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Hearing Acuity & so are not easily heard by people

with sensorineural hearing loss.

Gross Assessment
Should be performed in a quiet room HEARING ASSESSMENT
-test the patient’s ability to hear your • Tuning Fork Test
whispered or spoken voice or the ticking - Measure the air conduction (AC) and
of a watch bone conduction (BC) of sound
o AC- when sound waves are
Precise Assessment transmitted through the air into the
-Audioscopy- uses an audioscope auditory canal and so to the
• 40 dB intensity eardrum, middle ear and inner ear
• Frequency: 510, 1000,2000,4000 o BC- transmission of sound waves
cycles per second (Hz) through the cranial bones and inner
-done with special equipment ear.
(audiometer) * AC is normally more sensitive than BC
• Test one ear at a time while masking
the hearing in the other ear 2 types
• To “mask” an ear, have the patient 1. Weber
place a finger on the ear’s tragus & 2. Rinne test
push it quickly in and out of the
auditory meatus.  WEBER TEST
1. Distinguishes between conductive
 WATCH TICKING TEST and sensorineural hearing. Strikes a
- Hold a watch a few inches away from 512 Hz tuning fork softly
the patient’s ear 2. Place the vibrating fork on the
- Move the watch slowly away from the middle of the client’s head
ear and ask the patient to say “now” 3. Ask client if the sound is heard
when ticking can no longer be heard better in one ear or the same in
- Document the distance from the watch both ears.
to the ear from the point where ticking 4. If hearing is normal, the sound is
stopped being heard. symmetrical with no lateralization
• Sound localizes toward the poor ear
 WHISPERED WORD TEST with a conductive loss
- Stand 1-2 feet behind the client so they • Sound localizes toward the good ear
can read your lips with a sensorineural hearing loss.
- Instruct client to place one finger on
tragus of left ear to obscure sound  RINNE TEST
- Whisper word with 2 distinct syllables 1. Test compares air and bone
towards client’s right ear. conduction on hearing , Strike 512
- Ask client to repeat word back Hz tuning for softly
- Repeat test for left ear 2. Place vibrating fork on the base fo
- Client should correctly repeat two the mastoid bone
syllable word 3. Ask the client to tell you when the
• Whispered words & watch ticking test sound is no longer heard.
consist mainly of high-frequency sound
4. Note the time interval and - Pure tones presented at frequencies for
immediately move the tuning fork hearing, speech, music and other
to the auditory meatus common sounds
5. Ask the client to tell you when the - Tested both for AC (earphones) and BC
sound is no longer heard. (bone oscillator)
6. Note the time interval and findings. - Result is recorded as an audiogram
-N or (+) Rinne AC >BC
-AbN or (-) Rinne AC<BC o Instruct the client
o Objective of the test is to determine
TUNING FORK TEST the softest sound that will elicit a
response (threshold)
 SCHWABACH TEST o Tones will be presented that will
- Examiner’s ear is assumed to be sound like bells or tuning forks
normal o Upon hearing- client should raise
- Tuning fork placed near pinna of hand or press button on presenting
subject side.
- Confirmed by the examiner when o When sound is no longer heard –
sound is no longer heard client lowers hand or releases button
- Results: o Test better ear first
o Prolonged: conductive loss
o Diminished: sensorineural loss • SPEECH AUDIOMETRY
- Speech reception threshold- minimum
 ROMBERG TEST loudness to repeat simple words.
- Done to test client equilibrium - Uses a series of simple recorded words
- Have client stand with arms at side and spoken at various volumes into
feet together headphones worn by the patient being
- Have client perform initially with eyes tested
open and then with eyes closed - The patient repeats each word back to
- Client should maintain position for 20 the audiologist as it is heard.
seconds with only minimal swaying - And adult with normal hearing will be
able to recognize and repeat 90-100%
• AUDIOMETRY of the words.
- Measure of hearing acuity
o Highness or lowness of sound - Tests ability to distinguish similar
o The higher the frequency, the higher sounds or words with similar sounds
the pitch - Assesses understanding of speech
- Intensity - Uses 25-50 monosyllabic words
o Expressed in decibels (dB) phonemically balanced with equal
o Normal threshold -0 dB (51% of the difficulty
time) - 30-40 dB above speech reception
o Painful for persons with normal threshold
- Test determines the functionality of the - Patient should have adequate vision to
tympanic membrane by observing its follow visual targets
response to waves of pressure, and - detects both central and peripheral
measuring the pressure. disease of the vestibular system
- Assess mobility of eardrums -Detects nystagmus or the vestibule-
- Varies air pressure in the external ocular reflex
auditory canal -May be contraindicated in patients with
- For middle ear pathologic-conditions. history of previous seizures due to ocular
stimulation with lights.
- Represents the electrical response of evaluate acoustic nerve which provides
the CN VIII and some portion of the hearing and balance.
brainstem which occurs 10-12 msec  This test may be recommended
after an auditory stimulus is sensed by 1. When someone is experiencing
the inner ear dizziness or vertigo
- Series of clicks are presented at 75 dB 2. When there is hearing loss with
or 80 dB above threshold suspected toxicity from certain
- Results is similar to EEG- waves are antibiotics
interpreted 3. With some anemias
- Used in newborn hearing screening  Caloric stimulation is performed to
evaluate the acoustic nerve, which
provides hearing and helps with
Other Ancillary Tests balance.
• CT Scan- structures of the ear 4. When psychological causes or vertigo
• MRI- greater sensitivity to soft tissue are suspected
changes 5. To determine the presence or extent
of brain damage in a comatose
Precautions for Vestibular tests person
• Performed last because may induce
nausea and vomiting LABORATORY TESTS
• Prior to test, patient should be advised • Dix-Hallpike Test
to come in with companion - make sure that the patient has no neck
• Limit food intake prior to test injury!
-Pull patient to a supine position form a
• Advice against driving after the test;
sitting position
arrange for transportation
-Induces vertigo in patients with BPV
• Have emesis basin, tissue/towel/drapes
-Nystagmus is evident within 5-10 sec
• Hold patient in examination room until
balance is regained
-swivel 360 degrees to check for
stimulation of the vestibular system. At
Vestibular tests
right, an astronaut at NASA undergoes
*Electronystamography or
a test on a Barany chair.
STRUCTURES OF NOSE AND SINUSES • Largest and most accessible
-Nose is lined with respiratory mucosa, • Located on either side of the nose in
except the vestibule (lined with skin the maxillary bones
containing nasal hairs/ vibrissae)
-Frontal sinuses
-Mucus secreted from respiratory mucosa • Lower forehead between and above
is carried back into the nasopharynx by the eyes
ciliary movements
- Sphenoid sinuses
-nasal mucosa is normally redder than oral • Rear of the nasal cavity
mucosa because the lining of the nasal
cavities is very vascular - Ethmoid sinuses
• Between the eyes and nose
-Blood carries moisture and heat to the
mucosa - Olfactory cells
• Located in the olfactory membrane
-Nasal blood supply comes from the covering the roof of the nose and the
external and internal carotid systems. floor of the anterior cranial fossa

