Mosby's Guide to Physical Examination, 7th Edition

CHAPTER 8. Ears, Nose, and Throat

EQUIPMENT

image Otoscope with pneumatic attachment

image Tuning fork (512-1024 Hz)

image Nasal speculum

image Tongue blades

image Gloves

image Gauze

image Penlight, sinus transilluminator, or light from otoscope

EXAMINATION

Have patient sit.

TECHNIQUE

FINDINGS

EARS

Inspect auricles and mastoid area

Examine lateral and medial surfaces and surrounding tissue.

 

image

 

imageSize/shape/symmetry

EXPECTED:Familial variations. Auricles of equal size and similar appearance. Darwin tubercle.

UNEXPECTED:Unequal size or configuration. Cauliflower ear and other deformities.

imageLesions

UNEXPECTED:Moles, cysts or other lesions, nodules, or tophi.

imageColor

EXPECTED:Same color as facial skin.

UNEXPECTED:Blueness, pallor, or excessive redness.

imagePosition

Draw imaginary line between inner canthus and most prominent protuberance of occiput. Draw imaginary line perpendicular to first line and anterior to auricle.

EXPECTED:Top of auricle touching or above horizontal line. Vertical position.

UNEXPECTED:Auricle positioned below line (low-set); unequal alignment. Lateral posterior angle greater than 10 degrees.

imagePreauricular area

EXPECTED:Preauricular pits, skin tags, or smooth skin.

UNEXPECTED:Openings in preauricular area, discharge.

imageExternal auditory canal

EXPECTED:No discharge, no odor; canal walls pink.

UNEXPECTED:Serous, bloody, or purulent discharge; foul smell.

Palpate auricles and mastoid area

 

EXPECTED:Firm and mobile, readily recoils from folded position; no tenderness in postauricular or mastoid area.

UNEXPECTED:Tenderness, swelling, nodules. Pain when pulling on lobule.

Inspect auditory canal with otoscope

 

EXPECTED:Minimal cerumen in varying color and texture. Uniformly pink canal. Hairs in outer third of canal.

UNEXPECTED:Cerumen obscures tympanic membrane, odor, lesions, discharge, scaling, excessive redness, foreign body.

Inspect tympanic membrane

imageLandmarks

Vary light direction to observe entire membrane and annulus.

EXPECTED:Visible landmarks (umbo, handle of malleus, light reflex).

UNEXPECTED:Perforations, landmarks not visible.

imageColor

EXPECTED:Translucent, pearly gray.

UNEXPECTED:Amber, yellow, blue, deep red, chalky white, dull, white flecks, or dense white plaques; air bubbles or fluid level.

Tympanic membrane. From Barkauskas et al, 2001.

image

 

Contour

EXPECTED:Slightly conical with concavity at umbo.

UNEXPECTED:Bulging (more conical, usually with loss of bony landmarks and distorted light reflex) or retracted (more concave, usually with

 

accentuated bony landmarks and distorted light reflex).

Mobility

Seal canal with speculum, and gently apply positive (squeeze) and negative (release) pressure with pneumatic attachment.

EXPECTED:Movement in and out.

UNEXPECTED:No movement.

Assess hearing

imageQuestions during history

EXPECTED:Responds to questions appropriately.

UNEXPECTED:Excessive requests for repetition. Speech with monotonous tone and erratic volume.

imageWhispered voice

Have patient mask hearing in one ear by inserting a finger in ear canal. Stand 1 to 2 feet from other ear and softly whisper three letter and number combinations (e.g., 3, T, 9 or 5, M, 2). Use a different letter number combination in other ear.

EXPECTED:Patient repeats numbers and letters correctly more than 50% of time.

UNEXPECTED:Patient unable to repeat whispered words.

imageWeber test

Place base of vibrating tuning fork on midline vertex of head. Repeat with one ear occluded.

EXPECTED:Sound heard equally in both ears (unoccluded). Sound heard better in occluded ear.

UNEXPECTED:See table on p. 84.

