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Dc Revised Ears Nose Throat Mouth Part 2


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Dc Revised Ears Nose Throat Mouth Part 2

  1. 1. Ears, Nose, Mouth, Throat
  2. 2. Ears
  3. 3. Anatomy <ul><li>The ear is responsible for hearing and balance </li></ul><ul><li>Consists of 3 regions </li></ul><ul><ul><li>External ear </li></ul></ul><ul><ul><li>Middle ear </li></ul></ul><ul><ul><li>Inner ear </li></ul></ul>
  4. 4. Structure and Function <ul><li>External Ear </li></ul><ul><li>> auricle/pinna </li></ul><ul><li>- movable cartilage covered with skin </li></ul><ul><li>- Mastoid process= important Landmark </li></ul><ul><li>External Auditory Canal </li></ul><ul><li>- S-shaped pathway leading to the ME </li></ul><ul><li>- 2.5 to 3 cm. long in adult </li></ul>
  5. 5. <ul><li>Its skeleton of bone and cartilage is covered with sensitive skin ( outer 1/3 is cartilage, inner 2/3 consists of bone) </li></ul><ul><li>This canal lining is protected and lubricated with cerumen </li></ul>
  6. 7. <ul><li>- Lymphatic drainage of the external ear flows into parotid , mastoid, superficial cervical nodes </li></ul>
  7. 9. MIDDLE EAR <ul><li>> air filled cavity in the temporal bone </li></ul><ul><li>>It contains the ossicles ( malleus, incus,stapes) that transmit sound from the TM to the oval window of the inner ear </li></ul>
  8. 10. MIDDLE EAR <ul><li>>Tympanic membrane (eardrum) separates external and middle ear. </li></ul><ul><ul><li>Translucent membrane </li></ul></ul><ul><ul><li>Pearly, gray color </li></ul></ul><ul><ul><li>Cone of light reflection when using otoscope </li></ul></ul><ul><ul><li>Oval and slightly concave shape, pulled in at center by malleus </li></ul></ul>
  9. 11. Middle ear <ul><li>>Openings to </li></ul><ul><ul><ul><li>Outer ear covered by tympanic membrane </li></ul></ul></ul><ul><ul><ul><li>Inner ear = oval and round windows </li></ul></ul></ul><ul><ul><ul><li>Eustachian tube connects middle ear to the nasopharnyx for air passage (normally closed, opens with swallowing/yawning) </li></ul></ul></ul>
  10. 14. Middle ear has 3 functions <ul><li>Conducts sound vibration from outer ear to inner ear </li></ul><ul><li>Protects the inner ear by reducing the amplitude of loud sounds </li></ul><ul><li>Eustachian tube allows equalization of air pressure on each side of the ear drum to avoid rupture ( high altitudes) </li></ul>
  11. 15. Inner Ear <ul><li>Contains the Bony Labyrinth which holds the sensory organs for hearing and equilibrium </li></ul><ul><ul><li>Vestibule </li></ul></ul><ul><ul><li>Semicircular canals </li></ul></ul><ul><ul><li>Cochlea (contains the central hearing apparatus) </li></ul></ul>
  12. 17. Function of hearing <ul><li>3 levels </li></ul><ul><ul><li>Peripheral </li></ul></ul><ul><ul><li>> ear transmits sound and converts its vibrations into electrical impulses </li></ul></ul><ul><ul><li>> The electrical impulses are conducted by the auditory process of cranial nerve VIII (Acoustic) to the brain stem </li></ul></ul><ul><ul><ul><li>Amplitude=loudness </li></ul></ul></ul><ul><ul><ul><li>Frequency=pitch </li></ul></ul></ul>
  13. 18. <ul><li>Sound waves cause the eardrum to vibrate </li></ul><ul><li>> Vibrations travel via the ossicles thru the oval window > the cochlea > to the round window where they are dissipated </li></ul>
  14. 19. <ul><li>Vibrations in the basilar membrane of the cochlea that contain the organ of Corti receptor hair cells > translate the vibrations to electric impulses </li></ul><ul><li>> The stimulated impulses go to the brainstem via Acoustic nerve (VIII) </li></ul>
  15. 20. <ul><li>2. Brain stem </li></ul><ul><li>permits identification of sound and locating the direction of a sound in space. </li></ul><ul><li>Sensitive to intensity and timing from the ears </li></ul><ul><li>depending on head position </li></ul><ul><li>3. Cerebral cortex </li></ul><ul><li>- Intreprets the meaning of the sound and begins the appropriate response </li></ul>
  16. 21. Pathways of hearing <ul><li>Air conduction (AC)– normal pathway of hearing, the most efficient </li></ul><ul><li>Bone conduction (BC)– bones of the skull vibrate and transmit vibrations to the inner ear and acoustic nerve </li></ul>
  17. 24. Physical Examination <ul><li>The Auricle </li></ul><ul><li>1) inspect each auricle for size , shape, symmetry, color, position on the head, deformities, nodules and lesions </li></ul><ul><li>2) If ear pain, discharge or inflammation is </li></ul><ul><li>present, move the auricle up and down </li></ul>
  18. 25. <ul><li>3 ) Note tenderness of pinna and mastoid area. Press the tragus and press firmly behind the ear </li></ul>
  19. 26. Physical Examination <ul><li>Auricle </li></ul><ul><li>-Extends slightly outward from the skull </li></ul><ul><li>Positioned in a nearly vertical plane </li></ul><ul><li>The origin of the helix should be on a horizontal line with corner of the eye </li></ul><ul><li>It should have the same color as the facial skin w/o moles, cysts & other lesions </li></ul>
