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366 PHYSICAL EXAMINATION
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UNIT 2
SCIEN CE PHOTO L IBRARY/ DR P. MARAZ ZI
FIGURE 11.12 Perichondritis
Perichondritis is an inflammation of the fibrous connective tissue that overlies
P
the cartilage of the ear (
A tumour on the external ear is abnormal.
A
Basal cell and squamous cell carcinomas are the most common external ear
P
Figure 11.12).
tumours. Prolonged sunlight exposure is a predisposing factor for these tumours.
Purulent drainage is abnormal.
A
Purulent drainage usually indicates an infection.
P
Clear or bloody drainage is present.
A
Clear or bloody drainage may be due to cerebrospinal fluid leaking as a result of
P
head trauma or surgery.
A haematoma behind an ear over the mastoid bone is abnormal.
A
This is called Battle’s sign and indicates head trauma to the temporal bone of
P
the skull.
A hard, painless, irregular-shaped nodule on the pinna is abnormal.
A
Tophi are uric acid nodules and may indicate the presence of gout. These are
P
usually located near the helix. Many other nodules are benign
Sebaceous cysts are abnormal.
A
Sebaceous cysts or retention cysts form as a result of the blockage of the ducts to
P
fibromas.
the sebaceous gland.
Lymph nodes anterior to the tragus or overlying the mastoid are abnormal.
A
Lymph nodes may be enlarged due to a malignancy or an infection such as
P
external otitis.
Palpation
E
1. Palpate the auricle between the thumb and the index finger, noting any
tenderness or lesions. If the consumer has ear pain, assess the unaffected ear
first, then cautiously assess the affected ear.
2. Using the tips of the index and middle fingers, palpate the mastoid tip,
noting any tenderness.
3. Using the tips of the index and middle fingers, press inwards on the tragus,
noting any tenderness.
4. Hold the auricle between the thumb and the index finger and gently pull up
and down, noting any tenderness.
The consumer should not complain of pain or tenderness during palpation.
N
Auricular pain or tenderness is noted.
A
Auricular pain is a common finding in external ear infection and is called acute
P
otitis externa.
There is tenderness over the mastoid process.
A
Mastoid tenderness is associated with middle ear inflammation or mastoiditis.
P
The tragus is oedematous or sensitive.
A
This finding may indicate inflammation of the external or middle ear.
P
Otoscopic examination
This may not be part of your scope of practice; please review your context’s
requirements.
E
1. Ask the consumer to tip the head away from the ear being assessed.
2. Select the largest speculum that will comfortably fit the consumer.
3. Hold the otoscope securely in the dominant hand, with the handle held like
a pencil between the thumb and the forefinger.
4. Rest the back of the dominant hand on the right side of the consumer’s head
(Figure 11.13).
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
EARS, NOSE, MOUTH AND THROAT 367
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E
5. Use the free hand to pull the right ear in a manner that will straighten the
canal. In adults and in children over 3 years old, pull the ear up and back.
(See Chapter 20 for the assessment of children younger than 3.)
6. If hair obstructs visualisation, moisten the speculum with water or a
water-soluble lubricant.
7. If wax obstructs visualisation, it should be removed only by a skilled
practitioner, either by curettement (if the cerumen is soft or the tympanic
membrane is ruptured) or by irrigation (if the cerumen is dry and hard and
the tympanic membrane is intact).
8. Slowly insert the speculum into the canal, looking at the canal as the
speculum passes.
9. Assess the canal for inflammation, exudates, lesions and foreign bodies.
10. Continue to insert the speculum into the canal, following the path of the
canal until the tympanic membrane is visualised.
11. If the tympanic membrane is not visible, gently pull the pinna slightly
further in order to straighten the canal to allow adequate visualisation.
12. Identify the colour, light reflex, umbo, the short process, and the long handle
of the malleus. Note the presence of perforations, lesions, bulging or retraction
of the tympanic membrane, dilatation of blood vessels, bubbles or fluid.
13. Ask the consumer to close the mouth, pinch the nose closed, and blow
FIGURE 11.13 Position for otoscopic
examination
gently while you observe for movement of the tympanic membrane.
