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ASSESSMENT OF THE
THE EYE, EAR, NOSE
AND THROAT
ROMMEL LUIS C. ISRAEL III
ANATOMY
AND
PHYSIOLOGY
OF THE EAR
The ears are located on either side
the cranium at approximately eye
level.
The external ear, housed in the
temporal bone, includes the
pinna and the external auditory
canal.
The external ear is separated from
the middle ear by a disk-like
structure, the tympanic membrane
which is also known as the
BY: ROMMEL LUIS C. ISRAEL III
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BY: ROMMEL LUIS C. ISRAEL III
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ANATOMY AND
PHYSIOLOGY OF THE EAR
• The auricle, attached to the side of the
head by skin, is composed mainly of
cartilage, except for the fat and
subcutaneous tissue in the earlobe.
• The auricle collects the sound waves and
directs vibrations into the external
auditory canal.
BY: ROMMEL LUIS C. ISRAEL III
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ANATOMY
AND
PHYSIOLOGY
OF THE EAR
The external auditory
is approximately 2.5cm
long.
The lateral third is an
cartilaginous and dense
fibrous framework to
thin skin is attached.
The medial two thirds is
bone lined with thin skin.
The external auditory
ends at the tympanic
membrane.
BY: ROMMEL LUIS C. ISRAEL III
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ANATOMY
AND
PHYSIOLOGY
OF THE EAR
The skin of the canal contains hair,
sebaceous glands and ceruminous
glands, which secrete a brown, wax-
substance, the cerumen (ear wax).
The ear’s self-cleaning mechanism
moves old skin cells and cerumen to
the outer part of the ear.
Just anterior to the external
canal is the temporomandibular
BY: ROMMEL LUIS C. ISRAEL III
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ANATOMY
AND
PHYSIOLOGY
OF THE EAR
The middle ear, an air-filled
is connected by the Eustachian
tube to the nasopharynx and is
continuous with air-filled cells
the adjacent mastoid portion of
the temporal bone.
The Eustachian tube,
approximately 1mm wide and
35mm long, connects the
ear to the nasopharynx.
BY: ROMMEL LUIS C. ISRAEL III
7
ANATOMY AND
PHYSIOLOGY OF THE EAR
• The Eustachian tube is closed,
but it opens by action of the
tensor veli palatini muscle when
performing a Valsalva
manoeuvre or when yawning or
swallowing.
• The tube serves as a drainage
channel for normal and
abnormal secretions of the
middle ear and equalises
pressure in the middle ear with
that of the atmosphere
BY: ROMMEL LUIS C. ISRAEL III
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ANATOMY
AND
PHYSIOLOGY
OF THE EAR
The tympanic membrane, about 1cm in
diameter and very thin, is normally pearly
and translucent.
The tympanic membrane consists of three
layers of tissue:
An outer layer, continuous with the skin of
ear canal.
A fibrous middle layer.
An inner mucosal layer, continuous with the
lining of the middle ear cavity.
BY: ROMMEL LUIS C. ISRAEL III
9
ANATOMY AND
PHYSIOLOGY OF THE EAR
Ear
• Approximately 80% of the tympanic
membrane is composed of all three
layers and is called the pars tensa.
• The other 20% of the tympanic
membrane lacks the middle layer and
is called the pars flaccida.
• The absence of this fibrous middle
layer makes the pars flaccida more
vulnerable to pathologic disorders
than the pars tensa.
BY: ROMMEL LUIS C. ISRAEL III
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ANATOMY AND
PHYSIOLOGY OF THE EAR
Distinguishing landmarks of the
tympanic membrane include:
• The annulus, the fibrous border that
attaches the eardrum to the temporal
bone.
• The short process of the malleus.
• The long process of the malleus.
BY: ROMMEL LUIS C. ISRAEL III
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ANATOMY AND
PHYSIOLOGY OF THE EAR
• The umbo of the malleus, which attaches to the
tympanic membrane in the centre.
• The pars flaccida.
• The pars tensa.
• The tympanic membrane protects the middle ear
and conducts sound vibrations from the external
canal to the ossicles.
BY: ROMMEL LUIS C. ISRAEL III
12
ANATOMY AND
PHYSIOLOGY OF THE EAR
The middle ear contains the three smallest bones
(ossicles) of the body, that is, malleus, incus, and
The ossicles, which are held in place by joints,
muscles, and ligaments, assist in the transmission
sound.
Two small fenestrae (that is, oval and round
windows), located in the medial wall of the
ear, separate the middle ear from the inner ear.
BY: ROMMEL LUIS C. ISRAEL III
13
ANATOMY AND
PHYSIOLOGY OF THE EAR
• The footplate of the stapes sits in the oval
window, secured by a fibrous annulus, or ring-
shaped structure.
• The footplate transmits sound to the inner ear.
• The round window, covered by a thin membrane,
provides an exit for sound vibrations.
BY: ROMMEL LUIS C. ISRAEL III
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ANATOMY AND
PHYSIOLOGY OF THE EAR
• The inner ear is housed deep within the
temporal bone.
• The organs for hearing (cochlea) and balance
(semi-circular canals), as well as cranial nerves
VII (that is, facial nerve) and VIII (that is,
vestibulocochlear nerve) are housed in the bony
labyrinth.
• The bony labyrinth surrounds and protects the
membranous labyrinth, which is bathed in a fluid
called perilymph.
BY: ROMMEL LUIS C. ISRAEL III
15
ANATOMY AND
PHYSIOLOGY OF THE EAR
• The inner ear is housed deep within the
temporal bone.
• The organs for hearing (cochlea) and balance
(semi-circular canals), as well as cranial nerves
VII (that is, facial nerve) and VIII (that is,
vestibulocochlear nerve) are housed in the bony
labyrinth.
• The bony labyrinth surrounds and protects the
membranous labyrinth, which is bathed in a fluid
called perilymph.
BY: ROMMEL LUIS C. ISRAEL III
16
ANATOMY AND
PHYSIOLOGY OF THE EAR
• The organ of Corti is located in the
cochlea, a snail-shaped, bony tube about
3.5cm long with two and one-half spiral
turns.
• Membranes separate the cochlear duct
(that is, scala media) from the scala
vestibuli, and the scala tympani from the
basilar membrane.
• .
BY: ROMMEL LUIS C. ISRAEL III
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ANATOMY
AND
PHYSIOLOGY
OF THE EAR
The organ of Corti is located on
basilar membrane stretching from
the base to the apex of the
As sound vibrations enter the
perilymph at the oval window and
travel along the scala vestibuli,
pass through the scala tympani,
enter the cochlear duct, and cause
movement of the basilar
BY: ROMMEL LUIS C. ISRAEL III
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ANATOMY
AND
PHYSIOLOGY
OF THE EAR
The organ of Corti, also
the end organ for hearing,
transforms mechanical
into neural activity and
separates sounds into
frequencies.
This electrochemical impulse
travels through the acoustic
nerve to the temporal cortex
the brain to be interpreted as
meaningful sound.
BY: ROMMEL LUIS C. ISRAEL III
19
ANATOMY
AND
PHYSIOLOGY
OF THE EAR
In the internal auditory canal, the
cochlear (acoustic) nerve, arising
the cochlea, joins the vestibular
arising from the semi-circular
utricle, and saccule, to become the
vestibulo-cochlear nerve (cranial
nerve VIII).
This canal also houses the facial
and the blood supply from hearing
conducted over two pathways, that
air and bone.
BY: ROMMEL LUIS C. ISRAEL III
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ANATOMY
AND
PHYSIOLOGY
OF THE EAR
Sounds transmitted by air
conduction travel over the
filled, external ear and
ear through vibration of the
tympanic membrane and
ossicles.
Sounds transmitted by bone
conduction travel directly
through bone to the inner
bypassing the tympanic
membrane and ossicles
BY: ROMMEL LUIS C. ISRAEL III
21
ANATOMY
AND
PHYSIOLOGY
OF THE EAR
Normally, air conduction is the more efficient
pathway.
However, defects in the tympanic membrane
interruption of the ossicular chain disrupt
air conduction, which results in a loss of the
sound-to-pressure ratio and subsequently in a
conductive hearing loss.
Sound enters the ear through the external
auditory canal and causes the tympanic
membrane to vibrate. These vibrations
sound through the lever action of the ossicles
the oval window as mechanical energy
BY: ROMMEL LUIS C. ISRAEL III
22
• This mechanical energy is then
transmitted through the inner ear fluids
to the cochlea, stimulating the hair cells,
and is subsequently converted to
electrical energy.
• The electrical energy travels through the
vestibulo-cochlear nerve to the central
nervous system, where it is analysed and
interpreted in its final form as sound.
• Vibrations transmitted by the tympanic
membrane to the ossicles of the middle
ear are transferred to the cochlea, lodged
in the labyrinth of the inner ea
BY: ROMMEL LUIS C. ISRAEL III
23
ANATOMY
AND
PHYSIOLOGY
OF THE EAR
The stapes rocks, causing
(waves) in fluids contained in the
inner ear.