  20. 27. Otoscopic Exam <ul><li>1) Tip the patient’s head to the opposite side </li></ul><ul><li>2)Grasp the auricle firmly but gently, while pulling it upward, backward and slightly outward </li></ul><ul><li>3)Insert into the canal, sl down and forward, the largest ear speculum that the canal will accommodate </li></ul>
  21. 31. <ul><li>4) Observe the ff: </li></ul><ul><li>- patency of the ear canal </li></ul><ul><li>- describe the walls of the ear canal. Note </li></ul><ul><li>any redness or swelling </li></ul><ul><li>- identify any discharge, presence of cerumen or FB in the ear canal </li></ul><ul><li>- tympanic membrane </li></ul>
  22. 32. Inspect using Otoscope <ul><li>External canal </li></ul><ul><ul><li>Color </li></ul></ul><ul><ul><li>Swelling </li></ul></ul><ul><ul><li>Lesions </li></ul></ul><ul><ul><li>Discharge ; color and odor. Clean or change speculum before examining other ear. </li></ul></ul>
  23. 33. Tympanic membrane <ul><li>Color – normal is shiny, translucent, pearl-grey </li></ul><ul><li>Landmarks ( umbo, handle of malleus, light reflex) </li></ul><ul><li>Position – flat, slightly pulled in at the center and flutters when person holds nose and swallows </li></ul><ul><li>Integrity of membrane – intact </li></ul>
  24. 35. <ul><li>Perform the otoscope exam prior to hearing tests. </li></ul>
  25. 36. Hearing Evaluation <ul><li>Rough quantitative test for hearing loss </li></ul><ul><li>Whisper test </li></ul><ul><li>Tuning fork </li></ul>
  26. 37. <ul><li>Rough quantitative test for hearing loss </li></ul><ul><li>- begins when the patient responds to your questions and directions. The patient responds without excessive requests for repetition </li></ul><ul><li>- Speech with a monotonous tone and erratic volume may indicate hearing loss </li></ul>
  27. 38. WHISPER TEST <ul><li>Begins with the history-Conversational tone </li></ul><ul><li>The following tests may indicate the presence of hearing loss but not the degree. </li></ul>
  28. 39. <ul><li>Place your mouth at the side of the patient’s head ( 2 ft.) from her ear with the far ear covered </li></ul><ul><li>Whisper test questions that can’t be answered by yes or no </li></ul><ul><li>Test consistently with loud, medium and soft tones </li></ul>
  29. 40. <ul><li>Repeat on the opposite ear using another word, have the client identify the words (Used to detect high-tone loss) </li></ul><ul><li>Normal Response to Voice test </li></ul><ul><ul><li>Correct identification of whispered words bilaterally </li></ul></ul>
  30. 41. TUNING FORK TESTS <ul><li>Measure hearing by air conduction and bone conduction </li></ul><ul><li>Frequency of fork is 256-1024 cycles/sec. </li></ul><ul><li>To activate the tuning fork, hold it by the stem and strike the tines softly on the back of the hand </li></ul>
  31. 42. TUNING FORK TEST <ul><li>Weber test </li></ul><ul><li>> used when hearing is reported as better in one ear than the other ( bone conduction) </li></ul><ul><li>> with normal neurosensory hearing and no conductive loss, the sounds are equal in both ears </li></ul>
  32. 43. <ul><li>> lateralization of the sound to one ear indicates a conductive loss on the same </li></ul><ul><li>side or a perceptive loss/sensorineural loss on the other side </li></ul>
  33. 44. <ul><li>Weber Test </li></ul>
  34. 45. <ul><li>Rinne test – compares bone conduction and air conduction </li></ul><ul><ul><li>Normally sound is heard 2X as long by air conduction as by bone conduction </li></ul></ul><ul><ul><li>Normal response ; positive Rinne Test = AC>BC Bilaterally </li></ul></ul><ul><ul><li>Sound is heard longer by BC with a conductive loss. </li></ul></ul>
  35. 46. <ul><li>Rinne Test </li></ul>
  36. 47. Weber test Rinne test
  37. 48. Summary of any symptom should include PQRSTU <ul><li>P= provocative or palliative </li></ul><ul><li>Q= quality or quantity </li></ul><ul><li>R= region or radiation </li></ul><ul><li>S= severity scale </li></ul><ul><li>T= timing (onset, duration, frequency) </li></ul>
  38. 49. Subjective data <ul><li>Earaches </li></ul><ul><li>Tinnitus </li></ul><ul><li>Vertigo </li></ul><ul><li>Dizziness </li></ul><ul><li>Discharge </li></ul><ul><li>Hearing loss </li></ul>
  39. 50. HISTORY <ul><li>Always ask the following: </li></ul><ul><li>Tinnitus –ringing in the ears </li></ul><ul><li>causes: </li></ul><ul><li>a.Outer ear- cerumen, foreign body,polyp </li></ul><ul><li>in the external auditory canal </li></ul><ul><li>b. Middle ear – inflammation ,otosclerosis </li></ul><ul><li>c. Internal ear- fever, suppuration of the </li></ul><ul><li>labyrinth, SY,acoustic nerve tumor </li></ul>
  40. 51. <ul><li>internal ear – fracture at the base of the skull, meniere syndrome </li></ul><ul><li>d.Drugs </li></ul><ul><li>quinine, salicylates, aminoglycosides, gentamicin </li></ul>
  41. 52. <ul><li>Ear pain ( Otalgia ) </li></ul><ul><li>- pain may arise from inflammation of structure in the ear or be referred from other pharyngeal sites including the thyroid </li></ul>