Weber test.

image

 

Interpretation of Tuning Fork Tests

 

Weber Test

Rinne Test

Expected findings

No lateralization but will lateralize to ear occluded by patient

Air conduction heard longer than bone conduction by 2 : 1 ratio (Rinne positive)

Conductive hearing loss

Lateralization to deaf ear unless sensorineural loss

Bone conduction heard longer than air conduction in affected ear (Rinne negative)

Sensorineural hearing loss

Lateralization to better-hearing ear unless conductive loss

Air conduction heard longer than bone conduction in affected ear, but less than 2 : 1 ratio

imageRinne test

Place base of vibrating tuning fork against mastoid bone, note seconds until sound is no longer heard; then quickly move fork 1 to 2 cm (image to 1 inch) from auditory canal and note seconds until sound is no longer heard. Repeat with other ear.

EXPECTED:Measurement of air-conducted sound twice as long as measurement of bone- conducted sound.

UNEXPECTED:See table below.

Rinne test. A, Tuning fork against mastoid bone. B, Tuning fork near ear.

image image

 

TECHNIQUE

FINDINGS

NOSE AND SINUSES

Inspect external nose

imageShape/size

EXPECTED:Smooth. Columella directly midline, width is not greater than diameter of naris.

UNEXPECTED:Swelling or depression of nasal bridge. Transverse crease at junction of nose cartilage and bone.

imageColor

EXPECTED:Conforms to face color.

imageNares

EXPECTED:Oval. Symmetrically positioned

UNEXPECTED:Asymmetry, narrowing, discharge, nasal flaring on inspiration.

Palpate ridge and soft tissues of nose

Place one finger on each side of nasal arch and gently palpate from nasal bridge to tip.

EXPECTED:Firm and stable structures.

UNEXPECTED:Displacement of bone and cartilage, tenderness, or masses.

Evaluate patency of nares

Occlude one naris with finger on side of nose, ask patient to breathe through nose. Repeat with other naris.

EXPECTED:Noiseless, easy breathing.

UNEXPECTED:Noisy breathing; occlusion.

Inspect nasal mucosa and nasal septum

Tilt patient’s head toward opposite shoulder. Gently insert speculum without overdilating naris.

 

imageColor

EXPECTED:Mucosa and turbinates deep pink and glistening.

 

UNEXPECTED:Increased redness of mucosa or localized redness and swelling in vestibule. Turbinates bluish gray or pale pink.

imageShape

EXPECTED:Septum close to midline and fairly straight, thicker anteriorly than posteriorly. Inferior and middle turbinates visible.

UNEXPECTED:Asymmetry of posterior nasal cavities, septal deviation.

imageCondition

EXPECTED:Possibly film of clear discharge on septum. Possibly hairs in vestibule. Turbinates firm consistency.

UNEXPECTED:Discharge, bleeding, crusting, masses, or lesions. Swollen, boggy turbinates. Perforated septum. Polyps.

SENSE OF SMELL

See Chapter 18.

 

Inspect frontal and maxillary sinus area

 

UNEXPECTED:Swelling.

Sinuses.

image

 

TECHNIQUE

FINDINGS

Palpate frontal and maxillary sinuses

Press thumbs up under bony brow on each side of nose. Palpate with thumbs or index and middle fingers under zygomatic processes.

EXPECTED:Nontender on palpation.

UNEXPECTED:Tenderness or pain, swelling.

MOUTH

Inspect and palpate lips with mouth closed

Have patient remove lipstick (if applicable).

 

imageSymmetry

EXPECTED:Symmetric vertically and horizontally at rest and while moving.

UNEXPECTED:Asymmetric.

imageColor

EXPECTED:Pink in whites, bluish in individuals of darker skin, distinct border between lips and facial skin.

UNEXPECTED:Pallor, circumoral pallor, bluish purple, or cherry red.

imageCondition

EXPECTED:Smooth.

UNEXPECTED:Dry, cracked; deep fissues in mouth corners, swelling; lesions; plaques; vesicles; nodules, ulcerations; or round, oval, or irregular bluish gray macules.

Inspect teeth

imageOcclusion

Have patient clench teeth and smile with lips spread.

EXPECTED:Upper molars interdigitate with groove on lower molars. Premolars and canines interdigitate fully. Upper incisors slightly override lower incisors.

UNEXPECTED:Malocclusion. Protrusion of lower incisors. Problems with bite.

Teeth occlusion line. From Miyasaki-Ching, 1997.

image

 

imageColor

EXPECTED:Ivory, stained yellow or brown.

