1. The Head and Neck
Ear & Nose

2. The Ear The ear consists of external, middle, and inner structures.
The eardrum and the three tiny bones conduct sound from the eardrum to the cochlea.
The cochlea transmits the waves to the brain.

3. Pathway of hearing
conductive phase : ear canal to the eardrum and the three tiny bones conduct sound from the eardrum to the cochlea.
sensorineural phase : The cochlea transmits the waves to the cochlear nerve to the brain.

4. Health History Any hearing problems?
If hearing loss, one or both ears?
Sudden or gradual loss?
Any associated symptoms?
Earache (pain, fever, discharge, sore throat, URT infection)
Tinnitus( perceived sound that has no external stimuli, rushing or roaring)
Vertigo ; perception that the patient or the environment is rotating or spinning
Dizziness; non specific term ( feeling unsteady, light headed)

5. Health History Difficulty understanding people talk?
sensorineural
How does noise environment affect hearing?
Noisy environment
worse -- sensorineural
better-- conductive

6. Ear Exam Inspect auricle and surrounding tissues
Deformities
Lumps
Skin lesions
If pain, discharge, inflammation
palpate pinna and tragus for tenderness
Tug test:
Pain in acute otitis externa (swimmer’s ear)
Palpate mastoid process for tenderness

7. Ear Canal and Drum
Using the otoscope

8. Using the otoscope
Use the largest ear speculum that the canal will accommodate.
Position the patient’s head so that you can see comfortably through the instrument.
Straighten the ear canal by grasping the auricle firmly and pulling it upward, backward, and slightly away from the head

9. Using the otoscope
Holding the scope between your thumb and forefingers, brace your hand against the patient’s face. This allows your hand and instrument to follow unexpected movements by the patient
Insert the speculum gently into the ear canal
Direct it down and forward and through the hair in the canal if present

10. Ear Canal and Drum Use otoscope (retract ear backward and upward)
Examine:
External auditory canal
Discharge, foreign bodies, redness, swelling, cerumen
Tympanic membranes
Color, contour, cone of light
The otoscopic exam is performed by gently pulling the auricle upward and backward. In children, the auricle should be pulled downward and backward. This process will move the acoustic meatus in line with the canal. Hold the otoscope like a pen/pencil and use the little finger area as a fulcrum. This prevents injury should the patient turn suddenly.
Inspect the external auditory canal.
Evaluate Tympanic membrane
Note the color (red, white, yellow) and translucency (transparent, opaque) and position (retracted, neutral or bulging) of the drum  
Identify the pars tensa with its cone of light, the handle and short process of malleus, and the anterior and posterior folds of the pars flaccida and position of the malleus handle..
Air inflation Otoscopy (Pneumatic-otoscope) is very useful to evaluate middle ear disease. Assess the mobility of tympanic membrane by applying positive and negative pressures with the rubber squeeze bulb.

11. Ear Canal and Drum
Note any middle ear structures visualized through TMs
Handle of maleous, Short process of maleous, Incus
Look for perforation, bulging, …
Red pulgging drum in Acute purulent otitis media

12. Normal Findings
Auditory canal: Some hair, often with yellow to brown cerumen.
Ear drum: 
Pinkish gray in color, translucent and in neutral position. 
Malleus lies in oblique position behind the upper part of drum.

13. Ear Exam
Auditory Acuity: Assess hearing one ear at a time with whisper test, tuning fork (512 Hz), ticking watch, or others.
If hearing is abnormal, perform the Weber and Rinne tests to assess for sensorineural and/or conductive hearing loss

14. Weber Test (lateralization)
Vibrating fork (512 Hz)
Place on top of patient head or midforehead
Ask patient in which ear sound heard best (the sound should be heard equally well in both ears)

15. Weber Test (lateralization)
If sound is heard asymmetrically, it means one of two things:
In Conductive hearing sound
( lateralized to impaired ear)
In Sensorineural hearing sound
( lateralized to good ear)

16. Rinne Test (To compare AC & BC)
The vibrating tuning fork is placed on the mastoid process.
When patient can no longer hear sound, put lateral to the ear.
Ask if patient can still hear sound.

17. Rinne Test (To compare AC & BC)
Rinne test is a normal test: air conduction should be longer than bone conduction.
Sensorineural hearing loss; sound is heard longer through air ;Rinne test: AC>BC
Conductive hearing loss; sound is heard longer through bone ; Rinne test: AC<BC or AC=BC

18. Diseases Causing Hearing Loss
Conductive Hearing loss: Lesion between the receptors and environment (Ossicle lesion, otitis media, otosclerosis, impacted cerumen)
Sensorineural hearing loss: Lesion of the receptors or its pathway (Aging, drug toxicity, noise damage, acoustic neuroma)

19. The Nose and Sinuses

20. The Nose Health history: Rhinorrhea— Frequent or severe colds
Nasal discharge or runny nose--Continuous, watery, purulent, mucoid, bloody
Nasal congestion---stuffy nose, sneezing, watery eyes, throat discomfort, itching eyes, nose, throat.
Frequent or severe colds
Upper respiratory tract infection
How often?
Remedies?
Sinus pain
Headache, tenderness, fever

21. The Nose Health history: Trauma Epistaxis– bleeding from nose
Breath through nose? Any obstruction?
Epistaxis– bleeding from nose
How much? Teaspoon, does it pour out?
From one or both nostrils?
How do you treat them? Difficult to stop?
Allergies
Pollen, dust, hair?
How did you know?
Aggravating environment
Inhalers? Spray, drops
Any change in sense of smell

22. The Nose Inspect external nose Palpation
asymmetry, deformity, lesions, inflammation, nasal bone fracture
Inspect inferior surface of nose using a penlight
Palpation
If injury, palpate gently
Test patency– push nasal wing shut and ask patient to sniff inward to check for obstruction

23. The Nose Inspect using nasal speculum
Inspect nasal mucosa( covers septum & turbinates), nasal septum, any abnormalities
Color and integrity of nasal mucosa—normal red color, smooth moist surface
Swelling, discharge, bleeding, foreign body
Septum– deviation, perforation (cocaine), bleeding
Turbinates—light red color, any exudates/pus, swelling/hypertrophy,
polyps (smooth pale grey, avascular, mobile, nontender masses) or ulcers

24. The Nose Palpate sinus areas with thumbs Transillumination of sinuses
Frontal sinus, below eyebrows
Maxillary sinus, below cheekbones
Firm pressure, no pain
Note tenderness (chronic allergy, acute infection sinusitis)
Transillumination of sinuses
An inflamed sinus does not illuminate

25. Normal Findings
The septum is in the middle and the turbinates project into the nasal passages. 
There is sufficient room for the nasal passages.
The mucous membrane is red and compact over the turbinates.
There may be a small amount of thin secretions.