Assessment of Ear, Nose and Throat

Introduction

Assessing the ear, nose, and throat (ENT) is a fundamental part of a head-to-toe physical examination and is especially important when patients present with symptoms like hearing loss, sore throat, nasal congestion, or dizziness.

Ears are the anatomical machinery for hearing and balance and problems of the ear affect a person’s hearing and equilibrium.
Nose as an organ of the respiratory system is important for maintaining homeostatic balance of the body.

Throat or pharynx is the muscular/organ which serves as a common passageway for food and air.
Assessment of these organs ear, nose and throat includes history of present illness, cardinal signs and symptoms and a physical assessment.

Articles

1. Flashlight or headlight.
2. Tongue depressor.
3. Wax hook.
4. Probe.
5. Nasal forceps.
6. Ear forceps.
7. Tuning fork.
8. Laryngeal mirror.
9. Nasal speculum.
10. Auriscope/otoscope.

Procedure

The following assessments must be completed and documented:

History taking:

History of present illness and review of system:

1. Onset (sudden or gradual)
2. Chronology
3. Current situation (improving or deteriorating)
4. Location
5. Radiation
6. Quality
7. Timing (frequency and duration)
8. Severity
9. Precipitating and aggravating factors
10. Relieving factors
11. Associated symptoms
12. Effects on daily activities
13. Previous treatments
14. Efficacy of previous treatments.

Cardinal signs and symptoms:

In addition to the general characteristics outlined above, additional characteristics of specific symptoms should be elicited.

Ears

• Recent change in hearing
• Compliance with and effectiveness of hearing aid if using one
• Itching
• Earache
• Discharge
• Tinnitus  
• Vertigo
• Ear trauma
• Use of cotton swabs

Nose and sinuses

• Rhinorrhoea
• Epistaxis
• Obstruction of airflow
• Sinus pain and localized headache
• Itching
• Anosmia (loss of the sense of smell)
• Nasal trauma
• Sneezing
• Watery eyes

Mouth and throat

• Hoarseness or recent voice change
• Dental status
• Oral lesions
• Bleeding gums
• Changes on the tongue
• Sore throat
• Uvula malalignment
• Dysphagia (difficulty or dis comfort in swallowing)
• White patches on the inner cheeks, tongue, roof of the mouth and throat
• Redness or soreness
• Cottony feeling in the mouth with pain and burning sensation on tongue.

Neck

• Pain
• Swelling
• Enlarged lymph glands
• Increasing headache associated with flexing of neck.

Other associated symptoms:

• Fever
• Malaise
• Nausea or vomiting.

 Medical history

• Frequent ear or throat infections
• Sinusitis
• Trauma to the head or ENT area
• ENT surgery
• Hearing loss or audiometric screening results indicating hearing loss
• Asthma
• Chronic cough
• Meniere’s disease
• ENT cancer.

Personal and social history specific to ENT:

• Family and close contacts with similar symptoms
• Smoking tobacco, cannabis (marijuana)
• Use of chewing tobacco
• Exposure to vapors during vaping (inhaling vapors of substances like marijuana)
• Alcohol use
• Illicit drug use
• Frequent immersion of ears in water (e.g., swimming, bathing).
• Use of foreign objects to clean ear
• Crowded living conditions
• Personal and dental hygiene habits
• Exposure to cigarette smoke or other respiratory irritants.
• Recent air travel or scuba diving
• Occupational exposure to toxins and loud noises.

Physical assessment of the ears, nose and throat

1. Vital signs:

• temperature, pulse, respiration and BP

General appearance:

• Apparent state of health
• Appearance of comfort or distress
• Color of skin
• Nutritional status
• Hygiene
• Difficulty with gait or balance.

Ears:

Inspection

• Pinna: Look for lesions, abnormal appearance or position, skin covering mastoid process, redness or swelling behind pinna.
• Ear canal: Discharge, swelling, wax, foreign bodies.
• Tympanic membrane: Color, light reflex, land marks, bulging or retraction, perforation, scarring, air bubbles, fluid level.
• Estimate hearing with watch or whisper test.
• If whisper test fails, perform Weber and Rinne test with tuning fork.

Palpation

• Tenderness over tragus or on manipulation of the pinna.
• Tenderness on tapping of mastoid process.
• Size and tenderness of pre-, post-auricular and occipital nodes.

Nose and sinuses:

Inspection:

• Using the nasal speculum observe for abnormalities
• External: Inflammation, deformity, discharge or
  bleeding.
• Internal: Color of mucosa, edema, deviated or
  perforated septum, polyps, bleeding.
• Observe nasal versus mouth breathing.
• Place the lighted otoscope directly on the infraorbital rim (bone just below the eye). Ask the patient to open their mouth and look for light glowing through the mucosa of the upper mouth. In the setting of inflammation, the maxillary sinus becomes fluid filled and will not allow this transillumination.

Palpation:

• Sinus and nasal tenderness.

Mouth and throat:

Inspection:

• Lips: Color, lesions and symmetry.
• Oral cavity: Breath odor, color, lesions of buccal mucosa.
• Teeth and gums: Redness, swelling, caries, bleeding.
• Tongue: Color, texture, lesions, tenderness of floor of mouth.
• Throat and pharynx: Color, exudates, uvula, tonsillar symmetry and enlargement, masses.

Neck:

Inspection:

• Symmetry
• Swelling
• Masses
• Active range of motion
• Thyroid enlargement.

Palpation:

• Tenderness, enlargement, mobility, contour and consistency of nodes and masses.
• Nodes-pre- and post-auricular, occipital, tonsillar, submandibular, submental. anterior and posterior cervical, supraclavicular.
• Thyroid: Size, consistency, contour, position, tenderness.
• Parotid: Tenderness (diffuse versus discrete), enlargement, mobility, contour and consistency of nodes and masses.

Symptoms Requiring Urgent Referral

The first step is to determine if the ENT presentation requires an urgent referral to a physician are the following signs and symptoms:

• Positive Brudzinski sign (neck stiffness, light sensitivity and mental confusion)
• Pain and fever with mastoid tenderness
• Difficulty with secretions, drooling
• Displaced uvula
• Uncontrollable epistaxis
• Treatment failure after 3 days of otitis media, peritonsillar abscess
• Facial fractures
• Sudden onset of deafness
• Recent ENT surgery
• Hoarseness without fever or illness
• Unexplained vertigo
• Pain out of proportion to clinical findings (consider epiglottitis).

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
4. Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
5. Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
6. Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
7. AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884

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