LAB WEEK 6 EYES EARS NOSE AND MOUTH EYES

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Lab week 6: Eyes,

Lab week 6: Eyes, Ears, Nose and Mouth

Eyes

1. Test for visual acuity (near and/ or far) (CN II): use card to cover each eye and test each eye individually, and then both eyes with wall chart and hand held card.


Visual acuity
normal visual acuity: 20/20

[the top number (numerator) is the distance the distance that patient is standing from chart

the bottom number (denominator) is the distance at which the normal eye could have read that line]

poor visual acuity: 20/30

heightened visual acuity: 20/15



Myopia- nearsightedness, objects in distance appear blurred

Hyperopia- farsightedness, objects close up appear blurred

Presbyopia-decreased accommodation (cannot focus on objects that are close) this occurs with with age >40 years.




2. Inspect eyes, eyelids and eyebrows for:

Eyes: position and alignment.

Eyelids: position in relationship to eyeballs, edema, colour, lesions, condition and direction of eyelashes.

Eyebrows: bilateral and symmetrical movement with facial expression changes, absence of lesions and scaling.


3. Inspect sclera, conjunctiva, corneas, and lenses:

Sclera and conjunctiva for: colour, nodules, swelling, moisture, pus, and foreign bodies.        

Cornea and lens for: presence of opacities (cloudiness- there should be none).


4. Test pupillary reaction to light for direct and consensual (CN III): observe each pupil’s direct response to light as well as their consensual response to light.


5. Test extraocular movements (EMO): lead eyes through the six cardinal positions of gaze. Ensure that the head does not move during exam i.e., holds chin, slow deliberate movements of object through cardinal fields of gaze and stopping at each end of the six movements. (CN II; IV and VI)


Strabismus- is one of the more common eye conditions in children, that affects between 2- 4% of the paediatric population. It occurs when the eyes are not aligned properly. One or both of a child’s eyes may turn inward (esotropia), outward (exotropia), upward (hypertropia) or downward (hypotropia). A child can be born with strabismus or it be acquired later in life. Strabismus can also develop as the result of an accident or other health problem. In some children, strabismus is intermittent, while in others it is always present.



6. Test pupil reaction to accommodation (CN II and III): observe convergence (motion towards) of the axes of the eyeballs and papillary constriction. Ask client to fix eyes on wall, than ask the client to fix eyes on finger, slowly move finger from distance towards client’s nose - stop as you see convergence- eyes crossing. Check for ptosis (droopy eye lid- presence in 3rd nerve palsy or Horner’s syndrome).

Cranial Nerves
Cranial nerve II- The optic nerve carries sensory nerve fibers and its function is vision, and it is not involved in the movements of the eye. This nerve is assessed with the visual acuity test. 

Cranial nerve III- The oculomotor nerve carries both motor and parasympathetic fibers. The motor component of the nerve is involved in most extraocular movements (EOM), while the parasympathetic component is involved in the constriction of the pupil and change in the shape of the lens. This nerve is assessed with the extraocular movement and accommodation. 

Cranial nerve IV- The trochlear nerve carries motor fibers. This nerve is involved in the downward and inward movement of the eye. This nerve is assessed with the extraocular movement. 

Cranial nerve VI- The abducens nerve carries motor fibers. This nerve is involved in the lateral movement of the eye. This nerve is assessed with the testing of the extraocular movement. 



Ears                                                                                                               

1. Inspect the ears for: size, shape, positioning, alignment thickening, skin colour and lesions and inspect and palpate the tragus, mastoid process and helix of the external ear (auricle) for: alignment, deformity, and tenderness.


2. Perform an otoscopic examination on each ear: gently pull the auricle up and back straightening the S- shape of the canal. Ensure that you hold the otoscope upside down- using largest speculum that allows for comfort. 

Inspect the canals for: colour, swelling, lesions, foreign bodies and discharge.


Visualizes the tympanic membrane: the eardrum should be shiny, translucent and pearl grey in color.


Visualize the cone shape light reflex: it is present in the anter-inferior quadrant at 5 O’clock in R ear and 7 O’clock in the left ear.