  42. 53. <ul><li>Causes: </li></ul><ul><li>Auricle- trauma,hematoma,frostbite,burn,eczema, </li></ul><ul><li>lnsect bites, impetigo, herpes zoster </li></ul><ul><li>External auditory canal- </li></ul><ul><li>otitis externa ,carbuncle, eczema, hard cerumen, FB, herpes zoster </li></ul>
  43. 54. <ul><li>Middle ear- </li></ul><ul><li>acute otits media, acute mastoiditis </li></ul><ul><li>Referred pain- unerrupted lower third molar, carious </li></ul><ul><li>teeth, tonsillitis, carcinoma of pharynx, trigeminal neuralgia , subacute thyroiditis </li></ul>
  44. 55. <ul><li>Dizziness </li></ul><ul><li>- patient has a sense of disturbed relation to space </li></ul><ul><li>- described as being unsteady, weak, light headed or having the feeling of turning </li></ul><ul><li>Causes: </li></ul><ul><li>Endocrine </li></ul><ul><li>hypothyroidism,pregnancy, hypoparathyroidism </li></ul>
  45. 56. <ul><li>Idiopathic </li></ul><ul><li>multisystem atrophy </li></ul><ul><li>Infectious </li></ul><ul><li>tabes dorsalis, meningitis, encephalitis, brain abscess </li></ul><ul><li>Metabolic/ nutritional </li></ul><ul><li>pellagra, Vit.B12 def.,fluid & electrolyte imbalance </li></ul>
  46. 57. <ul><li>Mechanical/trauma </li></ul><ul><li>skull fracture, otosclerosis, eye muscle imbalance glaucoma </li></ul><ul><li>Neoplastic </li></ul><ul><li>Brain tumors </li></ul><ul><li>Neurologic </li></ul><ul><li>migraine, peripheral neuropathy </li></ul><ul><li>Psychosocial </li></ul><ul><li>anxiety disorder </li></ul><ul><li>Vascular </li></ul><ul><li>hypertension, orthostatic hypotension </li></ul>
  47. 58. <ul><li>Vertigo </li></ul><ul><li>- persistent stimulation of the semicircular </li></ul><ul><li>canals or vestibular nucleus when the </li></ul><ul><li>head is at rest </li></ul><ul><li>It gives a hallucination of motion </li></ul><ul><li>When the eyes open, the pts.surrounding </li></ul><ul><li>seems to be whirling or spinning </li></ul><ul><li>- When the eyes closed, the pt.continues to feel in motion </li></ul>
  48. 59. <ul><li>Causes: </li></ul><ul><li>Peripheral labyrinthine System </li></ul><ul><li>- otitis media with effusion, otosclerosis, </li></ul><ul><li>temporal bone fracture </li></ul><ul><li>Central labyrinthine system </li></ul><ul><li>- migraine, cerebellar hemorrhage, intracranial abscess </li></ul>
  49. 60. <ul><li>Cranial V111 infections </li></ul><ul><li>- Acute meningitis, tuberculous meningitis, tumors </li></ul><ul><li>Brainstem nuclei </li></ul><ul><li>- encephalitis, brain abscess, hemorrhage, multiple sclerosis </li></ul>
  50. 61. <ul><li>Hearing loss </li></ul><ul><li>a. Conductive- seen in people with external or middle ear problem </li></ul><ul><li>Causes: </li></ul><ul><li>-obstruction of external auditory canal (FB, impacted cerumen) </li></ul><ul><li>Disorder of the eardrum & middle ear ( perforated TM, pus/blood in the ME ) </li></ul><ul><li>Overgrowth of bone with fixation of the stapes ((Otosclerosis) </li></ul>
  51. 62. <ul><li>b. Sensorineural hearing loss ( Perceptive) </li></ul><ul><li>- involves the inner ear </li></ul><ul><li>Causes: </li></ul><ul><li>- disorders of the cochlea or the acoustic nerve (CN 8) </li></ul><ul><li>Aging ( Presbycusis ) due to nerve degeneration </li></ul><ul><li>Trauma </li></ul><ul><li>Drug toxicity </li></ul><ul><li>Tumors </li></ul><ul><li>infections </li></ul><ul><li>Heredity/congenital deafness </li></ul>
  52. 63. EAR SIGNS <ul><li>EXTERNAL EAR </li></ul><ul><li>Malformations of the Pinna </li></ul><ul><li>microtia – smaller than normal </li></ul><ul><li>macrotia – unusually large </li></ul><ul><li>lop or bat ear- pinna may protude at R angle </li></ul><ul><li>aztec or cagot ear – failure of </li></ul><ul><li>development of the lobule </li></ul>
  53. 64. Macrotia or large ear Before Surgery After Surgery
  54. 65. Before Surgery After surgery
  55. 66. <ul><li>Lop or Bat ear </li></ul><ul><li>- pinna may protrude at right angle </li></ul>
  56. 67. Lop or Bat Ears
  57. 68. <ul><li>satyr ear- pointed pinna </li></ul><ul><li>cauliflower ear- untreated hematomas heal as nodular and bulbous irregularities of the helix and and antihelix </li></ul><ul><li>- result of blunt trauma and </li></ul><ul><li>necrosis of the underlying </li></ul><ul><li>cartilage </li></ul>
  58. 69. Cauliflower Ears
  59. 70. <ul><li>b ) Pinna nodule </li></ul><ul><li>Darwin tubercle- harmless developmental </li></ul><ul><li>eminence in the upper 3 rd </li></ul><ul><li>of the posterior helix </li></ul><ul><li>Gouty tophus – small, whitish uric acid </li></ul><ul><li>crystals along the </li></ul><ul><li>peripheral margins of the </li></ul><ul><li>auricles, olecranon bursa, tendon sheaths </li></ul><ul><li>- nodules are painless hard, and irregular </li></ul>
  60. 71. Gouty deposits
  61. 72. <ul><li>b)External acoustic meatus </li></ul><ul><li>Cerumen Impaction </li></ul><ul><li>- due to excessive production of wax or a narrowed meatus leads to partial or complete obstruction of the canal </li></ul><ul><li>- complete obstruction leads to partial deafness acc. by tinnitus or dizziness </li></ul>
