HEAD, EYES, EARS, NOSE, AND THROAT

HISTORY & PE

HEAD

ANATOMY & PHYSIOLOGY

Regions of the head are named based on their underlying bones

structure
o Frontal: forehead region
o Nasal: nose region
o Zygomatic: cheek region
o Maxillary: upper lip region
o Mandibular: jaws region
o Parietal: superior region of the head
o Temporal: lateral region of the head above the ears
o Mastoid: inferior to the temporal
o Occipital: posterior region of the head
2 paired salivary gland found around the mandible:
o Parotid gland: superficial and posterior to the mandible
o Submandibular gland: deep to the mandible
Superficial temporal artery: readily palpable anteriorly to the ears

HEALTH HISTORY
Headache is an extremely common symptoms with always a careful
evaluation
o Always evaluate headache with OPQRST
o Important attributes:
Point to the area of pain /discomfort
Chronologic pattern
Severity
Is coughing, sneezing, or changing the head position has any
effect?
Most common recurring headache:
o Tension- temporal area
o Migraine retro-orbital area
Changing & progressively severe headache Tumor, Abscess or Mass
Extremely severe headache - Subarachnoid hemorrhage or meningitis

TECHNIQUE OF EXAMINATION
Hair: quantity, distribution, texture, pattern of lose, dandruff if present
o Fine hair hyperthyroidism
o Coarse hair hypothyroidism
o Ovoid granules eggs of lice/nits
Scalp: scaliness, lumps, nevi, or any lesion
 Skull: general size and contour
o Enlarge skull hydrocephalus/Pagets disease of the bone
Face: facial expression and contour. Observe for asymmetry,
involuntary movements, edema, and masses
Skin: color, pigmentation, texture, hair distribution and any lesion
o Acne adolescent
o Hirsutism women

EYES
ANATOMY & PHYSIOLOGY
Opening between the eyelids: palpebral fissure
Sclera: white portion of the eye
Conjunctiva: clear mucous membrane covering the sclera
o Bulbar conjunctiva: covering most eyeball; meet cornea in the
limbus
o Palpebral conjunctiva: lines the eyelid
Eyelashes
o Sebaceous glands (glands of Zeis) opens directly to the lashes
follicle
o Ciliary glands (glands of Moll) modified sweat glands; open
separately between adjacent lashes
o Tarsal glands: modified sebaceous gland that pour oily secretions
onto the margin of the lid; open behind eyelashes
Tarsal plates: crescent shape laminae of dense fibrous tissue; each
containing:
o Meibomian glands: secretes tear fluid; opens on the lid margin
o Lateral lateral palpebral ligament
o Medial medial palpebral ligament
Levator pelpabral muscle insertion in the anterior surface of the
superior tarsal plate
o Raises the upper eyelid
o Innervated by oculomotor nerve (CN III)
Tear fluid:
o Functions:
protects cornea and conjunctiva from drying
inhibits microbacterial growth
gives smooth surface for the cornea
o 3 source:
Meibomian glands
Conjunctival glands
Lacrimal glands: lies mostly at bony orbit, above & lateral
to the eyeball
o Drain to 2 holes called lacrimal puncta
 o Then, pass the lacrimal sac and to the nasolacrimal duct in the
nose
Muscles of the Iris control the papillary size:
o Sphincter papillae: constricts the pupils parasympathetic fiber
of CN III
o Dilator papillae: dilate the pupils sympathetic fibers of CN III
Muscles of the Ciliary Body control the thickness of lens
o Meridional fibers: contract, will pull the suspensory ligaments
forward and medially towards the cornea release the tension on
the lens
o Circular fibers: contract to lessen the pull of suspensory
ligaments by decreasing the diameter
Aqueous humor:
o Produce by the ciliary body
o Circulates from the posterior chamber to the pupil to the anterior
chamber
o Drains to the canal of schlemm
o Function: helps control the pressure inside the eye
Fundus: posterior part of the eye seen using opthalmoscope
o Optic disc: place where the optic nerve with retinal vessel enter
o Fovea centralis: darkened central area
o Macula: roughly circular area surrounds the fovea
o Vitrous body: transparent mass of gelatinous material fill the part
of eye behind the lens; helps maintain the shape of the eye
Visual Fields: entire area seen by the eye when it look at central point
o Divided into quadrants:
Upper nasal
Lower nasal
Upper temporal
Lower temporal
o Area overlapping of vision binocular
o lateral with no overlapping monocular
Visual Pathway
o Image projected: upside down (inverted) and reversed right to
left
Papillary Reaction
o Light reaction mediated by the oculomotor nerve (CN III)
Constriction of the light beamed eye direct reaction
Constriction of the opposite eye consensual reaction
o Near reaction mediated by oculomotor nerve (CN III)
Shifting of sight from far to near pupil constriction
Also happen with the shifting mechanism:
Convergence of the eye: extraocular movement
 Accommodation: increase convexity of the lens
Extraocular Movement
o 6 cardinal movement:

