HEAD, NECK, EYES and ENT

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HEAD, NECK, EYES and ENT

• Presented and Updated by Debbie King NP
• A Lecture by Colette Frena, NP
• Darlene Brannon, NP

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Inspection of Head

• Size- Head erect and midline, circumference of
  infants, expected size for age
• Shape-Skull normocephalic, any bulges or edema
• Symmetry-symmetrical and smooth, no deformities
• Lesions-scabs, parasites, nits, scaliness,
  crusting, unusual hairline, hair loss, thinning

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Inspection of facial features

• Symmetry- facial features symmetrical
• Shape- round, oval, diamond
• Characteristic facies- Cushing syndrome, Myxedema
  facies, Down Syndrome, Bells Palsy, Fetal Alcohol
  Syndrome
• Tics- facial nerve issues or psychogenic
• Unusual features- brows, nose lips

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Palpate head scalp

• Symmetry smoothness, no depressions
• Fontanels anterior slightly depressed, some
  pulsation. Bulging fontanel ICP?
• Tenderness- sinuses, TMJ, temporal arteritis
• Scalp movement- should move freely, feel hair for
  texture, brittleness

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Anatomy and physiology of the Neck

• Divide the neck into two triangles
• Anterior triangle
• Mandible above the sternomastoid laterally and
  the midline of the neck medially
• Posterior triangle
• The sternomastoid muscle, the trapezius, and
  clavicle
• Midline structures and thyroid gland
• Mobile hyoid bone
• Thyroid cartilage
• Cricoid cartilage
• The tracheal rings
• Thyroid gland

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Inspection of Neck

• Symmetry
• Alignment of trachea-midline
• Fullness
• Masses, webbing skin folds, thyroglossal duct
  cyst, brachial clef cyst
• Jugular vein distention
• Carotid artery prominence
• Full range of motion- torticollis, meningitis

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Palpate the neck

• Tracheal position
• Tracheal tug
• Movement of hyoid bone
• Movement of cartilages when swallowing
• Thyroid size, shape, tenderness, nodules
• Masses, goiters, lymphadenopathy, enlarged
  salivary glands.
• Always use gentle pressure when palpating neck.

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Neck Thyroid Gland

• Flex neck slightly forward
• Place fingers of both hands with index fingers
  just below the cricoid cartilage
• Ask patient to swallow feel for the thyroid
  isthmus rising up under your finger pads (not
  always palpable)
• With swallowing, the lower border of this large
  gland rises and looks less symmetric when there
  is a goiter
• Displace trachea to the right and palpate
  laterally for the right lobe of the thyroid
  repeat on the left side
• Note the size, shape, and consistency
• Identify any nodules or tenderness
• If enlarged, listen over lateral lobes to detect
  a bruit

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Auscultation of neck

• Temporal bone arteries bruits
• Carotid arteries bruits
• Thyroid - bruits

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Abnormalities of the neck

• Parotitis infection of the parotid gland.
• Cervical adenitis
• Lymphadenopathy
• Salivary gland infections
• Mononucleosis
• Cancers

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Inspection of ears

• Size genetic or abnormality
• Shape cauliflower, cysts, skin tags, tophi
  (gout white deposits.
• Symmetry
• Landmarks of outer ear
• Helix, antihelix, tragus, lobule, entrance to
  canal
• Color blueness, excessive redness, frost bite
• Position (draw imaginary line) low set ears may
  indicate chromosomal abnormalities or renal
  disorders
• Lesions or deformities congenital
• Discharge or odor
• Piercings

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What does an ear do other than hold earrings?

• It is a sensory organ used for lateralization,
  localization, interpretation of sound, maintains
  equilibrium.
• External ear- auricle to tympanic membrane moist
  with cerumen.
• Middle ear- transmits sound. Consists of 3 small
  bones, malleus, incus and stapes.
• Inner ear - transmits sound, vestibular
  function.
• Eustachian tube- ventilates the ear and equalizes
  pressure.

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Palpation of ears and mastoid area

• Tenderness infection, TMJ
• Swelling sebaceous cysts, otitis externa,
  hematoma, mastoiditis
• Nodules cysts
• Auricle should easily recoil

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Otoscopic exam

• Used to inspect the external auditory canal and
  the middle ear
• Use correct speculum size for adult and child
• Pull auricle up and back on adults
• Pull auricle downward and back on small children
  and infants
• Stabilize ear and slowly insert speculum
• Avoid touching bony wall- YEOW

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Normal finding on otoscopic exam

• Minimal cerumen, no impaction
• Uniformly pink-canal
• Hairs in the outer canal
• No lesions, discharge, foreign body, masses
• Myringotomy tubes- white or blue tubes

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Tympanic membrane

• Landmarks- umbo, handle of malleus, light reflex
• Color- translucent pearly gray, yellow, red or
  blue indicates blood and/or infection. White
  spots are healed inflammation.
• Perforations- d/t infection or trauma. Patient
  feels air coming out.
• Pneumatic otoscope- checks for mobility
• Mobility bulging, retracted, thickened,
  negative pressure.

