A look at ear, nose, and throat disorders

Because ear, nose, and throat disorders conditions can cause pain and severely impair a patient’s ability to communicate, they require careful nursing assessment and, in many cases, recommendations for follow-up treatment. For example, you may need to refer a patient with a hearing loss to an audiologist for further evaluation or refer a patient with rhinitis to a doctor for hypersensitivity testing.

Anatomy and physiology

Focus Topic: Ear, nose, and throat disorders

To perform an accurate physical assessment, you’ll need to understand the anatomy and physiology of the ear, nose, and throat. Let’s look at each of them.

Ear

Focus Topic: Ear, nose, and throat disorders

The ear, a sensory organ, enables hearing and maintains equilibrium. It’s divided into three main parts — the external ear, the middle ear, and the inner ear.

 

Ear, nose, and throat disorders

 

Ear, nose, and throat disorders: Let’s start outside

The external ear is made up of the skin-covered cartilaginous auricle (pinna) and the external auditory canal. The tympanic membrane (eardrum) separates the external ear from the middle ear at the proximal portion of the auditory canal.

Ear, nose, and throat disorders: Three in the middle

The middle ear, a small, air-filled cavity in the temporal bone, contains three small bones — the malleus, the incus, and the stapes.

Ear, nose, and throat disorders: Enter the inner labyrinth

This cavity leads to the inner ear, a bony and membranous labyrinth, which contains the vestibule, the semicircular canals (the vestibular apparatus), and the cochlea. (See A close look at the ear.)

Ear, nose, and throat disorders: How we hear here

The auricle picks up sound waves and channels them into the auditory canal. There, the waves strike the tympanic membrane, which vibrates and causes the handle of the malleus to vibrate too. These vibrations travel from the malleus, to the incus, to the stapes, through the oval window and the fluid in the cochlea, to the round window.

Ear, nose, and throat disorders: Hearing hair

The membrane covering the round window shakes the delicate hair cells in the organ of Corti, which stimulates the sensory endings of the cochlear branch of the acoustic nerve (cranial nerve VIII). The nerve sends the impulses to the auditory area of the temporal lobe in the brain, which then interprets the sound.

Nose, sinuses, and mouth

Focus Topic: Ear, nose, and throat disorders

Not only is the nose the sensory organ for smell, but it also warms, filters, and humidifies inhaled air. The sinuses are hollow, air-filled cavities that lie within the facial bones. They include the frontal, sphenoidal, ethmoidal, and maxillary sinuses. The same mucous membrane lines the sinuses and the nasal cavity. Consequently, the same viruses and bacteria that cause upper respiratory tract infections also infect the sinuses. In addition to aiding voice resonance, the sinuses may also warm, humidify, and filter inhaled air, although this role hasn’t been firmly established. (See A close look at the nose and mouth.)

Ear, nose, and throat disorders: Open wide

The lips surround the mouth anteriorly. The soft palate and uvula (a small, cone-shaped muscle lined with mucous membrane that hangs from the soft palate) border it posteriorly. The mandibular bone, which is covered with loose, mobile tissue, forms the floor of the mouth; the hard and soft palates form the roof of the mouth.

Throat

Focus Topic: Ear, nose, and throat disorders

Located in the anterior part of the neck, the throat includes the pharynx, epiglottis, and larynx (voice box). Food travels through the pharynx to the esophagus. Air travels through it to the larynx. The epiglottis diverts material away from the glottis during swallowing and helps prevent aspiration.

 

Ear, nose, and throat disorders

 

Ear, nose, and throat disorders: High jinx in the larynx

By vibrating exhaled air through the vocal cords, the larynx produces sound. Changes in vocal cord length and air pressure affect the voice’s pitch and intensity. The larynx also stimulates the vital cough reflex when a foreign body touches its sensitive mucosa. The most important function of the larynx is to act as a passage for air between the pharynx and the trachea.

Ear, nose, and throat disorders: Assessment

Now that you’re familiar with the anatomy and physiology of the ears, nose, and throat, you’re ready to assess them.

History

Focus Topic: Ear, nose, and throat disorders

Before the interview, determine whether the patient hears well. If not, use his preferred technique to communicate.

Current health status

Document in the patient’s own words his chief complaint. Ask relevant questions, such as:

  • Have you recently noticed a difference in hearing in one or both ears?
  • Do you have ear pain? Is it unilateral or bilateral?
  • Do you have any drainage from one or both ears? What color is it? How often does it occur?
  • Do you have frequent headaches, nasal discharge, or postnasal drip?
  • Do you experience frequent or prolonged nosebleeds, difficulty swallowing or chewing, or hoarseness or changes in the sound of your voice?