14. Gently withdraw the speculum and repeat the process with the left ear.
The ear canal should have no redness, swelling, tenderness, lesions, drainage,
N
foreign bodies or scaly surface areas. Cerumen varies in amount, consistency and
colour. The tympanic membrane should be pearly grey with clearly defined
landmarks and a distinct cone-shaped light reflex extending from the umbo
towards the anteroinferior aspect of the membrane. This light reflex is seen at
5 o’clock in the right ear and at 7 o’clock in the left ear. Blood vessels should be
visible only on the periphery, and the membrane should not bulge, be retracted,
or have any evidence of fluid behind it (
should move when the consumer blows against resistance.
A foreign body in the external auditory canal (EAC) is abnormal (Figure 11.15).
A
Figure 11.14). The tympanic membrane
FIGURE 11.14 Normal tympanic membrane
PEDIATRIC OTOLARYNGOLOGY
COUR TESY OF DR A NDREW B. SI LVA,
CHAPTER 11
CLINICAL REASONING
Practice tip: Clearing the external auditory canal (EAC) of cerumen (ear wax)
Two methods can be used to remove cerumen from the EAC in order to visualise the
tympanic membrane: manual removal and irrigation with water.
> Manual removal involves the use of a plastic loop or spoon. This method is quick and does not
expose the EAC to moisture; therefore it may reduce the risk of infection. However, it requires
a cooperative person and skilled practitioner to reduce the risk of trauma to the EAC.
> Irrigation with water at body temperature can be performed with a 20–30mL syringe with
a plastic catheter or a bulb syringe. The water should be instilled gently, and the canal
should be checked intermittently for clearance of cerumen. Oral jet irrigators are fast
and portable; however, they have been associated with trauma, as has irrigation with
small syringes. Do not use anything less than a 20mL size syringe – this is to reduce the
amount of pressure that is exerted in the ear canal – and be aware of where the end of
the syringe is touching during irrigation so mechanical trauma does not occur. Water
irrigation should be avoided in patients with tympanic membrane perforation, acute otitis
media, otitis externa, myringotomy tubes, ear surgery or vertigo.
> NOTE: if you cannot be sure there is no perforation to the tympanic membrane DO NOT
irrigate with water; this can cause balance loss and permanent hearing loss.
> Additionally, ears should not be irrigated if any discharge that is not normal cerumen is
noted. In this case a fungal or bacterial infection may be the cause.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
Advanced Assessment
FIGURE 11.15 A foreign body (a bean) in
the external auditory canal
PEDIATRIC OTOLARYNGOLOGY
COUR TESY OF DR A NDREW B. SI LVA,
368 PHYSICAL EXAMINATION
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UNIT 2
COUR TESY OF DR A NDREW B. SI LVA,
PEDIATRIC OTOLARYNGOLOGY
FIGURE 11.16 Tympanostomy tube
(grommets, T-Tube, pressure equalisation
tube)
Both adults and children can have foreign bodies in the EAC. Some objects are
P
more difficult to remove than others; for instance, vegetables in the EAC can
swell with time and make removal challenging.
Tympanostomy tubes, or T-tube, grommets or PE tubes (pressure equalisation)
P
(
Figure 11.16), are surgically placed for prolonged otitis media with effusion (OME).
The tubes allow drainage of the effusion, normal vibration of the ossicles, and
equalisation of pressures across the tympanic membrane. These tubes may fall out,
so the presence of the tubes (or lack of) needs to be documented upon examination.
A painful, boil-like pustule in the EAC is abnormal (
A
Furunculosis is an infection of a hair follicle. EAC oedema and otorrhoea may
P
Figure 11.17).
also be present.
Black or brown spores (
A
Figure 11.18A), yellow or orange spores (Figure 11.18B) or
white fluffy hyphae in the EAC are abnormal.
Prolonged use of aural antibiotics can cause otomycosis, or a fungal infection in
P
the ear (other causes of otomycosis is overuse of ear cleaning buds, insects, or water
in the ear canal). Different strains of fungi cause the variations in appearance.
Bony, hard lesions in the deep EAC (see
A
These are exostoses. Consumers who frequently participate in cold-water
P
Figure 11.19) are abnormal.
activities are at risk for developing them. If an exostosis becomes large enough,
it can block the EAC and trap debris between it and the tympanic membrane.
This can lead to infection.
Severe pain accompanied by erythema deep into the EAC and on the tympanic
A
membrane, along with serous-filled blebs (
This describes viral bullous myringitis. This can easily be mistaken for acute
P
Figure 11.20), is abnormal.
otitis media.