These fluid waves cause
of the basilar membrane to occur
that then stimulates the hair cells
the organ of Corti in the cochlea
move in a wavelike manner.
membrane
BY: ROMMEL LUIS C. ISRAEL III
24
ANATOMY
AND
PHYSIOLOGY
OF THE EAR
The movements of the tympanic
membrane set up electrical currents
stimulate the various areas of the
cochlea.
The hair cells set up neural impulses
are encoded and then transferred to
auditory cortex in the brain, where
are decoded into a sound message.
The footplate of the stapes receives
impulses transmitted by the incus and
the malleus from the tympanic
BY: ROMMEL LUIS C. ISRAEL III
25
ANATOMY AND
PHYSIOLOGY OF THE EAR
• The round window, which opens on
the opposite side of the cochlear
duct, is protected from sound waves
by the intact tympanic membrane,
permitting motion of the inner ear
fluids by sound wave stimulation.
• For example, in the normally intact
tympanic membrane, sound waves
stimulate the oval window first, and a
lag occurs before the terminal effect
of the stimulus reaches the round
window.
BY: ROMMEL LUIS C. ISRAEL III
26
ANATOMY AND
PHYSIOLOGY OF THE EAR
• This lag phase is changed, however, when a perforation of the
tympanic membrane is large enough to allow sound waves to
impinge on the oval and round windows simultaneously.
• This effect cancels the lag and prevents the maximal effect of
inner ear fluid motility and its subsequent effect in stimulating
the hair cells in the organ of Corti.
• The result is a reduction in hearing ability.
BY: ROMMEL LUIS C. ISRAEL III
27
ANATOMY AND PHYSIOLOGY
OF THE EAR
• Body balance is maintained by the cooperation of
the muscles and joints of the body (that is,
proprioceptive system), the eyes (that is, visual
system), and the labyrinth (that is, vestibular
system).
• These areas send their information about
equilibrium, or balance, to the brain (cerebellar
system) for coordination and perception in the
cerebral cortex
BY: ROMMEL LUIS C. ISRAEL III
28
ANATOMY AND PHYSIOLOGY
OF THE EAR
• . The brain obtains its blood supply from the heart and
arterial system.
• A problem in any of these areas, such as
arteriosclerosis or impaired vision, can cause a balance
disturbance.
• The vestibular apparatus of the inner ear provides
feedback regarding the movements and the position of
the head and body in space.
BY: ROMMEL LUIS C. ISRAEL III
29
ANATOMY
AND
PHYSIOLOGY
OF THE
NOSE
The Nose
The nose consists of the
external or outer nose and
the nasal fossae or
nose.
The outer nose is made up
of bone and cartilage and
divided internally into two
nasal fossae by the nasal
septum, and externally by
the columella.
BY: ROMMEL LUIS C. ISRAEL III
30
ANATOMY
AND
PHYSIOLOGY
OF THE
NOSE
Anterior openings into
nasal fossae are nostrils,
nares.
Each fossa has a lateral
extended ‘wing’ portion
called the ala nasi on the
outside and a vestibule
just inside the nostril.
BY: ROMMEL LUIS C. ISRAEL III
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• Superior, middle and
inferior measures or
grooves are located on
the lateral walls of the
nostrils just below the
corresponding conchae,
located on the lateral
walls of nostrils just
below the corresponding
conchae, or turbinates.
ANATOMY
AND
PHYSIOLOGY
OF THE
NOSE
BY: ROMMEL LUIS C. ISRAEL III
32
ANATOMY AND PHYSIOLOGY
OF THE NOSE
• The nasal turbinates are covered by mucous
membranes and greatly increase the surface
area of mucus membrane of the the nose
because of their shape.
• Kiesselbach’s plexus is a vascular area on the
nasal septum, and a common site for
nosebleeds
BY: ROMMEL LUIS C. ISRAEL III
33
ANATOMY AND PHYSIOLOGY
OF THE NOSE
The pathophysiology of breathing through nostrils
• Air enters the anterior nares, passes through the vestibule,
and enters the fossa.
• The vestibule contains nasal hairs and sebaceous glands.
• The fossae have both olfactory and respiratory functions.
• To protect the lungs from noxious agents, these structures of
the nose clean, filter, humidify and control temperature of
inspired air.
.
BY: ROMMEL LUIS C. ISRAEL III
34
ANATOMY AND PHYSIOLOGY
OF THE NOSE
The pathophysiology of breathing
through nostrils
• The mucous covering in the nose and
sinuses traps fine dust particles, and
lysosomes kill most of the bacteria.
• The tiny hairs of the nose (cilia) transport
the mucus and the particles to the
pharynx to be swallowed
BY: ROMMEL LUIS C. ISRAEL III
35
ANATOMY AND
PHYSIOLOGY OF THE NOSE
The pathophysiology of breathing through nostrils
• The nasal mucosa is capable of adding large amounts of
water to inspired air through evaporation from its surface.
• The rich vascular supply to the turbinates radiates heat to
the incoming air as it passes through the nasal cavity.
BY: ROMMEL LUIS C. ISRAEL III
36
ANATOMY AND
PHYSIOLOGY OF THE NOSE
The pathophysiology of breathing through nostrils
• Olfactory receptor cells are located in the upper parts of the
nasal cavity, the superior nasal conchae, and on parts of the
nasal septum and are covered by hair-like cilia that project
into the cavity.
• The chemical component of odours binds with the
receptors, causing nerve impulses to be transmitted to the
olfactory cortex, located in the base of the frontal lobe.
BY: ROMMEL LUIS C. ISRAEL III
37
ANATOMY AND
PHYSIOLOGY OF THE NOSE
• Sinuses
• Air-filled cavities lined with mucous membranes are present
in some of the cranial bones and are referred to as paranasal
sinuses.
• These air-filled sinuses lighten the weight of the skull and
ensure resonance to the quality of the voice.
BY: ROMMEL LUIS C. ISRAEL III
38
ANATOMY AND
PHYSIOLOGY OF THE NOSE
The sinuses
• The frontal, maxillary, ethmoid and
sphenoid paranasal sinuses open into the
nose.
• Only the frontal and maxillary sinuses
can be assessed in the physical
examination
BY: ROMMEL LUIS C. ISRAEL III
39
ANATOMY AND
PHYSIOLOGY OF THE
MOUTH AND THROAT
Mouth and Throat
• The lips are sensory structures found at the
opening of the mouth.
• The labial tubercle is the small projected area
in the midline of the upper lip.
• The area where the upper and lower lips meet
is the labial commissure.
BY: ROMMEL LUIS C. ISRAEL III
40
ANATOMY AND
PHYSIOLOGY OF THE
MOUTH AND THROAT
• The cheeks form the lateral walls of the mouth and are lined
with buccal mucosa.
• The posterior pharyngeal wall is at the back of the mouth.
• The roof of the mouth consists of the hard palate anteriorly
and the soft palate posteriorly.
• The linear raphe is a ridge in the middle of the hard palate
that is formed by two palatine bones and part of the
superior maxillary bone.
BY: ROMMEL LUIS C. ISRAEL III
41
ANATOMY
AND
PHYSIOLOGY
OF THE
MOUTH AND
THROAT
The tongue assists with
mastication, swallowing, speech
and mechanical cleansing of the
teeth.
Two of the three pairs of salivary
glands open into the mouth on
ventral surface of the tongue.
Sub-maxillary glands secrete
through Wharton’s ducts located
both sides of the frenulum.
BY: ROMMEL LUIS C. ISRAEL III
42
ANATOMY
AND
PHYSIOLOGY
OF THE
MOUTH AND
THROAT
Sublingual glands open
the floor of the mouth
posterior to Wharton’s
These salivary glands
produce 1,000 to 1,500ml
saliva per day to assist
digestion of food and
maintenance of oral
BY: ROMMEL LUIS C. ISRAEL III
43
ANATOMY
AND
PHYSIOLOGY
OF THE
MOUTH AND
THROAT
The tongue assists with
mastication, swallowing, speech
and mechanical cleansing of the
teeth.
Two of the three pairs of salivary
glands open into the mouth on
ventral surface of the tongue.
Sub-maxillary glands secrete
through Wharton’s ducts located
both sides of the frenulum.
BY: ROMMEL LUIS C. ISRAEL III
44
ANATOMY
AND
PHYSIOLOGY
OF THE
MOUTH AND
THROAT
Sublingual glands open
the floor of the mouth
posterior to Wharton’s
These salivary glands
produce 1,000 to 1,500ml
saliva per day to assist with
digestion of food and
maintenance of oral
BY: ROMMEL LUIS C. ISRAEL III
45
ANATOMY
AND
PHYSIOLOGY
OF THE
MOUTH AND
THROAT
Saliva prevents dental
caries by washing away
bacteria and destroying it
with antibodies and
proteolytic enzymes.
Gums, or gingivae, hold
teeth in place.
Adults have thirty two
permanent teeth
of four incisors, two
canines, four premolars
six molars in each half of
the mouth.
BY: ROMMEL LUIS C. ISRAEL III
46
ANATOMY
AND
PHYSIOLOGY
OF THE
MOUTH AND
THROAT
The three parts of the
are the top, or the crown,
the root, which is
embedded in the gum,
the neck, which connects
the root and the crown.
The teeth are well
for chewing.
