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Slide 1: Ears, Nose, Mouth, Throat
Slide 2: Ears
Slide 3: Anatomy   The ear is responsible for hearing and balance Consists of 3 regions    External ear Middle ear Inner ear
Slide 4: Structure and Function External Ear > auricle/pinna - movable cartilage covered with skin - Mastoid process= important Landmark   External Auditory Canal - S-shaped pathway leading to the ME - 2.5 to 3 cm. long in adult
Slide 5: - Its skeleton of bone and cartilage is covered with sensitive skin ( outer 1/3 is cartilage, inner 2/3 consists of bone) This canal lining is protected and lubricated with cerumen -
Slide 7: - Lymphatic drainage of the external ear flows into parotid , mastoid, superficial cervical nodes
Slide 9: MIDDLE EAR >air filled cavity in the temporal bone >It contains the ossicles ( malleus, incus,stapes) that transmit sound from the TM to the oval window of the inner ear
Slide 10: MIDDLE EAR >Tympanic membrane (eardrum) separates external and middle ear.     Translucent membrane Pearly, gray color Cone of light reflection when using otoscope Oval and slightly concave shape, pulled in at center by malleus
Slide 11: Middle ear >Openings to Outer ear covered by tympanic membrane Inner ear = oval and round windows Eustachian tube connects middle ear to the nasopharnyx for air passage (normally closed, opens with swallowing/yawning)
Slide 14: Middle ear has 3 functions 1. 2. 3. Conducts sound vibration from outer ear to inner ear Protects the inner ear by reducing the amplitude of loud sounds Eustachian tube allows equalization of air pressure on each side of the ear drum to avoid rupture ( high altitudes)
Slide 15: Inner Ear  Contains the Bony Labyrinth which holds the sensory organs for hearing and equilibrium 1. 2. 3. Vestibule Semicircular canals Cochlea (contains the central hearing apparatus)
Slide 17: Function of hearing  3 levels 1. Peripheral > ear transmits sound and converts its vibrations into electrical impulses > The electrical impulses are conducted by the auditory process of cranial nerve VIII (Acoustic) to the brain stem 1. 2. Amplitude=loudness Frequency=pitch
Slide 18:  Sound waves cause the eardrum to vibrate > Vibrations travel via the ossicles thru the oval window > the cochlea > to the round window where they are dissipated
Slide 19:  Vibrations in the basilar membrane of the cochlea that contain the organ of Corti receptor hair cells > translate the vibrations to electric impulses > The stimulated impulses go to the brainstem via Acoustic nerve (VIII)
Slide 20: 2. Brain stem permits identification of sound and locating the direction of a sound in space. Sensitive to intensity and timing from the ears depending on head position 3. Cerebral cortex - Intreprets the meaning of the sound and begins the appropriate response
Slide 21: Pathways of hearing 1. 2. Air conduction (AC)– normal pathway of hearing, the most efficient Bone conduction (BC)– bones of the skull vibrate and transmit vibrations to the inner ear and acoustic nerve
Slide 24: Physical Examination  The Auricle 1) inspect each auricle for size , shape, symmetry, color, position on the head, deformities, nodules and lesions 2) If ear pain, discharge or inflammation is present, move the auricle up and down
Slide 25: 3) Note tenderness of pinna and mastoid area. Press the tragus and press firmly behind the ear
Slide 26: Physical Examination Auricle -Extends slightly outward from the skull - Positioned in a nearly vertical plane - The origin of the helix should be on a horizontal line with corner of the eye - It should have the same color as the facial skin w/o moles, cysts & other lesions 
Slide 27: Otoscopic Exam 1) Tip the patient’s head to the opposite side 2)Grasp the auricle firmly but gently, while pulling it upward, backward and slightly outward 3)Insert into the canal, sl down and forward, the largest ear speculum that the canal will accommodate
Slide 31: 4) Observe the ff: - patency of the ear canal - describe the walls of the ear canal. Note any redness or swelling - identify any discharge, presence of cerumen or FB in the ear canal - tympanic membrane
Slide 32: Inspect using Otoscope  External canal     Color Swelling Lesions Discharge ; color and odor. Clean or change speculum before examining other ear.
Slide 33: Tympanic membrane     Color – normal is shiny, translucent, pearlgrey Landmarks ( umbo, handle of malleus, light reflex) Position – flat, slightly pulled in at the center and flutters when person holds nose and swallows Integrity of membrane – intact
Slide 35:  Perform the otoscope exam prior to hearing tests.