The appearance of chalk patches on the tympanic membrane (Figure 11.21)
A
is abnormal.
COUR TESY OF BRU CE BLAC K, MD, BRISB ANE, AUS TRALI A
FIGURE 11.17 Furunculosis
COUR TESY OF BRU CE BLAC K, MD, BRISB ANE, AUS TRALI A
FIGURE 11.19 Exostoses
COUR TESY OF BRU CE BLAC K, MD, BRISB ANE, AUS TRALI A
A. Aspergillus nigra
COUR TESY OF BRU CE BLAC K, MD, BRISB ANE, AUS TRALI A
B. Aspergillus avum
FIGURE 11.18 Otomycosis
COUR TESY OF BRU CE BLAC K, MD, BRISB ANE, AUS TRALI A
FIGURE 11.20 Bullous myringitis
URTE SY OF DR ANDR EW B. SILVA, P EDIATRIC
CO
OTOLARYNGOLOGY
FIGURE 11.21 Myringosclerosis and otitis media
with effusion
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
EARS, NOSE, MOUTH AND THROAT 369
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These are calcifications found in myringosclerosis, which can occur after
P
tympanic membrane surgery, infection or inflammation. Myringosclerosis can
be associated with a gradual hearing loss. Involvement of the entire tympanic
membrane is called tympanosclerosis.
Air bubbles on the tympanic membrane (
A
Conditions such as coryza and influenza and changes in extratympanic pressure
P
Figure 11.22) are abnormal.
(such as in scuba diving, plane travel) can lead to eustachian tube failure.
The presence of blood in the middle ear is abnormal (
A
Haemotympanum occurs as a result of trauma to the head. The tympanic
P
Figure 11.23).
membrane can have a bluish hue or can be red in appearance.
A severely retracted tympanic membrane has exaggerated landmarks. Mobility of
A
the tympanic membrane is decreased.
Retraction of the tympanic membrane can occur when the intratympanic
P
membrane pressures are reduced, as in eustachian tube blockage caused by otitis
media with effusion or allergies. Repeated negative pressure in the middle ear
sucks in the tympanic membrane and leads to retractions. Over time, keratinised
FIGURE 11.22 Barotrauma caused by
scuba diving
AUSTRALIA
COUR TESY OF BRU CE BLAC K, MD, BRISB ANE,
epithelial debris deposits itself in these retraction pockets and leads to ossicle
fixation. This leads to cholesteatoma (
Figure 11.24). A foul-smelling ear discharge,
as well as deafness, may accompany cholesteatoma.
There is redness, swelling, narrowing and pain of the external ear (Figure 11.25).
A
Drainage may be present.
Acute otitis externa (AOM) is caused by infectious organisms or allergic
P
reactions. Predisposing factors include excessive moisture in the ear related to
swimming, trauma from cleansing the ears with a sharp instrument, or allergies
to substances such as hairspray.
Hard, dry, and very dark yellow-brown cerumen is abnormal.
A
Old cerumen is harder and drier, and may become impacted if not removed.
P
The tympanic membrane is red, with decreased mobility and possible
A
bulging (
This is
P
Figure 11.26).
otitis media, or an inflammation of the middle ear. Pain and fever may
FIGURE 11.23 Haemotympanum
COUR TESY OF DR A NDREW B. SI LVA, PEDIATR IC
OTOLARYNGOLOGY
accompany the ear infection. Otalgia, fever, decreased hearing, irritability,
disturbed sleep and otorrhoea may accompany the middle ear infection.
Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis are the
major pathogens that cause AOM.
CHAPTER 11
A. Early AOM. Note the bulging
tympanic membrane.
FIGURE 11.26 Acute otitis media
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
COUR TESY OF BRU CE BLAC K, MD, BRISB ANE, AUS TRALI A
B. More advanced AOM with bleb formation.
Note the bulging tympanic membrane and purulent
effusion behind it. The pressure behind the membrane
caused a vesicle to form on the pars tensa.
FIGURE 11.24 Cholesteatoma
URTE SY OF BRUCE B LACK, M D, BRISBAN E, AUSTR ALIA
CO
FIGURE 11.25 Acute otitis externa
OTOLARYNGOLOGY
COUR TESY OF DR A NDREW B. SI LVA, PEDIATR IC
AUSTRALIA
COUR TESY OF BRU CE BLAC K, MD, BRISB ANE,
370 PHYSICAL EXAMINATION
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UNIT 2
Amber-yellow fluid on the tympanic membrane is abnormal. It may be
A
accompanied by a fluid line or bubbles behind the membrane. Bulging may be
present and mobility of the eardrum may be decreased (
Figures 11.27 and 11.28).