The uvula is a finger-like
projection of tissue that
hangs down from the
of the soft palate.
BY: ROMMEL LUIS C. ISRAEL III
47
OVERVIEW
OF EENT
DISORDER
SYMPTOMS
The kind of information to
be obtained while taking
history includes:
• The client's signs and
symptoms.
• Current health patterns.
• Previous illnesses.
BY: ROMMEL LUIS C. ISRAEL III
48
OVERVIEW OF EENT
DISORDER SYMPTOMS
Key signs and
symptoms of ENT
problems include:
Epistaxis (bleeding
from the nose)
Sore throat
Nasal congestion Hoarseness
Dysphagia
(difficulty
swallowing)
Odynophagia
(painful
swallowing)
Globus
(something in
throat) sensation
BY: ROMMEL LUIS C. ISRAEL III
49
OVERVIEW OF
EENT
DISORDER
SYMPTOMS
Key signs and
symptoms of
EENT problems
include
Sore throat Weight loss
Otalgia (ear
pain)
Neck lump Earache
Tinnitus
(ringing in the
ears)
Otorrhea
(discharge from
the external
ear)
Hearing loss
Dizziness
BY: ROMMEL LUIS C. ISRAEL III
50
OVERVIEW OF EENT
DISORDER SYMPTOMS
To find out about current health patterns carry out
the following:
• Inquire about nutrition, dental care, normal
mouth care habits, dental caries, use of partial or
full dentures, stress-related grinding, clenching,
or clamping of teeth.
• Ask about consumption of alcohol, smoking, use
of a pipe, and smokeless tobacco.
BY: ROMMEL LUIS C. ISRAEL III
51
OVERVIEW OF EENT
DISORDER SYMPTOMS
To find out about current health patterns carry out the
following
• Determine personal hygiene about ears.
• Are cotton swabs or other objects used for cleaning?
• Is there any loud noise exposure?
• Does the client frequently strain voice through talking,
singing, or shouting?
• What medications is the client taking? Have antibiotics been
used? For how long have they been used?
BY: ROMMEL LUIS C. ISRAEL III
52
OVERVIEW OF ENT
DISORDER SYMPTOMS
• Find out about Previous Illnesses by asking on the following:
• Is there a history of allergies?
• Is there any immunosuppressive illness, such as diabetes mellitus,
cancer, and human immunodeficiency virus (HIV) infection?
• Has there been any trauma?
• Is there a history of rhinitis, sinusitis, or ear infections?
• Is there a family history of any EENT problems or cancer?
• Surgeries done for example, adenotonsillectomy.
BY: ROMMEL LUIS C. ISRAEL III
53
ASSESSMENT OF THE EENT
Assessment of the ENT includes the following areas:
• Assessment of the ear
• Assessment of the nose
• Assessment of the sinuses
• Assessment of the mouth and throat
BY: ROMMEL LUIS C. ISRAEL III
54
ASSESSMENT OF THE EENT
Assessment of the Ear
Physical assessment of the ear consists of three parts:
• Inspection and palpation of the external ear
• Auditory screening (CN VIII)
• Otoscopic assessment
BY: ROMMEL LUIS C. ISRAEL III
55
ASSESSMENT OF THE EENT
Assessment of the Ear
Some of the Equipment to be used in this include:
• Otoscope with ear pieces of different sizes
• Nasal speculum
• Penlight
• Tuning fork, 512 Hz
• Tongue blade
• Watch
• Gauze
• Clean gloves
BY: ROMMEL LUIS C. ISRAEL III
56
GENERAL APPROACH TO
EENT ASSESSMENT
The following is the approach used for ENT assessment:
• Greet the client and explain the assessment techniques that
you will be using.
•
• Use a quiet room that will be free from interruptions.
BY: ROMMEL LUIS C. ISRAEL III
57
GENERAL APPROACH TO
EENT ASSESSMENT
• Ensure that the light in the room provides sufficient
brightness to allow adequate observation of the client.
• Place the client in an upright sitting position, preferably.
• Always compare right and left ears, as well as right and
left sides of the nose, sinuses, mouth and throat.
BY: ROMMEL LUIS C. ISRAEL III
58
ASSESSMENT OF THE ENT
Examining the Ear
To examine your client’s ears, you need a thorough
understanding of the organ’s anatomic structure as well as the
mechanisms that allow hearing.
The external ear is examined by inspection and direct
palpation, and the tympanic membrane is inspected with an
otoscope.
•
BY: ROMMEL LUIS C. ISRAEL III
59
ASSESSMENT OF THE ENT
• Evaluation of gross auditory acuity also is
included in every physical examination.
• The auricle and surrounding tissues should be
inspected for deformities, lesions, and
discharge, as well as size, symmetry, and angle
of attachment to the head.
BY: ROMMEL LUIS C. ISRAEL III
60
ASSESSMENT OF THE ENT
• Manipulation of the auricle does not
normally elicit pain. If this manoeuvre is
painful, acute external otitis is suspected.
• Tenderness on palpation in the area of the
mastoid process may indicate acute
mastoiditis or inflammation of the
posterior auricular node.
BY: ROMMEL LUIS C. ISRAEL III
61
ASSESSMENT
OF THE EENT
Occasionally, sebaceous cysts
and tophi (subcutaneous
mineral deposits) are present
on the pinna.
A flaky scaliness on or behind
the auricle usually indicates
seborrhoeic dermatitis and
can be present on the scalp
and facial structures as well.
BY: ROMMEL LUIS C. ISRAEL III
62
ASSESSMENT
OF THE EENT
Examining the Outer Ear
• You need to carry out the
following in the examination of the
outer ear:
• Inspect the auricle of each ear for
size, shape, symmetry, colour, and
position.
• The skin should be the same
colour as the facial skin.
• Observe for moles, cyst,
deformities, or altered skin
integrity.
• Note any drainage from the ear
canal.
BY: ROMMEL LUIS C. ISRAEL III
63
ASSESSMENT
OF THE ENT
Examining the Outer Ear
• To check the ears position,
draw an imaginary line from
the outer canthus of the eye
to the protuberance of the
occiput.
• The ear should touch or sit
just above this line.
• Expect the ear to be almost
vertical, with no more than a
100 posterolateral slant.
BY: ROMMEL LUIS C. ISRAEL III
64
ASSESSMENT OF THE EENT
Examining the Outer Ear
• Palpate the auricle (pinna) for tenderness, swelling,
or nodules.
• Gently pull on the tragus and again on the helix to
check for pain and tenderness.
• Gloves are optional for this examination.
• Palpate the mastoid process. Be alert for pain,
tenderness, swelling, nodules, or lesions.
BY: ROMMEL LUIS C. ISRAEL III
65
ASSESSMENT OF THE ENT
Performing an Otoscopic Examination
• To begin, assemble the otoscope.
• Attach the handle housing the battery pack to
the otoscope’s head, which contains a light
source and magnifying lens.
• Select and attach a speculum large enough to
fit the client’s ear canal comfortably.
BY: ROMMEL LUIS C. ISRAEL III
66
ASSESSMENT OF THE ENT
Performing an Otoscopic Examination
• out will additionally need to carry out the
following:
• Gently insert the otoscope into the ear canal
using one of two techniques.
• Hold the handle of the otoscope with the handle
facing up to allow you to brace your hand against
against the client’s head to stabilise the
instrument
BY: ROMMEL LUIS C. ISRAEL III
67
ASSESSMENT OF THE ENT
Performing an Otoscopic Examination
• . This helps to prevent injury if the client moves their head
quickly.
• Inspect the auditory canal for the cerumen, redness or
swelling.
• You will see hairs and cerumen in the ear canal distal two-
thirds.
• Note excessive cerumen that may obstruct your view.
• You may need to remove it to complete your inspection.
BY: ROMMEL LUIS C. ISRAEL III
68
ASSESSMENT OF THE ENT
Performing an Otoscopic Examination
• Inspect the tympanic membrane.
• Typically, middle ear problems will be evident by the
tympanic membrane’s appearance.
• Focus on the membrane’s colour and contour. It should be
pearly grey and appear concave at the umbo, handle of
malleus, and cone of light.
• Be alert for perforations, bulging, missing landmarks, or a
distorted cone of light.
BY: ROMMEL LUIS C. ISRAEL III
69
ASSESSMENT OF THE ENT
Performing an Otoscopic Examination
• Have the client sit in a comfortable position or lie down on
the side opposite the ear you wish to examine.
• Hold the otoscope handle in the space between your thumb
and index finger.
BY: ROMMEL LUIS C. ISRAEL III
70
ASSESSMENT OF THE ENT
Performing an Otoscopic Examination
• Assist the client to tilt their head toward the shoulder
opposite the ear you are examining.
• Keeping in mind how the ear canal curves in an adult.
• Gently grasp the auricle and pull it up and back to straighten
the ear canal before inserting the speculum.
BY: ROMMEL LUIS C. ISRAEL III
71
ASSESSMENT OF THE ENT
Auditory Testing
• After the otoscopic examination, you will have the idea of how
well the client hears.
• If they often ask you what you said or speak extra loudly, in a
monotone, or with erratic volume, you may rightly suspect a
hearing problem.
• To investigate further, use a tuning fork to assess hearing
acuity.