-air enter the nose through 2 nostrils - Nasolacrimal duct

(nares), separated by the nasal septum • Small duct communicating indirectly
(composed of cartilage and bone) with the lacrimal glands and the nose
-Nasal cavities, located between the roof
of the mouth and the frontal ethmoid, and FUNCTION OF NOSE AND SINUSES
sphenoid bones • Principal functions:
-On the lateral walls of each nasalcavity -olfaction (smelling)
are three projections. -Air conditioning (controlling air temp
• Superior turbinate and humidity and removing particles
• Middle turbinate before air enters the trachea, bronchi,
• Inferior turbinate and lungs).

- The turbinate conchae increase the -Olfactory cells- neurons that divide
area of mucus membrane over which into numerous hairlike processes in the
air passes olfactory membrane

- Paranasal sinuses are airfilled cavities, - Axons form the cell bodies become the
lined with mucous membrane olfactory nerve, which passes to the
surrounding the nasal cavities olfactory center in the brain.

- Sinuses drain into the nasal cavities -Turbulence from sniffing increases air
through opening in the grooves flow in supper turbinates near olfactory
between the turbinates. mucosa

- Maxillary sinuses (antra) FUNCTION OF NOSE AND SINUSES

-temp. is controlled by the enlargement - (anteriorly) using a nasal sepeculum
and contraction of “blood spaces” or” and (posteriorly) with a
swell spaces” in the erectile tissues in the nasopharyngeal mirror
turbinate bones. • Causes of nasal obstruction