The consumer may complain of ear popping, pain and decreased hearing.
Otitis media with effusion (OME), or serous otitis media, can be caused by
P
allergies, infections, and a blocked eustachian tube. Table 11.1 compares AOM,
OME and otitis externa.
TABLE 11.1 Comparison of acute otitis media (AOM), otitis media with effusion (OME) and otitis externa
OTITIS MEDIA WITH
ACUTE OTITIS MEDIA
EFFUSION OTITIS EXTERNA
COUR TESY OF DR A NDREW B. SI LVA, PEDIATR IC
OTOLARYNGOLOGY
FIGURE 11.27 Otitis media with effusion
COUR TESY OF DR A NDREW B. SI LVA, PEDIATR IC
OTOLARYNGOLOGY
FIGURE 11.28 Serous otitis media
OTOLARYNGOLOGY
COUR TESY OF DR A NDREW B. SI LVA, PEDIATR IC
FIGURE 11.29 Tympanic membrane
perforation
Tympanic
membrane colour
Tympanic
membrane
Diffuse red, dilated
peripheral vessels
Yellowish Within normal
limits
Bulging Bubbles, uid line Within normal
limits
appearance
Tympanic
membrane
Decreased Retracted with prominent
malleus
Within normal
limits
landmarks
Movement of
Painless Painless Painful
tragus
Hearing Within normal limits/
decreased
External auditory
Within normal limits Within normal limits Erythematous,
canal
The tympanic membrane appears to have a darkened area or a hole.
A
A perforated eardrum is caused by untreated ear infection secondary
P
Within normal limits/
decreased
Within normal
limits
oedematous
to increasing pressure. Trauma to the ear canal can also cause a
perforation (
The tympanic membrane is pearly grey and has dark patches.
A
These patches are usually old perforations in the tympanic membrane.
P
The tympanic membrane is pearly grey and has dense white plaques.
A
These plaques represent calcific deposits of scarring of the tympanic membrane
P
Figure 11.29).
from frequent past episodes of otitis media.
CLINICAL REASONING
Practice tip: Caution in taking nasal swabs
For any client who requires nasal swabs, care should be taken as people with a history
of nosebleeds (epistaxis) can have this triggered by the swabbing of the nares and nasal
passages, as most nose bleeds occur in the anterior nasal passages. Alternate testing
should be considered if possible. If this is not possible, the clinician needs to be prepared to
treat epistaxis and also educate the client that they may experience a nose bleed post swab
and what to do if this occurs after leaving the health settings.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
EARS, NOSE, MOUTH AND THROAT 371
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Examination of the nose
Inspection
External nose
E
Inspect the nose, noting any trauma, bleeding, lesions, masses, swelling
andasymmetry.
The shape of the external nose can vary greatly among individuals. Normally,
N
itis located symmetrically in the midline of the face and is without swelling,
bleeding, lesions or masses.
The nose is misshapen, broken or swollen.
A
The shape of the nose is determined by genetics; however, changes can occur
P
because of trauma or cosmetic surgery.
Patency
E
1. Have the consumer occlude one nostril with a finger.
2. Ask the consumer to breathe in and out through the nose as you observe and
listen for air movement in and out of the nostril.
3. Repeat on the other side.
Each nostril is patent.
N
You observe or the consumer states that air cannot be moved through
A
the nostril(s).
Occlusion of the nostrils can occur with a deviated septum, foreign body, upper
P
respiratory infection, allergies or nasal polyps.
Nasal drainage is observed from only one side of the nose.
A
Unilateral nasal drainage may be a sign of nasal obstruction (on the side of
P
no drainage).
CHAPTER 11
Internal nose
Depending on context, this may be foundation or advanced practice.
E
1. Position the consumer with the head in an extended position.
2. Place the nondominant hand firmly on top of the consumer’s head.
3. Using the thumb of the same hand, lift the tip of the consumer’s nose.
4. Gently insert a nasal speculum or an otoscope with a short, wide nasal
speculum (
the nostrils.
5. Assess each nostril separately.
6. Inspect the mucous membranes for colour and discharge.
7. Inspect the middle and inferior turbinates and the middle meatus for colour,
swelling, drainage, lesions and polyps.
