Ear, Nose, and Throat Adapted from Mosby’s Guide to Physical Examination, 6 th Ed. Ch. 12.
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Transcript of Ear, Nose, and Throat Adapted from Mosby’s Guide to Physical Examination, 6 th Ed. Ch. 12.
Ear, Nose, and Throat
Adapted from Mosby’s Guide to Physical Examination, 6th
Ed.Ch. 12
Development
• Maxillary and ethmoid sinuses– present at birth, though very small
• Sphenoid sinus– tiny cavity at birth– not fully developed
until puberty
• Frontal sinus– develops by 7-8 years
Infant
• External auditory canal is shorter and has an upward curve
• Eustachian tube is relatively wider, shorter and more horizontal
– Reflux of nasopharyngeal secretions
Child
• As the child grows, the eustachian tube lengthens and its pharyngeal orifice moves inferiorly
• Growth of adenoids may occlude the eustachian tube– Interferes with aeration of the middle
ear
• Salivation increases by 3 months– Drools until swallowing
is learned
Teeth
20 deciduous teeth • appear between 6
and 24 months
Teeth
• Eruption of permanent teeth begins about 6 years of age
• Completed ~14-15 years old
• 3rd molar (“wisdom tooth”)– 18 years old
Ear, Nose, Mouth Exam
“Frequent site of congenital malformation therefore thorough
examination is important.”
Inspection
• Auricle– Well formed, all landmarks present– Very flexible
• Should have instant recoil after bending
CLINCAL NOTE: Premature infant– May appear flattened with limited incurving
of the upper auricle– Slower ear recoil
• The tip of the auricle should cross an imaginary line between the outer canthus of the eye and the prominent portion of the occiput (EOP)
• Low or poorly shaped auricles– Associated with renal disorders and
congenital abnormalities
• NO skin tags should be present
• Preauricular skin tagor preauricular pit– anterior to the tragus– remnant of 1st branchial cleft
Internal Ear Exam
1. Lay the infant supine/prone2. Turn head to the side3. Hold otoscope so that the ulnar surface
of your hand rests against the infant’s head
*Prevent trauma to auditory canal
4. Other hand stabilizes infant’s head5. Pull auricle down to straighten the
canal
Newborns
• Auditory canal is often obstructed with vernix (newborn)
• Tympanic membrane may be in an extremely oblique position until 1 month old
*Should be examined within the first few weeks of life
In neonates, you may note…
• Limited mobility• Dullness and opacity of a pink or
red tympanic membrane• Light reflex may appear diffuse
– Tympanic membrane is not conical for several months
“As the middle ear matures in the first
few months, the tympanic
membrane takes on the expected appearance.”
Hearing
Use a bell, toy, voice, or clap your hands
• Make sure the infant is not responding to air movement or visual stimulus
• Remember, responses to repeated sound stimuli will diminish as the infant tunes it out
Expected Hearing Response
Birth to 3 months
Startle reflex, crying, cessation of breathing or movement in response to sudden noise; quiets to parent’s voice
4 to 6 months Turns head toward source of sound but may not always recognize location of sound; responds to parent’s voice; enjoys sound producing toys
Expected Hearing Response
6 to 10 months Responds to own name, telephone ringing, and person’s voice, even if not loud; begins localizing sounds above and below, turns head 45 degrees towards sound
10 to 12 months Recognizes and localizes source of sound; imitates simple words and sounds
Infant Nose Exam
External Nose• Symmetric appearance• Positioned in the vertical midline on the
face– Deviation of the nose may be related to
fetal position
• Only minimal movement of the nares with breathing should be apparent
Consider a possible congenital abnormality if…
• Saddle-shaped nose with a low bridge and broad base
• Short small nose• Large nose
Internal nose• Inspect by shining a light inside
– Gently tilt the nose tip up with your thumb
• In infants, you may see a small amount of clear fluid discharged; crying
• Nasal patency must be determined at the time of birth
– Obligatory nose breathers
Mouth closed, occlude one naris and then the other
Observe the respiratory pattern
With total obstruction, the infant will not be able to inspire or expire through the noncompressed naris
Consider:• Septal deviation
– Delivery trauma
• Choanal atresia
Infant Sinuses
• Maxillary and ethmod sinuses are small during infancy
• Few problems arise in these areas
• Examination is generally unnecessary
Infant Mouth Exam
• Crying provides an opportunity to examine the mouth
• Avoid depressing the tongue– Stimulates a strong reflex protrusion– Makes visualization of the mouth
difficult
• Well formed with no cleft
• Buccal mucosa– Pink and moist – No lesions
• NOTE: Secretions that accumulate in the newborn’s mouth may indicate esophageal atresia
• Scrape any white patches with a tongue blade
– Nonadherent• milk deposits
– Adherent• candidiasis (thrush)
Drooling• Normal from 6 weeks
to 6 months
• Consider a neurologic disorder if it persists >12 months
Gums • Should be endentulous
– smooth with a serrated edge of tissue along the buccal margins
Teeth• Count deciduous teeth• Note any unusual sequence of eruption
Tongue• fits well in the floor of the mouth• protrudes beyond the alveolar ridge
– If not, possible feeding difficulties
• Frenulum– Usually attaches midway between the
ventral surface of the tongue and its tip
• Insert your finger into the infant’s mouth– Fingerpad to the