  62. 73. <ul><li>Otorrhea( ear discharge) </li></ul><ul><li>yellow discharge- melted cerumen </li></ul><ul><li>serous discharge- eczema in the meatal </li></ul><ul><li>wall, early ruptured acute OM </li></ul><ul><li>bloody discharge- temporal bone fracture </li></ul><ul><li>purulent discharge- chronic external otitis, </li></ul><ul><li>chronic suppurative OM, </li></ul><ul><li>cholesteatoma, TB, polyps </li></ul>
  63. 74. <ul><li>Foreign body </li></ul><ul><li>Insect invaders </li></ul><ul><li>Polyps </li></ul><ul><li>Furuncle </li></ul>
  64. 75. <ul><li>Tympanic membrane </li></ul><ul><li>Retracted Tympanic membrane : </li></ul><ul><li>- Seen in Serous Otitis media </li></ul><ul><li>- more concave TM </li></ul><ul><li>- accentuated bony landmarks </li></ul><ul><li>- distorted light reflex </li></ul>
  65. 76. Normal Tympanic Membrane Retracted Tympanic Membrane
  66. 77. <ul><li>Bulging Tympanic membrane: </li></ul><ul><li>seen in Acute suppurative otitis media </li></ul><ul><li>more conical </li></ul><ul><li>loss of bony landmarks </li></ul><ul><li>distorted light reflex </li></ul>
  67. 78. Normal Tympanic Membrane Bulging Tympanic Membrane
  68. 79. <ul><li>Perforated Tympanic membrane: </li></ul><ul><li>- previous suppurative middle ear infection has eroded thru the membrane producing </li></ul><ul><li>holes </li></ul><ul><li>- perforation appears as oval holes thru which the darkened middle ear cavity is seen </li></ul>
  69. 80. Perforated Tympanic Membrane
  70. 81. Perforated Tympanic Membrane
  71. 82. COMMON DISORDERS OF THE EAR <ul><li>Otitis Externa </li></ul><ul><li>a) Acute external otitis </li></ul><ul><li>-due to Ps.aeruginosa, staph, strep, proteus </li></ul><ul><li>- pain maybe mild or severe accentuated by movement of the pinna </li></ul><ul><li>- swimmers’ ear </li></ul><ul><li>- preauricular, postauricular , Ant cervical LN </li></ul>
  72. 83. <ul><li>b) Chronic external otitis </li></ul><ul><li>- commonly due to bacteria and fungal </li></ul><ul><li>- pruritus is the main complain instead of pain </li></ul><ul><li>- aural discharge maybe present </li></ul>
  73. 84. <ul><li>Otitis Media </li></ul><ul><li>a) Chronic suppurative otitis media </li></ul><ul><li>- ass. with permanent perforation of the eardrum </li></ul><ul><li>-hearing is always impaired </li></ul><ul><li>- painless aural discharge </li></ul><ul><li>- pain and vertigo indicates development of complications like brain abscess </li></ul>
  74. 85. <ul><li>b) Cholesteatoma </li></ul><ul><li>- collection of desquamated epithelial cells in the middle ear </li></ul><ul><li>- foul smelling discharge, marginal </li></ul><ul><li>perforation,hearing loss, pearly gray mass </li></ul><ul><li>superior part of tympanic membrane </li></ul><ul><li>- eustachian tube dysfunction causes </li></ul><ul><li>retraction of tympanic membrane </li></ul>
  75. 86. <ul><li>Vertiginous disorder </li></ul><ul><li>Acute Labyrinthitis </li></ul><ul><li>- most frequent cause of vertigo </li></ul><ul><li>- patient gradually develop a sense of whirling that reaches a climax in 24-48 hrs. disappear gradually in 3-6 wks. </li></ul><ul><li>- N/V may occur at the height of symptoms </li></ul><ul><li>- no accompanying tinnitus or hearing loss </li></ul>
  76. 87. <ul><li>b) Benign Paroxysmal positional Vertigo </li></ul><ul><li>(BPPV) </li></ul><ul><li>Calcium deposits in the labyrinth ( otoliths) </li></ul><ul><li>are dislodged and move in response to gravity eliciting a feeling of motion </li></ul><ul><li>More common in older individuals </li></ul><ul><li>Sudden onset, often when rolling over in bed or arising in the morning </li></ul><ul><li>No headaches/fever but with nausea and inability to stand </li></ul><ul><li>Avoid any head motion to lessen symptoms </li></ul>
  77. 88. Thank You
  78. 89. Nose, Throat and Mouth
  79. 90. Nose <ul><li>First segment of the respiratory system </li></ul><ul><li>Warms, moistens and filters inhaled air </li></ul><ul><li>Sensory organ for smell </li></ul><ul><li>Resonance of laryngeal sound </li></ul>
  80. 92. External parts <ul><li>Bridge – frontal and maxillary bones </li></ul><ul><li>Tip </li></ul><ul><li>Nares – anterior openings of the nos </li></ul><ul><li>Columella - divides the nares </li></ul><ul><li>Ala nasi –lateral outside wing of the nose bilaterally </li></ul><ul><li>Upper 1/3 nose is bone; rest is cartilage </li></ul>
  81. 93. Internal <ul><li>Nasal cavity </li></ul><ul><li>-floor of the nose ( hard and soft palate) </li></ul><ul><li>- roof of the nose ( frontal and sphenoid bone) </li></ul><ul><li>Nasal hair </li></ul><ul><li>Nasal Septum-divides cavity into 2 passages </li></ul><ul><li>Nasal turbinates </li></ul>
  82. 94. Internal <ul><li>Superior, middle, inferior turbinates- 3 parallel bony projections on lateral walls of each cavity </li></ul><ul><li>Meatus- cleft/ groove underlying each turbinate. </li></ul>
  83. 95. <ul><li>Inspired air enters thru the nares > passes thru the vestibule> to the choanae which are posterior openings > leading to the nasopharynx </li></ul>
