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356 PHYSICAL EXAMINATION

Upper jaw (maxilla) Lower jaw (mandible)

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UNIT 2

Incisors

Canines

Premolars

Molars

FIGURE 11.8 Permanent teeth

Mandibular archMaxillary arch

ASSESSMENT: TAKING THE CONSUMER’S HEALTH HISTORY

Assessment is the ﬁrst phase of the nursing process, and involves collecting subjective information about the consumer’s health status in order to identify consumer problem areas to focus on.

Subjective data is most frequently collected during a health history and serves

as the starting point for the health professional to base the depth of their assessment on.

The sections for the health history include:

> Consumer prole > Chief complaint (explained systematically using variations of location, quality,

quantity, associated manifestations, aggravating factors, alleviating factors, setting and timing. This is a variation on the OPQRST assessment mnemonic you may use for other conditions like pain assessment)

> Past health history (including medical history, surgical history, allergies,

medications, injuries and accidents, special needs and childhood illnesses)

> Family health history Social history (including alcohol, tobacco and drug use, sexual practice, work

and home environment, hobbies and leisure activities, stress and culture).

HEALTH HISTORY

CONSUMER PROFILE

The ears, nose, mouth and throat health history provides insight into the link between a consumer’s life and lifestyle and ears, nose and sinuses, mouth and throat information and pathology. Diseases or changes that are age-, sex- and race-specic for the ears, nose, mouth and throat are listed.

AGE EARS > Elderly consumers:

NOSE > Elderly consumers:

MOUTH AND THROAT Orthodonture

• Hearing loss related to presbycusis, sensorineural

degeneration or otosclerosis

• Excessive or impacted cerumen

• Decrease in ability to smell

> Elderly consumers:

• Tooth loss and gum disease

• Candidiasis related to immunosuppression

• Decrease in ability to taste

EARS, NOSE, MOUTH AND THROAT 357

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SEX EARS Female: Calcications of the ossicles

NOSE AND SINUSES Male: Rhinophyma, deviated septum related to trauma, polyps

Female: polyps

MOUTH AND THROAT Male: Singer’s nodule on the larynx (over 30), cancer of the

larynx, leukoplakia of the tongue, gums, and buccal mucosa

CHAPTER 11

CHIEF COMPLAINT

CULTURAL BACKGROUND

Common chief complaints for the ears, nose, mouth and throat are dened, and information on the characteristics of each sign or symptom is provided.

EAR

1. CHANGE IN OR LOSS OF HEARING

CHINESE > Nasopharyngeal cancer

INDIVIDUALS FROM MEDITERRANEAN COUNTRIES, SOUTH-EAST ASIA, INDONESIA, SOUTH AMERICA

Reduction in the perception of sound

LOCATION Unilateral, bilateral

QUALITY Loud sounds heard, soft sounds heard

QUANTITY Partial or complete

ASSOCIATED MANIFESTATIONS

AGGRAVATING FACTORS Loud noises, excessive or impacted cerumen, swimming

ALLEVIATING FACTORS Hearing aid, removal of excessive cerumen, turning up

SETTING Work (jobs with loud background noise or machinery)

> Rhinoscleroma

Tinnitus, vertigo, drainage, swelling, fever, ear pain

volume when possible, cupping the ear, facing the speaker

TIMING Constant or intermittent, after drug therapy, onset sudden,

2. OTORRHOEA Drainage of liquid from the ear

LOCATION Unilateral or bilateral

QUALITY Painful or nontender, watery, bloody or purulent, foul odour

ASSOCIATED MANIFESTATIONS

AGGRAVATING FACTORS Upright or supine position

ALLEVIATING FACTORS Upright or supine position

TIMING Following trauma, continuous, intermittent

3. OTALGIA Discomfort in the ear

LOCATION Unilateral or bilateral, in jaw region, in pinna region

QUALITY Aching, dull, sharp

ASSOCIATED MANIFESTATIONS

AGGRAVATING FACTORS Tooth infection, upper respiratory infection, perforated

gradual, or slow

Hearing loss, headache, fever, vertigo, upper respiratory infection

Drainage, tinnitus, dysphagia, sore throat, vertigo, diminished hearing

tympanic membrane, insect bites in the ear, upright or supine position, objects in ear, change in air pressure