Slide 36: Hearing Evaluation  Rough quantitative test for hearing loss Whisper test Tuning fork  
Slide 37: Rough quantitative test for hearing loss - begins when the patient responds to your questions and directions. The patient responds without excessive requests for repetition - Speech with a monotonous tone and erratic volume may indicate hearing loss 
Slide 38: WHISPER TEST   Begins with the history-Conversational tone The following tests may indicate the presence of hearing loss but not the degree.
Slide 39:  Place your mouth at the side of the patient’s head ( 2 ft.) from her ear with the far ear covered Whisper test questions that can’t be answered by yes or no Test consistently with loud, medium and soft tones  
Slide 40:  Repeat on the opposite ear using another word, have the client identify the words (Used to detect high-tone loss)  Normal Response to Voice test  Correct identification of whispered words bilaterally
Slide 41: TUNING FORK TESTS  Measure hearing by air conduction and bone conduction Frequency of fork is 256-1024 cycles/sec. To activate the tuning fork, hold it by the stem and strike the tines softly on the back of the hand  
Slide 42: TUNING FORK TEST  Weber test > used when hearing is reported as better in one ear than the other ( bone conduction) > with normal neurosensory hearing and no conductive loss, the sounds are equal in both ears
Slide 43: > lateralization of the sound to one ear indicates a conductive loss on the same side or a perceptive loss/sensorineural loss on the other side
Slide 44:  Weber Test
Slide 45:  Rinne test – compares bone conduction and air conduction 1. 2. Normally sound is heard 2X as long by air conduction as by bone conduction Normal response ; positive Rinne Test = AC>BC Bilaterally Sound is heard longer by BC with a conductive loss.
Slide 46:  Rinne Test
Slide 47: Weber test Rinne test
Slide 48: Summary of any symptom should include PQRSTU      P= provocative or palliative Q= quality or quantity R= region or radiation S= severity scale T= timing (onset, duration, frequency)
Slide 49: Subjective data       Earaches Tinnitus Vertigo Dizziness Discharge Hearing loss
Slide 50: HISTORY Always ask the following:  Tinnitus –ringing in the ears causes: a.Outer ear- cerumen, foreign body,polyp in the external auditory canal b. Middle ear – inflammation ,otosclerosis c. Internal ear- fever, suppuration of the labyrinth, SY,acoustic nerve tumor
Slide 51: internal ear – fracture at the base of the skull, meniere syndrome d.Drugs quinine, salicylates, aminoglycosides, gentamicin
Slide 52:  Ear pain ( Otalgia ) - pain may arise from inflammation of structure in the ear or be referred from other pharyngeal sites including the thyroid
Slide 53: Causes: Auricletrauma,hematoma,frostbite,burn,eczema, lnsect bites, impetigo, herpes zoster External auditory canalotitis externa ,carbuncle, eczema, hard cerumen, FB, herpes zoster
Slide 54: Middle earacute otits media, acute mastoiditis Referred painunerrupted lower third molar, carious teeth, tonsillitis, carcinoma of pharynx, trigeminal neuralgia , subacute thyroiditis
Slide 55: Dizziness - patient has a sense of disturbed relation to space - described as being unsteady, weak, light headed or having the feeling of turning Causes: Endocrine hypothyroidism,pregnancy, hypoparathyroidism 
Slide 56: Idiopathic multisystem atrophy Infectious tabes dorsalis, meningitis, encephalitis, brain abscess Metabolic/ nutritional pellagra, Vit.B12 def.,fluid & electrolyte imbalance
Slide 57: Mechanical/trauma skull fracture, otosclerosis, eye muscle imbalance glaucoma Neoplastic Brain tumors Neurologic migraine, peripheral neuropathy Psychosocial anxiety disorder Vascular hypertension, orthostatic hypotension
Slide 58: Vertigo - persistent stimulation of the semicircular canals or vestibular nucleus when the head is at rest - It gives a hallucination of motion - When the eyes open, the pts.surrounding seems to be whirling or spinning - When the eyes closed, the pt.continues to feel in motion 
Slide 59: Causes: Peripheral labyrinthine System - otitis media with effusion, otosclerosis, temporal bone fracture Central labyrinthine system - migraine, cerebellar hemorrhage, intracranial abscess
Slide 60: Cranial V111 infections - Acute meningitis, tuberculous meningitis, tumors Brainstem nuclei - encephalitis, brain abscess, hemorrhage, multiple sclerosis
Slide 61: Hearing loss a. Conductive- seen in people with external or middle ear problem Causes: -obstruction of external auditory canal (FB, impacted cerumen) - Disorder of the eardrum & middle ear ( perforated TM, pus/blood in the ME ) - Overgrowth of bone with fixation of the stapes ((Otosclerosis) 