Superior Inferior Superior

Rectus Oblique Rectus
(III) (III)

Lateral Medial Lateral

Rectus Rectus Rectus
(VI) (III) (VI)

Inferior Superior Inferior

Rectus oblique Rectus
HEALTH HISTORY
(III) (IV) (III)
Have you ever have problem with your vision?
Onset:
o Sudden retinal detachment, vitreous hemorrhage, or
occlusion of artery
Hyperopia: farsightedness eyeball is too short or lens is too weak
Myopia: nearsightedness too long an eyeball or too strong
refractive power of lens
Presbyopia: losing of the lens ability to change shape
o Causing eye can only focus at a permanent distance
Astigmatism: refractive error of the eye that causes the visual
image in one plane to focus at a difference distance from that of the
plane at right angle
Check for pain around the area of the eye
Diplopia: double vision
Flashing lights detachment of vitreous humor from the retina
Scotomas: fixed defects suggest lesion in the retina or visual
pathway

TECHNIQUE OF EXAMINATION
Visual Acuity: using the Snellen Chart
o 20/200 normal: that at 20 feet, patient can read print that a
person with normal vision can read at 200 feet
Visual Fields:
o Screening: begins at temporal fields
Made an imaginary bowl
Move finger from 2 feet distance from the patients ears
along the imaginary bowl, while wiggling it
Ask the patient to point when he/she can see any wiggling
hand
Normal: patient can see both hand at the same time
 o Further testing: if we found defect, test one eye at a time
o Homonymous hemianopsia condition in which temporal defect
of one eye followed by nasal defect of other eye
o Bitemporal hemiopsia condition in which both temporal is
affected
o Quadrantic defect defect in any bilateral quadrant
Position and Alignment of the Eye
o Stand in front of the patient
o Inspect the alignment of both eyes
o Abnormal protrusion due to graves disease
Eyebrows
o Quantity, distribution & scaliness
o Scaliness seborrheic dermatitis
o Lateral sparseness - hypothyroidism
Eyelids
o Width of palpebral fissure
o Edema
o Color
o Lesions
o Condition & distribution of the eyelids
o Adequacy of closing of the lids
Lacrimal Apparatus
o Excessive tearing:
Increase production conjunctival inflammation & corneal
irritation
Impaired drainage ectropion & nasocrimal obstruction
o Dryness
o Swelling of Lacrimal duct and sac
Conjunctiva & Sclera
o Ask the patient to look up as we depress both lower lids with our
tumbs
Check color
Look for nodule or swelling
o For even fuller viewing: rest our thumb and finger in the bones of
cheek and brow, and spread the lids
Cornea and Lens
o Oblique lighting
o Inspect for opacity in any
Iris
o Same time with the cornea & lens
o Oblique lighting from the temporal side
o Inspect for crescentic shadow. Normal: no shadow
Pupils
o Inspect size, shape, and symmetry of pupil
 o Miosis constriction of pupil. Large >5mm
o Mydriasis dilation of pupil. Small <3mm
o Anisocoria pupilary inequality of <0.5mm
o Pupilary reaction to light: direct and consensual reaction; darken
the room
o Near reaction: normal lighting
Extraocular Muscles
o Inspect refraction of light shine the light from 2 feet distance
Normal: refraction in the nasal area of both eyes
o Assess movement
Conjugate movement vs. deviation
Nystagmus: fine rhythmic oscillation of the eye when
seeing extreme side
Lid lag: movement above-downward, with a rim of sclera
seen between the upper lid and the iris
o Made big H which lead the patient to follow:
Far right of the patient
Right and upward
Down and upward
Without stopping, far left of the patient
Left and upward
Left and downward
Check for lid lag by medial movement up-down
Opthalmoscopic Examination

