Head, eyes nose and throat examination – (El) examen de la cabeza, los ojos, la nariz y la garganta

EQUIPMENT NEEDED:

• Light
• Gloves
• Measuring tape (possible)
• Tongue blade
• Gauze square (possible)
• Cup of water (optional)
• Tuning Fork Otoscope & Ophthalmoscope

Eyes - External Eye Structures

SUBJECTIVE DATA

VISION DIFFICULTY - decreased acuity, blurring, blind spots
PAIN - sudden onset is possible emergency

STRABISMUS OR DIPLOPIAREDNESS OR SWELLING WATERING OR DISCHARGE PAST HX OF OCULAR PROBLEMS USE OF GLASSES OR CONTACTS

EYE EXAM

Check Vision (visual acuity)
Inspect & Palpate External Eye Structures
Pupil Reactions
Check Visual Fields (by Confrontation)
Check Extraocular Muscles (EOM’s)
Corneal Light Reflex (Hirschberg Test Cardinal Fields of Gaze Cover/Uncover Corneal Reflex: Not usually done)

CHECK VISION

VISION TESTING Tests

CN IINumerator - indicates distance of client from chart

Denominator - distance at which average eye can read line

Legal Blindness - vision not correctable better than 20/200 CN II: Optic - Sensory Snellen Eye Chart Usually done before the PEStand at a distance of 20 ft Wear glasses or contact lenses

One eye tested at a time (Occluder over one eye)
Read each line until you cannot read the letters”
Record the smallest line successfully read (Normal = 20/20 to 20/30) Abnormal:

Difference between eyes of two lines or more Acuity < 20/30Children - Snellen E chart Hand-held acuity chart Snellen
E EYE TERMS MYOPIA - nearsightedness
PRESBYOPIA - farsightedness
O.S. = left eye
O.D. = right eye
O.U. = both eyes

INSPECT EXTERNAL EYE

Eyelids Lashes,
Brows
Palpebral Folds
Lacrimal Apparatus
Conjunctiva Sclera Lens,
Cornea Pupils: light response
Conjunctiva and Sclera Muddy Brown sclera
Conjunctiva and Sclera Inspection
Inspect Nasolacrimal Duct

EYE ABNORMALITIES

EYE LID POSITION: ABNORMALITIESEYE LID: RED ABNORMALITIES CHECK EXTRAOCULAR MUSCLES (EOM’s) Corneal light Reflex (Hirschberg Test) Cover/Uncover Cardinal Fields of Gaze Accommodation CN III, IV & VI: EOM’s - MotorCover-Uncover Test Cover one eye at a time. Assess with cover & with uncoverLook for slight eye movements with both cover & uncover Repeat on opposite side Six Cardinal Positions of Gaze Far Vision, Pupils Dilate Near Vision, Pupils Constrict Test Accommodation Range of Peripheral Visual Fields EYE MUSCLES & CRANIAL NERVES: CN III: OCULOMOTOR, CN IV: TROCHLEAR & CN VI: ABDUCENS EOM FINDINGS Corneal Light Reflex Light is symmetrically placed on both eyesCover/Uncover Test No movement of eyes with cover or uncover Cardinal Fields of Gaze Normal: Both eyes move smoothly & symmetrically through 6 fields of gaze. A few beats of nystagmus withextreme lateral gaze. Accomodation: pupils constrict & converge Abnormals Abnormal eye positions Inability to move both eyes in all directions Nystagmus greater than 1-2 beats or if it occurs other than in lateral gaze EYE MISALIGNMENT EYE MOVEMENT ABNORMALITIES PUPIL RESPONSE PERRLA - pupils equal, round, reactive to light & accommodation MYDRIASIS - pupil size > 6mm that fails to constrictMIOSIS - pupil size constriction to < 2mm Pupils Equal, Round, Reactive to Light & Accommodation CN III: OCULOMOTOR PUPIL REACTION ParasympatheticDim lights “Look into the distance.” Shine bright light obliquely into each pupil, in turn Look for the Direct Reaction (same eye)Look for the Consensual Reaction (other eye)

Repeat opposite eye Record pupil size in mm & response Note any asymmetry CN V & VII: CORNEAL REFLEX Sensory & MotorTest of CN II:CN V Trigeminal: Sesonry Component CN VII Facial: Motor Component Lightly stroke the cornea with a cotton wisp Normal = bilateral blink OPHTHALMOSCOPE Front view Back viewOCULAR FUNDUS NORMAL RETINA Red reflex EYES & VISUAL SYSTEM SummaryVisual acuity OU Peripheral vision Extraocular muscles for movement Eyebrows, eyelids, eyelashes Lacrimal punctaBulbar conjunctiva Sclera & cornea Anterior chamber & iris shape, color Pupils - size, shape, light reaction, accommodation Internal eye - red reflex, optic disc, retinal vesselsEARS: Chapter 15 Hearing Exam INSPECT the auricles. Move them gently. Ask the person if this is painful PALPATE the mastoid process for tenderness of deformity Otoscopic exam CHECK HEARING Conductive Hearing Loss Involves mechanical dysfunction of external or middle ear Impacted cerumen - common in elderly Foreign bodies Perforated tympanic membrane Otitis media - middle ear infection; do NOT prop bottle in bed with baby Otosclerosis - decrease in mobility of ossicles Sensorineural Hearing Loss Caused by impairment in organ of Corti, CN VIII, or auditory areas of cerebral cortex Meniere’s disease - increased fluid in labyrinth that causes vertigo & tinnitus Ototoxicity - from drugs or high-intensity sounds Presbycusis - gradual nerve degeneration that occurs with agingClues to Possible Hearing Loss Person lip reading or watching face & lips closely rather than your eyes Frowning or straining forward to hear Posturing of head to catch sounds Misunderstands questions or frequently asks you to repeat Acts irritable when your voice is raised Person’s speech sounds garbledInappropriately loud voice SUBJECTIVE DATA EarachesInfectionsDischarge Hearing loss Environmental noise