roof of the mouth
Evaluate the infant’s suckPalpate the hard and soft palatesStimulate a gag reflex by touching
the tonsillar pillars
Normally…
• Should have a strong suck– Tongue pushing vigorously upward against
the finger
• Palatal arch should be dome shaped• Neither hard nor soft palate should have
palpable clefts• Soft palate should rise symmetrically
when the infant cries
Note in records if…
• Narrow, flat palate roof OR• High, arched palate
– affect the tongue’s placement– feeding and speech problems
*Associated with congenital anomolies
Child ENT Exam
Modifying Your Instruments
• Oto/ophthalmoscope– Decorative covers
http://quickmedical.com/pediapals/products
• Postpone until the end– often resist otoscopic and oral exams
• Be prepared to use restraint if encouraging the child fails– Ask parent to restrain
the child
Restraining a Child – Oral Exam
• Seated in the parent’s lap, back to the parent and legs between the adult’s legs
• Parent can reach around to restrain the child’s arms with one arm and control the child’s head with the other
• Can usually be accomplished without forcing– Force only makes them more angry…
Restraining a Child - Otoscope
• Face the child sideways with one arm placed around parent’s waist
• Parent holds the child firmly against his/her trunk– One arm restrains the head– One arm restrains the body
• Doctor further stabilizes the child’s head while inserting the otoscope
Restraining a Child - Supine
If the child actively resists…• Place child supine on the exam table• Parent holds arms extended above the
head and assists in restraining the head• Doctor lies across the child’s trunk and
stabilizes the child’s head • Third person may need to hold the
child’s legs
Remember
“Children of any age who are not too big to sit on a parent’s lap are better examined there than in a prone or supine position on the
examining table.”
Child Ear Exam
Otoscopic exam• Pull auricle either down and back OR up
and back – gain best view of the tympanic membrane
As the child grows, the shape of the auditory canal changes to the S-shaped curve of the adult.
• If the child is crying or has recently cried vigorously…– Dilation of blood vessels in the
tympanic membrane can cause redness “red reflex”
• Cannot assume that redness of the membrane alone is a middle ear infection
Pneumatic Otoscope• needed to differentiate
Crying Red Moveable
Infection RedNo mobility *see common
conditions at the end of this ENT section
Tympanometry
• Accurate way to identify middle ear effusion– Ear piece must be sealed in the canal
to provide accurate reading– Wax, ruptured membrane, tubes
Toddler’s Hearing
• Observe response to a whispered voice and various noise makers– Rattle, bell, tissue paper– Outside of the child’s vision
• As they get older, ask child to perform tasks in a soft voice– May want to have a parent do it…– Avoid visual cues
• Use words that have meaning for them– Big Bird, Mickey Mouse, Barney
Child’s Hearing
Weber, Rinne, and Schwabach tests• Used only when a child
understands directions and can cooperate with the examiner– Usually 3-4 years of age
• Refer for audiometric screenings
Nose Exam
Inspect internal nose• Usually adequate to tilt the nose
tip upward– Largest otoscopic speculum may be
used• Visualization of larger area
“Adenoidal” or “Allergic Salute”
• Children often wipe their noses with an upward sweep of the palm of the hand– If repeated often enough, causes a
crease
• Transverse crease at the juncture between the cartilage and the bone of the nose
Sinuses – Child
• Maxilary sinuses should be palpated
• Few sinus problems occur since the sinuses are still developing– Wide variation however– Do not rule out sinusitis simply on the
basis of age
Child Mouth Exam
Getting cooperation• Let the child hold and manipulate
the tongue blade and light– Reduce fear of the procedure
• Start by asking to see their teeth– Usually not threatening
• Ask child to protrude the tongue and say “ ah”– Tongue blade is often
unnecessary
• Ask the child to pant “like a puppy”– Raises the palate
If child refuses to open mouth…
• Insert a tongue blade through the lips to the back molars
• Gently but firmly insert the tongue blade between the back molars and press the blade to the tongue
• This should stimulate the gag reflex– Gives you a brief view of the mouth
and oropharynx
Inspection
• Highly arched palate– Children who are chronic mouth
breathers
Why are they breathing through their mouth?
• Flattened edges on the teeth– Bruxism
• Unconscious grinding of the teeth
Why are they grinding?
• Baby bottle syndrome– Multiple brown areas (caries) on
upper and lower incisors– d/t bedtime bottle of juice/milk
• Black or grey colored teeth– Pulp decay– Oral iron therapy
• Mottled or pitted teeth– Tetracycline treatment during tooth
development– Enamel dysplasia
Tonsils• Should blend with the color of the
pharynx• Gradually enlarge to their peak size
between 2 - 6 years– should retain an unobstructed passage
• Graded to describe their size
Grading Tonsils
1+ -visible2+ -halfway
between tonsillar pillars and the uvula
3+ -nearly touching the uvula
4+ -touching each other
Common Abnormalities
Choanal Atresia
• Congenital nasal obstruction of the posterior nares– Junction between nasal
cavity and nasopharynx
• Newborns may experience respiratory distress– Obligatory nose breathers
*Will breathe when crying
Copyright © 2006 University of Washington.