  84. 96. Internal <ul><li>Olfactory receptors </li></ul><ul><li>- roof of the nasal cavity & upper part of septum above the superior turbinate. </li></ul><ul><li>-merge into the olfactory nerve (I) > goes to the temporal lobe of the brain </li></ul><ul><li>Kiesselbach plexus </li></ul><ul><li>- a vascular network located superficially on the anterior superior portion of the septum </li></ul><ul><li>- site of most anterior nosebleeds </li></ul>
  85. 98. SINUSES <ul><li>Paranasal sinuses </li></ul><ul><li>- air-filled paired extensions of the nasal cavities within the bones of the skull </li></ul><ul><li>- lined with mucous membranes and cilia that move secretions along excretory pathways </li></ul><ul><li>- sinus openings are narrow, susceptible to occlusion> resulting in inflammation /sinusitis. </li></ul><ul><li>- drained into the medial meatus </li></ul>
  86. 99. <ul><li>Purpose </li></ul><ul><ul><li>Serve as resonators for sound </li></ul></ul><ul><ul><li>Provide mucous for the nasal cavity </li></ul></ul><ul><ul><li>Types: </li></ul></ul><ul><ul><li>Frontal sinuses </li></ul></ul><ul><ul><li>Maxillary sinuses </li></ul></ul><ul><ul><li>Ethmoid sinuses </li></ul></ul><ul><ul><li>Sphenoid sinuses </li></ul></ul><ul><ul><li>Frontal & Maxillary sinuses are accessible to examination </li></ul></ul>
  87. 102. Physical Examination
  88. 103. <ul><li>Nose – Inspect and </li></ul><ul><li>palpate </li></ul><ul><li>INSPECT for: </li></ul><ul><ul><li>Symmetry, deformity </li></ul></ul><ul><ul><li>Inflammation </li></ul></ul><ul><ul><li>Skin lesions </li></ul></ul><ul><ul><li>Color </li></ul></ul><ul><ul><li>Nasal flaring </li></ul></ul><ul><ul><li>discharges </li></ul></ul>
  89. 104. <ul><li>Palpate </li></ul><ul><li>- ridge & soft tissues of the nose </li></ul><ul><li>- note any displacement of the bone, </li></ul><ul><li>cartilage </li></ul><ul><li>- note for tenderness & any mass </li></ul><ul><li>- The nasal structures should be firm and stable to palpation </li></ul><ul><li>- if with injury, palpate gently </li></ul>
  90. 105. <ul><li>Test for sense of smell (CN 1) </li></ul><ul><li>Evaluate the patency of the nose </li></ul><ul><li>- nasal breathing should be noiseless and easy thru the open nares </li></ul>
  91. 106. Nasal Cavity <ul><li>Use the nasal speculum and good light source to inspect the nasal cavity </li></ul><ul><li>Nasal mucosa </li></ul><ul><li>- inspect for color, discharge, lesions, masses </li></ul><ul><li>- it should appear deep pink ( pinker than the buccal mucosa) & glistening </li></ul>
  92. 107. <ul><li>b) nasal septum </li></ul><ul><li>- In normal adult, the nasal septum is seldom precisely a midline structure </li></ul><ul><li>- No perforations, bleeding or crusting should be apparent </li></ul><ul><li>- a film of clear discharge is often apparent on the nasal septum </li></ul>
  93. 108. <ul><li>c) Nasal Turbinates </li></ul><ul><li>- only the inferior and middle turbinates will be visible </li></ul><ul><li>- it should be the same color as the surrounding area and have a firm consistency </li></ul>
  94. 110. <ul><li>Paranasal Sinuses: Inspect and Palpate </li></ul><ul><ul><li>Press thumbs over frontal & maxillary sinuses ( palpate the cheeks and supraorbital ridges) </li></ul></ul><ul><ul><li>No tenderness or swelling over the soft tissue should be present </li></ul></ul>
  95. 111. <ul><li>Transillumination test </li></ul><ul><li>a) Frontal & Maxillary sinuses </li></ul><ul><ul><li>b) nasal septum </li></ul></ul><ul><ul><li>Best perform in a dark room </li></ul></ul><ul><ul><li>Look for a bright light in the supraorbital ridge </li></ul></ul><ul><ul><li>and maxilla </li></ul></ul><ul><ul><li>Look for deviation, perforation, masses in the </li></ul></ul><ul><ul><li>transilluminated septum </li></ul></ul>
  96. 116. SYMPTOMS <ul><li>Loss of smell ( anosmia ) </li></ul><ul><li>- lesion of CN 1 or nasal obstruction </li></ul><ul><li>- commonly due to closed head trauma </li></ul><ul><li>- invariably accompanied by a perceived change in taste of food ( bland & unpalatable) </li></ul>
  97. 117. <ul><li>Abnormal smell/ taste (dysgeusia) </li></ul><ul><li>- this is a common complaint in patients who have loss of smell </li></ul><ul><li>- if it is paroxysmal and associated with behavioral symptoms, it suggests complex partial seizures </li></ul>
  99. 119. Basal Cell Carcinoma
  100. 120. SIGNS <ul><li>Discharge </li></ul><ul><li>- Describe discharge as to its character </li></ul><ul><li>( watery, mucoid, purulent , bloody) </li></ul><ul><li>- color ( greenish, whitish, bloody) </li></ul><ul><li>- bilateral or unilateral </li></ul>
  101. 121. <ul><li>Running Nose </li></ul>
  102. 123. <ul><li>. 1.Unilateral </li></ul><ul><li>- Choanal atresia </li></ul><ul><li>- Foreign body- foul purulent discharge </li></ul><ul><li>- neoplasm – bloody discharge </li></ul><ul><li>- Head injury or surgery – clear spinal fluid </li></ul><ul><li>2. Bilateral </li></ul><ul><li>- allergy </li></ul><ul><li>- infection ( upper respiratory) </li></ul>
  103. 124. Foreign Body
