1. Adapted from Mosby’s Guide to Physical Examination, 6th Ed. Ch. 12
Ear, Nose, and Throat
Adapted from Mosby’s Guide to Physical Examination, 6th Ed.
Ch. 12

2. Development Maxillary and ethmoid sinuses Sphenoid sinus Frontal sinus
present at birth, though very small
Sphenoid sinus
tiny cavity at birth
not fully developed until puberty
Frontal sinus
develops by 7-8 years

3. Infant External auditory canal is shorter and has an upward curve
Eustachian tube is relatively wider, shorter and more horizontal
Reflux of nasopharyngeal secretions

4. Child
As the child grows, the eustachian tube lengthens and its pharyngeal orifice moves inferiorly
Growth of adenoids may occlude the eustachian tube
Interferes with aeration of the middle ear

5. Salivation increases by 3 months
Drools until swallowing is learned

6. Teeth
20 deciduous teeth
appear between and 24 months

7. Teeth Eruption of permanent teeth begins about 6 years of age
Completed ~14-15 years old
3rd molar (“wisdom tooth”)
18 years old

8. Ear, Nose, Mouth Exam
“Frequent site of congenital malformation therefore thorough examination is important.”

9. Inspection Auricle CLINCAL NOTE: Premature infant
Well formed, all landmarks present
Very flexible
Should have instant recoil after bending
CLINCAL NOTE: Premature infant
May appear flattened with limited incurving of the upper auricle
Slower ear recoil

10. The tip of the auricle should cross an imaginary line between the outer canthus of the eye and the prominent portion of the occiput (EOP)

11. Low or poorly shaped auricles
Associated with renal disorders and congenital abnormalities

12. NO skin tags should be present Preauricular skin tag
or preauricular pit
anterior to the tragus
remnant of 1st branchial cleft

13. Internal Ear Exam Lay the infant supine/prone Turn head to the side
Hold otoscope so that the ulnar surface of your hand rests against the infant’s head
*Prevent trauma to auditory canal
Other hand stabilizes infant’s head
Pull auricle down to straighten the canal

14. Newborns Auditory canal is often obstructed with vernix (newborn)
Tympanic membrane may be in an extremely oblique position until 1 month old
*Should be examined within the first few weeks of life

15. In neonates, you may note…
Limited mobility
Dullness and opacity of a pink or red tympanic membrane
Light reflex may appear diffuse
Tympanic membrane is not conical for several months

16. “As the middle ear matures in the first few months, the tympanic membrane takes on the expected appearance.”

17. Hearing Use a bell, toy, voice, or clap your hands
Make sure the infant is not responding to air movement or visual stimulus
Remember, responses to repeated sound stimuli will diminish as the infant tunes it out

18. Expected Hearing Response
Birth to 3 months
Startle reflex, crying, cessation of breathing or movement in response to sudden noise; quiets to parent’s voice
4 to 6 months
Turns head toward source of sound but may not always recognize location of sound; responds to parent’s voice; enjoys sound producing toys

19. Expected Hearing Response
6 to 10 months
Responds to own name, telephone ringing, and person’s voice, even if not loud; begins localizing sounds above and below, turns head 45 degrees towards sound
10 to 12 months
Recognizes and localizes source of sound; imitates simple words and sounds

20. Infant Nose Exam External Nose Symmetric appearance
Positioned in the vertical midline on the face
Deviation of the nose may be related to fetal position
Only minimal movement of the nares with breathing should be apparent

21. Consider a possible congenital abnormality if…
Saddle-shaped nose with a low bridge and broad base
Short small nose
Large nose

22. Inspect by shining a light inside
Internal nose
Inspect by shining a light inside
Gently tilt the nose tip up with your thumb
In infants, you may see a small amount of clear fluid discharged; crying

23. Nasal patency must be determined at the time of birth
Obligatory nose breathers
Mouth closed, occlude one naris and then the other
Observe the respiratory pattern

24. With total obstruction, the infant will not be able to inspire or expire through the noncompressed naris
Consider:
Septal deviation
Delivery trauma
Choanal atresia

25. Infant Sinuses Maxillary and ethmod sinuses are small during infancy
Few problems arise in these areas
Examination is generally unnecessary

26. Infant Mouth Exam Crying provides an opportunity to examine the mouth
Avoid depressing the tongue
Stimulates a strong reflex protrusion
Makes visualization of the mouth difficult

27. Well formed with no cleft Buccal mucosa
Pink and moist
No lesions
NOTE: Secretions that accumulate in the newborn’s mouth may indicate esophageal atresia

28. Scrape any white patches with a tongue blade
Nonadherent
milk deposits
Adherent
candidiasis (thrush)

29. Drooling
Normal from 6 weeks to 6 months
Consider a neurologic disorder if it persists >12 months

30. Note any unusual sequence of eruption
Gums
Should be endentulous
smooth with a serrated edge of tissue along the buccal margins
Teeth
Count deciduous teeth
Note any unusual sequence of eruption

