Heent - Ears, Nose, And Throat

Front 1

External ear

Back 1

Auricle or pinna, collects sound and transmits to middle ear

Front 2

Tympanic membrane

Back 2

Separates external and middle ear
Three layers- skin, fibrous tissue and mucous membrane

Front 3

Pars flaccida, pars tensa, umbo

Back 3

Pars flaccida - upper portion, little support
Pars tensa - lower portion, taut
Umbo - center, attached to tip of malleus

Front 4

Middle ear

Back 4

Transmits sound vibrations across bony ossicle chain to inner ear
Protects auditory apparatus from intense vibrations
Equalizes air pressure on both sides of TM to prevent rupture

Front 5

Auditory ossicles

Back 5

Malleus (hammer), incus (anvil), stapes (stirrup)
Linked in a chain and vibrate in place

Front 6

Eustachian tube

Back 6

links middle ear with nasopharynx to equalize air pressure
Normal function keeps nasopharynx contaminants from middle ear
Opens during yawning/swallowing
URI/allergies can obstruct middle ear drainage -> otitis media, effusion

Front 7

Inner ear

Back 7

closed fluid filled space within temporal bone

Front 8

Bony labyrinth

Back 8

Vestibule and Semicircular canal maintain equilibrium
Semicircular canals contain cristae- respond to body movement, control balance
Cochlea- the organ of hearing

Front 9

External exam - auricle

Back 9

Inspect for position and symmetry of auricle, tip of ear should line up with the corner of eye. Check skin color, for lesions/nodules. Palpate auricle and pre and post auricular lymph nodes, pull helix back check for tenderness, palpate and percuss mastoiditis.

Front 10

External exam - external auditory canal (EAC)

Back 10

Inspect opening for;
Discharge- color, consistency
Redness
Odor
Nodules, masses, cysts, pimples
Foreign bodies

Front 11

Otoscope exam

Back 11

Note cerumen, hair, scaling, redness in EAC, TM should be pearly gray, transparent, light reflex tells you if TM is bulging, inflamed or retracted. Note placement of malleus and umbo. Insufflate and note mobility of TM.

Front 12

Normal placement of light reflex

Back 12

Use different “times” to note displacement of TM
4-6:00 in R ear normal
6-8:00 in L ear normal

Front 13

Decreased/increased mobility of TM

Back 13

Decreased motion can represent increased pressure in the inner ear (as with otitis media, serous otitis, eustachian tube dysfunction)
Increased mobility can represent perforation

Front 14

Cerumen

Back 14

Aids in sound conduction, protect from infection, moisten EAC, typically gray to brown color.

Front 15

Impaction of cerumen

Back 15

Blockage of EAC by cerumen – decreases hearing, causes discomfort, can affect equilibrium
Treat by flushing

Front 16

Otitis externa

Back 16

"Swimmer's ear"

Inflammation of EAC due to bacteria, fungus, trauma, irritation. Typically resulting in secondary infection
Ear pain (especially with auricle tug), redness of EAC, inflammation of EAC, flaking or maceration of tissue, discharge from EAC

Front 17

Acute otitis media (AOM)

Back 17

Infection of the middle ear
Results from inflammation of tissues in the nasopharynx that lead to Eustachian tube dysfunction
Ear pain (not affected by auricle tug), sensation of fullness in the ear, decreased hearing, URI symptoms, irritability in infants, fever

Front 18

Types of acute otitis media (AOM)

Back 18

OM
Serous OM
Bullous Myringitis

Front 19

Perforations

Back 19

Hole in the tympanic membrane – due to procedure, trauma, infection, or other

Front 20

Cholesteotoma

Back 20

A skin cyst of the middle ear that grows destructively and affects hearing, REFERRAL

Front 21

Whisper test

Back 21

Stand 2 ft behind the patient, have pt cover tragus of one ear with his finger
Whisper a number with 2-3 syllables
(68, 100, 99 etc)
Repeat with other ear

Front 22

Weber test

Back 22

Determines conductive vs sensorineural hearing loss
512 cycles per second tuning fork
Strike against your hand and place on top of patients head
Normal weber’s is equal hearing in both ears
Tone better in one ear = R or L lateralization
If lateralizes to impaired ear = conductive hearing loss
If lateralized to good ear = sensorineural hearing loss

Front 23

Rinne test

Back 23

Compares air conduction to bone conduction
Strike tuning fork with hand and place on mastoid process
When patient tells you tone stops, move to front of ear
Note each segments time in seconds
Normal: Air conduction = 2 times bone conduction
If in hearing loss ear
bone > air = conductive hearing loss
If in hearing loss ear
air > bone = sensorineural hearing loss

Front 24

External nose

Back 24

Inspect bridge, nares, vestibule, nasolabial fold for color, symmetry, masses, obstructions, changes. Palpate tip of nose, bridge, ala and paranasal bones.

Front 25

Internal nose

Back 25

Inspect nasal muscosa, turbinates, look for masses, septum.