BY: ROMMEL LUIS C. ISRAEL III
72
ASSESSMENT OF THE ENT
Auditory Testing
• You will then carry out a voice – whisper test.
• Begin estimating hearing acuity by checking whether the client can hear you whisper by
carrying out the following:
• Instruct the client to occlude one ear with a finger.
• Stand two feet behind the client’s other ear and whisper a two-syllable word or phrase that
is evenly accented.
• Ask the client to repeat the word or phrase.
• Repeat the test with the other ear.
BY: ROMMEL LUIS C. ISRAEL III
73
ASSESSMENT OF THE ENT
Auditory Testing
• Normal finding is that the client should be able to repeat
words whispered from a distance of two feet.
• Abnormal findings include the client being unable to repeat
the words correctly or stating that they were unable to hear
anything. This indicates hearing loss.
BY: ROMMEL LUIS C. ISRAEL III
74
ASSESSMENT OF THE ENT
Tuning Fork Tests
• Rinne and Weber tests help to determine whether the type of
hearing loss the client is experiencing is conductive or
sensorineural.
• In order to understand how these tests are evaluated, it is
important to know the difference between air and bone
conduction.
BY: ROMMEL LUIS C. ISRAEL III
75
ASSESSMENT OF THE ENT
Tuning Fork Tests
• Air conduction refers to the transmission of sound through
the ear canal, tympanic membrane and ossicular chain to the
cochlea and auditory nerve.
• Bone conduction refers to the transmission of sound through
the bones of the skull to the cochlea and auditory nerve.
BY: ROMMEL LUIS C. ISRAEL III
76
ASSESSMENT OF THE ENT
Tuning Fork Tests
• Tuning fork tests include:
• Rinne test
• Weber test
• Schwabach test
BY: ROMMEL LUIS C. ISRAEL III
77
ASSESSMENT OF THE ENT
A. Performing the Rinne Test
• If you suspect a hearing loss, perform the Rinne test.
• This test will help determine whether the loss is conductive
or sensor neural.
You will need to follow these steps:
• Without touching the tunes, hold a tuning fork by its base
with one hand.
• Activate the fork by striking it.
• Place the base of the vibrating tuning fork against the client’s
mastoid process, and ask the client to tell you when they no
longer hear the sound.
BY: ROMMEL LUIS C. ISRAEL III
78
ASSESSMENT OF THE ENT
BY: ROMMEL LUIS C. ISRAEL III
79
ASSESSMENT OF THE ENT
Performing the Rinne Test
• Begin timing the interval (counting the number of seconds)
until the client no longer hears the sound.
• Then carry out the following:
• Quickly change the forks position to about 1 to 2cm from
the auditory canal.
BY: ROMMEL LUIS C. ISRAEL III
80
ASSESSMENT OF THE ENT
Performing the Rinne Test
• Hold the fork so that the tines face forward, maximising the
sound.
• Continue timing the interval to determine how long the
client hears this sound by air conduction.
BY: ROMMEL LUIS C. ISRAEL III
81
ASSESSMENT OF THE ENT
• The following is a diagram illustrating this.
BY: ROMMEL LUIS C. ISRAEL III
82
ASSESSMENT OF THE ENT
B. Performing the Weber Test
• To perform this test, activate the tuning fork as before.
• Place the base of the fork midline on the client head or
forehead.
• Ask whether they hear the sound in one ear or both.
Normally, they should hear the sound equally in both ears.
• If they do not, ask them which ear hears well.
BY: ROMMEL LUIS C. ISRAEL III
83
ASSESSMENT OF THE ENT
Performing the Rinne Test
• An abnormal finding is when sound lateralises to the
affected ear indicating unilateral conductive hearing loss.
• When sound lateralises to the unaffected ear, this occurs
with sensorineural loss related to nerve damage in the
impaired ear.
BY: ROMMEL LUIS C. ISRAEL III
84
THE DIAGRAM THAT
FOLLOWS ILLUSTRATES THE
WEBER TEST.
BY: ROMMEL LUIS C. ISRAEL III
85
ASSESSMENT OF THE ENT
C. Performing the Schwabach Test
• To perform this test:
• Occlude one of the client’s ears by gently placing your finger
in the ear canal and moving it up and down to block hearing.
• Activate the tuning fork and place it on the mastoid process
behind the opposite ear.
BY: ROMMEL LUIS C. ISRAEL III
86
ASSESSMENT OF THE ENT
Performing the Schwabach Test
• If the client hears the sound, remove the tuning fork from
their mastoid process, occlude one of your own ears, and
place the tuning fork behind the mastoid process of your
other ear.
• Alternate the tuning fork between your mastoid process and
the client’s, and count the number of seconds until one of
you no longer hears the sound.
• Normally, you and the client will stop hearing the sound
after the same interval.
BY: ROMMEL LUIS C. ISRAEL III
87
ASSESSMENT OF THE ENT
Assessment of the Nose
• Inspect the nose, noting any trauma, bleeding, lesions,
masses, swelling and asymmetry.
• The normal finding includes the nose being located
symmetrically in the midline of the face and is without
swelling, bleeding, lesions or masses.
• Abnormal finding includes a broken or swollen nose.
BY: ROMMEL LUIS C. ISRAEL III
88
ASSESSMENT OF THE ENT
Assessment of the Nose
• Each nostril should be patent.
• Common abnormal findings include a nostril with a deviated
septum, foreign body, upper respiratory tract infection
allergies or polyps.
• A nasal speculum is also used to aid in viewing the nostrils.
BY: ROMMEL LUIS C. ISRAEL III
89
ASSESSMENT OF THE ENT
Assessment of the Nose
• Inspect the mucus membranes for colour and discharge.
• Normal otoscopic findings include the nasal mucosa being
be pink or dull red without swelling or polyps.
• The septum is at the midline and without perforation, lesions
or bleeding.
BY: ROMMEL LUIS C. ISRAEL III
90
ASSESSMENT OF THE ENT
Assessment of the Sinuses
• Observe the client’s face for any swelling around the nose
and eyes. Normal findings include there being no swelling
around the nose and eyes.
• When swelling is noted especially below the eyes, this may
be indicative of acute sinusitis that is characterised by
accumulation of purulent material in the paranasal sinuses.
BY: ROMMEL LUIS C. ISRAEL III
91
ASSESSMENT OF THE ENT
• On palpation and percussion, the client should experience no
discomfort during palpation or percussion.
• The sinuses should be air-filled and therefore resonant to
percussion.
• Abnormal findings on percussion include dullness sound
produced is indicative of fluid or cells present in the sinus
cavity from an infectious or allergic process.
BY: ROMMEL LUIS C. ISRAEL III
92
ASSESSMENT OF THE ENT
Assessment of the Mouth and Throat
• This assessment involves smelling the client’s breath, lips, tongue,
buccal mucosa, gums and teeth, and throat.
• The breath should smell fresh.
• A foul smell of halitosis can be a symptom of tooth decay, poor
oral hygiene, diseases of the gums, tonsils or sinuses.
• Breath that smells of acetone is common in malnourished clients
or those who have DKA.
BY: ROMMEL LUIS C. ISRAEL III
93
ASSESSMENT OF THE ENT
Assessment of the Mouth and Throat
• The lips and membranes should be pink and moist with no
evidence of lesions or inflammation.
• Pallor of the lips is an indicator of anaemia.
• Central cyanosis assessed on the lips signifies chronic
pulmonary disease or circulatory failure.
BY: ROMMEL LUIS C. ISRAEL III
94
ASSESSMENT OF THE ENT
• Swollen lips could be due to allergic reactions to medication,
food or other allergens.
• Cracked corners of the mouth on the lips, is a condition
referred to as angular cheilosis.
• It is either due to accumulation of saliva in the corners of the
mouth or nutritional deficiencies such as lack of riboflavin.
BY: ROMMEL LUIS C. ISRAEL III
95
ASSESSMENT OF THE ENT
• The tongue should be in the midline of the mouth.
• It should be pink moist, rough (from the taste buds) and
without lesions.
• The ventral surface of the tongue has prominent blood
vessels and should be moist without lesions.
• The lateral aspects of the tongue should be pink, smooth
and lesion free.
BY: ROMMEL LUIS C. ISRAEL III
96
ASSESSMENT OF THE ENT
• The tongue should be in the midline of the mouth.
• It should be pink moist, rough (from the taste buds) and
without lesions.
• The ventral surface of the tongue has prominent blood
vessels and should be moist without lesions.
• The lateral aspects of the tongue should be pink, smooth
and lesion free.
BY: ROMMEL LUIS C. ISRAEL III
97
ASSESSMENT OF THE ENT
• The buccal mucosa (inside of the cheeks) can be assessed using a
penlight.
• It should be pink, moist, smooth and free of inflammation and
lesions.
• An adult normally has 32 teeth which should be white with
smooth edges in proper alignment and without caries.
• Black patches on the surface of the teeth may indicate dental
caries or cavities resulting from poor oral hygiene.
BY: ROMMEL LUIS C. ISRAEL III
98
ASSESSMENT OF THE ENT
Assessment of the Mouth and Throat
• The throat can be assessed by asking the client to tilt the
head back and open the mouth widely.