  104. 125. . Unilateral - Choanal atresia - Foreign body - neoplasm - Head injury or surgery . Unilateral - Choanal atresia - Foreign body - neoplasm - Head injury or surgery
  105. 126. <ul><li>Epistaxis ( nosebleed) </li></ul><ul><li>-Kiesselbach plexus – most common site of bleeding anteriorly </li></ul><ul><li>- Back 3 rd of the Inferior Meatus – most common site posteriorly </li></ul>
  106. 127. <ul><li>Causes: </li></ul><ul><li>Local </li></ul><ul><li>- coughing </li></ul><ul><li>- sneezing </li></ul><ul><li>- nose pricking </li></ul><ul><li>- fracture </li></ul><ul><li>- foreign bodies </li></ul>
  107. 128. <ul><li>2. Generalized </li></ul><ul><li>- Congenital – hereditary telangiectasia </li></ul><ul><li>- inflammatory/immune – wegener </li></ul><ul><li>granulomatosis </li></ul><ul><li>- infectious – typhoid fever, dengue, </li></ul><ul><li>diphtheria </li></ul><ul><li>- Metabolic/toxic – aspirin, scurvy </li></ul>
  108. 129. <ul><li>Mechanical – change in atmospheric </li></ul><ul><li>pressure ( mountain climbing, flying), exertion </li></ul><ul><li>Neoplastic – nasopharyngeal Ca </li></ul><ul><li>leukemia </li></ul><ul><li>vascular- hemophilia, thrombocytopeni </li></ul>
  109. 130. <ul><li>trauma- nasal and maxillary fracture </li></ul><ul><li>Elevated venous pressure- Cor pulmonale Congestive Heart failure </li></ul><ul><li>Elevated arterial pressure – HPN, </li></ul><ul><li>coarctation of aorta </li></ul>
  110. 131. <ul><li>Nasal septum </li></ul><ul><li>a) Deviation </li></ul><ul><li>- the cartilagenous and bony septum </li></ul><ul><li>may deviate as a hump, spur, shelf to </li></ul><ul><li>enroach on one nasal chamber </li></ul><ul><li>occlusion causing obstruction </li></ul>
  111. 132. <ul><li>b) Perforation </li></ul><ul><li>- a hole in the nasal septum (transillumination test) is commonly caused by chronic infection, nasal surgery, </li></ul><ul><li>repeated trauma in picking off crusts, </li></ul><ul><li>cocaine abuse </li></ul><ul><li>- rarely due to SY, TB </li></ul>
  112. 133. Nasal Septum Perforation
  113. 134. Nasal Syndromes <ul><li>Acute Rhinitis ( infectious) ( common cold) </li></ul><ul><li>Rhinoviruses infect the mucous membranes of the nose & sinuses causing inflammation and inc. nasal secretions </li></ul><ul><li>- Watery nasal discharge, sneezing, discharge becomes purulent acc. by fever and body malaise </li></ul>
  114. 135. <ul><li>Symptoms 3-10 days </li></ul><ul><li>Severe local pain suggest a complication-bacterial sinusitis </li></ul>
  115. 136. <ul><li>Allergic rhinosinusitis </li></ul><ul><li>- itching of the nose & eyes, rhinorrhea, lacrimation, sneezing </li></ul><ul><li>- headache is common </li></ul><ul><li>- maybe seasonal or perennial </li></ul><ul><li>- common allergens are pollens, molds, house dust, mites, coachroach, animal danders </li></ul>
  116. 137. <ul><li>Vasomotor Rhinitis </li></ul><ul><li>- nonallergic mucosal edema and rhinorrhea ass. with vasodilatation of the nasal vessels, mucosal edema & inc. mucous production </li></ul><ul><li>- due to chronic environmental irritants </li></ul><ul><li>( dust , smoke, strong odor, cold air), </li></ul><ul><li>pregnancy, estrogens, progesterone </li></ul>
  117. 138. <ul><li>Suppurative Paranasal Sinusitis </li></ul><ul><li>- due to Strep. pneumonia, H. influenza </li></ul><ul><li>- severe pain in the face occuring 7-14 days after signs & symptoms of an acute URTI </li></ul><ul><li>- pain & pressure without fever suggest sinus obstruction requiring decongestants </li></ul>
  118. 139. <ul><li>Cavernous Sinus Thrombosis </li></ul><ul><li>-This is the most feared complication of nasal infections. It can cause blindness or death </li></ul><ul><li>- Infection spreads from the nose>angular veins> cavernous sinus> septic thrombosis </li></ul>
  119. 140. <ul><li>- patient complains of pain deep in the eyes </li></ul><ul><li>- Both eyes are involved, immobilization of the globes, periorbital edema, chemosis </li></ul><ul><li>May involve CN 3,4, &6 </li></ul><ul><li>Sudden chills, high fever, prostated, comatose, death within 2-3 days </li></ul>
  120. 141. THANK YOU
  121. 142. THANK YOU
  122. 143. Mouth <ul><li>First segment of the digestive system </li></ul><ul><li>Airway for the respiratory system </li></ul><ul><li>ORAL CAVITY </li></ul><ul><ul><li>Lips </li></ul></ul><ul><ul><li>Palate </li></ul></ul><ul><ul><ul><li>Hard </li></ul></ul></ul><ul><ul><ul><li>Soft </li></ul></ul></ul><ul><ul><ul><li>Uvula – hangs down from the soft palate </li></ul></ul></ul>
  123. 144. <ul><li>Cheeks- side walls of cavity </li></ul><ul><li>Tongue </li></ul><ul><ul><li>Papillae- rough, bumpy elevations on dorsal </li></ul></ul><ul><ul><li>Frenulum </li></ul></ul><ul><ul><li>Taste buds </li></ul></ul><ul><li>Teeth – 32 permanent </li></ul>
  124. 146. <ul><li>Salivary glands </li></ul><ul><ul><li>Parotid- largest of the glands, located in the cheeks, front of the ear. Stenson’s duct opens in buccal mucosa </li></ul></ul><ul><ul><li>Submandibular- walnut size, beneath the mandible at the angle of the jaw. Wharton’s duct either side of the frenulum </li></ul></ul><ul><ul><li>Sublingual –smallest, almond shape, under tongue </li></ul></ul>
