EARS, MOUTH, THROAT NOSE, AND SINUSES ASSESSMENT

General Approach to Ears, Nose, Mouth and Throat Assessment

1. Greet the patient and explain the assessment techniques that you will be using.
2. Use a quiet room that will be free from interruptions.
3. Ensure that the light in the room provides sufficient brightness to allow adequate
observation of the patient.
4. Place the patient in an upright sitting position on the examination table. For
clients who cannot tolerate the sitting position, gain access to the patient’s head
so that it can be rotated from side to side for assessment.
5. Visualize the underlying structures during the assessment process to allow
adequate description of findings.
6. Always compare right and left ears, sides of the nose, sinuses, mouth and throat.
7. Use a systematic approach that is followed consistently each time the
assessment is performed

ASSESSMENT OF THE EAR

Physical assessment of the ear consists of three parts:

1. Auditory screening (CNVIII)
2. Inspection and palpation of the external ear
3. Otoscopic assessment

Preparing the Client

(same as eye assessment)

Equipment
 Watch with a second hand for Romberg test
 Tuning fork
 Otoscope

Physical Assessment

EXTERNAL EAR STRUCTURES

Inspection and Palpation:

 Inspect the auricle, tragus and lobule. Note size, shape and position.
o Normal Findings:
 Ears are equal in size bilaterally (4-10cm)
 Auricle aligns with the corner of the eye and within a 10-degree
angle of the vertical position
 Earlobes may be free, attached or soldered (tightly attached to
adjacent skin with no apparent lobe)
 o Abnormal Findings:
 Malaligned or low-set ears may be seen with genitourinary
disorders or chromosomal defects.

 Palpate the auricle and mastoid process.

o Normal Findings:
 The auricle, tragus and mastoid process are not tender.

o Abnormal Findings:
 A painful auricle ir tragus is associated with otitis externa or a
postairicular cyst.
 Tenderness over the mastoid process suggests mastoiditis.
 Tenderness behind the ear may occur with otitis media.

INTERNAL EAR STRUCTURES

Inspection:
 Inspect the external auditory canal. (use the otoscope)
o Normal Findings:
 A small amount of odourless cerumen (ear wax) is the only
discharge normally present.
 Cerumen may be yellow, orange, red, brown, gray or black and
soft, moist, dry, flaky or even hard.

o Abnormal Findings:
 Foul smelling, sticky, yellow discharge – otitis externa or impacted
foreign body.
 Bloodym purulent discharge – otitis media with ruptured
tymphanic membrane.
 Blood or watery drainage – skull trauma

 Observe the color and consistency of the ear canal walls and inspect the
character of any nodules.
o Normal Findings:
 The canal walls should be pink and smooth and without nodules
o Abnormal Findings:
 Reddened, swollen canal – otitis externa
 Exostoses (non-malignant nodular swellings)
 Polyps
  Inspect the tympanic membrane (eardrum). Note the color, shape, consistency
and landmarks.
o Normal Findings:
 The tympanic membrane should appear pearly, gray, shiny,
translucent with no bulging or retraction.
o Abnormal Findings:
 Acute otitis media – red bulging eardrum and distorted,
diminished or absent light reflex.
 Serous otitis media – yellowish, bulging membrane with bubbles
behind
 Bluish or dark re color-blood behind the eardrum from skull
trauma.
 White spots – scarring from infections

HEARING AND EQUILIBRIUM TESTS

 Perform Voice-Whisper Test

1. Instruct the patient to occlude one ear with finger.
2. Stand 2 feet behind the patient’s other ear and whisper a two-syllable word or
phrase that is evenly accented.
3. Ask the patient to repeat the word or phrase.
4. Repeat the test with the other ear.
o Normal Findings:
 The patient should be able to repeat the words whispered from a
distance of 2 feet.

 Perform Weber’s Test if the client reports diminished or lost hearing in one ear.
1. Hold the handle of the tuning fork and strike the tines on the ulnar border of
the palm to activate it.
2. Place the stem of the fork firmly against the middle of the patient’s forehead,
on top of the head at the midline.
3. Ask the patient if the sound is heard centrally or toward one side.
o Normal Findings:
 Vibrations are heard equally well in both ears. No lateralization of
sound to either ear.
o Abnormal Findings:
 Conductive hearing loss – client reports lateralization of sound to
the poor ear – that is, the client “hears” the sound in the poor ear.
The good ear is distracted by background noise, conducted air,
which the poor ear has trouble hearing. Thus the poor ear
receives most of the sound conducted by bone vibration.
 Sensorineural hearing loss – client reports lateralization of sound
to the good ear. This is because of limited perception of the sound
 due to nerve damage in the bad ear, making sound seem louder in
the unaffected area.

 Perform the Rinne Test

1. Stand behind or to the side of the patient and strike the turning fork.
2. Place the stem of the tuning fork against the patient’s right mastoid process
to test bone conduction.
3. Instruct the patient to indicate if sound is heard.
4. Ask the patient to tell you when the sound stops.
5. When the patient says that the sound stopped, move the tuning fork, with
the tines facing forward, in front of the right auditory meatus, and ask the
patient if the sound is still heard. Note the length of time the patient hears
the sound (testing air conduction)
6. Repeat the test on the left ear.
o Normal Findings:
 Air conduction sound is normally longer than the bone conduction
(AC>BC)
o Abnormal Findings:
 Conductive (BC≥AC)
 Sensorineural (AC≥BC)

 Perform the Romberg Test

- tests the client’s equilibrium

- Ask the client to stand with feet together and arm at sides and eyes open and
then with the eyes closed.

o Normal Findings:
 Client maintains position for 20 seconds without swaying or with
minimal swaying.