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Ear infections

• Acute otitis media pain, retracted TM, red,
  yellow or blue bulging TM.
• Chronic otitis media- recurrent infections.
  Consider myringotomy with tubes.
• External otitis media pain on palpation of
  auricle, edema, erythema and discharge in the
  canal.
• Serous otitis media- fluid in the middle ear.
  Cant always see fluid. Tympanogram is
  diagnostic.
• Mastoiditis - ear infection that enters the
  mastoid bone. CT of temporal bone is diagnostic.

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Treatment for acute otitis media

• Controversy over treating.
• Treatment should be age specific.
• Antibiotics
• Decongestants
• Nasal steroid sprays help ventilate the ears
• Pain medication, Auralgan ear drops

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Treatment for otitis externa

• Antibiotic ear drops
• Sometime oral antibiotic and steroids- depends on
  the severity
• Pain medication
• Ear wicks are helpful
• No water in ears during treatment

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Treatment for serous otitis media

• Decongestants- varies on effectiveness
• Nasal steroid sprays
• Antihistamines
• Increase fluids
• Tympanogram shows increase in negative pressure.

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Ears - Hearing

• Auditory acuity
• Test one ear at a time
• Whisper test, standing 1-2 feet behind patient,
  softly say nine-four, baseball
• Ticking Watch
• Air and bone conduction
• Weber
• Lateralization of sound to impaired ear suspect
  unilateral conductive hearing loss
• Rinne
• Compare time of air vs. bone conduction
• If bone conduction is equal or greater than air
  conduction, then suspect conductive loss

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Assess Hearing CN VIII

• HPI
• FHX
• Loud noise exposure history
• Response to questions during history

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Hearing loss

• Conductive hearing loss sound transmission is
  impaired through the external or middle ear d/t
  infection, cholesteatoma, growth or mass,
  structural problems.
• Sensorineural hearing loss nerve damage,
  misinterpretation of speech.
• Tinnitus- ringing. Can be early sign of high
  frequency hearing loss.
• Otosclerosis hereditary condition. More common
  in women. A fixation of the stapes.

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Eyes - Inspection

• Lacrimal apparatus in the medial canthus
• Lacrimal gland and sac for swelling
• Sclera covered by conjunctiva
• Color, vascular pattern
• Cornea and lens - opacities
• Iris markings clearly defined
• Pupils size, shape, symmetry, reaction to light
  (direct and consensual)

• Position and alignment of eyes
• Eyebrows - quantity, distribution
• Eyelids
• Width of palpebral fissures
• Edema, color, lesions
• Condition and direction of eyelashes
• Adequacy of closed eyelids
• Lateral canthus

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Review cross section of the eye

• Iris
• Pupil
• sclera
• Vitreous body
• Choroid retina fovea
• Central retinal artery and vein
• Optic nerve
• Physiologic cup
• Extraocular muscle

• Inner eye
• Optic disc
• Physiologic cup
• Fovea
• Macula
• Artery vein

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Eyes Techniques of Examination

• Visual acuity
• Central vision Snellen eye chart position
  patient 20 feet from the chart
• Patients should wear glasses if needed
• Test one eye at a time
• Near vision hand-held card (can also use to test
  visual acuity at the bedside) hold 14 inches
  from patients eyes

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Light tests of the eyes

• Start with the light reflex, use the lighting in
  the room, make sure the ceiling light reflects in
  the same part of the eye bilaterally
• Next examine the red reflex, stand one foot away
  look at both eyes at once and compare the
  redness, they should be the same shade of red
• To exam the optic disk, cup, vessels examine
  the patients right eye with your right eye,
  patients left eye with your left eye
• Place one hand on the patients head
• Get the red reflex and continue to move closer to
  the patients head until you can see vessels. You
  can then follow vessels to the optic disk
• Follow these directions instead of the text book

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Eyes Techniques of Examination (cont.)