8. Observe the nasal septum for deviation, perforation, lesions and bleeding.
The nasal mucosa should be pink or dull red without swelling or polyps. The
N
septum is at the midline and without perforation, lesions or bleeding. A small
amount of clear, watery discharge is normal.
A nasal septum that is ‘pushed’ to one side can be an abnormal finding
A
Figure 11.31).
(
Figure 11.30). If using a nasal speculum, use a penlight to view
FIGURE 11.30 Internal inspection of
the nose
Middle turbinate
Nasal septum
FIGURE 11.31 Deviated septum
COUR TESY OF DR A NDREW B. SI LVA, PEDIATR IC
OTOLARYNGOLOGY
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
372 PHYSICAL EXAMINATION
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Septum
UNIT 2
Adenoid
FIGURE 11.32 Nasal cavity blocked
by adenoid
COUR TESY OF DR A NDREW B. SI LVA, PEDIATR IC OTOLA RYNGOL OGY
Nasal septum
Inferior
turbinate
OTOLARYNGOLOGY
COUR TESY OF DR A NDREW B. SI LVA, PEDIATR IC
FIGURE 11.33 Oedematous inferior
turbinate causing almost total occlusion of
the nasal cavity. Note the slight difference
in colour between the septum and the
turbinate. These ndings can occur in
consumers with allergic rhinitis.
Septum
Middle
turbinate
Purulent
discharge
Nasal
COUR TESY OF DR A NDREW B. SI LVA, PEDIATR IC
OTOLARYNGOLOGY
FIGURE 11.34 Purulent discharge in the
nasal cavity at the middle turbinate
catheter
Polyp
CLINICAL REASONING
Practice tip: Assessing patency of the nose
This is a basic part of assessing the nose. It is important to nd the reason for reduced
patency. This can be easily assessed by checking for the consumer’s sense of smell. The
sense of smell (CN I) is evaluated during testing of cranial nerves. Refer to Chapter 7. If the
consumer has a reduced sense of smell, then the clinician can check for reasons behind
this reduction (e.g. physical obstruction either by foreign object, change in physiology or
presence of mucus should be ruled out before considering nerve issues as the cause).
Depression has also been linked to a reduction of sense of smell and taste.
A deviated septum can be a naturally occurring finding, or it can be caused by
P
trauma to the face and nasal area.
A nasal septum with a hole or fissure is abnormal.
A
A perforated nasal septum may be caused by nasal insufflation (snorting) of
P
cocaine, which can lead to necrosis of the septal cartilage. Long-term intranasal
corticosteroids can also result in a perforated nasal septum if an incorrect
administration technique is used.
A nasal cavity that is occluded is abnormal.
A
There are many causes of an occluded nasal cavity. Foreign bodies may be
P
present, especially in children. Trauma may induce nasal oedema, sinus
infection may produce copious discharge, an adenoid may be so large that it
occludes the nasal cavity (
turbinates (
The nasal mucosa is red and swollen with copious clear, watery discharge. This is
A
Figure 11.33).
Figure 11.32), and allergies can lead to oedematous
rhinitis, an inflammation of the nasal mucosa.
These findings indicate the occurrence of the common cold (coryza) when there
P
is an acute onset of symptoms. Discharge may become purulent if a secondary
bacterial infection develops.
Nasal mucosa is pale and oedematous with clear, watery discharge.
A
These findings usually indicate the presence of allergies or hay fever.
P
Following trauma to the head, there is a clear, watery nasal discharge with
A
normal-appearing mucosa. This discharge tests positive for glucose.
These findings indicate the presence of cerebrospinal fluid. This may occur
P
following head injury or complications of nose or sinus surgery or dental work.
Immediate referral is warranted.
Nasal mucosa is red and swollen with purulent nasal discharge (see Figure 11.34).
A
These findings are usually worse on one side but may be found bilaterally.
These are common findings in bacterial sinusitis.
P
Smooth, round masses that are pale and shiny are noted protruding from the
A
middle meatus.
These masses are nasal polyps (see
P
Figure 11.35), which may obstruct air passages.
They are often seen in consumers who have chronic allergic rhinitis, asthma or
cystic fibrosis. They are usually found bilaterally. A unilateral polyp is suspect for
a malignancy until proven otherwise.