Visualize the malleus: the handle and short process of malleus are visible through the translucent drum (located about 2 O’clock is the short and pointing downwards from short is the handle).


Visualize the incus: it is located at 11 O'clock.


3. Test Hearing Acuity via the Watch/ Whisper test- Perform a Watch test or Whisper test (2-syllable word, distance of 12"). Have client gently press on tragus of ear not being assessed for hearing. 


Measuring Hearing via Air Conduction & Bone Conduction:

4. Perform Weber test (*): place vibrating tuning fork in the midline of the person’s skull to assess if tone sound is same in both ears and better in one ear. This test is valuable when a person reports hearing difference is one ear.


With sensorineral loss the sound is heard in good ear.


With conductive hearing loss the sound is heard in impaired ear (e.g. as a result of acute otitis media and perforation).


5. Perform Rinne test (*) with both ears: place stem of vibrating tuning fork on client’s mastoid process and ask him/ her to identify when he/ she stops hearing the sound (bc). Then quickly invert the fork so the vibrating end is near the ear canal and ask the client to identify when this sound goes away (ac).

   Normal response: ac > bc

           In conductive hearing loss: bc = ac or bc >ac

           In sensory hearing loss: ac >> bc                     



The acoustic cranial nerve CN VIII has 2 divisions:

1) hearing cochlear division.

2) balance vestibular division.



*Within some health care facilities the Weber and Rinne are not used for general screening of hearing as some evidence has shown that the data obtained may not be precise or reliable (Bafai et al., 2006 as cited in Jarvis 2013)


Assess Vestibular Apparatus function:
6. Perform Rhomberg test:

With eyes open: have patient stand with arms at side, legs together- look at posture and for variations of balance and for body swaying.

With eyes closed: have patient stand with arms at side, legs together- look at posture and for variations of balance and for body swaying.


Nose and Sinuses

1. Inspect the external nose for: deformity, alignment, asymmetry, inflammation, lesions, and nasal flaring.       

                                                 

2. Test patency of nostrils (one at a time): have client push a nasal wing shut with finger while asking the client to sniff inward through the other nare.    

                                                                                  

3. Inspect (using otoscope) nasal mucosa and turbinates for: scolour, swelling, exudate and bleeding.


4. Inspects (using otoscope) septum for: bleeding, perforation, and deviation of septum.


5. Palpate maxillary and frontal sinuses for: the presence of tenderness and pain. The frontal sinuses are located below the eyebrows and the maxillary sinuses are located below the cheekbones.


The olfactory nerve CN I is tested when neurological damage is suspected. Have the client push a nasal wing shut with finger and ask the client to sniff and identify a common smell –do with both nasal wings. It is important to assess for allergies prior to testing and to consider cultural factors in the selection of the scents.

 

Mouth and Pharynx                                                                                    

1. Inspect lips for: colour, symmetry, hydration, fissures, lesions and swelling.


2. Inspect (using otoscope and tongue depressor) gums for: ccolour, swelling, bleeding and lesions.


3. Inspect (using otoscope and tongue depressor) dentition for: prescence, shape, position, looseness, caries and repair.        

                

4. Inspect (using otoscope and tongue depressor) buccal mucosa for: colour and moistness.    

                                          

5. Inspect (using otoscope and tongue depressor) tongue for: symmetry, colour, hydration, lesions and atrophy. Assess for lateral deviation, range of movement. 
Ask client to say "light, tight, dynamite". Assess tongue strength. The range of motion of tongue involves the CN #XII hypoglossal.    

                      

6. Inspect (using otoscope and tongue depressor) the uvula for: position and movement. Ask the client to say “ahhh”.   


7. Inspect (using otoscope and tongue depressor) hard and soft palate for: colour, lesions, structure/intactness.


8. Inspect (with and otoscope and tongue depressor) tonsils, pharynx for: colour, lesions, exudate, and tonsil enlargement      


9. Check gag reflex:  touch the posterior wall with a tongue blade. This involves CN IX glossopharyngeal and CN X vagus (e.g. with talking and swallowing).




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