358 PHYSICAL EXAMINATION

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UNIT 2

4. TINNITUS ‘Ringing’ in the ears

ALLEVIATING FACTORS Analgesics, upright or supine position, avoiding swimming,

avoiding pressure changes, removal of objects, change in air pressure

SETTING Outdoors, high altitudes, noisy environments

TIMING Continuous, intermittent; after swimming, following trauma

to the head or ear, following loud noises, after pressure changes, ying

LOCATION Unilateral or bilateral

QUALITY Pulsatile, buzzing, high-pitched ringing

ASSOCIATED MANIFESTATIONS

AGGRAVATING FACTORS Medications, uid in the middle ear, perforation of the

ALLEVIATING FACTORS Discontinuing medications, position change,

SETTING Work (high noise levels), outdoors

TIMING Longstanding, recent; constant, intermittent; following drug

NOSE AND SINUSES

1. PAIN Discomfort in the nose and sinuses

QUALITY Aching, throbbing, sharp

ASSOCIATED MANIFESTATIONS

AGGRAVATING FACTORS Exposure to allergens, decreased humidity indoors,

ALLEVIATING FACTORS Use of medications (decongestant or antihistamine),

Vertigo, drainage, pain, nausea, fullness or pressure in the ears, hearing loss, upper respiratory infection, allergies, middle ear infection, inner ear lesions, eustachian tube inammation

tympanic membrane, position, pressure on the neck, excessive cerumen

avoiding allergens

therapy, after exposure to loud noises

Fever, chills, visual changes, swelling, sneezing, nasal discharge

cocaine use

removal of allergens, humidication of the environment, discontinuation of cocaine

2. DRAINAGE/RHINITIS Excessive discharge of nasal secretions

SETTING Outdoors, dry heat, low humidity

TIMING Seasonal, in the morning

QUALITY Unilateral or bilateral, amount, viscosity, colour, odour,

blood-tinged

ASSOCIATED MANIFESTATIONS

AGGRAVATING FACTORS Allergens, infections

ALLEVIATING FACTORS Medication, hydration, avoiding allergens

SETTING Outdoors, indoors

TIMING In the morning, seasonal, after trauma

Fever, sneezing, pain, mouth breathing, swelling, skin irritation around drainage site, itchy eyes

EARS, NOSE, MOUTH AND THROAT 359

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3. BLOCKAGE OR CONGESTION

4. LOSS OF SMELL Loss or alteration or reduction in smell function secondary to disease or virus

Reduced ability to move air through the nose and sinuses secondary to obstruction

QUALITY Complete, partial

ASSOCIATED MANIFESTATIONS

AGGRAVATING FACTORS Infection, allergens, medications, objects in nose

ALLEVIATING FACTORS Mouth breathing, medications, avoidance of allergens,

SETTING Outdoors, indoors

TIMING Following drug therapy, trauma after oral intake, after nasal

QUALITY Complete (anosmia), altered (dysnosmia) or

ASSOCIATED MANIFESTATIONS

AGGRAVATING FACTORS Brain injuries, COVID-19, other viral respiratory infections,

Mouth breathing, snoring, pain, disgurement, sneezing, itchy eyes, sinus infection

removal of objects, immunotherapy to reduce response to allergens

surgery, may be seasonal or perennial

partial (hyposmia)

loss of taste, with or without u symptoms, loss of appetite, cough, congestions or rhinitis

radiation therapy, antidepressants, antibiotics, nasal polyps, sinusitis, cancers, Alzheimer’s disease, Parkinson’s disease, smoking, hypothyroidism