UNEXPECTED:Discolorations on crown may indicate caries.

imageCondition

EXPECTED:32 teeth, firmly anchored.

UNEXPECTED:Caries and loose or missing teeth.

Inspect buccal mucosa

Have patient remove any dental appliances and then partially open mouth. Use tongue blade and bright light to assess.

 

imageColor

EXPECTED:Pinkish red, patchy pigmented mucosa in individuals with dark skin.

UNEXPECTED:Deeply pigmented. Whitish or pinkish scars.

imageCondition

EXPECTED:Smooth and moist. Whitish yellow or whitish pink Stensen duct. Fordyce spots.

UNEXPECTED:Adherent thickened white patch; white, round, or oval ulcerative lesions; red spot at opening of Stensen duct; stones or exudate from Stensen duct.

Inspect and palpate gingiva

Use gloves to palpate.

 

imageColor

EXPECTED:Slightly stippled and pink, may be more hyperpigmented in individuals with dark skin.

UNEXPECTED:Blue-black line about 1 mm from gum margin.

imageCondition

EXPECTED:Clearly defined, tight margin at each tooth. Gingival enlargement with pregnancy and puberty.

UNEXPECTED:Inflammation, swelling, bleeding, or lesions under dentures or on gingiva; induration, thickening, masses, or tenderness. Enlarged crevices between teeth and gum margins. Pockets containing debris at tooth margins.

Inspect tongue

imageSize/symmetry

Ask patient to extend tongue.

EXPECTED:Midline, no fasciculations.

UNEXPECTED:Atrophied, deviation to one side.

imageColor

EXPECTED:Dull red.

imageDorsum surface

Have patient extend tongue and hold extended.

EXPECTED:Moist and glistening. Anterior: Smooth yet roughened surface with papillae and small fissures. Posterior: Smooth, slightly uneven or rugated surface with thinner mucosa than anterior. Possibly geographic.

UNEXPECTED:Smooth, red, slick; hairy; swollen; coated; ulcerated; fasciculations; or limitation of movement.

imageVentral surface and floor of mouth

Have patient touch tip of tongue to palate behind upper incisors.

EXPECTED:Ventral surface pink and smooth with large veins between frenulum and fimbriated folds. Wharton ducts apparent on each side of frenulum.

UNEXPECTED:Difficulty touching hard palate. Swelling, Varicosities, ranula (mucocele).

imageLateral borders

Wrap tongue with gauze and pull to each side. Scrape white or red margins to remove food particles.

UNEXPECTED:Any fixed white or red margins. Leukoplakia, ulceration, induration.

Inspecting lateral border of tongue.

image

 

Palpate tongue and floor of mouth

 

EXPECTED:Smooth and even texture.

UNEXPECTED:Lumps, nodules, induration, ulcerations, or thickened white patches.

Inspect palate and uvula

Have patient tilt head back.

 

imageColor and landmarks

EXPECTED:Hard palate (whitish and dome shaped with transverse rugae) contiguous with pinker soft palate. Uvula at midline. Bony protuberance of hard palate at midline (torus palatinus).

UNEXPECTED:Nodule on palate, not at midline.

imageMovement

Ask patient to say “ah” while observing soft palate. (Depress tongue if necessary.)

EXPECTED:Soft palate rises symmetrically, with uvula remaining in midline.

UNEXPECTED:Failure of soft palate to rise bilaterally. Uvula deviation. Bifid uvula.

Inspect oropharynx

Depress tongue with tongue blade.

 

imageTonsils

Inspect the tonsillar pillars and size of tonsils.

EXPECTED:Tonsils, if present, blend into pink color of pharynx. Possible crypts in tonsils where cellular debris and food particles collect.

UNEXPECTED:Tonsils projecting beyond limits of tonsillar pillars. Tonsils red, enlarged, covered with exudate.

imagePosterior wall of pharynx

EXPECTED:Smooth, glistening, pink mucosa with some small, irregular spots of lymphatic tissue and small blood vessels.

UNEXPECTED:Red bulge adjacent to tonsil extending beyond midline. Yellowish mucoid film in pharynx.

Elicit gag reflex

Prepare patient and touch posterior wall of pharynx on each side.

EXPECTED:Bilateral response.

UNEXPECTED:Unequal response or no response.