Previous health status

To gather information about the patient’s past ENT health, inquire about previous hospitalization, drug therapy, or surgery for an ENT disorder or other relevant condition. Also, be sure to ask these questions:

  • Have you ever had an ear injury? Do you suffer from frequent ear infections?
  • Have you experienced ringing or crackling in your ears?
  • Have you had drainage from your ears or problems with balance, dizziness, or vertigo?
  • Have you had sinus infections or tenderness, allergies that cause breathing difficulty, or sensations that your throat is closing?

Family health status

Next, question the patient about possible familial ENT disorders. Ask whether anyone in the patient’s family has ever had hearing, sinus, or nasal problems.

Lifestyle patterns

To explore the patient’s daily habits that might affect the ears, nose, or throat, ask these questions:

  • Do you work around loud equipment, such as printing presses, air guns, or airplanes? If so, do you wear ear protectors?
  • Do you listen to loud music with headphones?
  • Do you smoke, chew tobacco, use cocaine, or drink alcohol? If so, to what extent?

Physical examination

Focus Topic: Ear, nose, and throat disorders

You’ll primarily use inspection and palpation to assess the ears, nose, and throat. If appropriate, you’ll also perform an otoscopic examination.

Inspecting and palpating the ears

Examine ear color and size. The ears should be similarly shaped, colored the same as the face, sized in proportion to the head, and symmetrically placed. Look for drainage, nodules, and lesions. Cerumen is usually present and varies from gray-yellow to light brown and black.

Palpate pinna to process; then pull for pain

Palpate the external ear, including the pinna and the tragus, and the mastoid process to discover areas of tenderness, swelling, nodules, or lesions. Then gently pull the helix of the ear backward to determine whether the patient feels pain or tenderness.

Performing an otoscopic examination

Before examining the auditory canal and the tympanic membrane, become familiar with the function of the otoscope. (See Using an otoscope.)

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Assessing the nose

Inspect the nose for midline position and proportion to other facial features. To assess nasal symmetry, ask the patient to tilt his head back; then observe the position of the nasal septum. The septum should be aligned with the bridge of the nose. With the head in the same position, use a nasal speculum to inspect the inferior and middle turbinates, the nasal septum, and the nasal mucosa. Note the color of the mucosa, evidence of bleeding, and the color and character of drainage. The nasal mucosa is normally redder than the oral mucosa. Identify abnormalities such as polyps.

Palpate me tender

Next, palpate the nose, checking for painful or tender areas, swelling, and deformities. Evaluate nostril patency by gently occluding one nostril with your finger and having the patient exhale through the other.

 

Ear, nose, and throat disorders

 

Assessing the sinuses

To assess the paranasal sinuses, inspect, palpate, and percuss the frontal and maxillary sinuses. (The ethmoidal and sphenoidal sinuses lie above the middle and superior turbinates of the lateral nasal walls and can’t be assessed.) To assess the frontal and maxillary sinuses, first inspect the external skin surfaces above and to the side of the nose for inflammation or edema. Then palpate and percuss the sinuses. (See Palpating the maxillary sinuses.) If the nose and sinuses require more extensive assessment, use the techniques of direct inspection and transillumination.

 

Ear, nose, and throat disorders

 

Assessing the mouth and throat

Use inspection and palpation to assess the mouth and throat. First, inspect the patient’s lips. They should be pink, moist, symmetrical, and without lesions. Use a tongue blade and a bright light to inspect the oral mucosa. Have the patient open his mouth; then place the tongue blade on top of his tongue. The oral mucosa should be pink, smooth, moist, and free from lesions and unusual odors.

Past the teeth, past the gums

Next, observe the gums (gingivae). They should be pink and moist and should have clearly defined margins at each tooth. Inspect the teeth, noting their number and condition and whether any are missing or crowded.

Next stop, the tongue

Next, inspect the tongue. It should be midline, moist, pink, and free from lesions. It should move easily in all directions, and it should lie straight to the front at rest.

Uvula and oropharynx and tonsils — Oh, my!

Inspect the back of the throat (oropharynx) by asking the patient to open his mouth while you shine the penlight on the uvula and palate. You may need to insert a tongue blade into the mouth to depress the tongue. The uvula and oropharynx should be pink and moist, without inflammation or exudates. The tonsils should be pink and shouldn’t be hypertrophied. Ask the patient to say “Ahhh.” Observe for movement of the soft palate and uvula. The uvula should be centered at the midline.

Palpation station

Finally, wearing clean gloves, palpate the lips, tongue, and oropharynx. Note lumps, lesions, ulcers, or edema of the lips or tongue. Assess the patient’s gag reflex by gently touching the back of the pharynx with a cotton-tipped applicator or the tongue blade. This should produce a bilateral response.

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