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

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Presentation on theme: "Ear, Nose, and Throat Adapted from Mosby’s Guide to Physical Examination, 6 th Ed. Ch. 12."— Presentation transcript:

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

2 Development Maxillary and ethmoid sinuses –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 6 and 24 months

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

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

9 Inspection Auricle –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 1 st branchial cleft

13 Internal Ear Exam 1.Lay the infant supine/prone 2.Turn head to the side 3.Hold otoscope so that the ulnar surface of your hand rests against the infant’s head *Prevent trauma to auditory canal 4.Other hand stabilizes infant’s head 5.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 monthsStartle reflex, crying, cessation of breathing or movement in response to sudden noise; quiets to parent’s voice 4 to 6 monthsTurns 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 monthsResponds 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 monthsRecognizes 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 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 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 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 –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 /pediapals/products

37 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

40

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 Pneumatic Otoscope needed to differentiate CryingRed Moveable InfectionRed 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 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 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 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.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 –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 –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! 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


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