CHAPTER 11

ALLEVIATING FACTORS Disease progression

SETTING Usually in community cases

TIMING Varied; for viral disease between 5 days and 6 months,

for others may be permanent or uctuate with condition and treatment

MOUTH AND THROAT

1. HALITOSIS Unpleasant odour of the breath

QUALITY Ammonia, acetone, newly mown grass or old wine odour; foul

ASSOCIATED MANIFESTATIONS

AGGRAVATING FACTORS Poor oral hygiene, poor nutrition, poor diabetic control,

ALLEVIATING FACTORS Good oral hygiene, control of systemic diseases, breath

TIMING Associated with systemic disease or acute infectious process

2. LESIONS Disruptions in the mucosa of the mouth or tongue

QUALITY Tender, nontender

Gum disease, caries, systemic disease, sinusitis, pharyngitis, gastro-oesophageal reux disease (GORD), smoking

alcohol intake, decreased hydration, inadequate renal function

mints, good nutrition, adequate dental care, treatment of infection

ASSOCIATED MANIFESTATIONS

AGGRAVATING FACTORS Eating, drinking, spices, smoking, hot or cold stimuli,

Malnutrition, odour, pain, swelling, fever, stress

alcohol, dehydration

360 PHYSICAL EXAMINATION

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ALLEVIATING FACTORS Medications, avoiding eating, hydration, proper nutrition,

avoiding smoking and alcohol

UNIT 2

PAST HEALTH HISTORY

TIMING Associated with systemic disease, intermittent, continuous

3. SWELLING Oedema of the pharynx

QUALITY Mild, moderate, severe

ASSOCIATED MANIFESTATIONS

AGGRAVATING FACTORS Exposure to allergens, heat

ALLEVIATING FACTORS Medications, avoiding allergens, ice, saltwater gargles

TIMING Following drug therapy, after eating, after an insect bite,

4. LOSS OF TASTE (AGEUSIA)

The various components of the past health history are linked to ears, nose, mouth and throat pathology and ear-, nose-, mouth- and throat-related information.

MEDICAL HISTORY

See loss of smell – usually loss of taste and smell occur simultaneously for the same causes

EAR-SPECIFIC Acute otitis media, acute otitis externa, serous otitis media,

NOSE- AND SINUSESSPECIFIC

MOUTH- AND THROATSPECIFIC

Dysphagia, urticaria, wheezing, pruritus, rhinorrhoea, difculty breathing, lesions, chills, sweats, fever, sneezing, itchy eyes

after trauma, during or after an infectious process

hearing difculties

Polyps, septal deviation, sinus infection, allergic rhinitis, anosmia, epistaxis

Tonsillitis, caries, herpes simplex virus, Candida infections, streptococcal throat, frequent upper respiratory infections, tonsillar abscess

FAMILY HEALTH HISTORY

NON-EAR-, NOSE- AND SINUSES-, MOUTH- AND THROAT-SPECIFIC

SURGICAL HISTORY Neurosurgery, tonsillectomy, adenoidectomy, tumour removal, cosmetic surgery of head or neck,

repair of septal deviation, oral surgery, tympanostomy tube placement

ALLERGIES Pollen: sneezing, nasal congestion, watery or itchy eyes, cough

Insect stings: swelling of the throat, around the eyes Animal dander: sneezing, nasal congestion, watery or itchy eyes, cough

MEDICATIONS Antibiotics, antihistamines, decongestants, steroids, chemotherapy, immunotherapy,

immunosuppressive drugs

INJURIES AND ACCIDENTS

SPECIAL NEEDS Deafness, speech disorders

CHILDHOOD ILLNESSES Frequent tonsillitis, frequent ear infections

Ear, nose and sinuses, mouth and throat diseases that are familial are listed. Hearing loss, otosclerosis, neonatal blindness secondary to cataracts from mother contracting rubella in pregnancy.