  125. 148. Throat <ul><li>Area behind the mouth & nose </li></ul><ul><li>Oropharynx – separated from the mouth by a fold of tissue on each side called anterior tonsillar pillars </li></ul><ul><li>Tonsils – lymphoid tissue behind pillars </li></ul>
  126. 149. <ul><li>Posterior pharyngeal wall located behind the tonsils </li></ul><ul><li>Nasopharynx continues from the oropharynx but it is above it and behind the nasal cavity. </li></ul><ul><li>-It holds the adenoids and the eustachian tube openings. </li></ul>
  127. 151. Physical Examination
  128. 152. <ul><li>Preparation for examination </li></ul><ul><li>a) Face the patient with both of you seated at the same level </li></ul><ul><li>b) Remove any dentures to see the mucosa underneath </li></ul><ul><li>c) Hold the tongue blade in the left hand and penlight in the right hand </li></ul><ul><li>d) A good light source is needed </li></ul>
  129. 153. INSPECT AND PALPATE <ul><li>Use gloves, tongue depressor, light </li></ul><ul><li>Lips </li></ul><ul><li>Teeth </li></ul><ul><li>Gums </li></ul><ul><li>Tongue </li></ul><ul><li>Buccal mucosa </li></ul><ul><li>Mouth ( roof and floor of the mouth) </li></ul>
  130. 154. <ul><li>Lips </li></ul><ul><li>- remove lipstick </li></ul><ul><li>- should be pink , smooth surface, free of lesions. </li></ul><ul><li>- distinct border between the lips and facial skin should not be interrupted by lesions </li></ul><ul><li>- Vertical and horizontal symmetry both at rest and with movements </li></ul>
  131. 155. rest Rest Movement
  132. 156. <ul><li>- Inspect the inner surface of the lips by retracting them with a tongue blade </li></ul>
  133. 158. Retraction of the Upper Lip Retraction of the lower Lip
  134. 159. <ul><li>Teeth </li></ul><ul><li>- ask patient to clench his/her teeth , smile and observe the occlusion of the teeth. </li></ul><ul><li>- facial nerve is also tested </li></ul><ul><li>Make sure teeth are firmly anchored, probing each with a tongue blade </li></ul><ul><li>Generally ivory white in color with 32 permanent teeth in adults </li></ul>
  135. 160. Proper Occlusion of Teeth
  136. 161. <ul><li>Buccal mucosa </li></ul><ul><li>- with mouth open, using a tongue blade, </li></ul><ul><li>inspect for color, pigmentation, nodules, white patches </li></ul><ul><li>- normally pinkish red, smooth, moist </li></ul><ul><li>- orifice of the stensen duct should appear as a whitish yellow or whitish pink protrusion in alignment with the 2 nd upper molar </li></ul>
  137. 162. Retraction of the cheek to view the Buccal Mucosa Buccal Mucosa with prominent Papilla of Stensen Duct
  138. 163. <ul><li>Gums </li></ul><ul><li>- using a tongue blade, gums should have pink appearance with clearly defined tight margin at each tooth </li></ul><ul><li>- gum surface beneath dentures should be free of inflammation, swelling or bleeding </li></ul><ul><li>- Using gloves, palpate gums for tenderness, mass, induration, thickening </li></ul>
  139. 164. <ul><li>Tongue </li></ul><ul><li>- should fit well in the floor of the mouth </li></ul><ul><li>- ask the patient to extend the tongue while you inspect for color, lesions, deviation, tremor, limitation of movement </li></ul><ul><li>- Ask the patient to touch the tongue tip to the hard palate area directly behind the upper central incisors. There should be no difficulty. </li></ul>
  140. 165. <ul><li>Inspect the dorsum of the tongue </li></ul><ul><li>it should appear dull red ,moist, glistening </li></ul><ul><li>note also for any swelling, coating, ulcerations </li></ul><ul><li>Inspect the ventral surface of the tongue </li></ul><ul><li>it should be pink and smooth with large veins bet. the frenulum and fimbriated folds </li></ul>
  141. 166. <ul><li>- Wharton ducts should be apparent on each side of the frenulum </li></ul>
  142. 168. Mouth <ul><li>>Roof of the mouth </li></ul><ul><li>- hard and soft palate </li></ul><ul><li>Floor of the mouth </li></ul><ul><li>- tongue </li></ul><ul><li>Take note of the smell coming from the oral cavity </li></ul><ul><li>Ask the patient to tilt his head to inspect the palate and uvula </li></ul>
  143. 170. Uvula , soft palate, bilateral fauces
  144. 171. Throat <ul><li>Tonsils </li></ul><ul><li>- usually blend into the pink surface of the pharynx </li></ul><ul><li>- surface of the tonsils have crypts where cellular debris and food collect </li></ul><ul><li>- in normal adult, tonsils seldom protrude beyond the faucial pillars </li></ul>
  145. 173. <ul><li>Posterior wall of the pharynx </li></ul><ul><li>It should be smooth and glistening pink mucosa with some irregular spots of lymphatic tissue and small blood vessels </li></ul><ul><li>Test CN 9 and 10 </li></ul><ul><li>touch the posterior wall of the pharynx on each side </li></ul><ul><li>(+) gag reflex </li></ul>
  146. 174. <ul><li>Larynx </li></ul><ul><li>- immediately behind and below the oral cavity </li></ul><ul><li>- it is on the anterior wall of the pharynx </li></ul><ul><li>- it is viewed in the laryngeal mirror held behind it </li></ul>