Slide 62: b. Sensorineural hearing loss ( Perceptive) - involves the inner ear Causes: - disorders of the cochlea or the acoustic nerve (CN 8) - Aging ( Presbycusis ) due to nerve degeneration - Trauma - Drug toxicity - Tumors - infections - Heredity/congenital deafness
Slide 63: EAR SIGNS  a) EXTERNAL EAR Malformations of the Pinna microtia – smaller than normal macrotia – unusually large lop or bat ear- pinna may protude at R angle aztec or cagot ear – failure of development of the lobule
Slide 64: Macrotia or large ear Before Surgery After Surgery
Slide 65: Before Surgery After surgery
Slide 66: Lop or Bat ear - pinna may protrude at right angle
Slide 67: Lop or Bat Ears
Slide 68: satyr ear- pointed pinna cauliflower ear- untreated hematomas heal as nodular and bulbous irregularities of the helix and and antihelix - result of blunt trauma and necrosis of the underlying cartilage
Slide 69: Cauliflower Ears
Slide 70: b) Pinna nodule Darwin tubercle- harmless developmental eminence in the upper 3rd of the posterior helix Gouty tophus – small, whitish uric acid crystals along the peripheral margins of the auricles, olecranon bursa, tendon sheaths - nodules are painless ,hard, and irregular
Slide 71: Gouty deposits
Slide 72: b)External acoustic meatus Cerumen Impaction - due to excessive production of wax or a narrowed meatus leads to partial or complete obstruction of the canal - complete obstruction leads to partial deafness acc. by tinnitus or dizziness
Slide 73: Otorrhea( ear discharge) yellow discharge- melted cerumen serous discharge- eczema in the meatal wall, early ruptured acute OM bloody discharge- temporal bone fracture purulent discharge- chronic external otitis, chronic suppurative OM, cholesteatoma, TB, polyps
Slide 74: Foreign body Insect invaders Polyps Furuncle
Slide 75:  Tympanic membrane Retracted Tympanic membrane : - Seen in Serous Otitis media - more concave TM - accentuated bony landmarks - distorted light reflex
Slide 76: Normal Tympanic Membrane Retracted Tympanic Membrane
Slide 77: Bulging Tympanic membrane: - seen in Acute suppurative otitis media - more conical - loss of bony landmarks - distorted light reflex
Slide 78: Normal Tympanic Membrane Bulging Tympanic Membrane
Slide 79: Perforated Tympanic membrane: - previous suppurative middle ear infection has eroded thru the membrane producing holes - perforation appears as oval holes thru which the darkened middle ear cavity is seen
Slide 80: Perforated Tympanic Membrane
Slide 81: Perforated Tympanic Membrane
Slide 82: COMMON DISORDERS OF THE EAR  Otitis Externa a) Acute external otitis -due to Ps.aeruginosa, staph,strep,proteus - pain maybe mild or severe accentuated by movement of the pinna - swimmers’ ear - preauricular, postauricular , Ant cervical LN
Slide 83: b) Chronic external otitis - commonly due to bacteria and fungal - pruritus is the main complain instead of pain - aural discharge maybe present
Slide 84: Otitis Media a) Chronic suppurative otitis media - ass. with permanent perforation of the eardrum -hearing is always impaired - painless aural discharge - pain and vertigo indicates development of complications like brain abscess 
Slide 85: b) Cholesteatoma - collection of desquamated epithelial cells in the middle ear - foul smelling discharge, marginal perforation,hearing loss, pearly gray mass superior part of tympanic membrane - eustachian tube dysfunction causes retraction of tympanic membrane
Slide 86: Vertiginous disorder a) Acute Labyrinthitis - most frequent cause of vertigo - patient gradually develop a sense of whirling that reaches a climax in 24-48 hrs. disappear gradually in 3-6 wks. - N/V may occur at the height of symptoms - no accompanying tinnitus or hearing loss 
Slide 87: b) Benign Paroxysmal positional Vertigo (BPPV) - Calcium deposits in the labyrinth ( otoliths) are dislodged and move in response to gravity eliciting a feeling of motion - More common in older individuals - Sudden onset, often when rolling over in bed or arising in the morning - No headaches/fever but with nausea and inability to stand - Avoid any head motion to lessen symptoms
Slide 88: Thank You
Slide 89: Nose, Throat and Mouth
Slide 90: Nose  First segment of the respiratory system Warms, moistens and filters inhaled air Sensory organ for smell Resonance of laryngeal sound   
Slide 92: External parts       Bridge – frontal and maxillary bones Tip Nares – anterior openings of the nos Columella - divides the nares Ala nasi –lateral outside wing of the nose bilaterally Upper 1/3 nose is bone; rest is cartilage
Slide 93: Internal Nasal cavity -floor of the nose ( hard and soft palate) - roof of the nose ( frontal and sphenoid bone)  Nasal hair  Nasal Septum-divides cavity into 2 passages  Nasal turbinates 
Slide 94: Internal  Superior, middle, inferior turbinates- 3 parallel bony projections on lateral walls of each cavity Meatus- cleft/ groove underlying each turbinate. 