Foreign bodies; trauma to the ears, nose, mouth, throat; noxious fumes; sports injuries to the face; motor vehicle accidents

Diabetes mellitus, renal disease, atherosclerotic disease, hypertension, inammatory processes, infections (viral or bacterial), immunosuppressive disease, dental pathology, blood dyscrasias, sexually transmitted infections, anaphylaxis, nutritional disturbances

EARS, NOSE, MOUTH AND THROAT 361

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SOCIAL HISTORY

The components of the social history are linked to ear, nose and sinuses, mouth and throat factors and pathology.

ALCOHOL USE Predisposes the person to cancer of the oral cavity as well as decreased nutrition leading to cheilosis

TOBACCO USE Smoking predisposes the person to mouth, lip or throat cancer

DRUG USE Snorting cocaine may cause perforation of the nasal septum

SEXUAL PRACTICE Herpes simplex viruses I and II and gonorrhoea can be contracted from oral sex

WORK ENVIRONMENT Exposure to toxins, chemicals, infections, excess noise, allergens

HOME ENVIRONMENT Exposure to loud music may cause hearing loss

HOBBIES AND LEISURE ACTIVITIES

STRESS With frequent upper respiratory infections, hearing teeth brush together or grind together can

Shooting without proper ear protection may cause hearing loss

be decreased

PERSON-CENTRED HEALTH EDUCATION

When conducting a health assessment, opportunities for the provision of personcentred health education will arise. This is a signiﬁcant consideration in relation to the assessment process for examination of the ears, nose, mouth and throat due to the number of health conditions that are preventable. These occasions are identiﬁed as individualised education and may generate further data that can be added to the assessment. All education given should be documented so that in future, health professionals can assess the impact of previous information provided to the consumer. (Refer to Chapter 1 for initiating health education.) Refer to the following examples.

CHAPTER 11

CLINICAL REASONING

Practice tip: Risk factors for hearing loss

Consumers who t any of the following hearing loss risk factors should be assessed for hearing damage. This is also an opportunity to provide person-centred health education about possible ways to avoid hearing loss based on the risk factor that are identied.

> Noise exposure

> Smoking

> Ototoxic drugs

> Congenital or heredity

> Cardiovascular disease

> Ageing

> Tumours

INDIVIDUALISED HEALTH EDUCATION INTERVENTIONS

Assessing the consumer for the following health-related activities can assist in identifying the need for education about these factors. This information provides a bridge between the health maintenance activities and ears, nose, mouth and throat functions.

Sleep Deprivation may be associated with frequent upper respiratory infections

Diet Deciencies may affect integrity of nasal and oral mucosa and increase

risk of oral cancers

Use of safety devices Use of mouth guard for sports participants; face shields for sports, job or

home projects; ear protection when around loud noise to prevent damage to hearing

> Trauma > Chronic infection > Systemic disease > Tympanic membrane perforation > Ménière’s disease > Barotrauma

Health check-ups Hearing assessment, dental examination

362 PHYSICAL EXAMINATION

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UNIT 2

PLANNING FOR PHYSICAL EXAMINATION

The planning phase refers to evaluating subjective data to narrow the focus on physical examination, determining what objective data needs to be gathered, as well as considering the environment and equipment that will be required.

At this time, you will identify which of the four diagnostic techniques you will need to implement the physical examination, and how you will sequence these. For the physical examination of the ears, nose, mouth and throat, you will include inspection, palpation and percussion.

Objective data is:

> collected during the physical examination of the consumer

> usually collected after subjective data

> information that is measured or observed by the clinician as opposed to being

reported by the consumer

> vital to the overall health assessment, to enable you to make clinical decisions

that are representative of the whole consumer picture.

Evaluating subjective data to focus physical examination

Before commencing the physical examination of the consumer’s ears, nose and sinuses, mouth and throat, consider what information the health history has provided. Critical consideration, linked to knowledge of anatomy and physiology, should focus the physical assessment so your examination will be more effective and efﬁcient.

Environment

Assessment of ears, nose and sinuses, mouth and throat can be done in most physical environments in healthcare settings. Adequate privacy is required as for any health assessment, with some consideration needed for noise levels and the ability to accurately assess hearing in your environment.

