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12-3

Key Points

Ball: Seidel’s Guide to Physical Examination, 8th Edition

Chapter 12: Ears, Nose, and Throat

Key Points

This review discusses examination of the ears, nose, and throat.

Before the exam, gather the necessary equipment: an otoscope with a pneumatic attachment, nasal speculum, tongue blades, tuning fork, gauze, gloves, and penlight (or similar light).

To examine the ears and hearing, perform the following.

Examine the external ear, including the auricles, external auditory canal, and mastoid area.

Inspect the auricles for size, shape, symmetry, landmarks, and color. The auricles should be symmetrical and the same color as the facial skin, with no deformities, lesions, nodules, or discharge.

Assess the position of the auricles by drawing an imaginary horizontal line between the inner canthus and the most prominent protuberance of the occiput. The top of the auricle should be at or above this line. Draw an imaginary vertical line perpendicular to the first one, just anterior to the auricle. The auricle should be almost vertical at this line.

Inspect the external auditory canal. It should have no discharge or odor.

Palpate the auricles and mastoid area. The auricle should be firm and mobile. There should be no tenderness, swelling, or nodules.

Perform an otoscopic examination, following these four steps.

First, with the patient’s head tilted to the opposite shoulder, gently pull the auricle up and back while inserting the speculum. This simple action gives you the best view by straightening the ear canal.

Second, inspect the auditory canal, noting any discharge, scaling, redness, lesions, foreign bodies, or cerumen. Expect to see minimal cerumen, uniform pinkness, and hairs in the outer third of the canal.

Third, inspect the tympanic membrane for landmarks, color, contour, and perforations. The umbo, handle of malleus, and light reflex should be visible. The tympanic membrane should be translucent, pearly gray, and conical with no perforations.

Fourth, assess tympanic membrane mobility, using the otoscope’s pneumatic attachment. The tympanic membrane should move in and out with pressure changes, causing the cone of light to change in appearance.

Evaluate hearing—and cranial nerve (CN) VIII—in four ways.

First, simply notice how the patient responds to questions and directions. You should not have to repeat your requests excessively.

Second, check the patient’s response to your whispered voice. In each ear, the patient should hear at least three of six whispered letters and numbers correctly.

Third, perform the Weber test by placing the stem of a vibrating tuning fork on the midline of the head. The patient should hear the sound equally in both ears.

Fourth, perform the Rinne test by placing the stem of a vibrating tuning fork on the mastoid bone to test bone conduction. Time how long the sound is heard. When the patient no longer hears it, move the tuning fork 1 to 2 cm from the auditory canal to test air conduction. Again, time how long the sound is heard. The patient should hear air-conducted sound twice as long as bone-conducted sound.

To examine the nose, nasal cavity, and sinuses, perform the following.

Examine the external nose in four steps.

First, inspect the nose for deviations in shape, size, and color.

Next, observe the nares for discharge and flaring or narrowing. If discharge is present, describe its character, amount, and color and note whether it is unilateral or bilateral.

Then palpate the bridge and soft tissues of the nose. Note any tenderness, masses, or displacement of cartilage or bone.

Last, evaluate nasal patency by blocking one naris at a time as the patient breathes. Breathing should be noiseless and easy through the open naris.

Assess the nasal cavity using a nasal speculum and light. Watch out when inserting the speculum because touching the nasal septum can cause pain. Observe three aspects.

First, inspect the nasal mucosa, which should be deep pink and glistening. Observe for any discharge, masses, lesions, or swelling of the turbinates.

Second, inspect the nasal septum. It should be close to midline and fairly straight. Note any perforation, bleeding, or crusting.

Third, test the sense of smell and CN I with vials of different odors as described in the audio review of the neurologic system.

Examine the sinuses using inspection and palpation.

Inspect the front and maxillary sinus areas.

Palpate the frontal sinuses by pressing your thumbs up under the bones on each side of the nose. Palpate the maxillary sinuses by pressing up under the zygomatic processes. Swelling, tenderness, or pain suggests infection or obstruction. If a sinus infection is suspected, transilluminate the maxillary and frontal sinuses in a darkened room. An opaque or dull response suggests the sinus is full of secretions or never developed. Asymmetrical transillumination is significant.

To examine the mouth, oral cavity, and oropharynx, perform the following.

Inspect and palpate the lips for color, symmetry, edema, and lesions. The lips should be pink, symmetrical, smooth, and free of lesions.

Have the patient clench the teeth and smile. This tests CN VII and lets you observe tooth occlusion. In proper occlusion, the upper and lower molars interdigitate, and the premolars and canines interdigitate.

With a tongue blade and bright light, examine the buccal mucosa, gums, and teeth using four key assessments.

First, observe the mucous membrane, which should pinkish red, smooth, and moist. The Stenson duct should appear as a whitish protrusion near the second upper molar. There should be no lesions.

Second, inspect the gums, which should be slightly stippled and pink with a clear, tight margin at each tooth. They should have no inflammation, swelling, or bleeding.

Third, palpate the gums for any lesions, induration, thickening, or masses. Palpation should not cause tenderness.

Fourth, inspect and count the teeth, noting wear, notches, caries, and loose or missing teeth.

Examine the oral cavity in seven ways.

First, inspect the dorsum of the tongue. Note any swelling, coating, ulcerations, or variation in the size or color. The tongue should appear dull red, moist, and glistening with no coating or lesions.

Second, test CN XII by having the patient stick out the ir tongue while you observe for deviation, tremor, and limited movement.

Third, have the patient touch the tip of the tongue to the palate behind the upper incisors while you inspect the floor of the mouth and the ventral surface of the tongue. The ventral surface should be pink and smooth with large veins. The Wharton ducts should appear on each side of the frenulum.

Fourth, inspect the lateral borders of the tongue, staying alert for white or red margins.

Fifth, palpate the tongue and the floor of the mouth. No lumps, nodules, induration, or ulceration should be present.

Sixth, inspect the palate and uvula with the patient’s head tilted back. The hard palate should be whitish and dome-shaped with transverse rugae. The soft palate should be contiguous with the hard palate but pinker. The uvula should be midline. There should be no nodules.

Seventh, evaluate soft palate movement. While the patient says “ah,” watch for the soft palate to rise symmetrically and the uvula to remain midline. This maneuver also tests CNs IX and X.

Using a tongue blade, assess the oropharynx in three ways. Even when you are not testing the gag reflex, the tongue blade may cause gagging. If so, moisten it in warm water, depress the tongue gently, and try to relieve the patient’s anxiety.

First, inspect the oropharynx and tonsillar pillars. Note the size of the tonsils, if present. They usually match the pink of the pharynx and fit within the pillars.

Second, observe the posterior wall of pharynx. It should be smooth, glistening, and pink.

Touch the posterior wall of the pharynx on each side to elicit the gag reflex, which tests CNs IX and X.