  147. 175. SIGNS
  148. 176. <ul><li>Lips </li></ul>
  149. 177. Cyanotic Lips
  150. 178. Chapped dry lips
  151. 179. <ul><li>> Cheilitis </li></ul><ul><li>- dry cracked lips due to dehydration from wind chapping, dentures , braces, or excessive lip licking </li></ul><ul><li>- angular cheilitis due to candidiasis </li></ul>
  152. 180. Chapped Lips with Cheilitis
  153. 181. <ul><li>Cheilosis ( angular stomatitis) </li></ul><ul><li>- ulcerations of skin at the corners of the mouth due to crusting 2ndary to riboflavin deficiency or ill fitting dentures </li></ul>
  154. 182. Cheilosis (Angular Stomatitis)
  155. 183. <ul><li>Cleft lip </li></ul><ul><li>- due to incomplete fusion of the frontonasal process with the 2 maxillary processes </li></ul>
  156. 184. Cleft Lip
  157. 185. Retraction of the Lower Lip showing white scars Traumatized Lip (Green arrows)
  158. 186. <ul><li>Hard palate </li></ul>Maxillary Torus
  159. 187. <ul><li>Maxillary torus </li></ul><ul><li>- bony protuberance at the midline </li></ul><ul><li>- no clinical significance </li></ul>
  160. 188. <ul><li>Cleft palate </li></ul><ul><li>- a midline opening in the hard palate </li></ul><ul><li>- congenital failure of the fusion of the maxillary process </li></ul><ul><li>- usually ass. with cleft palate </li></ul>
  161. 189. Cleft Palate
  162. 190. <ul><li>Tonsils </li></ul>Enlarged tonsils
  163. 191. <ul><li>- Grading tonsillar enlargement </li></ul><ul><ul><li>Grade size 1+ visible </li></ul></ul><ul><ul><li>…………… .2+ ½ way b/t tonsillar pillars and uvula </li></ul></ul><ul><ul><li>…………… .3+ touching the uvula </li></ul></ul><ul><ul><li>…………… .4+ touching each other </li></ul></ul>
  164. 192. <ul><li>Uvula </li></ul>Deviation of the uvula
  165. 193. <ul><li>Posterior pharyngeal wall </li></ul>After tonsillectomy
  166. 194. Posterior Pharyngeal Wall With a yellow Pseudocyst Posterior Pharyngeal Wall with White removable mass of mucus
  167. 195. <ul><li>Acute viral pharyngitis </li></ul><ul><li>- mucosa of oropharynx shows lymphoid tissue are elevated but noo edema </li></ul><ul><li>- sore throat, rhinorrhea, malaise, myalgia </li></ul><ul><li>Streptococal or staphylococcal pharyngitis </li></ul><ul><li>Pharyngeal mucosa is bright red, swollen, edematous studded with white or yellow follicles </li></ul><ul><li>Tonsils maybe enlarged </li></ul>
  168. 196. <ul><li>Pharyngeal diptheria </li></ul><ul><li>- patch of white membrane in the tonsils. </li></ul><ul><li>- pharyngeal mucosa bleeds on surface, reddened , reddened, swollen ,edematous </li></ul><ul><li>Candidiasis </li></ul><ul><li>- shining raised white patches on posterior pharynx, buccal mucosa and tongue </li></ul>
  169. 197. <ul><li>Tongue </li></ul>Lingual Deviation
  170. 198. Tongue-tie or shortened frenulum
  171. 199. Folliate Papillae(Green) Circumvallate Papillae(blue) Elongated filiform Papillae
  172. 200. Large reddened fungiform Papillae Circumvallate Papillae
  173. 201. <ul><li>Gums </li></ul>Gingival Fibrous Nodule At the mucogingival junction
  174. 202. <ul><li>Bleeding gums </li></ul><ul><li>local causes: </li></ul><ul><li>traumatic – toothbrush, laceration, dental caries, tartar on the teeth </li></ul><ul><li>infection – pyorrhea alveolaris, stomatitis </li></ul><ul><li>neoplasm – epulis, papilloma of gums </li></ul>
  175. 203. <ul><li>General causes: </li></ul><ul><li>Scurvy, syphilis </li></ul><ul><li>Metal poisoning –phosporous, lead, mercury </li></ul><ul><li>Blood dyscrasia – hemophilia, leukemia, thrombocytopenia </li></ul>
  176. 204. <ul><li>Deep red or purple gums </li></ul><ul><li>- tender , swollen, spongy and easily bleeds </li></ul><ul><li>- due to scurvy ( ascorbic acid deficiency) </li></ul>
  177. 205. <ul><li>Teeth </li></ul>Malocclusion of teeth
  178. 206. <ul><li>Periodontitis ( Pyorrhea Alveolaris) </li></ul><ul><li>- lower teeth are involved </li></ul><ul><li>- with purulent and retracted gums </li></ul><ul><li>Epulis </li></ul><ul><li>- fibrous tumor arising from periosteum and emerges from between the teeth. </li></ul>
  179. 207. <ul><li>Larynx </li></ul><ul><li>> hoarseness </li></ul><ul><li>acute laryngitis – most common cause of hoarseness </li></ul><ul><li>> laryngeal edema </li></ul><ul><li>signs of obstruction – hoarseness, dyspnea and stridor </li></ul>
  180. 208. <ul><li>Laryngeal spasm </li></ul><ul><li>- acute obstruction of the upper airways accompanied by hoarse brassy cough, dyspnea in children </li></ul><ul><li>- due to allergy, infection, FB, neoplasm </li></ul><ul><li>Laryngeal paralysis </li></ul><ul><li>- Due to immobile vocal cords </li></ul>
  181. 209. <ul><li>Halitosis ( fetor Oris) bad breath </li></ul><ul><li>Poor hygiene </li></ul><ul><li>Dental or tonsillar infections </li></ul><ul><li>Atrophic rhinitis </li></ul><ul><li>Putrefaction of food in the stomach from pyloric obstruction </li></ul><ul><li>Infected sputum form lung abscess and bronchiectasis </li></ul>
  182. 210. THANK YOU