Septum
OTOLARYNGOLOGY
COUR TESY OF DR A NDREW B. SI LVA, PEDIATR IC
FIGURE 11.35 Nasal polyp
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
EARS, NOSE, MOUTH AND THROAT 373
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PUTTING IT IN CONTEXT
Allergy assessment
Jenny Adams is a 13-year-old Caucasian female attending high school. She presents to
the general practice with her mother complaining of hay fever symptoms that have been
worsening over the past 6 months. Mum states she notices Jenny is increasingly restless
when sleeping, becoming cranky and easily upset, unable to concentrate for long, has
watery eyes, sneezes up to 17 times in a row, and normal doses of antihistamines are not
helping. Jenny states that sometimes her eyes are so itchy and watery that she has trouble
with her vision from rubbing them so hard; she wakes up with a dry mouth and bad breath
and mum reports she has been snoring lately.
On examination Jenny’s visual acuity is normal, her eyes are slightly reddened, she
hasa small amount of periorbital oedema, and you observe her sneeze 12 times in a row.
Her tonsils are normal size, with no redness or swelling in her mouth or throat. She has had
a Claratyne this morning along with ibuprofen for her headache, which she states is in her
temples and behind her eyes. She consistently rubs her eyes and appears tired, yawning
frequently and has dark shadows under her eyes.
A skin prick test shows Jenny has a 9 times ‘normal’ size allergy wheal to dust mites,
and within 8 minutes of the skin prick test has a red itchy line travelling up her arm to her
shoulder. Jenny is diagnosed with severe allergy to dust mites. On inspection of her nasal
passages, she has approximately 80% blockage on each side of her septum. Jenny starts
to have trouble breathing within 14 minutes of her skin prick test and is given adrenalin for
a mild anaphylactic reaction to the dust mite allergen. The nurse educates Jenny and her
mum on how to modify her environment to reduce allergen levels. Jenny commences on
immunotherapy to reduce her sensitivity. She is also placed on large doses of antihistamines to reduce the histamine response that her symptoms are showing.
CHAPTER 11
Bleeding is noted from an area of the lower portion of the nasal septum
A
(also known as epistaxis).
Kiesselbach’s plexus, a vascular area on the septum, is the site of most nosebleeds
P
(see
Figure 11.36). Repeated nosebleeds warrant attention for blood dyscrasias,
environmental causes, medication use (e.g. anticoagulants) and malignancies,
among other aetiologies.
There is unilateral purulent discharge; however, the consumer does not
A
experience other symptoms of an upper respiratory infection. Nasal mucosa on
the unaffected side appears normal.
Unilateral purulent discharge without other findings of an upper respiratory
P
infection indicates the development of a local infection. A common cause of
localised infection is the presence of a foreign body.
Nasal mucosa is inflamed and friable with possible septal perforation. There is no
A
infection present.
These findings may indicate nasal inhalation of cocaine or amphetamines, or the
P
overuse of nasal spray.
Examination of the sinuses
Inspection
E
Observe the consumer’s face for any swelling around the nose and eyes.
There is no evidence of swelling around the nose and eyes.
N
Swelling is noted above or below the eyes.
A
Acute sinusitis may result in swelling of the face around the eyes due to
P
inflammation and accumulation of purulent material in the paranasal sinuses.
Nasal septum
Kiesselbach’s
plexus
FIGURE 11.36 Kiesselbach’s plexus
COUR TESY OF DR A NDREW B. SI LVA, PEDIATR IC OTOLA RYNGOL OGY
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
374 PHYSICAL EXAMINATION
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https://t.me/medicina_free
UNIT 2
A. Palpation of frontal sinuses
B. Palpation of maxillary sinuses
FIGURE 11.37 Palpation of sinuses
Palpation and percussion
To palpate and percuss the frontal sinuses:
E
1. Stand facing the consumer.
2. Gently press the thumbs under the bony ridge of the upper orbits
(see
Figure 11.37A). Avoid applying pressure on the globes themselves.
3. Observe for the presence of pain.
4. Percuss the areas using the middle or index finger of the dominant hand
(direct percussion).
5. Note the sound.
N
P
A
Refer to maxillary sinuses.
To palpate and percuss the maxillary sinuses:
E
1. Stand in front of the consumer.
2. Apply gentle pressure in the area under the infraorbital ridge using the
thumb or middle finger (
Figure 11.37B).