• Ask the client to say, ‘ah’.
• A penlight is necessary during this assessment or a good
source of light.
BY: ROMMEL LUIS C. ISRAEL III
99
ASSESSMENT OF THE ENT
Assessment of the Mouth and Throat
• The throat should be pink and vascular and without swelling,
exudates or lesions.
• The client’s gag reflex should be present.
• Abnormal findings include the posterior pharynx being red with
white patches and this is a sign of infection (tonsillitis).
• A greyish membrane covering the tonsils, uvula and soft palate is
indicative of diphtheria
BY: ROMMEL LUIS C. ISRAEL III
100

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  • 1. ASSESSMENT OF THE THE EYE, EAR, NOSE AND THROAT ROMMEL LUIS C. ISRAEL III
  • 2. ANATOMY AND PHYSIOLOGY OF THE EAR The ears are located on either side the cranium at approximately eye level. The external ear, housed in the temporal bone, includes the pinna and the external auditory canal. The external ear is separated from the middle ear by a disk-like structure, the tympanic membrane which is also known as the BY: ROMMEL LUIS C. ISRAEL III 2
  • 3. BY: ROMMEL LUIS C. ISRAEL III 3
  • 4. ANATOMY AND PHYSIOLOGY OF THE EAR • The auricle, attached to the side of the head by skin, is composed mainly of cartilage, except for the fat and subcutaneous tissue in the earlobe. • The auricle collects the sound waves and directs vibrations into the external auditory canal. BY: ROMMEL LUIS C. ISRAEL III 4
  • 5. ANATOMY AND PHYSIOLOGY OF THE EAR The external auditory is approximately 2.5cm long. The lateral third is an cartilaginous and dense fibrous framework to thin skin is attached. The medial two thirds is bone lined with thin skin. The external auditory ends at the tympanic membrane. BY: ROMMEL LUIS C. ISRAEL III 5
  • 6. ANATOMY AND PHYSIOLOGY OF THE EAR The skin of the canal contains hair, sebaceous glands and ceruminous glands, which secrete a brown, wax- substance, the cerumen (ear wax). The ear’s self-cleaning mechanism moves old skin cells and cerumen to the outer part of the ear. Just anterior to the external canal is the temporomandibular BY: ROMMEL LUIS C. ISRAEL III 6
  • 7. ANATOMY AND PHYSIOLOGY OF THE EAR The middle ear, an air-filled is connected by the Eustachian tube to the nasopharynx and is continuous with air-filled cells the adjacent mastoid portion of the temporal bone. The Eustachian tube, approximately 1mm wide and 35mm long, connects the ear to the nasopharynx. BY: ROMMEL LUIS C. ISRAEL III 7
  • 8. ANATOMY AND PHYSIOLOGY OF THE EAR • The Eustachian tube is closed, but it opens by action of the tensor veli palatini muscle when performing a Valsalva manoeuvre or when yawning or swallowing. • The tube serves as a drainage channel for normal and abnormal secretions of the middle ear and equalises pressure in the middle ear with that of the atmosphere BY: ROMMEL LUIS C. ISRAEL III 8
  • 9. ANATOMY AND PHYSIOLOGY OF THE EAR The tympanic membrane, about 1cm in diameter and very thin, is normally pearly and translucent. The tympanic membrane consists of three layers of tissue: An outer layer, continuous with the skin of ear canal. A fibrous middle layer. An inner mucosal layer, continuous with the lining of the middle ear cavity. BY: ROMMEL LUIS C. ISRAEL III 9
  • 10. ANATOMY AND PHYSIOLOGY OF THE EAR Ear • Approximately 80% of the tympanic membrane is composed of all three layers and is called the pars tensa. • The other 20% of the tympanic membrane lacks the middle layer and is called the pars flaccida. • The absence of this fibrous middle layer makes the pars flaccida more vulnerable to pathologic disorders than the pars tensa. BY: ROMMEL LUIS C. ISRAEL III 10
  • 11. ANATOMY AND PHYSIOLOGY OF THE EAR Distinguishing landmarks of the tympanic membrane include: • The annulus, the fibrous border that attaches the eardrum to the temporal bone. • The short process of the malleus. • The long process of the malleus. BY: ROMMEL LUIS C. ISRAEL III 11
  • 12. ANATOMY AND PHYSIOLOGY OF THE EAR • The umbo of the malleus, which attaches to the tympanic membrane in the centre. • The pars flaccida. • The pars tensa. • The tympanic membrane protects the middle ear and conducts sound vibrations from the external canal to the ossicles. BY: ROMMEL LUIS C. ISRAEL III 12
  • 13. ANATOMY AND PHYSIOLOGY OF THE EAR The middle ear contains the three smallest bones (ossicles) of the body, that is, malleus, incus, and The ossicles, which are held in place by joints, muscles, and ligaments, assist in the transmission sound. Two small fenestrae (that is, oval and round windows), located in the medial wall of the ear, separate the middle ear from the inner ear. BY: ROMMEL LUIS C. ISRAEL III 13
  • 14. ANATOMY AND PHYSIOLOGY OF THE EAR • The footplate of the stapes sits in the oval window, secured by a fibrous annulus, or ring- shaped structure. • The footplate transmits sound to the inner ear. • The round window, covered by a thin membrane, provides an exit for sound vibrations. BY: ROMMEL LUIS C. ISRAEL III 14
  • 15. ANATOMY AND PHYSIOLOGY OF THE EAR • The inner ear is housed deep within the temporal bone. • The organs for hearing (cochlea) and balance (semi-circular canals), as well as cranial nerves VII (that is, facial nerve) and VIII (that is, vestibulocochlear nerve) are housed in the bony labyrinth. • The bony labyrinth surrounds and protects the membranous labyrinth, which is bathed in a fluid called perilymph. BY: ROMMEL LUIS C. ISRAEL III 15
  • 16. ANATOMY AND PHYSIOLOGY OF THE EAR • The inner ear is housed deep within the temporal bone. • The organs for hearing (cochlea) and balance (semi-circular canals), as well as cranial nerves VII (that is, facial nerve) and VIII (that is, vestibulocochlear nerve) are housed in the bony labyrinth. • The bony labyrinth surrounds and protects the membranous labyrinth, which is bathed in a fluid called perilymph. BY: ROMMEL LUIS C. ISRAEL III 16
  • 17. ANATOMY AND PHYSIOLOGY OF THE EAR • The organ of Corti is located in the cochlea, a snail-shaped, bony tube about 3.5cm long with two and one-half spiral turns. • Membranes separate the cochlear duct (that is, scala media) from the scala vestibuli, and the scala tympani from the basilar membrane. • . BY: ROMMEL LUIS C. ISRAEL III 17
  • 18. ANATOMY AND PHYSIOLOGY OF THE EAR The organ of Corti is located on basilar membrane stretching from the base to the apex of the As sound vibrations enter the perilymph at the oval window and travel along the scala vestibuli, pass through the scala tympani, enter the cochlear duct, and cause movement of the basilar BY: ROMMEL LUIS C. ISRAEL III 18
  • 19. ANATOMY AND PHYSIOLOGY OF THE EAR The organ of Corti, also the end organ for hearing, transforms mechanical into neural activity and separates sounds into frequencies. This electrochemical impulse travels through the acoustic nerve to the temporal cortex the brain to be interpreted as meaningful sound. BY: ROMMEL LUIS C. ISRAEL III 19
  • 20. ANATOMY AND PHYSIOLOGY OF THE EAR In the internal auditory canal, the cochlear (acoustic) nerve, arising the cochlea, joins the vestibular arising from the semi-circular utricle, and saccule, to become the vestibulo-cochlear nerve (cranial nerve VIII). This canal also houses the facial and the blood supply from hearing conducted over two pathways, that air and bone. BY: ROMMEL LUIS C. ISRAEL III 20
  • 21. ANATOMY AND PHYSIOLOGY OF THE EAR Sounds transmitted by air conduction travel over the filled, external ear and ear through vibration of the tympanic membrane and ossicles. Sounds transmitted by bone conduction travel directly through bone to the inner bypassing the tympanic membrane and ossicles BY: ROMMEL LUIS C. ISRAEL III 21
  • 22. ANATOMY AND PHYSIOLOGY OF THE EAR Normally, air conduction is the more efficient pathway. However, defects in the tympanic membrane interruption of the ossicular chain disrupt air conduction, which results in a loss of the sound-to-pressure ratio and subsequently in a conductive hearing loss. Sound enters the ear through the external auditory canal and causes the tympanic membrane to vibrate. These vibrations sound through the lever action of the ossicles the oval window as mechanical energy BY: ROMMEL LUIS C. ISRAEL III 22
  • 23. • This mechanical energy is then transmitted through the inner ear fluids to the cochlea, stimulating the hair cells, and is subsequently converted to electrical energy. • The electrical energy travels through the vestibulo-cochlear nerve to the central nervous system, where it is analysed and interpreted in its final form as sound. • Vibrations transmitted by the tympanic membrane to the ossicles of the middle ear are transferred to the cochlea, lodged in the labyrinth of the inner ea BY: ROMMEL LUIS C. ISRAEL III 23
  • 24. ANATOMY AND PHYSIOLOGY OF THE EAR The stapes rocks, causing (waves) in fluids contained in the inner ear. These fluid waves cause of the basilar membrane to occur that then stimulates the hair cells the organ of Corti in the cochlea move in a wavelike manner. membrane BY: ROMMEL LUIS C. ISRAEL III 24