- When inspired air is cold and dry water Examination of Nasopharnyx

is absorbed by it from the nasal • Best examined with a mirror with the
mucosa tongue depressed with a tongue blade
- A blanket of serum and mucus covers or gauze
the nasal mucosa surface • Specialist may use a
- As much as 1L of moisture can be nasopharyngoscope to examine the
evaporated from the nose during 24 nasopharynx
hours of normal breathing
- Submucosal glands replenish the Examination of Paranasal Sinuses
moisture • Inspecting and plapating the soft
- Particle control is achieved by the overlying tissues
mucous throughout the nose, sinuses, • Observing any nasal secretions
pharynx, trachea, bronchi, and • Transillumination of the maxillary and
bronchioles frontal sinuses
- Airborne particles cling to this viscid • To more completely assess sinus
blanket conditions, sinus x-rays may be used
- The mucous blanket secretions contain
the enzyme lysozyme to combat Smell Assessment
microorganisms • Senses of taste and smell are closely
- The beating action of cilia carries the related
blanket back toward the pharynx, • Smell and Taste are affected by
where it is swallowed - Many conditions (viral infection, normal
- Any residual bacteria are then aging, head injury, local obstruction)
destroyed by gastric juice and HCL - Medications( metronidazole, local
- Sinus function is not definitely know anesthetics, some antibiotics,
- Lighten the weight of the skull allopurinol, codeine, morphine,
- Give vocal resonance and timbre carbamazepine, lithium)
- Produce mucus for the nasal cavity • Smell impairment
ASSESSMENT OF NOSE AND - Hyposomia (decrease in smell
SINUSES sensitivity)
• History - Anosmia (bilateral and complea
• Examination of Nose, Nasopharynx and absence of smell sensitivity)
Paranasal Sinuses
• Smell assessment  Have the patient identify various odors
• Diagnostic procedures  Test each nostril separately
 Have the patient sniff tubes (first with
Examination of Nose eyes open)
• External nose
 Document whether the patient can
-symmetry, swelling, redness, lumps
o Perceive each odor
• Nasal Chamber
o Identify each oder accurately
 Smell is perceived mainly via Olfactory temporary relief, the nose becomes
nerve (CN1) although some are more stuffy.
perceived via the trigeminal nerves • Vasoconstrictors can be systematically
(CN V) absorbed and should not be used by
 Trigeminal irritants are perceived even hypertensive patients unless
by patient with anosmia prescribed
• Some nasal medication may cause
Olfactory and Trigeminal Stimulants distressing symptom (restlessness,
• Olfactory heart palpitations and tension)
- Coffee (instant powder) • Oil-based solutions are of usually used
- Phenylethyl alcohol since they interfere with normal ciliary
- Almod oil action and may cause pneumonitis if
- Peppermint aspirated
- Musk
 Instilling Nose Drops
• Trigeminal • Direct nose drops toward the problem
- Ammonia area by positioning the patient in such
- Acetone a way that the drops flow toward the
- Menthol affected area
• Support the person’s head with one
- Nose and Throat cultures • Observe the person’s reaction to the
- X-ray medication
- CT scan • Ask the patient to remain still for at
- MRI least 5 mins after the drops are
instilled and to breathe through the
• Solution can drain into the posterior
 Nasal Medications nose give the person a basin to
• Drops, spray, aerosol (nebulizer) expectorates solution running into the
• Most often instilled into the nose are oropharynx and motuh
vasoconstrictors (phenylephrine) used • Have tissues available to wipe excess
mainly to reduce nasal congestion solution from the external nares and
• Use only as prescribed to avoid face
rebound effect
• 0turbinate engorgement is controlled  Nasal Aerosol
by ANS • Also used to diffuse medication over
• Vasoconstrictors stimulates the nose’s inner surface
sympathetic nerves, hence, • Usually self-administered
compensatory relaxation of the turbinal • Shake aerosol before use
vesssels occur after the medication has • Tilt head back
stopped • Occlude one nostril and insert tip into
• This relaxation is accompanied by other nostril and administer one dose
nasal stuffiness, thus, after a period of of medication
 Nasal Irrigation - Breather through mouth