3. Observe for the presence of pain.
4. Percuss the area using the dominant middle or index finger.
5. Note the sound.
The consumer should experience no discomfort during palpation or percussion.
N
The sinuses should be air-filled and therefore resonant to percussion.
The consumer complains of pain or tenderness at the site of palpation
A
or percussion.
Sinusitis can be due to viral, bacterial or allergic processes that cause
P
inflammation of the mucous membranes and obstruction of the
drainage pathways.
Percussion of the sinuses elicits a dull sound.
A
Dullness can be caused by fluid or cells present in the sinus cavity from an
P
infectious or allergic process, or congenital absence of a sinus.
A. Frontal sinus
B. Maxillary sinus
FIGURE 11.38 Transillumination of sinuses
Transillumination of the sinuses
If palpation and percussion of the sinuses suggest sinusitis, transillumination of the
frontal and maxillary sinuses may be performed by the advanced practitioner.
To evaluate the frontal sinuses:
1. Place the consumer in a sitting position facing you in a dark room.
2. Place a strong light source such as a transilluminator, penlight, or tip of
an otoscope with the speculum under the bony ridge of the upper orbits
(
Figure 11.38A).
3. Observe the red glow over the sinuses and compare the symmetry of the
two sides.
To evaluate the maxillary sinuses:
1. Place the consumer in a sitting position facing you in a dark room.
2. Place the light source firmly under each eye and just above the infraorbital
ridge (Figure 11.38B).
3. Ask the consumer to open the mouth; observe the red glow on the
hard palate.
4. Compare the two sides.
• The glow on each side is equal, indicating air-filled frontal and
maxillary sinuses.
• Absence of glow is abnormal.
• Absence of glow suggests sinus congestion or the congenital absence
of a sinus.
• An extremely bright glow is abnormal.
• This phenomenon may be present in an elderly consumer with decreased
subcutaneous fat.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
Advanced Assessment
EARS, NOSE, MOUTH AND THROAT 375
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Examination of the mouth and throat
1. Physical examination of the oral cavity should include the following: breath,
lips, tongue, buccal mucosa, gums and teeth, hard and soft palates, throat
(oropharynx), and temporomandibular joint (see Chapters 9 and 16).
2. If the consumer is wearing dentures or removable orthodontia, ask that they
be removed before the examination begins.
3. Use gloves and a good light source such as a penlight for optimum
visualisation of the oral cavity and pharynx.
Examination of breath
E
1. Stand facing the consumer and about 30cm away.
2. Smell the breath.
The breath should smell fresh.
N
The breath smells foul.
A
The foul smell of halitosis can be a symptom of tooth decay, poor oral hygiene,
P
or diseases of the gums, tonsils or sinuses, or gastrointestinal ulcers.
The breath smells of acetone.
A
Acetone or ‘fruity’ breath is common in consumers who are malnourished or
P
who have diabetic ketoacidosis. The consumer may also be on a low
carbohydrate diet.
The breath smells musty.
A
Foetor hepaticus is the musty smell of the breath of a consumer in liver failure
P
and is caused by the breakdown of nitrogen compounds.
The breath smells of ammonia.
A
The smell of ammonia can be detected in a consumer in end-stage renal failure
P
(uraemia) because of the inability to eliminate urea.
CHAPTER 11
Examination of the lips
Inspection
E
1. Observe the lips for colour, moisture, swelling, lesions and other signs of
inflammation.
2. Instruct the consumer to open the mouth.
3. Use a tongue blade to inspect the membranes that connect the upper and
lower lips to the gums for colour, inflammation, lesions and hydration.
The lips and membranes should be pink and moist with no evidence of lesions
N
or inflammation.
The lips are pale or cyanotic.
A
Refer to Chapter 14.
P
The lips are dry and cracked.
A
Chapping or superficial cracking of the lips may be due to exposure to wind, sun, or
P
a dry environment, dehydration of the consumer, or persistent licking of the lips.
Swelling of the lips is noted.
A
Allergic reactions to medications, insect bites, foods or other allergens can result
P
in swelling of the lips.
The skin at the outer corners of the mouth is atrophic, irritated and cracked.
A
Angular cheilosis may be due to increased accumulation of saliva in the corners
P
of the mouth or constant drooling from the mouth. This occurs in nutritional
deficiencies (such as riboflavin), poorly fitting dentures, and deficiencies of the
immune system. Candida infections may also be present.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
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