Equipment

> Otoscope with earpieces of different sizes and pneumatic attachment > Penlight > Tuning fork, 512Hz > Tongue blade > Watch > Gauze square > Nonsterile gloves > Transilluminator > Nasal speculum > Cotton-tipped applicator

CLINICAL REASONING

Practice tip: The person with decreased hearing

Observe the consumer for signs of hearing difculty and deafness during the health history and physical examination. Turning the head to facilitate hearing, lip reading, speaking in a loud voice, or asking you to write words are signs of hearing difculty. If the consumer is wearing a hearing aid, ask if it is turned on, when the batteries were last changed, and if the device causes any irritation of the ear canal.

Advanced Assessment

EARS, NOSE, MOUTH AND THROAT 363

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IMPLEMENTATION: CONDUCTING THE PHYSICAL EXAMINATION

Implementation of the physical examination requires you to consider your scope of practice as well. In this section, depending on your context, you may be performing foundation assessment with aspects of advanced assessment if you are practising in a specialised area.

EXAMINATION IN BRIEF: EARS, NOSE AND SINUSES, MOUTH AND THROAT

CHAPTER 11

Examination of the ear

Auditory screening

> Voice-whisper test > Tuning fork tests

· Weber test

· Rinne test

Inspection

> External ear

Palpation

> Otoscopic examination

Examination of the nose

Inspection

> External nose > Patency > Internal nose

Palpation and percussion

Transillumination of the sinuses

Examination of the mouth and throat Examination of the breath Examination of the lips

Inspection

Palpation

Examination of the tongue Examination of the buccal mucosa Examination of the gums Examination of the teeth Examination of the palate Examination of the throat

Examination of the sinuses

Inspection

Physical examination of the ear consists of three parts:

1. Auditory screening (CN VIII)

2. Inspection and palpation of the external ear

3. Otoscopic assessment. Note that in some contexts this would be considered

advanced practice.

Inspection

URGENT FINDING

Cerebrospinal uid (CSF) drainage from the ear

If the consumer has cerebrospinal uid (clear liquid that tests positive for glucose on Dextrostix) leaking from the ear, be sure to use good hand washing technique and avoid placing any objects into the ear canal in order to prevent the development of meningitis. A consumer with this nding needs immediate referral to a qualied specialist for emergency assessment.

General approach to examination of the ears, nose and sinuses, mouth and throat

1. Greet the consumer and explain the techniques that you will be using.

2. Use a quiet room that will be free from interruptions.

3. Ensure that the light in the room provides sufﬁcient brightness to allow

adequate observation of the consumer.

Advanced Assessment

364 PHYSICAL EXAMINATION

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UNIT 2

4. Place the consumer in an upright sitting position on the examination table

or, for consumers who cannot tolerate the sitting position, gain access to the consumer’s head so that it can be rotated from side to side for assessment.

5. Visualise the underlying structures during the assessment process to allow

adequate description of ﬁndings.

6. Always compare right and left ears, as well as right and left sides of the nose,

sinuses, mouth and throat.

7. Use a systematic approach that is followed consistently each time the

assessment is performed.

Examination of the ear

Auditory screening

Voice-whisper test

1. Instruct the consumer to occlude one ear with a ﬁnger.

2. Stand 60cm behind the consumer’s other ear and whisper a two-syllable

word or phrase that is evenly accented.

3. Ask the consumer to repeat the word or phrase.

4. Repeat the test with the other ear.

The consumer should be able to repeat words whispered from a distance

of 60 cm.

The consumer is unable to repeat the words correctly or states that he or she was

unable to hear anything.

This indicates a hearing loss in the high-frequency range that may be caused by

excessive exposure to loud noises.

FIGURE 11.9 Weber test

Tuning fork tests

Depending on context, this may be foundation or advanced practice.

Weber and Rinne tests help to determine whether the type of hearing loss

the consumer is experiencing is conductive or sensorineural. In order to understand how these tests are evaluated, it is important to know the difference between air and bone conduction. Air conduction refers to the transmission of sound through the ear canal, tympanic membrane and ossicular chain to the cochlea and auditory nerve. Bone conduction refers to the transmission of sound through the bones of the skull to the cochlea and auditory nerve.

