Ears, Nose and Sinuses

• Hearing


  The ability to perceive sounds by detecting vibrations, changes in the pressure of the surrounding medium through time & through the ears
• 3 PARTS OF THE EAR

  • External Ear (pinna)
  • Middle Ear
  • Inner Ear
• External Ear (pinna)


  • External auditory canal - 1 inch in (2.5-3cm)in length, narrows toward mid-portion & widens near eardrum, "S" shaped pathway leads to middle ear
• Middle Ear

  • Tympanic membrane - thin, translucent, pearly gray color & lies obliquely in the canal, Sound waves entering the auditory canal strike the membrane causing it to vibrate, Vibrations transferred to the ossicles or bones of the middle ear (malleus, incus & stapes),

  
• Inner Ear


  • Bony labyrinth which consists of a central cavity called Vestibule, 3 semicircular canals.
• AIR CONDUCTION is the primary mechanism of hearing
• How Do We Hear?

  1. Sound waves through external auditory canal

  2. Tympanic membrane (TM)

  3. Sound vibrations cause the TM & the malleus (hammer), incus (anvil), & stapes (stirrup) bones to move

  4. Vibrations to inner ear structures

  
• PURPOSE OF PHYSICAL EXAMINATION: To evaluate the condition of the external ear, condition and patency of the ear canal, BC and AC of sound vibrations, hearing acuity, equilibrium

  
• PREPARATION OF THE CLIENT: Provide for privacy, Position the client seated comfortably during the ear examination, Explain the procedure to the patient
• EQUIPMENT


  • Tuning fork (512 HZ)
  • Watch with a second hand for Romberg Test
  • Otoscope
  • Medical or clean gloves
• INSPECTION - HEARING


  • Angle of Attachment - Draw an imaginary line from top of the helix to the external canthus of the eye, then, draw a line perpendicular to the ear & note angle of attachment
  • Normal Shape & Presence of Landmarks - Helix, antihelix, antitragus, tragus, & lobule, Darwinian tubercle - benign protrusion on upper part of helix, Absence of pits, creases & lesions
  • Position - Helix of ear - level with imaginary line drawn through inner & outer canthus to occiput, Ears should be rotated from 0–15 degrees posteriorly
• ABNORMAL FINDINGS: AURICLE / PINNA

  • Microtia (small) - Ears less than 4 cm vertical height in adults seen in some genetic disorders
  • Macrotia - Ears greater than 10 cm vertical height in adults
  • Missing or Malformed Landmarks - Associated with hearing deficit
  • Creased Earlobes - Associated with heart conditions
  • Ear Pits or Sinuses usually located anterior to the Tragus - Associated with internal ear anomalies
  • Low - Set ears or Lobes rotated posteriorly more than 15 degrees - Associated with mental retardation
  • Anotia - absence of the external ear
  • Shape: Cauliflower ear, Bat ear – auricle protrudes anteriorly
  • Color – red ( perichondritis)
  • Position- displacement of auricle forward , laterally or inferiorly-mastoid abscess

  
• ABNORMAL FINDINGS: EXTERNAL EAR

  • Drainage - Bloody – trauma, Pus – infection, Clear Drainage – spinal fluid, head injury
  • Impacted Cerumen - Excessive cerumen secretion
  • Redness - Inflammation may indicate infection, fever
  • Otitis Externa - Ear pain, especially with movement of the tragus or pulling of ear lobe, Redness of external auditory canal or auricle of external ear, Inflammation or infection of external ear, often caused by excessive swimming, chronic irritation, or removal of cerumen
  • Acute Otitis Media - Ear pain with reddened TM, Signs of conductive hearing loss, Inflammation, Infection of middle ear

  
• MENIERE'S DISEASE


  • Chronic disorder of the membranous labyrinth of the inner ear that is marked by recurrent attacks of dizziness, tinnitus & hearing loss.(permanent), Affects proprioception, Sensation of fullness or pressure, May also experience nausea, vomiting & profuse sweating, Subjective sensation of ear fullness, vertigo, tinnitus, Disturbance of balance & gait, Instruct patient to avoid sudden head movements

  
• ABNORMAL FINDINGS


  • PRESBYCUSIS- hearing loss related to aging, common after the age of 50 years
  • OTORRHEA – purulent, bloody discharge due to infection of the external ear
  • LESIONS - e.g., skin cancer from sun
  • CYSTS - occur when oils are produced in a skin gland faster than they can be released from the gland; occur if the oil gland opening has become blocked & a cyst forms under the skin

  
• PALPATION - EARS

  • AURICLE / PINNA SUPERFICIAL PALPATION
  • - Use finger pads (digital palpation of cartilage & soft tissue,
• INSPECTION - HEARING


  • Condition of Skin - Intact, no lesions, Note if skin piercings are present, Color - Consistent with skin color, Drainage - Earwax, Cerumen - only normal drainage, Mastoid process - bone behind & below the ear canal (mastoid part of temporal bone)

  
• OTOSCOPE

  • Medical device (flashlight like) used to visualize the eardrum & external ear canal