Suckling Callus
• Newborn’s upper lips (other body parts)– First few weeks
• Plaques or crusts
Natal Teeth
• Teeth or tooth buds in a newborn
• If loose, potential for aspiration– May be removed
Retention Cystsaka Epstein Pearls
• Appear along the buccal margin
• Pearl-like retention cysts
• Disappear in 1-2 months
Macroglossia
• Abnormally large tongue
• Associated with congenital anomalies– Congenital hypothyroidism– Down Syndrome
Short Frenulum
Associated with• Feeding problems• Speech difficulties
Cleft Lip and Palate • Fissure in the upper lip and/or palate
– Congenital malformation
• Complete cleft– Extends through the lip and hard and
soft palates to the nasal cavity
• Partial Cleft– Any of the tissues
Long term issues:– feeding problems – chronic otitis media– hearing loss– speech difficulties– improper tooth development and
alignment
Otitis Externa (swimmer’s ear)
• Infection of the auditory canal
– trauma or moist environment • favor bacterial or fungal growth
• Initial Symptoms– Itching in the ear canal
• Pain– Intense with movement of pinna– Chewing
• Discharge– Watery, then purulent & thick mixed with pus and
epithelial cells– Musty, foul-smelling
• Hearing– Conductive loss caused by exudate and swelling of ear
canal• Inspection
– Canal is red, edematous; tympanic membrane obscured
Bacterial Otitis Media• Infection of the middle ear
– Often follows or accompanies an upper respiratory tract infection
Most common infection in childhood
• Initial Symptoms– Fever, feeling of blockage, tugging earlobe,
anorexia, irritability, dizziness, vomiting & diarrhea• Pain
– Deep-seated earache• Discharge
– Only if tympanic membrane ruptures or through tympanostomy tubes; foul-smelling
• Hearing– Conductive loss as middle ear fills with pus
• Inspection– Tympanic membrane may be red, thickened,
bulging; full, limited, or no movement to +/- pressure
Otitis Media with Effusion• Inflammation of the
middle ear resulting in the collection of liquid (effusion) – Serous, mucoid, or purulent
• Causes:– Allergies– Enlarged lymph tissue
(nasopharynx)– Obstructed or dysfunctional
eustachian tube
Once the obstruction occurs…• middle ear absorbs the air,
creating a vacuum
• mucosa secretes a transudate into the middle ear
Average duration: 23 days
• Initial Symptoms– Sticking or cracking sound on yawning or swallowing;
no signs of acute infection• Pain
– Uncommon; feeling of fullness• Discharge
– uncommon• Hearing
– Conductive loss as middle ear fills with fluid• Inspection
– Tympanic membrane is retracted, impaired mobility, yellowish; air fluid level and/or bubbles
Sinusitis• Infection of or more paranasal sinuses
– May be a complication of a viral URTI, dental infection, allergies, or a structural defect of the nose
– Blockage of the sinus meatus prevents drainage
Symptoms:– Fever, headache, local tenderness, and pain
Signs:– May be swelling of the skin overlying the
involved sinus and copious nasal discharge
• Children may alternatively suffer from:– upper respiratory symptoms– nasal discharge– low-grade fever– daytime cough– malodorous breath– cervical adenopathy– intermittent painless morning eye
swelling– NO facial pain or headache
Tonsillitis• Inflammation or infection of the
tonsils– Frequently caused by streptococci
Symptoms:– Sore throat, referred pain to the ears,
dysphagia, fever, fetid breath, and malaise
Signs:– Tonsils appear red and swollen;
purulent exudate• yellow follicles are associated
with streptococcal infection
– Anterior cervical lymph nodes enlarged
Peritonsillar Abscess• Infection of the tissue between the tonsil
and pharynx*Complication of tonsillitis
Symptoms:– Dyphagia, drooling, severe sore throat with
pain radiating to the ear, muffled voice, fever
Signs:– Tonsil, tonsillar pillar and adjacent soft palate
become red and swollen– Tonsil may appear pushed forward or
backward, possibly displacing the uvula
Epiglottitis
• Impending airway obstruction d/t acute inflammation of the epiglottis
• Though rare, it should always be considered!
Suspected with…• Sudden high fever• Croupy cough• Sore throat• Drooling• Apprehension• Focus on breathing
– Tripod position, neck extended
Caution!
• Inserting tongue blade may be deadly!– may result in complete airway
obstruction
• Treat this as a medical emergency• No one should examine the child’s
mouth until intubation equipment is available
Obstructive Sleep Apnea
• Periodic cessation of breathing during sleep d/t airflow obstruction– Can be seen in children with
excessively large tonsils
– Loud snoring, restless sleep– Daytime sleepiness– Morning headaches
Developmental delay Frequent infection