• Occasionally prescribed to clean the - Periodically assess nasal packings
nose - Elevate head
• Normal saline solution is most - Do not blow nose
commonely used - Patient’s mouth may become dry and
• Usually self-administered for chronic develop an unpleasant taste and odor
nasal conditions due to mouth breathing blood and post
• Aspiration is a potential hazard nasal discharges.
 Alteration in comfort due to pain and
 Nasal Packs anxiety
• Made of small petroleum gauze or - Nasal surgery is not usually painful but
small cotton ball soaked in epinephrine may be uncomfortable because of the
• Inserted by a physician packing
• Explain procedure to patient - Ice packs or cold compress may be
• Take and document the patient’s VS prescribed to reduce pain and edema
periodically through the procedure - Pain may be reduced by promoting
• Assist the physician while inserting the drainage
packing - Help the person to relax
• Help the patient into a comfortable
sitting position  Alteration in nutrition, less than body
• Encourage patient to breath through requirements due to difficulty
the mouth swallowing
• Tell the patient to expectorate any - Give fluids as prescribed (usually liquid
blood accumulating in the nasopharynx diet)
and not to swallow it - Be sure that gag reflex has returned
• Airway obstruction can occur if a before giving oral liquids
posterior nasal pack accidentally slips - Oral hygiene before meals may
out of place improve the person’s appetite
• When packing is removed, tell patient - Encourage fluid intake
not to blow the nose for 48 hrs.
because of danger of bleeding COMMON NASAL AND SINUS
Nursing intervention for Post- • Rhinitis
Nasal Surgery patients • Common cold
 Remind the patient to • Allergic rhinitis
- Breathe through the moth (because of • Non-allergic vasomotor rhinitis
nasal packing) • Nasal polyps
- Do not blow the nose • Hypertrophied turbinates
- Spit out drainage accumulating in the • Foreign bodies
nasopharynx • Nosebleed (epistaxis)
 After sinus surgery, If GA is given, turn • Deviated nasal septum
the patient on to the side to prevent • Nasal Fx
aspiration of bloody drainage before • Infected an Hypertrophied adenoids
consciousness returns. • Sinusitis
 Ineffective airway clearance
 Epistaxis
- Nosebleed  Nasal Fx
- May occur spontaneously or result form - Nasal & nasopharyngeal bleeding
diease or trauma - Disfiguring soft tissue edema around
- Minor trauma is the most common the nose after the injury
cause - Apply ice bag and tightly hold the nose
- More severe causes - Once edema occurs, wait for 2 or 3
o Severe trauma days for the edema to subside before
o Deviated or perforated nasal septum setting the Fx
o Acute sinusitis - Skull x-rays to rule out possible skull Fx
o Local cancer - And identify the location of Fx and
o HPN, sclerotic blood vessels, acute bone fragments
rheumatic fever, leukemia - Reduced under anesthesia, displaced
Emergency care for Anterior Nosebleed bone fragment are pushed into proper
- Position client upright and leaning alignment and held in place with
forward intranasal packing or external
- Reassure and reduce anxiety dressings or nasal splints
- Apply direct lateral pressure to the  Common Cold
nose for 5 minutes - Simple acute viral rhinitis (coryza)
- Apply ice or cold compress to the nose - Most common problem of the nose and
if possible sinuses
- To prevent re-bleeding, instruct to - Inflammation of the nasal mucosa
avoid blowing the nose - Caused by filterable virus and is spread
- Seek medical assistance if persistent by droplet contact from sneezing
- Contagious for the first two or three
 Nasal Polyp days
- Benign, grapelike clusters of mucous - Causes
membrane and connective tissue o Rhinovirus, adenovirus, influenza,
- Gradually form from recurrent,, virus, parainfluenza virus,
localized swellings of the nasal sinus mycoplasma
- Once fully developed, they appear as • Symptoms
smooth pale tumors with pedunculated - Burning or irritation in the nasopharynx
bases - Sneezing, chillness, copious nasal
- Usually multiple and insensitive to discharge, muscular aching, malaise,
touch mild fever
- Most common site in the nose is the - Headache for the first 2 days
middle meatus - Nasal discharge becomes purulent and
- Most frequently develop in people who increasing nasal obstruction occurs