EARS
ANATOMY & PHYSIOLOGY
3 compartments:
External ear:
o Auricle: compose main of cartilage covered by skin with firm,
elastic consistency
Helix
Antihelix
Tragus
Lobule
o Ear canal: opens behind tragus, curved inward about 24mm
Outer portion: surround by cartilage, surround by hair and
gland producing cerumen (wax)
Inner portion: surround by bones and thin hairless skin.
Pressure in this area may cause pain
Middle ear: air filled cavity that transmit sound by way 3 tiny bones,
the ossicles
o Lateral marking: tymphanic membrane
o Connected to the nasopharynx Eustachian tube
 o The ossicles:
Malleus: held the eardrum on its center
Has 2 landmarks: handle and short process
Umbo: where the eardrum meets the malleus
Cone of light: anterior and inferior projection when
the tymphanic membrane is illuminate
Pars flaccida: part between the anterior and posterior
malleolar folds
Pars tensa: the remainder of the tymphanic
membrane
Incus: the long process can be seen through the tymphanic
membrane
Stapes: smallest bone of the whole body
Inner ear
Pathway of hearing:
o Conductive pathway: 1st part, external ear middle ear
Disorder here will cause conductive hearing loss
o Sensorineural pathway: 2nd part, involving cochlea and cochlear
nerve
Disorder here will cause sensorineural hearing loss
o Air conduction: normal 1st phase of pathway
o Bone conduction: bypasses the external & middle ear
Labyrinth: inner ear sense the position of the head and helps
maintain balance

HEALTH HISTORY
How was your hearing?Have you had any problem with your hearing?
Hearing loss: try to distinguish the type of hearing loss

Earache:
o Medication: NSAIDs, aminoglycosides, aspirin, quinine,
furosemide
o Otitis externa: pain the external ear
o Otitis media: pain associated with respiratory problem; inner ear
Ear Discharge
Tinnitus perceived sound without external stimulus; musical ringing,
rushing or roaring sound
Vertigo: perception that the patient surrounding is rotating or spinning
o Associated with central or peripheral lesion in CN VIII

TECHNIQUE OF EXAMINATION
Auricle
o Inspect for deformities, lumps or nodes
 Ear canal and drum
o Pull the auricle upward and backward gently
o Insert the speculum gently: using the largest pendulum
o Inspect the eardrum
o Identify the handle and short process of malleus
Auditory Acuity
o Occlude one ear
o Take 1-2 feet distance from the patient
o Whisper to the patient; using words with 2 accented syllables
o Took cautious that the patient wont read your lips
Air & Bone Conduction
o Distinguishing the type of hearing loss
Quiet room and tuning fork (512hz)
o Lateralization (Webers test)
Place the base of the tuning fork firmly on top of the
patients head or the mid-forehead
Normal: sound is heard in both ear
Unilateral conductive hearing loss sound heard in the
impaired ear
Unilateral sensorineural hearing loss sound heard in the
Good ear
o Compare Air Conduction (AC) and Bone Conduction (BC) (Rinne
Test)
Place the vibrating fork in the mastoid bone
When the patient cannot hear any sound anymore transfer
the tuning fork close to the ear canal
AC: if the sound heard when the tuning fork is place close
to the ear canal
BC: if the sound heard when the tuning fork is place at the
mastoid bone
Normal: AC > BC
Conductive hearing loss: BC > AC
Sensorineural hearing loss: AC > BC

NOSE
ANATOMY & PHYSIOLOGY