EXAMINATION EXAMINATION OF EAR , NOSE AND THROAT,

3. EXT E RNAL EAR MIDD L E EAR INNER EAR

4. E AR EXTERNAL: A URICLE/PI N NA E X TERNAL A U D I T O R Y CANAL MIDDLE: OSSICLES TYMPANIC MEMBRANE EU S T A C H IAN TUBE INNER: LABYRINTH VESTIBULE SEMICIRCULAR CANAL COCHLEA

5. The visible portion that is commonly referred to as "the ear" Helps localize sound sources Directs sound into the ear Each individual's pinna creates a distinctive imprint on the acoustic wave traveling into the auditory canal

6. Extends from the pinna to the tympanic membrane About 26 millimeters (mm) in length and 7 mm in diameter in adult ear. Size and shape vary among individuals. It contains hair, sebaceous land, ceruminous lands(wax)

7. The purpose of wax: Repel water Trap dust, sand particles, micro- organisms, and other debris Moisturize epithelium in ear canal Odor discourages insects Antibiotic, antiviral, antifungal properties Cleanse ear canal

8. The eardrum separates the outer ear from the middle ear Creates a barrier that protects the middle and inner areas from foreign objects Cone-shaped in appearance – about 17.5 mm in diameter The eardrum vibrates in response to sound pressure waves.

9. The eustachian tube (1MM WIDE 35 MM LONG) connects the middle ear with the nasopharynx Th e eu s t a chian t u b e norm al l y i t i s clo s ed, w h i c h opens during swallowing and yawning – Thi s equ a li z es the p r essu r e o n e ither sid e o f the eardrum, which is necessary for optimal hearing.

10. Malleus (hammer) Incus (anvil) Stapes (stirrup) smallest bone of the body

11. The cochlea resembles a snail shell and spirals for about 2 3/4 turns around a bony column Within the cochlea are three canals: Scala Vestibuli Scala Tympani Scala Media

12. FUN C TIONS Hearing Balance & equilibrium

13. History of present illness General – onset, chronology, current situation, location, radiation, quality, timing, factors, associated symptoms, previous treatments Cardinal signs&symptoms: EAR: Recent changes in hearing, itching, earache, discharge, tinnitus, vertigo,ear trauma, Q-TIP Use

14. NOSE&SINUSES: Rhinorrhea, epistaxis, obstruction of airflow, sinus pain & localised headache, itching, anosomia, nasal trauma. Sneezing MOUTH& THROAT: Hoarseness, dental chanes, oral lesions, bleeding gums, sore throat, dysphagia NECK: Pain, swelling, enlarged glands OTHERS: Fever, malaise, N/V

15. Medical conditions& surgeries Allergies(season) Medications Herbal preparations

16. MEDICAL HISTORY RELATED TO ENT Frequent ear or throat infections Sinusitis Trauma to head, ENT ENT Surgery Seasonal allergies Asthma Hearing loss Meniere’s disease ENT Cancer

17. PERSONAL & SOCIAL HISTORY Smoking Frequent exposure to water Use of foreign object to ear Over crowding Use of ear protection Recent air travels Occupational exposure to toxins or loud noises

18. Inspection: auricle & surrounding tissue should be inspected for deformities, lesions & discharge Palpation: palpate the auricle – if pain – A/C External otitis, tenderness on mastoid – A/C Mastoiditis

19. Tympanic membrane is inspected with otoscope E x a m in e r h ol d the o t o s c op e in rig h t hand in a pencil hold position Use opposite hand to grasp and gently pull back the auricle Speculum is slowly inserted into ear canal, with examiner’s eye held close to the lens of otoscope and visualise for discharge, inflammation& foreign body Assess the T.M – Pearly gray and is positioned obliquely at the base of canal – check for fluid, air bubbles, blood, masses in middle ear

20. Place the base of vibrating tunic fork on mastoid process When sound is no longer heard, the fork is placed just outside (2 Inch)the ear Normal : 20 sec bone conduction, 30-40 sec air conduction

21. Vibrating tunic fork is placed in the middle of fore head Patient is asked to report in which ear sound is heard louder Normal : equal in both ears

22. HEARING STATUS WEBER RINNE N o rm a l E qual A C > BC Conductive Sound is heard best in affected ear Sound is heard as long or longer in affected ear Sensori neural Sound is heard best in normal hearing ear Air conduction is audible longer than bone conduction in affected ear

23. WHISPER TEST Examiner cover the untested ear with palm of the hand Then the examiner whispers softly from a distance of 1 or 2 feet from unoccluded ear and out of the patients sight The patient with normal acuity repeat what was whispered.