• Visual fields
• Screening by Confrontation
• Both eyes at same time start in the temporal
  fields
• Further testing
• If a defect is found, test one eye at a time
• Extraocular movements/six cardinal directions of
  gaze
• Normal conjugate movements
• Nystagmus
• Lid lag
• Convergence

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Tips for Using the Ophthalmoscope

• Darken the room and have the patient look off in
  the distance
• Switch the ophthalmoscope light and turn the lens
  disc to the large round beam of white light
• Turn lens disc to the 0 diopter
• Hold the ophthalmoscope in your right hand to
  examine the patients right eye with your right
  eye hold it in your left hand to examine the
  patients left eye with your left eye
• Stand directly in front of the patient, 15 inches
  away, and start at an angle of 15 degrees lateral
  to the patients line of vision
• Shine the beam of light onto the pupil and look
  for an orange glow this is the red reflex
• Follow the red reflex and move inward towards the
  nasal aspect of the visual field

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Variations and Abnormalities of the Eyes

• Ptosis-drooping of the upper lid
• Entropion-inward turning of the lid margin
• Ectropion-margin of the lower lid turns outward
• Lid retraction and exophthalmos-wide eyed stare,
  eye balls may protrude forward
• Pinguecula- harmless yellowish triangular nodule
  in the bulbar conjunctiva
• Episcleritis- localized ocular redness from
  inflammation of the episcleral vessels
• Chalazion-subacute nontender and usually painless
  nodule

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Inspection of the nose

• Shape- flaring (O2 hunger), deviations,
  asymmetry, nasal injury, fx, transverse crease,
  nasal valve collapse.
• Outer landmarks
• Bridge, tip, anterior naris, vestibule, ala nasi
• Size self explanatory
• Color
• Evaluate patency of nares nasal valve collapse,
  deviated septum, foreign body, infection
• Palpate ridge and soft tissue

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Inspection of inner nose

• Discharge
• Hair
• Septum- deviation, perforation
• Drug use Afrin, cocaine
• Turbinates anterior, middle inferior. Purpose
  to humidify and filter air.
• Color- red, pale, bluish
• Boggy
• Nasal polyps, folliculitis
• Sense of smell- anosmia, putrid, dead animal

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Inspect and palpate sinuses

• Frontal forehead
• Ethmoid between the eyes
• Maxillary - cheeks
• Sphenoid center of head
• Swelling, redness, tenderness
• May transilluminate area- absence of glow
  indicates sinus is filled with fluid or infection
  or sinus never developed.

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Treatment of sinusitis

• Controversy over treatment
• Antibiotics, pain medication, decongestants,
  mucus thinners, nasal steroid sprays.
• Recurrent sinus infections- ENT referral

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Inspection of lips

• Symmetry
• Color- cyanosis, pallor, circumoral pallor,
  cherry red, bluish gray, yellow (jaundice,
  cigarettes)
• Edema
• Surface abnormalities herpes, plaques, lesions,
  cleft lip, cleft palate
• Remove lipstick
• Dry, cracked (cheilitis)
• Fissures, allergies ,angioedema
• Drooling

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Abnormalities of the lips

• Angular Cheilitis-starts with softening of the
  skin at the angles followed by fissuring
• Actinic Cheilitis-results from excessive exposure
  to sunlight and affects primarily the lower lip,
  it loses its normal color and becomes scaly and
  thickened and everted
• Angioedema- diffuse nonpitting tense swelling of
  the dermis and subcutaneous tissue

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Inspection of mouth

• Gingivae
• Color- hyperpigmentation
• Lesions- thrush, herpes, cancer, Koplik spots
• Tenderness
• Teeth- dental caries, loose, missing, baby bottle
  syndrome, grinding, discolored, Epstein pearls
• Tongue color, moisture, symmetry, swelling,
  macroglossia
• Palate, tonsils, and uvula
• Elicit gag reflex

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Findings in or under the tongue

• Geographic tongue- benign condition, dorsum
  shows scattered smooth red ares denuded of
  papillae, gives a maplike pattern
• Hairy tongue- benign hairy yellowish to brown or
  black elongated papillae
• Smooth tongue or Atrophic Glossitis-smooth and
  often sore tongue-vitamin B deficiency
• Tori Mandibularis- rounded bony growths on the
  inner surfaces of the mandible are harmless

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Inspection of oropharynx

• Moisten tongue blade
• Tonsils
• Size grades I-IV
• I-visible
• II-halfway between tonsillar pillars and the
  uvula
• III- nearly touching the uvula
• IV- touching each other
• Shape
• Symmetry abscess, cancer
• Cryptic
• Tonsillolith
• Peritonsillar abscess

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Inspection of oropharynx

• Uvula
• length
• bifurcated
• Palatal bulk
• Cleft lip and or palate
• Choanal Atresia congenital nasal obstruction of
  the posterior nares resulting in respiratory
  distress in infants- cant breath through nose.
• Torus Palatinus bony overgrowth on palate

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Common or Concerning Symptoms
Head Headache, history of head injury
Eyes Visual disturbances, spots (scotomas), flashing lights, use of corrective lenses, pain, redness, excessive tearing, double vision (diplopia)
Ears Hearing loss, ringing (tinnitus), vertigo, pain, discharge
Nose Drainage (rhinorrhea), congestion, sneezing, nose bleeds (epistaxis)
Oropharynx Sore throat, gum bleeding, hoarseness,
Neck Swollen glands, goiter