Slide 95:  Inspired air enters thru the nares > passes thru the vestibule> to the choanae which are posterior openings > leading to the nasopharynx
Slide 96: Internal  Olfactory receptors - roof of the nasal cavity & upper part of septum above the superior turbinate. -merge into the olfactory nerve (I) > goes to the temporal lobe of the brain Kiesselbach plexus - a vascular network located superficially on the anterior superior portion of the septum - site of most anterior nosebleeds 
Slide 98: SINUSES  Paranasal sinuses - air-filled paired extensions of the nasal cavities within the bones of the skull - lined with mucous membranes and cilia that move secretions along excretory pathways - sinus openings are narrow, susceptible to occlusion> resulting in inflammation /sinusitis. - drained into the medial meatus
Slide 99:  Purpose  Serve as resonators for sound  Provide mucous for the nasal cavity Types: 1. 2. 3. 4. Frontal sinuses Maxillary sinuses Ethmoid sinuses Sphenoid sinuses Frontal & Maxillary sinuses are accessible to examination
Slide 102: Physical Examination
Slide 103:  Nose – Inspect and palpate INSPECT for:        Symmetry, deformity Inflammation Skin lesions Color Nasal flaring discharges
Slide 104:  Palpate - ridge & soft tissues of the nose - note any displacement of the bone, cartilage - note for tenderness & any mass - The nasal structures should be firm and stable to palpation - if with injury, palpate gently
Slide 105:  Test for sense of smell (CN 1) Evaluate the patency of the nose - nasal breathing should be noiseless and easy thru the open nares 
Slide 106: Nasal Cavity  a) Use the nasal speculum and good light source to inspect the nasal cavity Nasal mucosa - inspect for color, discharge, lesions, masses - it should appear deep pink ( pinker than the buccal mucosa) & glistening
Slide 107: b) nasal septum - In normal adult, the nasal septum is seldom precisely a midline structure - No perforations, bleeding or crusting should be apparent - a film of clear discharge is often apparent on the nasal septum
Slide 108: c) Nasal Turbinates - only the inferior and middle turbinates will be visible - it should be the same color as the surrounding area and have a firm consistency
Slide 110:  Paranasal Sinuses: Inspect and Palpate  Press thumbs over frontal & maxillary sinuses ( palpate the cheeks and supraorbital ridges) No tenderness or swelling over the soft tissue should be present 
Slide 111:  Transillumination test a) Frontal & Maxillary sinuses b) nasal septum - Best perform in a dark room Look for a bright light in the supraorbital ridge and maxilla - Look for deviation, perforation, masses in the transilluminated septum
Slide 116: SYMPTOMS  Loss of smell ( anosmia ) - lesion of CN 1 or nasal obstruction - commonly due to closed head trauma - invariably accompanied by a perceived change in taste of food ( bland & unpalatable)
Slide 117:  Abnormal smell/ taste ( dysgeusia) - this is a common complaint in patients who have loss of smell - if it is paroxysmal and associated with behavioral symptoms, it suggests complex partial seizures
Slide 118: SIGNS SKIN LESIONS
Slide 119: Basal Cell Carcinoma
Slide 120: SIGNS  Discharge - Describe discharge as to its character ( watery, mucoid, purulent , bloody) - color ( greenish, whitish, bloody) - bilateral or unilateral
Slide 121:   Running Nose
Slide 123: . 1.Unilateral - Choanal atresia - Foreign body- foul purulent discharge - neoplasm – bloody discharge - Head injury or surgery – clear spinal fluid 2. Bilateral - allergy - infection ( upper respiratory)
Slide 124: Foreign Body
Slide 125: . Unilateral - Choanal atresia - Foreign body - neoplasm - Head injury or surgery
Slide 126:  Epistaxis ( nosebleed) -Kiesselbach plexus – most common site of bleeding anteriorly - Back 3rd of the Inferior Meatus – most common site posteriorly