  
• PALPATION


  • Palpate for consistency & tenderness, Always palpate tragus, helix & mastoid process for tenderness prior to otoscopic exam
• HEARING TESTS


  • Whisper Test
  • Watch Tick Test
  • Weber Test
  • Rinne Test
  • Romberg's Test
• Whisper Test


  For LOW – PITCH deficits, Have patient cover opposite ear being tested, Stand about 1–2 ft behind patient & whisper, Note patient's ability to hear sound, NORMAL - Patient repeats most words whispered in each ear at a distance of 1–2 ft, DEVIATIONS FROM NORMAL - Inability to repeat words: Low-tone frequency loss

  
• Watch - Tick Test

  For HIGH – PITCH Deficits, Have patient cover opposite ear being tested, Hold ticking watch within 5 inches from ear, Note patient's ability to hear sound, NORMAL - Patient hears tick of a watch in each ear at a distance of 5 inches, DEVIATIONS FROM NORMAL - Inability to hear watch ticking: High-tone frequency loss

  
• Weber Test


  To evaluate the conduction of sound waves through bone to help distinguish between CONDUCTIVE HEARING and SENSORINEURAL HEARING

  
• Rinne Test


  Compares air & bone conduction sounds, Strike tuning fork & place base of the vibrating tuning fork on the client's mastoid process, Ask the client to tell you when the sound is no longer heard, Move the prongs of the tuning fork in front of ear (external auditory canal), Continue to note the length of time until patient no longer hears sound, Ask the client to tell you if the sound is audible after the fork is removed,

  NORMAL - Air conduction (AC) sound is normally twice as long for bone conduction or normally heard longer (AC>BC), The ratio of AC to BC is similar in both ears

  
• Sensorineural hearing loss(WEBER TEST)


  Lateralization of sound to the good ear; client "hears" the sound in the good ear but there is a limited perception of the sound due to nerve damage in the poor ear, making sound seem louder in the unaffected ear, root cause lies in the inner ear or sensory organ

  
• RINNE TEST


  1. Strike tuning fork & place base of the vibrating tuning fork on the client's mastoid process

  2. Ask the client to tell you when the sound is no longer heard

  3. Move the prongs of the tuning fork in front of ear (external auditory canal)

  4. Continue to note the length of time until patient no longer hears sound

  5. Ask the client to tell you if the sound is audible after the fork is removed
• NORMAL RINNE TEST


  • Air conduction (AC) sound is normally twice as long for bone conduction or normally heard longer (AC>BC)
  • The ratio of AC to BC is similar in both ears
• CONDUCTIVE HEARING LOSS(RINNE)


  • AC less than twice BC, BC sound is heard longer than or equally as long as AC sound (BC ≥ AC), possibly due to: Ear wax, impacted cerumen; Otitis media (middle ear infection); Serous otitis media (allergies); Damage to the ossicles of the middle ear; Fluid in middle ear; Eustachian tube dysfunction; Perforated eardrum; Benign tumors; Infection in the ear canal (external otitis); Presence of a foreign body

  
• ROMBERG TEST


  1. Ask client to stand with feet together, arms at side & eyes open, then with the eyes closed

  2. Stand close by in case patient loses balance

  3. Note patient's ability to maintain balance

  4. Patient stands with feet together & eyes closed

  5. When performing this test, put your arms around the client without touching him or her to prevent falls
• Eustachian or auditory tube - connects middle ear with nasopharynx, allows for equalization of air pressure with atmospheric pressure, conducts sound vibration from external ear to inner ear & protects inner ear by reducing loud sound vibrations
• NORMAL ROMBERG TEST


  • Client maintains position for 20 seconds without swaying or minimal swaying; maintains balance; negative Romberg
• DEVIATIONS FROM NORMAL ROMBERG TEST

  • Client moves feet apart to prevent falls or starts to fall from loss of balance, may indicate a vestibular disorder; Loss of balance due to: inner ear disorder, cerebellar damage, ingestion of intoxicants
• Nose


  A triangular projection of bone & cartilage situated midline on the face, the only externally visible organ of the respiratory system
• Paranasal sinuses


  Mucus-lined, air filled cavities that surround the nasal cavity & perform air-processing functions of filtration, moistening & warming
• Functions of nose & sinuses

  • Provide airway for respiration
  • Filter, warm & humidify air flowing into the respiratory tract
  • Provide resonance of voice
  • House the receptors for olfaction
• Nares (Nostrils) / Vestibules

  Provide access to the nasopharynx through structured lines with mucous membranes, rich with blood vessels covered with CILIA, the beginning of each nasal passage
• Nasal Mucosa


  Ciliated epithelium cells with goblet cells produce mucus, which traps bacteria and air pollutants
• Nasal Septum


  Composed of the ethmoid bone & vomer, divides the nasal cavities
• Cilia

  Small hairs that filter air
• Turbinates (Superior, middle, and inferior)


  Bony conchae (folds) of the internal nasal walls that increase the surface area for air to be filtered, warmed, & humidified before entering the lungs