NurseReview.Org - Ears Nose Throat Mouth Nursing Lecture

Slide 1: Ears, Nose, Mouth, Throat

Slide 2: Ears

Slide 3: 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

Slide 4: Anatomy  The ear is responsible for hearing and balance  Consists of 3 regions  External ear  Middle ear  Inner ear

Slide 5: 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

Slide 9: External Ear  2 types of cerumen  Whites and blacks – wet, sticky, and honey colored  Asians and Native Americans – dry and flaky Lubricates & protects Moves to meatus with chewing & talking  Outer 1/3 of canal is cartilage, inner 2/3 consists of bone covered with skin

Slide 11: 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

Slide 13: 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

Slide 14: Middle ear  Tiny air–filled cavity in the temporal bone contains: Auditory ossicles (bones) Malleus Incus Stapes Openings to Outer ear covered by tympanic membrane Inner ear = oval and round windows Eustachian tube connects middle ear to the nasopharnyx for air passage (normally closed, opens with swallowing/yawning)

Slide 15: 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)

Slide 16: 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)

Slide 17: Function of hearing  3 levels 1. 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

Slide 18:  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)

Slide 19: 1. 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

Slide 20: 1. Cerebral cortex – interprets the meaning of the sound and begins the appropriate response

Slide 21: 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

Slide 23: 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

Slide 24: Hearing loss 1. 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 2. Equilibrium – labyrinth feeds info to the brain about the body’s position in space, inflammation causes vertigo.

Slide 25: Subjective data  Earaches  Infections- otitis media  Discharge  Hearing loss  Environmental noise  Tinnitus- ototoxic: ASA, Aminoglycosides (gentamicin) etc.  Vertigo  Self care behaviors

Slide 26: Objective data  External ear = Inspect and Palpate  Size and shape  Skin condition  Tenderness- pinna & tragus; mastoid process  External auditory meatus- cerumen

Slide 27: 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

Slide 28: Inspect using Otoscope  External canal  Color  Swelling  Lesions  Discharge ; color and odor. Clean or change speculum before examining other ear.

Slide 30:  Perform the otoscope exam prior to hearing tests.

Slide 31:  The following slide show a furuncle which is an infected hair follicle

Slide 33: 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

Slide 34: Hearing tests  Begins with the history-Conversational tone  The following tests may indicate the presence of hearing loss but not the degree.

Slide 35: 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)

Slide 36:  Normal Response to Voice test  Correct identification of whispered words bilaterally

Slide 37:  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 2. Weber test – used when hearing is reported as better in one ear than other (bone conduction)

Slide 38:  Normal finding for the Weber test is  Tone heard = loud bilaterally If sound lateralizes to one ear it indicates conductive or sensorineural loss.

Slide 39: 1. 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.

Slide 40: Weber test Rinne test

Slide 41: Nose, Throat and Mouth

Slide 42: Nose  First segment of the respiratory system  Warms, moistens and filters inhaled air  Sensory organ for smell

Slide 43: 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

Slide 44: 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

Slide 45: 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

Slide 47: 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

Slide 49: Foreign Body

Slide 51:  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

Slide 52: 1. Frontal sinuses 2. Maxillary sinuses 3. Ethnoid sinuses 4. Sphenoid sinuses Frontal & Maxillary sinuses are accessible to examination

Slide 55: Mouth  First segment of the digestive system  Airway for the respiratory system  ORAL CAVITY  Lips  Palate 1. Hard 2. Soft 3. Uvula – hangs down from the soft palate

Slide 56:  Cheeks- side walls of cavity  Tongue 1. Papillae- rough, bumpy elevations on dorsal 2. Frenulum 3. Taste buds  Teeth – 32 permanent

Slide 58:  Salivary glands 1. 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

Slide 60: 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

Slide 61:  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.

Slide 62: Subjective data Nose  Discharge  Frequent colds  Sinus pain  Trauma  Epistaxis  Allergies  Altered smell

Slide 63: Subjective data Mouth and Nose  Sores, lesions  Sore throat  Bleeding gums  Toothache  Hoarseness  Dysphagia  Altered taste

Slide 64:  Smoking  Alcohol intake  Self care behaviors

Slide 65: Objective behavior  Nose – Inspect and palpate  INSPECT for:  Symmetry, deformity  Inflammation  Skin lesions  Color  If injury – palpate gently

Slide 66:  Test for Patency  Test for Sense of Smell – Cranial nerve I (olfactory)

Slide 67:  Inspect nasal cavity/ septum  Deviated septum?  Can see middle & inferior turbinates

Slide 68:  Inspect and palpate Paranasal Sinuses  Press thumbs over frontal & maxillary sinuses  Transillumination for sinus inflammation  Frontal & Maxillary sinuses  Darken room

Slide 71: Mouth - Inspect Use gloves, tongue depressor, light  Lips  Teeth  Gums  Tongue  Buccal mucosa –Stenson’s duct (parotid)  Palate

Slide 74: 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 ????