31. fits well in the floor of the mouth
Tongue
fits well in the floor of the mouth
protrudes beyond the alveolar ridge
If not, possible feeding difficulties
Frenulum
Usually attaches midway between the ventral surface of the tongue and its tip

32. Insert your finger into the infant’s mouth
Fingerpad to the roof of the mouth
Evaluate the infant’s suck
Palpate the hard and soft palates
Stimulate a gag reflex by touching the tonsillar pillars

33. Normally… Should have a strong suck Palatal arch should be dome shaped
Tongue pushing vigorously upward against the finger
Palatal arch should be dome shaped
Neither hard nor soft palate should have palpable clefts
Soft palate should rise symmetrically when the infant cries

34. Note in records if… Narrow, flat palate roof OR High, arched palate
affect the tongue’s placement
feeding and speech problems
*Associated with congenital anomolies

35. Child ENT Exam

36. Modifying Your Instruments
Oto/ophthalmoscope
Decorative covers

37. Be prepared to use restraint if encouraging the child fails
Postpone until the end
often resist otoscopic and oral exams
Be prepared to use restraint if encouraging the child fails
Ask parent to restrain the child

38. Restraining a Child – Oral Exam
Seated in the parent’s lap, back to the parent and legs between the adult’s legs
Parent can reach around to restrain the child’s arms with one arm and control the child’s head with the other
Can usually be accomplished without forcing
Force only makes them more angry…

39. Restraining a Child - Otoscope
Face the child sideways with one arm placed around parent’s waist
Parent holds the child firmly against his/her trunk
One arm restrains the head
One arm restrains the body
Doctor further stabilizes the child’s head while inserting the otoscope

41. Restraining a Child - Supine
If the child actively resists…
Place child supine on the exam table
Parent holds arms extended above the head and assists in restraining the head
Doctor lies across the child’s trunk and stabilizes the child’s head
Third person may need to hold the child’s legs

42. Remember
“Children of any age who are not too big to sit on a parent’s lap are better examined there than in a prone or supine position on the examining table.”

43. Child Ear Exam Otoscopic exam
Pull auricle either down and back OR up and back
gain best view of the tympanic membrane
As the child grows, the shape of the auditory canal changes to the S-shaped curve of the adult.

44. If the child is crying or has recently cried vigorously…
Dilation of blood vessels in the tympanic membrane can cause redness “red reflex”
Cannot assume that redness of the membrane alone is a middle ear infection

45. *see common conditions at the end of this ENT section
Pneumatic Otoscope
needed to differentiate
Crying
Red
Moveable
Infection
No mobility
*see common conditions at the end of this ENT section

46. Tympanometry Accurate way to identify middle ear effusion
Ear piece must be sealed in the canal to provide accurate reading
Wax, ruptured membrane, tubes

47. Toddler’s Hearing
Observe response to a whispered voice and various noise makers
Rattle, bell, tissue paper
Outside of the child’s vision
As they get older, ask child to perform tasks in a soft voice
May want to have a parent do it…
Avoid visual cues
Use words that have meaning for them
Big Bird, Mickey Mouse, Barney

48. Child’s Hearing Weber, Rinne, and Schwabach tests
Used only when a child understands directions and can cooperate with the examiner
Usually 3-4 years of age
Refer for audiometric screenings

49. Nose Exam Inspect internal nose
Usually adequate to tilt the nose tip upward
Largest otoscopic speculum may be used
Visualization of larger area

50. “Adenoidal” or “Allergic Salute”
Children often wipe their noses with an upward sweep of the palm of the hand
If repeated often enough, causes a crease
Transverse crease at the juncture between the cartilage and the bone of the nose

51. Sinuses – Child Maxilary sinuses should be palpated
Few sinus problems occur since the sinuses are still developing
Wide variation however
Do not rule out sinusitis simply on the basis of age

52. Child Mouth Exam Getting cooperation
Let the child hold and manipulate the tongue blade and light
Reduce fear of the procedure
Start by asking to see their teeth
Usually not threatening

53. Ask child to protrude the tongue and say “ ah”
Tongue blade is often unnecessary
Ask the child to pant “like a puppy”
Raises the palate

54. If child refuses to open mouth…
Insert a tongue blade through the lips to the back molars
Gently but firmly insert the tongue blade between the back molars and press the blade to the tongue
This should stimulate the gag reflex
Gives you a brief view of the mouth and oropharynx

55. Why are they breathing through their mouth?
Inspection
Highly arched palate
Children who are chronic mouth breathers
Why are they breathing through their mouth?

56. Flattened edges on the teeth
Bruxism
Unconscious grinding of the teeth
Why are they grinding?

57. Baby bottle syndrome
Multiple brown areas (caries) on upper and lower incisors
d/t bedtime bottle of juice/milk

58. Black or grey colored teeth
Pulp decay
Oral iron therapy
Mottled or pitted teeth
Tetracycline treatment during tooth development
Enamel dysplasia

59. Should blend with the color of the pharynx
Tonsils
Should blend with the color of the pharynx
Gradually enlarge to their peak size between years
should retain an unobstructed passage
Graded to describe their size

60. Grading Tonsils 1+ -visible
2+ -halfway between tonsillar pillars and the uvula
3+ -nearly touching the uvula
4+ -touching each other

61. Common Abnormalities

62. *Will breathe when crying
Choanal Atresia
Congenital nasal obstruction of the posterior nares
Junction between nasal cavity and nasopharynx
Newborns may experience respiratory distress
Obligatory nose breathers
*Will breathe when crying
Copyright © 2006 University of Washington.