Weber test

1. Hold the handle of a 512Hz (vibrates 512 cycles per second to create a

speciﬁc frequency) tuning fork and strike the tines on the ulnar border of the palm to activate it.

2. Place the stem of the fork ﬁrmly against the middle of the consumer’s

forehead, on the top of the head at the midline (

Figure 11.9), or on the

front teeth.

3. Ask the consumer if the sound is heard centrally or towards one side.

The consumer should perceive the sound equally in both ears or ‘in the middle’.

The sound lateralises to the affected ear.

This occurs with unilateral conductive hearing loss because the sound is being

conducted directly through the bone to the ear. Conductive hearing loss occurs

when there are external or middle ear disorders such as impacted cerumen,

perforation of the tympanic membrane, serum or pus in the middle ear, or a

fusion of the ossicles.

ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology

EARS, NOSE, MOUTH AND THROAT 365

A. Assessing bone conduction

B. Assessing air conduction

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The sound lateralises to the unaffected ear.

This occurs with sensorineural loss related to nerve damage in the impaired ear.

Sensorineural hearing loss occurs when there is a disorder in the inner ear, the auditory nerve, or the brain. Disorders include congenital defects, effects of ototoxic drugs, and repeated or prolonged exposure to loud noise.

Rinne test

1. Stand behind or to the side of the consumer and strike the tuning fork.

2. Place the stem of the tuning fork against the consumer’s right mastoid

process to test bone conduction (

3. Instruct the consumer to indicate if the sound is heard.

4. Ask the consumer to tell you when the sound stops.

5. When the consumer says that the sound has stopped, move the tuning fork,

with the tines facing forwards, in front of the right auditory meatus, and ask the consumer if the sound is still heard. Note the length of time the consumer hears the sound (testing air conduction) (

6. Repeat the test on the left ear.

Air conduction is heard for twice as long as bone conduction when the consumer

hears the sound through the external auditory canal (air) after it is no longer heard at the mastoid process (bone). This is denoted as AC > BC, or a ⊕ Rinne.

The consumer reports hearing the sound longer through bone conduction; that is,

bone conduction is equal to or greater than air conduction. This is a This occurs when there is conductive hearing loss resulting from disease,

obstruction, or damage to the outer or middle ear. Bone conduction is prolonged in the context of a normal tympanic membrane,

patent eustachian tube, and middle ear disease. These ﬁndings are typical of otosclerosis.

Figure 11.10A).

Figure 11.10B).

Rinne.

CHAPTER 11

Inspection

External ear

1. Inspect the ears and note their position, colour, size and shape.

2. Note any deformities, nodules, inﬂammation or lesions.

3. Note colour, consistency and amount of cerumen.

The ear should match the ﬂesh colour of the rest of the consumer’s skin and

should be positioned centrally and in proportion to the head. The top of the ear should cross an imaginary line drawn from the outer canthus of the eye to the occiput (see Figure 11.11). Cerumen should be moist and not obscure the tympanic membrane. There should be no foreign bodies, redness, drainage, deformities, nodules or lesions.

The ears are pale, red or cyanotic.

Vasomotor disorders, fevers, hypoxaemia and cold weather can account for

various colour changes. The ears are abnormally large or small.

These abnormalities can be congenitally determined or the result of trauma.

An ear that is permanently swollen and deformed resembling a ‘cauliﬂower’ is abnormal.

Perichondrial haematoma (cauliﬂower ear) is a condition common among

footballers, wrestlers and boxers. It is caused by blunt trauma to the external ear resulting in a blood clot formation and ﬂuid collection under the perichondrium, which leads to ﬁbrosis and deformity of the external ear.

An external ear that is erythematous, oedematous, warm to the touch, and

painful is abnormal.

FIGURE 11.10 Rinne test

FIGURE 11.11 Normal ear alignment

ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology

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