Slide 127: Causes: 1. Local - coughing - sneezing - nose pricking - fracture - foreign bodies
Slide 128: 2. Generalized - Congenital – hereditary telangiectasia - inflammatory/immune – wegener granulomatosis - infectious – typhoid fever, dengue, diphtheria - Metabolic/toxic – aspirin, scurvy
Slide 129: - Mechanical – change in atmospheric pressure ( mountain climbing, flying), exertion Neoplastic – nasopharyngeal Ca leukemia vascular- hemophilia, thrombocytopeni - -
Slide 130: - trauma- nasal and maxillary fracture Elevated venous pressure- Cor pulmonale Congestive Heart failure Elevated arterial pressure – HPN, coarctation of aorta - -
Slide 131:  Nasal septum a) Deviation - the cartilagenous and bony septum may deviate as a hump, spur, shelf to enroach on one nasal chamber occlusion causing obstruction
Slide 132: b) Perforation - a hole in the nasal septum (transillumination test) is commonly caused by chronic infection, nasal surgery, repeated trauma in picking off crusts, cocaine abuse - rarely due to SY, TB
Slide 133: Nasal Septum Perforation
Slide 134: Nasal Syndromes  - Acute Rhinitis ( infectious) ( common cold) Rhinoviruses infect the mucous membranes of the nose & sinuses causing inflammation and inc. nasal secretions - Watery nasal discharge, sneezing, discharge becomes purulent acc. by fever and body malaise
Slide 135: - Symptoms 3-10 days Severe local pain suggest a complicationbacterial sinusitis -
Slide 136:  Allergic rhinosinusitis - itching of the nose & eyes, rhinorrhea, lacrimation, sneezing - headache is common - maybe seasonal or perennial - common allergens are pollens, molds, house dust, mites, coachroach, animal danders
Slide 137:  Vasomotor Rhinitis - nonallergic mucosal edema and rhinorrhea ass. with vasodilatation of the nasal vessels, mucosal edema & inc. mucous production - due to chronic environmental irritants ( dust , smoke, strong odor, cold air), pregnancy, estrogens, progesterone
Slide 138:  Suppurative Paranasal Sinusitis - due to Strep. pneumonia, H. influenza - severe pain in the face occuring 7-14 days after signs & symptoms of an acute URTI - pain & pressure without fever suggest sinus obstruction requiring decongestants
Slide 139: Cavernous Sinus Thrombosis -This is the most feared complication of nasal infections. It can cause blindness or death - Infection spreads from the nose>angular veins> cavernous sinus> septic thrombosis 
Slide 140: -patient complains of pain deep in the eyes - Both eyes are involved, immobilization of the globes, periorbital edema, chemosis - May involve CN 3,4, &6 Sudden chills, high fever, prostated, comatose, death within 2-3 days -
Slide 141: THANK YOU
Slide 142: THANK YOU
Slide 143: Mouth    First segment of the digestive system Airway for the respiratory system ORAL CAVITY   Lips Palate 1. 2. 3. Hard Soft Uvula – hangs down from the soft palate
Slide 144:  Cheeks- side walls of cavity Tongue 1. 2. 3.  Papillae- rough, bumpy elevations on dorsal Frenulum Taste buds  Teeth – 32 permanent
Slide 146:  Salivary glands 1. 2. 3. Parotid- largest of the glands, located in the cheeks, front of the ear. Stenson’s duct opens in buccal mucosa Submandibular- walnut size, beneath the mandible at the angle of the jaw. Wharton’s duct either side of the frenulum Sublingual –smallest, almond shape, under tongue
Slide 148: Throat  Area behind the mouth & nose Oropharynx – separated from the mouth by a fold of tissue on each side called anterior tonsillar pillars Tonsils – lymphoid tissue behind pillars  
Slide 149:  Posterior pharyngeal wall located behind the tonsils Nasopharynx continues from the oropharynx but it is above it and behind the nasal cavity. -It holds the adenoids and the eustachian tube openings. 