Sample Objective Data

 Equal in size bilaterally
 Auricles aligned with the corner of each eye within a 10-degree angle of vertical
position
 Skin smooth, no lumps, lesions, nodules
 No discharge
 Non-tender on palpation
 Small amount of moist yellow cerumen in external canal.
  Tympanic membrane pearly gray, shiny transparent, no bulging.

Appropriate Nursing Diagnoses

Wellness Diagnoses
 Readiness for enhanced communication related to use of hearing aid.

Risk Diagnoses
 Risk for injury related to hearing impairment

Actual Diagnoses
 Disturbed sensory perception: Auditory related to conductive or sensorineural
hearing loss.

ASSESSMENT OF THE MOUTH, NOSE, THROAT AND SINUSES

Equipment:
 Gloves
 4x4 inch gauze
 Penlight
 Short, wide tipped speculum attached to the head of an otoscope
 Tongue depressor
 Nasal speculum

MOUTH

Inspection and Palpation:

 Inspect the lips. Observe lip consistency and color.
o Normal Findings:
 Lips are smooth and moist without lesions or swelling

 Inspect the teeth and gums. Ask the client to open mouth. Note the number,
color, condition and alignment of the teeth.
o Normal Findings:
 32 teeth with smooth surfaces and edges, 28 if 4 molars are not
yet errupted
 Put on gloves and retract the client’s lips and cheeks to check gums for color
and consistency.
o Normal Findings:
 Gums are pink, moist and firm with tight margins to the tooth. No
lesions or masses.
 Inspect the buccal mucosa.
o Normal Findings:
 Tissue is smooth and moist, without lesion.

 Inspect and palpate the tongue.

o Normal Findings:
 Tongue is pink, moist, moderate size with papillae present

 Assess the ventral surface of the tongue.

o Normal Findings:
 Smooth, shiny, pink or slightly pale with visible veins and no
lesions.

 Inspect for Wharton’s ducts- openings from the submandibular salivary glands
located on either side of the frenulum on the floor of the mouth
o Normal Findings:
 Frenulum is midline
 Wharton’s ducts are visible
 No swelling, redness or pain

 Observe the sides of the tongue.

o Normal Findings:
 No lesions, ulcers, or nodules

 Check the strength of the tongue

o Normal Findings:
 With string resistance.

 Check the anterior tongue’s ability to taste.

o Normal Findings:
 Can distinguish between sweet and salty.

 Inspect the hard and soft palates and uvula.

o Normal Findings:
 Hard palate is pale and whitish with firm transverse rugae.

 Note odor.
o Normal Findings:
 No unusual or foul odor.

 Assess the uvula.

o Normal Findings:
  The uvula is fleshy, solid structure that hangs freely in the
midline.
 No redness, exudates.
 Midline elevation of the evula and symmetric elevation of the
soft palate.

 Inspect the tonsils.

o Normal Findings:
 May be present or absent
 Pink and symmetric, no exudates, swelling or lesions

 Inspect the posterior pharyngeal wall.

o Normal Findings:
 Throat is normally pink without exudates or lesions.

NOSE

Inspection and Palpation:

 Inspect and palpate the external nose. Note nasal color, shape, consistency and
tenderness.
o Normal Findings:
 Color is the same as the rest of the face.
 Smooth and symmetric
 No tenderness

 Check patency of air flow through nostrils.

o Normal Findings:
 Able to sniff through each nostril while other is occluded.

 Inspect the internal nose.

o Normal Findings:
 Nasal mucosa is dark pink, moist and free of exudates.
 Nasal septum intact, free of ulcers or perforations

SINUSES

Palpation:
 Palpate the sinuses.
o Normal Findings:
 Frontal and maxillary sinuses are non-tender to palpation and no
crepitus is evident.

Percussion:
 Percuss the sinuses.
o Normal Findings:
 Not tender.

 Transilluminate the sinuses.

o Normal Findings:
 A red glow transilluminates the frontal sinuses, indicating normal
air-filled sinus.

Sample Documentation of Objective Data

 Lips pink, smooth and moist without lesions
 Buccal mucosa, pink, moist and without exudates.
 Parotid ducts visible with no redness or swelling
 Moist bubbles are seen near ducts
 32 white to yellowish teeth present
 Gums pink without redness or swelling frenulum in the midline with visible veins
present
 Midline and symmetric elevation of the uvula and soft palate with phonation.
 Nose somewhat large but smooth and symmetric

Appropriate Nursing Diagnoses

Wellness Diagnoses
 Readiness of Enhanced Effective management of the teeth and gums.

Risk Diagnoses
 Risk fir aspiration related to decreased or absent gag reflex

Actual Diagnoses
 Ineffective health maintenance related to poor oral hygiene.