AIDS TO DIFFERENTIAL DIAGNOSIS

image

Pediatric Variations

EXAMINATION

TECHNIQUE

FINDINGS

EARS

Inspect tympanic membrane

In infants, pull auricle downward and back to straighten canal.

EXPECTED:Tympanic membrane may be red from crying. If red from crying, it will be mobile.

Assess hearing

imageEvaluate response to auditory stimuli (bell, clapped hands, tissue paper)

EXPECTED:For infants, see table on p. 95. Young children should turn toward sound consistently.

Sequences of Expected Hearing and Speech Response in Infants

Age

Response

Birth to 3 months

Startles, wakes, or cries when hearing a loud sound; quiets to parent’s voice; makes vowel sounds “oh” and “ah.”

4 to 6 months

Turns head toward interesting sound; moves eyes in direction of sound but may not always recognize location of sound; responds to parent’s voice; enjoys sound-producing toys; starts babbling with many speech sounds

7 to 12 months

Responds to own name, telephone ringing, and person’s voice, even if not loud; begins localizing sounds above and below; turns eyes and head toward sound; babbles with short and long strings of sounds; begins to imitate speech sounds; correctly uses mama and dada.

Modified from American Speech Language and Hearing Association (2008). Birth to one year: How does your child hear and talk, retrieved June 23, 2008, from www.asha.org/public/speech/development/01.htm.

TECHNIQUE

FINDINGS

NOSE AND SINUSES

Evaluate patency of nares With infant’s mouth closed or with infant sucking on bottle or pacifier, occlude one naris and then the other. Observe respiratory pattern.

EXPECTED:Breathes easily; obligatory nose breathing until 2 to 3 months of age.

Pediatric sinuses.

image

 

MOUTH

Inspect and palpate lips with mouth closed

 

EXPECTED:Drooling in infants ages 6 weeks to 6 months, sucking calluses in newborns.

UNEXPECTED:Drooling persistent after age 6 months not associated with teething.

Inspect teeth

imageColor

EXPECTED:0 to 20 teeth until age 6 years. Permanent teeth start erupting around age 6 years.

UNEXPECTED:Natal teeth.

Inspect buccal mucosa

imageCondition

EXPECTED:In infants, nonadherent white patches (milk).

UNEXPECTED:In infants, adherent white patches.

Inspect and palpate gingiva

imageCondition

EXPECTED:In infants up to 2 months, pearl-like retention cysts.

Inspect and palpate hard palate

imageCondition

EXPECTED:Strong suck and Epstein pearls in young infants.

UNEXPECTED:No cleft of hard or soft palate.

AIDS TO DIFFERENTIAL DIAGNOSIS

ABNORMALITY

DESCRIPTION

Cleft lip and palate

Subjective Data:Difficulty sucking, failure to gain weight.

Objective Data:Unilateral or bilateral fissure or cleft in lip, hard palate, or soft palate that extends into the nasal cavity.

SAMPLE DOCUMENTATION

Subjective.A 55-year-old man has concerns about hearing loss for the past few months; it is particularly difficult to hear people talking. He has difficulty hearing on phone and when in conversations with multiple people talking. He hears “noise” in both ears when trying to go to sleep at night. There is no ear pain or discharge, no nasal discharge or sinus pain, no mouth lesions or masses, no recent dental problems, no sore throat and no head trauma or exposure to ototoxic medications.

Objective.Ears: Auricles in alignment; lobes without masses, lesions, or tenderness. Canals totally obstructed by cerumen bilaterally. After irrigation, tympanic membranes are pearly gray, noninjected, intact, with bony landmarks and light reflex visualized bilaterally. No evidence of fluid or retraction. Conversational hearing appropriate. Able to hear whispered voice. Weber—lateralizes equally to both ears; Rinne—air conduction greater than bone conduction bilaterally (30 seconds/15 seconds).

Nose: No discharge or polyps, mucosa pink and moist, septum midline, patent bilaterally. No edema over frontal or maxillary sinuses. No sinus tenderness to palpation.

Mouth: Buccal mucosa pink and moist without lesions. Twenty-six teeth present in various states of repair. Lower second molars (18, 30) absent bilaterally. Gingiva pink and firm. Tongue midline with no tremors or fasciculation. Pharynx clear without erythema; tonsils 1+ without exudate. Uvula rises evenly, and gag reflex is intact. No hoarseness.