Front 26

Unilateral rhinorrhea

Back 26

Typically an obstruction (paper, toy, bead, candy, etc.)

Front 27

Epistaxis

Back 27

Most common area is anterior and inferior septum in Kiesselbach's plexus = Anterior Bleed
Posterior bleeds are less common but more problematic

Front 28

Sinusitis

Back 28

Inflammation of the sinus mucosa due to infection, irritation, trauma, or other
Headache, sinus pressure, congestion, rhinorrhea, fever
Inspection: of turbinate show edema and rhinorrhea
Palpation: tenderness
Percussion: tenderness, dullness
Transillumination: absence of glow suggests opacification of sinuses. Reddish glow is normal

Front 29

Mouth and throat - external

Back 29

Inspect lips, nasolabial folds, skin, palpate for masses

Front 30

Angioedema

Back 30

Rapidly developing, tense swelling of the lips, tongue and oral mucosa, usually allergic in origin

Front 31

Herpes labialis

Back 31

Cluster of vesicles due to herpes simplex 1, healing in 10-14days (cold sore, fever blister)

Front 32

Angular chelitis

Back 32

Fissures at the corners of the mouth.
Causese: nutritional deficiency, over closure of mouth, infection

Front 33

Squamous cell carcinoma of the lip

Back 33

cancer of the lip, usually lower lip. Firm, scaly plaque, ulcer (with or without crust), or nodular mass of the lip

Front 34

Hereditary hemorrhagic telangiectasia

Back 34

petechial red spots on the lips and oral mucosa. Areas may bleed with trauma/irritation. Friable=bleeds easily, occurs in the entire GI tract.

Front 35

Cyanosis

Back 35

Bluish coloring of the lips d/t lack of systemic oxygenation

Front 36

Mouth and throat - internal

Back 36

Inspect teeth, gums, oral mucosa, tongue, floor of mouth, soft and hard palate, pharynx. Palpate gums, teeth, salivary ducts, floor of mouth, tongue.

Front 37

Checking CN XII

Back 37

Ask pt to protrude tongue, asymmetric protrusions suggest CN XII lesion, tongue will point toward muscular deficit.

Front 38

Torus palatinus

Back 38

Midline bony growth on hard palate

Front 39

Leukoplakia

Back 39

“white patch” thickened white patch on the oral mucosa or tongue, results from local irritant. Common in chewing tobacco can lead to cancer

Front 40

Aphthous ulcer

Back 40

(canker sore) a painful, round, ulcer White ulcer on a red base. Can occur on gums, tongue, and oral mucosa

Front 41

Petechiae

Back 41

small red spots resulting from blood escaping capillaries into tissue. Cause: infectious, trauma, thrombocytopenia

Front 42

Koplick spots

Back 42

small white specks against a red backround. “grains of salt”. An early sign of measles

Front 43

Mucocele

Back 43

mucous cyst. Bluish, translucent.

Front 44

Inspect and palpate gums

Back 44

Inspect the color of the gums (normally pink), patchy brownness may be present, especially but not exclusively in black individuals
Redness of gingivitis
Black line of lead poisoning
Inspect and Palpate the gum margins and the interdental papillae for swelling or ulceration

Front 45

Inspect and palpate teeth

Back 45

Missing, discolored, misshapen, or abnormally positioned, caries (normal 32 teeth)
Palpate teeth gloved with index finger or tongue blade for tenderness and loose teeth

Front 46

Erosion of teeth

Back 46

chemical erosion of teeth enamel by toxic acids. Common in bulimia with gastric contents and ingested acids.

Front 47

Dental caries

Back 47

Cavities of the teeth. Causes are poor dental hygiene, methamphetamine use, and others

Front 48

Gingivitis

Back 48

Inflammation of the gums. The most common periodontal disease. Redness, swelling, and sometimes bleeding of the gums. Causes: bacteria

Front 49

Geographic tongue

Back 49

benign, smooth red areas denude of papillae. Map-like pattern that changes with time

Front 50

Hairy tongue

Back 50

yellow, brown, or black elongated papillae on the tongue. Benign. Causes: antibiotics, pepto bismol, tobacco, other

Front 51

Fissured tongue

Back 51

Fissuring increases with age. Benign.

Front 52

Atrophic glossitis

Back 52

smooth and sore tongue, lacks papillae. Causes: ribofalvin, niacin, folic acid, B12, pyridoxine, or iron deficiency, or recent chemotherapy.

Front 53

Cancer of the tongue

Back 53

irregular, nodular, red or white, sometimes ulcerated areas of abnormal tissue. Second most common cancer of the the mouth secondary only to the lip.

Front 54

Checking the pharynx

Back 54

Say "ah" with tongue depressor. Note the rise of the soft palate—a test of cranial nerve X. Inspect soft palate, anterior and posterior pillars, uvula, tonsils and pharynx. Note edema, exudates, ulcerations, crypts, masses, discolorations.