Tinnitus Vertigo Self-care behaviorsINSPECT EXTERNAL EAR StructuresPlacement Palpate Auricle Tragus Mastoid areasExternal Ear AUDITORY SCREENING Whisper Test Weber Test Rinne Test CN VIII: ACOUSTIC SensoryWeber / Rinne Tests CN VIII: WEBER & RINNE InterpretationCN VIII: ACOUSTIC SensoryTest Equilibrium Part of cerebellar assessment: Romberg Test OTOSCOPIC EXAM Positioning> 3 yo: Pull ear up & backwards < 3yo: Pull ear down Inspect Ear Using OtoscopeCERUMEN EXTERNAL AUDITORY CANAL TYMPANIC MEMBRANEUMBOEardrum NORMAL TMVestibular Function Romberg Test EARS & AUDITORY SYSTEM SummaryPosition of ears Shape, size, symmetry, color Discharge, lesions External & mastoid palpation Auditory canal TM landmarks- umbo, malleus, light reflex Condition of TM Auditory functionWhispered voice test; Finger-rubbing test; Rinne test; Weber test Vestibular function Romberg testTHE NOSE NOSE ANATOMY ASSESSMENT OF THE NOSE External Inspection Inspect the nose, noting any trauma, bleeding, lesions, masses, swelling, and asymmetry The shape maybe altered by genetics or trauma Patency Have the patient occlude one nostril with a finger Have patient breathe in and out -- listen for sound Repeat on the other side Altered with a deviated septum, foreign body, URI, allergies, and nasal polyps CN I: Olfactory Sensory

Test patency first Close eyes to identify smells Smells should be easily identifiable and non-noxious Coffee, chocolate, tobacco Vanilla, peppermint, orangeToothpaste, soap Internal Inspection It is often convenient to examine the nose after the ears Tilt the person’s head back slightly and hold breath for a few seconds. Place the nondominant hand on top of the patient’s head Using the thumb of the same hand gently lift the tip of the nose Insert otoscope into the nostril Inspect septum, turbinates, mucosa and drainage NASAL PATHOLOGY RhinitisNasal mucosa is red and swollen with copious clear, watery discharge Findings with common cold (coryza)Allergic rhinitis membrane pale After head trauma clear fluid -- Cerebral spinal fluid -- positive for glucose Purulent material -- infection or foreign body Septal perforation -- nasal cocaine, amphetamines, overuse of nasal spray MOUTH Inspect Odors Lips Teeth & GumsBuccal mucosa Hard & Soft Palate Uvula Tongue Test tongue strength THROAT Directions: Open mouth Use wooden tongue InspectTonsils & Pharynx Check uvula rise Clarity of speech Ability to swallow Check gag reflex if neededGLOSSOPHARYNGEAL & VAGUS: CN IX & X Motor & SensoryMotor Ability to swallow Clarity of speech Uvula rises with “ah” Gag reflex Sensory Taste Test: posterior 1/3 CN VII: FACIAL Sensory Taste: Anterior 2/3 of tongue SubstancesSalty = SaltSweet = Sugar Sour = Lemon Juice Bitter = Procedure Not routinely done Done with CN IX Glossopharyngeal [Taste posterior 1/3 of tongue – difficult to do!] Apply the solutions by applicators to the tongue. Do not close mouth before identifying Drink water if needed. DOCUMENTATION EENTPage 5 of 6

Eyes: Vision 20/20 bilaterally. Fields normal by confrontation. Corneal light reflex symmetrical. EOM’s intact. Cover/uncover test, eyes alligned, no deviations. Brows and lashes present. No ptosis. Conjunctiva clear, sclera white, no lesions or drainage. PERRLA.Ears: Pinna intact, no masses, lesions, tenderness or discharge. Whispered words heard bilaterally. Weber test – tone heard midline without lateralization. Rinne test – AC > BC and equal bilaterally. Nose: Symmetric, no deformity or skin lesions. Nares patent. Mucosa pink, no discharge, lesions or polyps. No septal deviation or perforation. Sinuses, no tenderness, transilluminate equally. Mouth: Able to clench teeth. Mucosa and gingivae pink, no masses or lesions. Teeth all present, straight and in good repair. Tongue smooth, pink, no lesions, protrudes voluntarily midline, no tremor. Throat: Mucosa pink, no lesions or exudate. Uvula rises in midline with phonation. Tonsils +1. Gag reflex present. DOCUMENTATION Cranial Nerves I: Identifies coffee & strawberry II: Vision 20/20 bilaterally. Peripheral fields intact by confrontation. Fundi normal.

III, IV, VI: EOM’s intact, no ptosis or nystagmus. PERRLA. V: Sensation intact and equal bilaterally. Jaw strength equal bilaterally.

VII: Facial muscles intact and symmetric. VIII: Hearing – Whispered words heard bilaterally. Weber test – tone is heard midline without lateralization. Rinne test – AC > BC and equal bilaterally. IX, X: Swallow intact. Gag reflex present. Uvula rises in midline with phonation. XI: Shoulder shrug, head and neck movement intact and equal bilaterally. XII:Tongue protrudes midline, no tremors.

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