63. Suckling Callus Newborn’s upper lips (other body parts)
First few weeks
Plaques or crusts

64. Natal Teeth Teeth or tooth buds in a newborn
If loose, potential for aspiration
May be removed

65. Retention Cysts aka Epstein Pearls Appear along the buccal margin
Pearl-like retention cysts
Disappear in 1-2 months

66. Macroglossia Abnormally large tongue
Associated with congenital anomalies
Congenital hypothyroidism
Down Syndrome

67. Short Frenulum
Associated with
Feeding problems
Speech difficulties

68. Cleft Lip and Palate Fissure in the upper lip and/or palate
Congenital malformation
Complete cleft
Extends through the lip and hard and soft palates to the nasal cavity
Partial Cleft
Any of the tissues

69. Long term issues: feeding problems chronic otitis media hearing loss
speech difficulties
improper tooth development and alignment

70. Otitis Externa (swimmer’s ear)
Infection of the auditory canal
trauma or moist environment
favor bacterial or fungal growth

71. Initial Symptoms
Itching in the ear canal
Pain
Intense with movement of pinna
Chewing
Discharge
Watery, then purulent & thick mixed with pus and epithelial cells
Musty, foul-smelling
Hearing
Conductive loss caused by exudate and swelling of ear canal
Inspection
Canal is red, edematous; tympanic membrane obscured

72. Bacterial Otitis Media
Infection of the middle ear
Often follows or accompanies an upper respiratory tract infection
Most common infection in childhood

73. Initial Symptoms
Fever, feeling of blockage, tugging earlobe, anorexia, irritability, dizziness, vomiting & diarrhea
Pain
Deep-seated earache
Discharge
Only if tympanic membrane ruptures or through tympanostomy tubes; foul-smelling
Hearing
Conductive loss as middle ear fills with pus
Inspection
Tympanic membrane may be red, thickened, bulging; full, limited, or no movement to +/- pressure

74. Otitis Media with Effusion
Inflammation of the middle ear resulting in the collection of liquid (effusion)
Serous, mucoid, or purulent
Causes:
Allergies
Enlarged lymph tissue (nasopharynx)
Obstructed or dysfunctional eustachian tube

75. Once the obstruction occurs…
middle ear absorbs the air, creating a vacuum
mucosa secretes a transudate into the middle ear
Average duration: 23 days

76. Initial Symptoms
Sticking or cracking sound on yawning or swallowing; no signs of acute infection
Pain
Uncommon; feeling of fullness
Discharge
uncommon
Hearing
Conductive loss as middle ear fills with fluid
Inspection
Tympanic membrane is retracted, impaired mobility, yellowish; air fluid level and/or bubbles

77. Sinusitis Infection of or more paranasal sinuses Symptoms: Signs:
May be a complication of a viral URTI, dental infection, allergies, or a structural defect of the nose
Blockage of the sinus meatus prevents drainage
Symptoms:
Fever, headache, local tenderness, and pain
Signs:
May be swelling of the skin overlying the involved sinus and copious nasal discharge

78. Children may alternatively suffer from:
upper respiratory symptoms
nasal discharge
low-grade fever
daytime cough
malodorous breath
cervical adenopathy
intermittent painless morning eye swelling
NO facial pain or headache

79. Tonsillitis Inflammation or infection of the tonsils Symptoms: Signs:
Frequently caused by streptococci
Symptoms:
Sore throat, referred pain to the ears, dysphagia, fever, fetid breath, and malaise
Signs:
Tonsils appear red and swollen; purulent exudate
yellow follicles are associated with streptococcal infection
Anterior cervical lymph nodes enlarged

80. Peritonsillar Abscess
Infection of the tissue between the tonsil and pharynx
*Complication of tonsillitis
Symptoms:
Dyphagia, drooling, severe sore throat with pain radiating to the ear, muffled voice, fever
Signs:
Tonsil, tonsillar pillar and adjacent soft palate become red and swollen
Tonsil may appear pushed forward or backward, possibly displacing the uvula

81. Epiglottitis
Impending airway obstruction d/t acute inflammation of the epiglottis
Though rare, it should always be considered!

82. Suspected with… Sudden high fever Croupy cough Sore throat Drooling
Apprehension
Focus on breathing
Tripod position, neck extended

83. Caution! Treat this as a medical emergency
Inserting tongue blade may be deadly!
may result in complete airway obstruction
Treat this as a medical emergency
No one should examine the child’s mouth until intubation equipment is available

84. Obstructive Sleep Apnea
Periodic cessation of breathing during sleep d/t airflow obstruction
Can be seen in children with excessively large tonsils
Loud snoring, restless sleep
Daytime sleepiness
Morning headaches
Developmental delay
Frequent infection