  • 25. ANATOMY AND PHYSIOLOGY OF THE EAR The movements of the tympanic membrane set up electrical currents stimulate the various areas of the cochlea. The hair cells set up neural impulses are encoded and then transferred to auditory cortex in the brain, where are decoded into a sound message. The footplate of the stapes receives impulses transmitted by the incus and the malleus from the tympanic BY: ROMMEL LUIS C. ISRAEL III 25
  • 26. ANATOMY AND PHYSIOLOGY OF THE EAR • The round window, which opens on the opposite side of the cochlear duct, is protected from sound waves by the intact tympanic membrane, permitting motion of the inner ear fluids by sound wave stimulation. • For example, in the normally intact tympanic membrane, sound waves stimulate the oval window first, and a lag occurs before the terminal effect of the stimulus reaches the round window. BY: ROMMEL LUIS C. ISRAEL III 26
  • 27. ANATOMY AND PHYSIOLOGY OF THE EAR • This lag phase is changed, however, when a perforation of the tympanic membrane is large enough to allow sound waves to impinge on the oval and round windows simultaneously. • This effect cancels the lag and prevents the maximal effect of inner ear fluid motility and its subsequent effect in stimulating the hair cells in the organ of Corti. • The result is a reduction in hearing ability. BY: ROMMEL LUIS C. ISRAEL III 27
  • 28. ANATOMY AND PHYSIOLOGY OF THE EAR • Body balance is maintained by the cooperation of the muscles and joints of the body (that is, proprioceptive system), the eyes (that is, visual system), and the labyrinth (that is, vestibular system). • These areas send their information about equilibrium, or balance, to the brain (cerebellar system) for coordination and perception in the cerebral cortex BY: ROMMEL LUIS C. ISRAEL III 28
  • 29. ANATOMY AND PHYSIOLOGY OF THE EAR • . The brain obtains its blood supply from the heart and arterial system. • A problem in any of these areas, such as arteriosclerosis or impaired vision, can cause a balance disturbance. • The vestibular apparatus of the inner ear provides feedback regarding the movements and the position of the head and body in space. BY: ROMMEL LUIS C. ISRAEL III 29
  • 30. ANATOMY AND PHYSIOLOGY OF THE NOSE The Nose The nose consists of the external or outer nose and the nasal fossae or nose. The outer nose is made up of bone and cartilage and divided internally into two nasal fossae by the nasal septum, and externally by the columella. BY: ROMMEL LUIS C. ISRAEL III 30
  • 31. ANATOMY AND PHYSIOLOGY OF THE NOSE Anterior openings into nasal fossae are nostrils, nares. Each fossa has a lateral extended ‘wing’ portion called the ala nasi on the outside and a vestibule just inside the nostril. BY: ROMMEL LUIS C. ISRAEL III 31
  • 32. • Superior, middle and inferior measures or grooves are located on the lateral walls of the nostrils just below the corresponding conchae, located on the lateral walls of nostrils just below the corresponding conchae, or turbinates. ANATOMY AND PHYSIOLOGY OF THE NOSE BY: ROMMEL LUIS C. ISRAEL III 32
  • 33. ANATOMY AND PHYSIOLOGY OF THE NOSE • The nasal turbinates are covered by mucous membranes and greatly increase the surface area of mucus membrane of the the nose because of their shape. • Kiesselbach’s plexus is a vascular area on the nasal septum, and a common site for nosebleeds BY: ROMMEL LUIS C. ISRAEL III 33
  • 34. ANATOMY AND PHYSIOLOGY OF THE NOSE The pathophysiology of breathing through nostrils • Air enters the anterior nares, passes through the vestibule, and enters the fossa. • The vestibule contains nasal hairs and sebaceous glands. • The fossae have both olfactory and respiratory functions. • To protect the lungs from noxious agents, these structures of the nose clean, filter, humidify and control temperature of inspired air. . BY: ROMMEL LUIS C. ISRAEL III 34
  • 35. ANATOMY AND PHYSIOLOGY OF THE NOSE The pathophysiology of breathing through nostrils • The mucous covering in the nose and sinuses traps fine dust particles, and lysosomes kill most of the bacteria. • The tiny hairs of the nose (cilia) transport the mucus and the particles to the pharynx to be swallowed BY: ROMMEL LUIS C. ISRAEL III 35
  • 36. ANATOMY AND PHYSIOLOGY OF THE NOSE The pathophysiology of breathing through nostrils • The nasal mucosa is capable of adding large amounts of water to inspired air through evaporation from its surface. • The rich vascular supply to the turbinates radiates heat to the incoming air as it passes through the nasal cavity. BY: ROMMEL LUIS C. ISRAEL III 36
  • 37. ANATOMY AND PHYSIOLOGY OF THE NOSE The pathophysiology of breathing through nostrils • Olfactory receptor cells are located in the upper parts of the nasal cavity, the superior nasal conchae, and on parts of the nasal septum and are covered by hair-like cilia that project into the cavity. • The chemical component of odours binds with the receptors, causing nerve impulses to be transmitted to the olfactory cortex, located in the base of the frontal lobe. BY: ROMMEL LUIS C. ISRAEL III 37
  • 38. ANATOMY AND PHYSIOLOGY OF THE NOSE • Sinuses • Air-filled cavities lined with mucous membranes are present in some of the cranial bones and are referred to as paranasal sinuses. • These air-filled sinuses lighten the weight of the skull and ensure resonance to the quality of the voice. BY: ROMMEL LUIS C. ISRAEL III 38
  • 39. ANATOMY AND PHYSIOLOGY OF THE NOSE The sinuses • The frontal, maxillary, ethmoid and sphenoid paranasal sinuses open into the nose. • Only the frontal and maxillary sinuses can be assessed in the physical examination BY: ROMMEL LUIS C. ISRAEL III 39
  • 40. ANATOMY AND PHYSIOLOGY OF THE MOUTH AND THROAT Mouth and Throat • The lips are sensory structures found at the opening of the mouth. • The labial tubercle is the small projected area in the midline of the upper lip. • The area where the upper and lower lips meet is the labial commissure. BY: ROMMEL LUIS C. ISRAEL III 40
  • 41. ANATOMY AND PHYSIOLOGY OF THE MOUTH AND THROAT • The cheeks form the lateral walls of the mouth and are lined with buccal mucosa. • The posterior pharyngeal wall is at the back of the mouth. • The roof of the mouth consists of the hard palate anteriorly and the soft palate posteriorly. • The linear raphe is a ridge in the middle of the hard palate that is formed by two palatine bones and part of the superior maxillary bone. BY: ROMMEL LUIS C. ISRAEL III 41
  • 42. ANATOMY AND PHYSIOLOGY OF THE MOUTH AND THROAT The tongue assists with mastication, swallowing, speech and mechanical cleansing of the teeth. Two of the three pairs of salivary glands open into the mouth on ventral surface of the tongue. Sub-maxillary glands secrete through Wharton’s ducts located both sides of the frenulum. BY: ROMMEL LUIS C. ISRAEL III 42
  • 43. ANATOMY AND PHYSIOLOGY OF THE MOUTH AND THROAT Sublingual glands open the floor of the mouth posterior to Wharton’s These salivary glands produce 1,000 to 1,500ml saliva per day to assist digestion of food and maintenance of oral BY: ROMMEL LUIS C. ISRAEL III 43
  • 44. ANATOMY AND PHYSIOLOGY OF THE MOUTH AND THROAT The tongue assists with mastication, swallowing, speech and mechanical cleansing of the teeth. Two of the three pairs of salivary glands open into the mouth on ventral surface of the tongue. Sub-maxillary glands secrete through Wharton’s ducts located both sides of the frenulum. BY: ROMMEL LUIS C. ISRAEL III 44
  • 45. ANATOMY AND PHYSIOLOGY OF THE MOUTH AND THROAT Sublingual glands open the floor of the mouth posterior to Wharton’s These salivary glands produce 1,000 to 1,500ml saliva per day to assist with digestion of food and maintenance of oral BY: ROMMEL LUIS C. ISRAEL III 45
  • 46. ANATOMY AND PHYSIOLOGY OF THE MOUTH AND THROAT Saliva prevents dental caries by washing away bacteria and destroying it with antibodies and proteolytic enzymes. Gums, or gingivae, hold teeth in place. Adults have thirty two permanent teeth of four incisors, two canines, four premolars six molars in each half of the mouth. BY: ROMMEL LUIS C. ISRAEL III 46
  • 47. ANATOMY AND PHYSIOLOGY OF THE MOUTH AND THROAT The three parts of the are the top, or the crown, the root, which is embedded in the gum, the neck, which connects the root and the crown. The teeth are well for chewing. The uvula is a finger-like projection of tissue that hangs down from the of the soft palate. BY: ROMMEL LUIS C. ISRAEL III 47
  • 48. OVERVIEW OF EENT DISORDER SYMPTOMS The kind of information to be obtained while taking history includes: • The client's signs and symptoms. • Current health patterns. • Previous illnesses. BY: ROMMEL LUIS C. ISRAEL III 48
