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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. Vestibule
2. Semicircular canals
3. 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=loudness
2. 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 sinuses
2. Maxillary sinuses
3. Ethnoid sinuses
4. 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. Frenulum
3. 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 ????