24. AUDIOMETRY : (music tone& speech) Frequency – 20-20,000 Hz Pitch – low 100 Hz –High 10,000 Hz Intensity : 0-15 dB – normal 15-25 dB- slight H.L 25- 40dB – mild H.L 40-55 dB-moderate H.L 55-70dB – Moderate to severe H.L 70-90dB – Severe H.L >90dB – Profound H.L

25. Measure middle ear muscle reflex to sound stimulation and compliance of tympanic membrane by changing air pressure in a sealed ear canal

26. Electrodes are placed on the patients scalp & an each ear lobe – connected to computer They record brain wave activity in response to sounds you hear through earphones.

27. Measurement of graphic recording of the changes in electrical potential created by eye movements during spontaneous, positionals(nystagmus) It is used to assess the occulomotor and vestibular system and their corresponding interactions

28. Used to assess the vestibulo occular system by analysing compensatory eye movements in response to clockwise and counter clock wise rotation of chair

29. PRINCIPAL NASAL SYMPTOMS A irway obstruction R unny nose (rhinorrhoea) S neezing L oss of smell (anosmia) F acial pain due to sinusitis S noring associated with nasal obstruction

30. INSPECTION  Shape - Deviation. Look from the sides & from above. – Abnormal Nasal Creases Deformities Scars Discharge or crusting Redness or evidence of skin disease Offensive odour (From the Patient) Rhinorrhoea

31. INSPECTION  Inspect the front of the nose first by tipping the nose up and inspecting without a speculum.

32. Insert a Thudicum speculum into the appropriate nostril. A light source is required to visualise the internal structures. Thudicum Speculum

33. You should be able to identify the septum medially, the turbinates laterally. The inferior turbinates should be easy to visualise.

34. INSPECTION Inspect for inflammation (Rhinitis) Comment on the septum. Is it straight or deviated. Look in the mouth. Occasionally large polyps or tumours may be visible from arising behind the soft palate. Polyp right nostril TURBINATE S E P T UM

35. PALPATION If you see what you believe is a polyp then it is useful to assess sensitivity. Polyps are not sensitive to touch whereas turbinates are tender to touch. Polyps are grey / yellow whereas turbinates are pink.

36. NASAL AIRWAY ASSESSMENT Hold a cold metal tongue depressor under the patient’s nose whilst they breath in and out through their nose. Condensation should be visible as air passes over the metal. To assess nasal airway efficiency. Occlude one nostril and ask the patient to sniff. This gives a reasonable idea on nasal airway efficiency.

37. THROAT EXAMINATION  Enquire on general history. Sore throat, feeling run down, visible lesions & causing pain.  Ask about alcohol & tobacco habits.  Ask about their general dental history.

38. INSPECTION 1  Ask the patient to remove any dentures.  Inspect the lips. Note the Vermillion border & the corners of the mouth for any deviation.  Retract the upper lip with the front teeth closed together. Note the maxillary labial frenum, gingivae, mucogingival line with teeth.

39. Vermillion border maxillary labial frenum mucogingival line gingivae INSPECTION 2

40. INSPECTION 3 Note oral hydration Halitosis? Note any varicosities, missing teeth, dental carries, ulceration or haemangiomas. Use a bright light & a tongue depressor, inspect the tonsils, uvula and the soft palate. Ask the patient to tilt their head upwards to inspect the hard palate.

41. INSPECTION 4 Note the mucosal lining of the cheeks, noting Stensen’s glands. Located behind the 2 nd molar. It carries saliva from the Parotid gland. Any blockage can render the mouth dry. Note the frenum. Note any ulceration / discharge. Ask the patient to lift their tongue upwards to inspect the floor of the mouth. Note if the tip of the tongue can touch the roof of the mouth. Failure to do so may indicated tongue tie. (Ankyloglosia.)

42. PAROTID The parotid salivary gland is located over the mandibular ramus, anteriorly and inferiorly to the ears. Inspection of stensen’s duct may require inspection if the mouth is dry or if any parotid swelling is detected upon external palpation.

43. PAROTID PALPATION Palpated bilaterally Start palpating anterior to the ears and move towards the cheek and then inferiorly towards the angle of the mandible.

44. INSPECTION 4  Any further examination of the larynx requires specialised equipment.  Inspection of the oral cavity may also have a neurological element. C.N’s 7.9 &12

45. ANY DOUBTS?