Eye, Ear & Maxillofacial Pathologies

Kimberly Lakhan, PA-C

SMDC ENT

Eye Anatomy

How to Use a Ophthalmoscope

Preparing your Equipment Check the battery Cover off Familiarize self with dials & levers, set all to

“0” Light should be bright, round, white Turn light down, dim

Preparing your patient Warn then about the light Position – sitting, looking on fixed spot over

your shoulder - slightly out (Be Specific)

Your Position Eye to Eye (Left to left, Right to Right) Try and keep your other eye open Begin at arm’s length by shining light into

the patient’s pupil. Continue to move forward until your

forehead rests on your thumb. The closer you are the wider your field of view.

Turn dial to focus on disc

What am I looking for? Red reflex

Optic disc

Vessels

Macula

Eye Pathology Conjunctivitis Hyphema Lacerated Eye Lid Corneal Abrasion Orbital Fx Ruptured Globe Detached Retina Strabismus Aniscoria Stye Raccoon Eyes

Conjunctivitis

Hyphema

Lacerated Eyelid

Corneal Abrasion

Orbital Fracture (“Blow-Out”)

Rupture of Globe

Retinal Detachment

Strabismus

Anisocoria

Stye

Raccoon Eyes Bilateral Temporal

Bone Fractures Also look for bleeding

from the ear canals and/or a hemotympanum (blood behind the ear drum)

Eye Referral Embedded object Decreased or partial vision Hyphema Diplopia Laceration of eyelid Strabismus Nystagmus Inverted or everted eye Eye swollen shut Abnormal pupil size

Nasal Anatomy

Nasal Anatomy

Nasal Pathology Epistaxis Nasal Fracture Deviated septum Perforated septum Polyps

Epistaxis

Control the bleeding

Nasal Fracture

Deviated Septum

Perforated Septum

Nasal Polyps

Nasal Referral Unable to breath out of one or both nostrils

CSF coming from nose/Halo Sign

Fx

Uncontrollable epistaxis

Ear Anatomy

Tympanic Membrane

Use of the Otoscope in Athletic Use of the Otoscope in Athletic TrainingTraining

Objectives Briefly discuss the types and features of the

otoscope Provide an overview of otoscopic assessment

procedures Present a clinical teaching model for teaching

your students to properly use the otoscope Provide educational resources for teaching

otoscopy

Types & Features of the OtoscopeTypes & Features of the Otoscope

Types of Otoscopes Pocket style

< $50

Pocket stylePocket style

Clinical modelClinical model

Clinical modelClinical model $200 - $400+$200 - $400+

Clinical modelClinical model $200 - $400+$200 - $400+

Features of the Otoscope Power source

Battery (most common in athletic training clinical setting)

Electric

Light source Incandescent bulb (produces a

yellow light) Hallogen bulb (best – produces a

white light)

Features of the Otoscope Magnifier

Not available on all models Provides better view of

tympanic membrane, particularly for beginners

Features of the Otoscope Speculum

Variety of sizes Reusable or disposable

Overview of Otoscopic AssessmentOverview of Otoscopic Assessment

Examination of the EarExamination of the Ear History Observation Palpation

Special tests Otoscopic assessment

Examination of the EarExamination of the Ear History

Trauma Allergies, colds, sinus drainage Changes in pressure (flying, diving) Dizziness Changes in hearing Duration of symptoms

Examination of the Ear Observation

Redness Swelling Drainage Foreign object Cuts, scrapes,

bruises

Examination of the Ear Palpation

Gentle pressure on tragus

Examination of the Ear Palpation

Traction on ear lobe & pinna

Otoscopic Assessment Evaluate the

noninvolved ear first This practice provides a

basis for comparison AND prevents cross-contamination

Otoscopic Assessment Step 1:

Place your patient in a seated position with his/her head turned slightly downward and away from the ear to be examined

Otoscopic Assessment Step 1 (cont.):

the “puppy position” (puppies always cock their heads to the side when you talk to them)

Otoscopic Assessment Step 2:

Select the largest possible speculum that can be comfortably inserted into the ear

Otoscopic Assessment Step 2 (cont.):

When inserted, the speculum should fit snugly in the outer third of the canal and rest against the tragus and anterior wall of the canal

Modified from Middle Ear Conditions. Anatomical Chart Co. Skokie, IL, 1999.

Otoscopic Assessment Step 2 (cont.):

Choosing a speculum that is too small will cause movement within the canal

Excessive movement can cause discomfort for your patient

Modified from Middle Ear Conditions. Anatomical Chart Co. Skokie, IL, 1999.

Otoscopic Assessment Step 3:

Choosing a speculum that is too small will cause movement within the canal

Excessive movement can cause discomfort for your patient

Otoscopic Assessment Step 3 (cont.):

The otoscope should be stabilized by placing the ring and little finger resting on the patient’s cheek or temple

Otoscopic Assessment

Pencil Grip Hammer Grip

Otoscopic Assessment Step 4:

Pull the Pull the pinna pinna upward and upward and backward to backward to straighten straighten the canalthe canal

Modified from Middle Ear Conditions. Anatomical Chart Co. Skokie, IL, 1999.