  • 49. OVERVIEW OF EENT DISORDER SYMPTOMS Key signs and symptoms of ENT problems include: Epistaxis (bleeding from the nose) Sore throat Nasal congestion Hoarseness Dysphagia (difficulty swallowing) Odynophagia (painful swallowing) Globus (something in throat) sensation BY: ROMMEL LUIS C. ISRAEL III 49
  • 50. OVERVIEW OF EENT DISORDER SYMPTOMS Key signs and symptoms of EENT problems include Sore throat Weight loss Otalgia (ear pain) Neck lump Earache Tinnitus (ringing in the ears) Otorrhea (discharge from the external ear) Hearing loss Dizziness BY: ROMMEL LUIS C. ISRAEL III 50
  • 51. OVERVIEW OF EENT DISORDER SYMPTOMS To find out about current health patterns carry out the following: • Inquire about nutrition, dental care, normal mouth care habits, dental caries, use of partial or full dentures, stress-related grinding, clenching, or clamping of teeth. • Ask about consumption of alcohol, smoking, use of a pipe, and smokeless tobacco. BY: ROMMEL LUIS C. ISRAEL III 51
  • 52. OVERVIEW OF EENT DISORDER SYMPTOMS To find out about current health patterns carry out the following • Determine personal hygiene about ears. • Are cotton swabs or other objects used for cleaning? • Is there any loud noise exposure? • Does the client frequently strain voice through talking, singing, or shouting? • What medications is the client taking? Have antibiotics been used? For how long have they been used? BY: ROMMEL LUIS C. ISRAEL III 52
  • 53. OVERVIEW OF ENT DISORDER SYMPTOMS • Find out about Previous Illnesses by asking on the following: • Is there a history of allergies? • Is there any immunosuppressive illness, such as diabetes mellitus, cancer, and human immunodeficiency virus (HIV) infection? • Has there been any trauma? • Is there a history of rhinitis, sinusitis, or ear infections? • Is there a family history of any EENT problems or cancer? • Surgeries done for example, adenotonsillectomy. BY: ROMMEL LUIS C. ISRAEL III 53
  • 54. ASSESSMENT OF THE EENT Assessment of the ENT includes the following areas: • Assessment of the ear • Assessment of the nose • Assessment of the sinuses • Assessment of the mouth and throat BY: ROMMEL LUIS C. ISRAEL III 54
  • 55. ASSESSMENT OF THE EENT Assessment of the Ear Physical assessment of the ear consists of three parts: • Inspection and palpation of the external ear • Auditory screening (CN VIII) • Otoscopic assessment BY: ROMMEL LUIS C. ISRAEL III 55
  • 56. ASSESSMENT OF THE EENT Assessment of the Ear Some of the Equipment to be used in this include: • Otoscope with ear pieces of different sizes • Nasal speculum • Penlight • Tuning fork, 512 Hz • Tongue blade • Watch • Gauze • Clean gloves BY: ROMMEL LUIS C. ISRAEL III 56
  • 57. GENERAL APPROACH TO EENT ASSESSMENT The following is the approach used for ENT assessment: • Greet the client and explain the assessment techniques that you will be using. • • Use a quiet room that will be free from interruptions. BY: ROMMEL LUIS C. ISRAEL III 57
  • 58. GENERAL APPROACH TO EENT ASSESSMENT • Ensure that the light in the room provides sufficient brightness to allow adequate observation of the client. • Place the client in an upright sitting position, preferably. • Always compare right and left ears, as well as right and left sides of the nose, sinuses, mouth and throat. BY: ROMMEL LUIS C. ISRAEL III 58
  • 59. ASSESSMENT OF THE ENT Examining the Ear To examine your client’s ears, you need a thorough understanding of the organ’s anatomic structure as well as the mechanisms that allow hearing. The external ear is examined by inspection and direct palpation, and the tympanic membrane is inspected with an otoscope. • BY: ROMMEL LUIS C. ISRAEL III 59
  • 60. ASSESSMENT OF THE ENT • Evaluation of gross auditory acuity also is included in every physical examination. • The auricle and surrounding tissues should be inspected for deformities, lesions, and discharge, as well as size, symmetry, and angle of attachment to the head. BY: ROMMEL LUIS C. ISRAEL III 60
  • 61. ASSESSMENT OF THE ENT • Manipulation of the auricle does not normally elicit pain. If this manoeuvre is painful, acute external otitis is suspected. • Tenderness on palpation in the area of the mastoid process may indicate acute mastoiditis or inflammation of the posterior auricular node. BY: ROMMEL LUIS C. ISRAEL III 61
  • 62. ASSESSMENT OF THE EENT Occasionally, sebaceous cysts and tophi (subcutaneous mineral deposits) are present on the pinna. A flaky scaliness on or behind the auricle usually indicates seborrhoeic dermatitis and can be present on the scalp and facial structures as well. BY: ROMMEL LUIS C. ISRAEL III 62
  • 63. ASSESSMENT OF THE EENT Examining the Outer Ear • You need to carry out the following in the examination of the outer ear: • Inspect the auricle of each ear for size, shape, symmetry, colour, and position. • The skin should be the same colour as the facial skin. • Observe for moles, cyst, deformities, or altered skin integrity. • Note any drainage from the ear canal. BY: ROMMEL LUIS C. ISRAEL III 63
  • 64. ASSESSMENT OF THE ENT Examining the Outer Ear • To check the ears position, draw an imaginary line from the outer canthus of the eye to the protuberance of the occiput. • The ear should touch or sit just above this line. • Expect the ear to be almost vertical, with no more than a 100 posterolateral slant. BY: ROMMEL LUIS C. ISRAEL III 64
  • 65. ASSESSMENT OF THE EENT Examining the Outer Ear • Palpate the auricle (pinna) for tenderness, swelling, or nodules. • Gently pull on the tragus and again on the helix to check for pain and tenderness. • Gloves are optional for this examination. • Palpate the mastoid process. Be alert for pain, tenderness, swelling, nodules, or lesions. BY: ROMMEL LUIS C. ISRAEL III 65
  • 66. ASSESSMENT OF THE ENT Performing an Otoscopic Examination • To begin, assemble the otoscope. • Attach the handle housing the battery pack to the otoscope’s head, which contains a light source and magnifying lens. • Select and attach a speculum large enough to fit the client’s ear canal comfortably. BY: ROMMEL LUIS C. ISRAEL III 66
  • 67. ASSESSMENT OF THE ENT Performing an Otoscopic Examination • out will additionally need to carry out the following: • Gently insert the otoscope into the ear canal using one of two techniques. • Hold the handle of the otoscope with the handle facing up to allow you to brace your hand against against the client’s head to stabilise the instrument BY: ROMMEL LUIS C. ISRAEL III 67
  • 68. ASSESSMENT OF THE ENT Performing an Otoscopic Examination • . This helps to prevent injury if the client moves their head quickly. • Inspect the auditory canal for the cerumen, redness or swelling. • You will see hairs and cerumen in the ear canal distal two- thirds. • Note excessive cerumen that may obstruct your view. • You may need to remove it to complete your inspection. BY: ROMMEL LUIS C. ISRAEL III 68
  • 69. ASSESSMENT OF THE ENT Performing an Otoscopic Examination • Inspect the tympanic membrane. • Typically, middle ear problems will be evident by the tympanic membrane’s appearance. • Focus on the membrane’s colour and contour. It should be pearly grey and appear concave at the umbo, handle of malleus, and cone of light. • Be alert for perforations, bulging, missing landmarks, or a distorted cone of light. BY: ROMMEL LUIS C. ISRAEL III 69
  • 70. ASSESSMENT OF THE ENT Performing an Otoscopic Examination • Have the client sit in a comfortable position or lie down on the side opposite the ear you wish to examine. • Hold the otoscope handle in the space between your thumb and index finger. BY: ROMMEL LUIS C. ISRAEL III 70
  • 71. ASSESSMENT OF THE ENT Performing an Otoscopic Examination • Assist the client to tilt their head toward the shoulder opposite the ear you are examining. • Keeping in mind how the ear canal curves in an adult. • Gently grasp the auricle and pull it up and back to straighten the ear canal before inserting the speculum. BY: ROMMEL LUIS C. ISRAEL III 71
  • 72. ASSESSMENT OF THE ENT Auditory Testing • After the otoscopic examination, you will have the idea of how well the client hears. • If they often ask you what you said or speak extra loudly, in a monotone, or with erratic volume, you may rightly suspect a hearing problem. • To investigate further, use a tuning fork to assess hearing acuity. BY: ROMMEL LUIS C. ISRAEL III 72
  • 73. ASSESSMENT OF THE ENT Auditory Testing • You will then carry out a voice – whisper test. • Begin estimating hearing acuity by checking whether the client can hear you whisper by carrying out the following: • Instruct the client to occlude one ear with a finger. • Stand two feet behind the client’s other ear and whisper a two-syllable word or phrase that is evenly accented. • Ask the client to repeat the word or phrase. • Repeat the test with the other ear. BY: ROMMEL LUIS C. ISRAEL III 73