Front 55

CN X Paralysis

Back 55

Soft palate fails to rise and the uvula deviates toward the opposite side of muscular defect

Front 56

Tonsillar crypts

Back 56

tonsils have crypts, or deep in-foldings of squamous epithelium, whitish spots of normal exfoliating epithelium or food particles may sometimes be seen in these crypts

Front 57

Pharyngitis

Back 57

Inflammation of the pharynx commonly due to infection (bacterial or viral), irritant, trauma, allergies. Redness, edema, increased vascularity, sore throat, possible fever and cervical adenopathy.
Viral makes up 90% of all pharyngitis.
Of the 10% of bacterial pharyngitis Strep causes 90%
Allergic – may see cobble stoning

Front 58

Oral candidiasis

Back 58

yeast infection due to Candida.
White plaques that are adherent, but removable to underlying tissue. Causes: immune suppression, recent antibiotics

Front 59

Peritonsillar abscess

Back 59

A complication of tonsillitis which results in collection of pus near the tonsil (abscess). Red, edematous tonsils and pharynx, exudates, mass like uvula deviation.

Front 60

Inspecting the neck

Back 60

Note symmetry and masses or scarring, look for enlarged parotid or submandibular glands, visible lymph nodes. Identify midline structures.

Front 61

Identify the following midline structures...

Back 61

(1) the mobile hyoid bone just below the mandible
(2) the thyroid cartilage, readily identified by the notch on its superior edge
(3) the cricoid cartilage
(4) the tracheal rings
(5) the thyroid gland

Front 62

Lymph nodes in neck

Back 62

10 sets:
Preauricular, postauricular, occipital, tonsillar, submandibular, submental, superficial cervical, posterior cervical, deep cervical chain, and supraclavicular.

Front 63

Palpating lymph nodes

Back 63

Use the pads of your fingers to palpate the 10 sets of lymph nodes. Rubbing your fingers over the node and checking it’s mobility. You should usually examine both sides at once.
Supraclavicalar enlargement suggests metastasis
Hard fixed notes suggest malignancy

Front 64

Diffuse lymphadenopathy

Back 64

Suspicion for HIV/AIDs or lymphoma

Front 65

Parotitis

Back 65

Inflammation of the parotid gland due to infection, obstruction, or autoimmune disease

Front 66

Anterior cervical adenopathy

Back 66

Seen in URI and strep throat

Front 67

Posterior cervical and occipital adenopathy

Back 67

Seen in mononucleosis

Front 68

Inspecting the trachea

Back 68

For deviation and masses. Place finger between trachea and sternomastoid muscle, note symmetry. Tracheal deviation may signify important problems in the thorax, such as a mediastinal mass, atelectasis, or a large pneumothorax (away from pneumothorax).

Front 69

Inspecting the thyroid

Back 69

enlargements (Goiter), symmetry, masses, movement with swallowing. Ask pt to flex neck slightly forward, place fingers of both hands on pts neck so that index fingers are below the cricoid cartilage. Ask pt to swallow, feel thyroid isthmus. Below, feel lobes of thyroid. Note size, shape, consistency and identify nodules or tenderness.

Front 70

Enlarged thyroid

Back 70

Listen over the lateral lobes with a stethoscope to detect a bruit, a sound similar to a cardiac murmur but of noncardiac origin.

Front 71

Goiter

Back 71

Soft enlargement, non-tender

Front 72

Thyroiditis

Back 72

Tender enlargement of gland

Front 73

Hashimoto's thyroiditis

Back 73

Firm enlargement

Front 74

Thyroid masses

Back 74

Nodules/cyst – firm, clear margins, non-tender
Malignant – firm, asymmetry of mass, and ill defined margins, non-tender

Front 75

Hyperthyroidism

Back 75

Nervousness, weight loss despite increased appetite, excessive sweating and heat intolerance, palpitations, frequent bowel movements, muscular weakness. Warm, smooth, moist skin, with Grave's disease, eye signs such as stare, lid lag, and exophthalmos. Increased systolic and decreased diastolic BP. Tachycardia and atrial fibrillation. Hyperdynamic cardiac pulsations with an accentuated S1.

Front 76

Hypothyroidism

Back 76

Fatigue, lethargy, modest weight gain with anorexia, dry coarse skin and cold intolerance. Swelling of face, hands and legs. Constipation. Weakness, muscle cramps, arthralgias, paresthesias, impaired memory and hearing. Skin sometimes yellowish from carotene, with nonpitting edema and loss of hair. Periorbital puffiness. Decreased systolic and increased diastolic BP. Bradycardia and hypothermia. Intensity of heart sounds sometimes decreased.

Front 77

Jugular venous distention (JVD)

Back 77

May be visible in sitting position. Caused by venous engorgement.

Front 78

Thyroglossal duct cyst

Back 78

fibrous cyst that are due to persistent thyroglossal duct formed during embryonic development of the thyroid gland. Midline mass, non-tender

Front 79

Branchial cleft cyst

Back 79

an epithelial cyst usually on the lateral side of the neck that is caused by failure of obliteration of the second branchial during embryonic development