Otoscopic Assessment Step 5:

While maintaining traction on the pinna, place the speculum of the otoscope at, but not in the ear canal

Otoscopic Assessment Caution:

Never insert the otoscope blindly

Always“Watch your way in”

Otoscopic Assessment Tip:

If the patient experiences pain, reposition the canal by adjusting the angle and degree of traction on the pinna

Otoscopic Assessment Caution:

If the patient’s If the patient’s discomfort persists discomfort persists even after even after readjustment of the readjustment of the canal, halt the canal, halt the examination and examination and refer the patient to refer the patient to a physician.a physician.

Otoscopic Assessment Step 6:

Once the tympanic membrane comes into view, rotate the speculum to view as much of the membrane as possible

Marty DR. The Ear Book. Jefferson City, MO: Lang ENT Publishing. 1987;Color plate 1.

Otoscopic Assessment Tip

Like trying to view the corners of a room through a key hole

Tip Like trying to view

the corners of a room through a key hole

Marty DR. The Ear Book. Jefferson City, MO: Lang ENT Publishing. 1987;Color plate 1.

Modified from Middle Ear Conditions. Anatomical Chart Co. Skokie, IL, 1999.

This is due to the angle of the This is due to the angle of the membrane within the canalmembrane within the canal

Otoscopic Assessment Tip

The posterior inferior portion of the membrane is often difficult to see

Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53,54.

Modified from Middle Ear Conditions. Anatomical Chart Co. Skokie, IL, 1999.

Otoscopic Assessment

Step 7: Inspect the membrane

for color, clarity, & position

Pearly gray Semitransparent Not bulging or retracted

LR

Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53,54.

Otoscopic Assessment

Step 8: Identify key landmarks

LR

Umbo

Short processMalleusMalleus

• ManubriumManubrium• Short process Short process • UmboUmbo

• ManubriumManubrium• Short process Short process • UmboUmbo

Light reflexLight reflex

Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53,54.

Otoscopic Assessment

Step 8 (cont.): Identify key landmarks

LR

Note that manubrium Note that manubrium angles toward the 10 angles toward the 10 o’clock position in the left o’clock position in the left ear and the 2 o’clock ear and the 2 o’clock position in the right earposition in the right ear

Note that manubrium Note that manubrium angles toward the 10 angles toward the 10 o’clock position in the left o’clock position in the left ear and the 2 o’clock ear and the 2 o’clock position in the right earposition in the right ear

Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53,54.

Otoscopic Assessment

Step 8 (cont.): Identify key landmarks

LR

Pars tensa

Pars flaccida Pars flaccida

Pars tensa Pars tensa

Annulus Annulus

Pars flaccida

Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53,54.

Otoscopic Assessment

Step 8 (cont.): Identify key landmarks

Look beyond the membrane

• Stapes• Incus

Identify key landmarksLook beyond the membrane

• Stapes• Incus

Fincher AL. Use of the otoscope in the evaluation of common injuries and illnesses of the ear. J Athl Train. 1994;29:53.

Otoscopic Assessment

Step 9: Look for abnormalities

Fluid Perforations

PerforationMarty DR. The Ear Book. Jefferson City, MO: Lang ENT Publishing. 1987;Color plate 8.

Fluid & Air BubblesFincher AL. Use of the otoscope in the evaluation of common injuries andillnesses of the ear. J Athl Train. 1994;29:54.

Otoscopic Assessment

Step 10: Work with your team physician to develop

your confidence and skill

PRACTICE, PRACTICE, PRACTICE !!!

You must look at many ears to develop to become comfortable with “normal”

Ear Pathology Hematoma Auris Otitis Externa Otitis Media Perforated/ruptured tympanic membrane

Hematoma Auris

Otitis Externa

Otitis Media

Perforated membrane

Ear Referral Blood or CSF coming from ear

Battle’s sign

Hearing loss or diminished in one or both ears

Guided, Self-Directed Activities

Content Recognition of pathology – visual images

PerforationMarty DR. The Ear Book. Jefferson City, MO: Lang ENT Publishing. 1987;Color plate 8.

Middle ear fluidMarty DR. The Ear Book. Jefferson City, MO: Lang ENT Publishing. 1987;Color plate 3.

Guided, Self-Directed Activities – Post Lab

Content Recognition of pathology – visual images

Perforation

Modified from Middle Ear Conditions. Anatomical Chart Co., Skokie, IL. 1999.

Otitis Media

Modified from Middle Ear Conditions. Anatomical Chart Co., Skokie, IL. 1999.

Facial/Tooth Anatomy

Tooth Pathology Tooth Fx Jaw Fx Tooth Intrusion Tooth Luxation Tooth Extrusion

Tooth Injuries - Fx

Jaw Fx

Tooth Intrusion

Tooth Luxation Lingual Displacement

Facial Displacement/Luxation

Tooth Extrusion

Facial Lacerations/Stitches

Tooth/Facial referral Suspected Fx Lacerations that need stitches Fx Tooth Avulsed tooth Malocclusion P c breathing TMJ dislocation When accompanied by closed head injury

Tonsil Anatomy

Tonsil

Uvula

Tonsil Grade

Other ENT Pathologies

Rhinitis

Tonsillitis

Strep Throat

Other ENT Pathologies Laryngitis

Pharyngitis

Sinusitis

Antibiotics and URIs Difficult to determine if Viral or Bacteria

cause Many physicians treat with antibiotics

regardless

Summary A directed history and thorough physical

exam are key.