  • 74. ASSESSMENT OF THE ENT Auditory Testing • Normal finding is that the client should be able to repeat words whispered from a distance of two feet. • Abnormal findings include the client being unable to repeat the words correctly or stating that they were unable to hear anything. This indicates hearing loss. BY: ROMMEL LUIS C. ISRAEL III 74
  • 75. ASSESSMENT OF THE ENT Tuning Fork Tests • Rinne and Weber tests help to determine whether the type of hearing loss the client is experiencing is conductive or sensorineural. • In order to understand how these tests are evaluated, it is important to know the difference between air and bone conduction. BY: ROMMEL LUIS C. ISRAEL III 75
  • 76. ASSESSMENT OF THE ENT Tuning Fork Tests • Air conduction refers to the transmission of sound through the ear canal, tympanic membrane and ossicular chain to the cochlea and auditory nerve. • Bone conduction refers to the transmission of sound through the bones of the skull to the cochlea and auditory nerve. BY: ROMMEL LUIS C. ISRAEL III 76
  • 77. ASSESSMENT OF THE ENT Tuning Fork Tests • Tuning fork tests include: • Rinne test • Weber test • Schwabach test BY: ROMMEL LUIS C. ISRAEL III 77
  • 78. ASSESSMENT OF THE ENT A. Performing the Rinne Test • If you suspect a hearing loss, perform the Rinne test. • This test will help determine whether the loss is conductive or sensor neural. You will need to follow these steps: • Without touching the tunes, hold a tuning fork by its base with one hand. • Activate the fork by striking it. • Place the base of the vibrating tuning fork against the client’s mastoid process, and ask the client to tell you when they no longer hear the sound. BY: ROMMEL LUIS C. ISRAEL III 78
  • 79. ASSESSMENT OF THE ENT BY: ROMMEL LUIS C. ISRAEL III 79
  • 80. ASSESSMENT OF THE ENT Performing the Rinne Test • Begin timing the interval (counting the number of seconds) until the client no longer hears the sound. • Then carry out the following: • Quickly change the forks position to about 1 to 2cm from the auditory canal. BY: ROMMEL LUIS C. ISRAEL III 80
  • 81. ASSESSMENT OF THE ENT Performing the Rinne Test • Hold the fork so that the tines face forward, maximising the sound. • Continue timing the interval to determine how long the client hears this sound by air conduction. BY: ROMMEL LUIS C. ISRAEL III 81
  • 82. ASSESSMENT OF THE ENT • The following is a diagram illustrating this. BY: ROMMEL LUIS C. ISRAEL III 82
  • 83. ASSESSMENT OF THE ENT B. Performing the Weber Test • To perform this test, activate the tuning fork as before. • Place the base of the fork midline on the client head or forehead. • Ask whether they hear the sound in one ear or both. Normally, they should hear the sound equally in both ears. • If they do not, ask them which ear hears well. BY: ROMMEL LUIS C. ISRAEL III 83
  • 84. ASSESSMENT OF THE ENT Performing the Rinne Test • An abnormal finding is when sound lateralises to the affected ear indicating unilateral conductive hearing loss. • When sound lateralises to the unaffected ear, this occurs with sensorineural loss related to nerve damage in the impaired ear. BY: ROMMEL LUIS C. ISRAEL III 84
  • 85. THE DIAGRAM THAT FOLLOWS ILLUSTRATES THE WEBER TEST. BY: ROMMEL LUIS C. ISRAEL III 85
  • 86. ASSESSMENT OF THE ENT C. Performing the Schwabach Test • To perform this test: • Occlude one of the client’s ears by gently placing your finger in the ear canal and moving it up and down to block hearing. • Activate the tuning fork and place it on the mastoid process behind the opposite ear. BY: ROMMEL LUIS C. ISRAEL III 86
  • 87. ASSESSMENT OF THE ENT Performing the Schwabach Test • If the client hears the sound, remove the tuning fork from their mastoid process, occlude one of your own ears, and place the tuning fork behind the mastoid process of your other ear. • Alternate the tuning fork between your mastoid process and the client’s, and count the number of seconds until one of you no longer hears the sound. • Normally, you and the client will stop hearing the sound after the same interval. BY: ROMMEL LUIS C. ISRAEL III 87
  • 88. ASSESSMENT OF THE ENT Assessment of the Nose • Inspect the nose, noting any trauma, bleeding, lesions, masses, swelling and asymmetry. • The normal finding includes the nose being located symmetrically in the midline of the face and is without swelling, bleeding, lesions or masses. • Abnormal finding includes a broken or swollen nose. BY: ROMMEL LUIS C. ISRAEL III 88
  • 89. ASSESSMENT OF THE ENT Assessment of the Nose • Each nostril should be patent. • Common abnormal findings include a nostril with a deviated septum, foreign body, upper respiratory tract infection allergies or polyps. • A nasal speculum is also used to aid in viewing the nostrils. BY: ROMMEL LUIS C. ISRAEL III 89
  • 90. ASSESSMENT OF THE ENT Assessment of the Nose • Inspect the mucus membranes for colour and discharge. • Normal otoscopic findings include the nasal mucosa being be pink or dull red without swelling or polyps. • The septum is at the midline and without perforation, lesions or bleeding. BY: ROMMEL LUIS C. ISRAEL III 90
  • 91. ASSESSMENT OF THE ENT Assessment of the Sinuses • Observe the client’s face for any swelling around the nose and eyes. Normal findings include there being no swelling around the nose and eyes. • When swelling is noted especially below the eyes, this may be indicative of acute sinusitis that is characterised by accumulation of purulent material in the paranasal sinuses. BY: ROMMEL LUIS C. ISRAEL III 91
  • 92. ASSESSMENT OF THE ENT • On palpation and percussion, the client should experience no discomfort during palpation or percussion. • The sinuses should be air-filled and therefore resonant to percussion. • Abnormal findings on percussion include dullness sound produced is indicative of fluid or cells present in the sinus cavity from an infectious or allergic process. BY: ROMMEL LUIS C. ISRAEL III 92
  • 93. ASSESSMENT OF THE ENT Assessment of the Mouth and Throat • This assessment involves smelling the client’s breath, lips, tongue, buccal mucosa, gums and teeth, and throat. • The breath should smell fresh. • A foul smell of halitosis can be a symptom of tooth decay, poor oral hygiene, diseases of the gums, tonsils or sinuses. • Breath that smells of acetone is common in malnourished clients or those who have DKA. BY: ROMMEL LUIS C. ISRAEL III 93
  • 94. ASSESSMENT OF THE ENT Assessment of the Mouth and Throat • The lips and membranes should be pink and moist with no evidence of lesions or inflammation. • Pallor of the lips is an indicator of anaemia. • Central cyanosis assessed on the lips signifies chronic pulmonary disease or circulatory failure. BY: ROMMEL LUIS C. ISRAEL III 94
  • 95. ASSESSMENT OF THE ENT • Swollen lips could be due to allergic reactions to medication, food or other allergens. • Cracked corners of the mouth on the lips, is a condition referred to as angular cheilosis. • It is either due to accumulation of saliva in the corners of the mouth or nutritional deficiencies such as lack of riboflavin. BY: ROMMEL LUIS C. ISRAEL III 95
  • 96. ASSESSMENT OF THE ENT • The tongue should be in the midline of the mouth. • It should be pink moist, rough (from the taste buds) and without lesions. • The ventral surface of the tongue has prominent blood vessels and should be moist without lesions. • The lateral aspects of the tongue should be pink, smooth and lesion free. BY: ROMMEL LUIS C. ISRAEL III 96
  • 97. ASSESSMENT OF THE ENT • The tongue should be in the midline of the mouth. • It should be pink moist, rough (from the taste buds) and without lesions. • The ventral surface of the tongue has prominent blood vessels and should be moist without lesions. • The lateral aspects of the tongue should be pink, smooth and lesion free. BY: ROMMEL LUIS C. ISRAEL III 97
  • 98. ASSESSMENT OF THE ENT • The buccal mucosa (inside of the cheeks) can be assessed using a penlight. • It should be pink, moist, smooth and free of inflammation and lesions. • An adult normally has 32 teeth which should be white with smooth edges in proper alignment and without caries. • Black patches on the surface of the teeth may indicate dental caries or cavities resulting from poor oral hygiene. BY: ROMMEL LUIS C. ISRAEL III 98
  • 99. ASSESSMENT OF THE ENT Assessment of the Mouth and Throat • The throat can be assessed by asking the client to tilt the head back and open the mouth widely. • Ask the client to say, ‘ah’. • A penlight is necessary during this assessment or a good source of light. BY: ROMMEL LUIS C. ISRAEL III 99
  • 100. ASSESSMENT OF THE ENT Assessment of the Mouth and Throat • The throat should be pink and vascular and without swelling, exudates or lesions. • The client’s gag reflex should be present. • Abnormal findings include the posterior pharynx being red with white patches and this is a sign of infection (tonsillitis). • A greyish membrane covering the tonsils, uvula and soft palate is indicative of diphtheria BY: ROMMEL LUIS C. ISRAEL III 100