have allergic rhinitis - A sore throat does not usually occur
- Symptoms of nasal obstruction occur with a common cold
when the polyps become large enough
to obstruct the airways - Self-limited
- Large persistent polyps are surgically
removed (polypectomy)
- Treatment is symptomatic
- No specific cure - Sensitivity to contacts constantly
- Antibiotics aer not indicated present in our environment (domestic
- Secondary invasion of bacteria may animal hair, dandruff, newspaper, wool,
complicate a common cold causing house dust, foods, tobacco)
symptoms to persist and become - Less severe than seasonal allergic
worse rhinitis but treatment is more difficult
since it us usually hard to identify the
 Allergic Rhinitis allergen
- Hay fever
- Triggered by hypersensitivity reactions  Non-allergic Vasomoto rhinitis
to airborne allergens - Chronic, intermittent nasal obstruction
- May be seasonal and acute or or stuffiness often accompanied by
perennial and chronic nasal discharge
• S/sx - May result from stress, nervousness,
- Sneezing, nasal obstruction, tearing, tension, or some endocrine problems
recurrent thin nasal discharge, frontal - Symptoms may be aggravated by
headache, itchiness of eyes and nose changes in environmental changes in
- Turbinates are typically hyperemic and environmenta temp
edematous - Treatment
- Nasal mucosa appear smooth and o Sympathomimetics
• Treatment - Nasal congestion resulting from
- Eliminate or limit intake of chocolate, estrogen-mediated mucosal engorgement
milk, and eggs -May occur with oral contraception
- Cover mattress and pillow with plastic
- Do not touch domestic animals > Rhinitis Medicamentosa/Drug-
- Use non-allergenic cosmetics induced
- Cover overstuffed furniture -“Rebound: nasl congestion from overuse
- Use antihistamines as prescribed of nose drops or sprays
- Install air condition in the house avoid
wool bedding.  SINUSITIS
- Inflammation of sinus producing an
 Seasonal Allergic Rhinitis inflammatory mucosal change
- Acute episodes lasting for several - Head pain and mucoid nsal discharge
weeks and then disappears and recurs are often attributed to sinusitis
the same time the next year. - Causes:
- Usually caused by grass pollens, o Infection spread from the nasal
flowers or trees passages to the sinuses
o Blocked routes of normal sinus
 Chronic Rhinitis drainage
- Constantly present or may occur - Purulent or non-purulent
intermittently w/o any seasonal pattern - Acute or chronic
over a period of many years - Types (ethmoid, frontal, maxillary or
- Often associated with allergic sinusitis sphenoid)
- Caused by infection (pneumonia, Anatomy of the Pharynx
influenza, rhinitis) passing into the • Nasopharynx
sinuses via the nasal passages -Located behind the nose, above the soft
- Assessment palate
o Malaise, lack of appetite, nausea, - Contains adenoids (pharyngeal tonsils)
nasal obstruction, congestion and openings of the Eustachian tube
o Purulent nasal discharge, fever
pressure over the involved sinuses, • Oropharynx
pain - Extends from the soft palate to the
-Tx base of the tongue
o Relieve pain with analagesics - With palatin tonsils (faucial tonsils)
o Promotes sinus drainage by adequate
fluid intake, moist steam inhalation, • Laryngopharynx
mucolytics - Extends from the base of the tongue to
o Control infection the esophagus
o Increase resistance with rest, well- - Critical dividing point between
balanced diet and reduced stress respiratory and digestive passages

 SINUSITIS Physiolgy of Pharynx

-Surgery • Respiration
- Maxillary antral puncture and • Deglutition
lavage • Voice resonance
- Caldwell-Luc procedure • Articulation
- Repeated or sustained sinus infections 3 stages
cause the mucous membrane lining to • Voluntary movement of food from the
become thickened mouth into the pharynx
- Difficult to treat and is directed at • Transport of the food through the
correcting underlying cause (remove pharynx
polyp, eradicate dental infections, • Passage of the bolus through the
straighten deviated nasal septum and esophagus
treat allergy) • After mastication, food is positioned on
- S/sx the middle 3rd of the tongue
o Lethargy, difficulty sleeping, chronic • Elevation of tongue and soft palate
sough, chronic purulent nasal forces the bolus into the oropharynx
discharge, inability to smell, chronic • Suprahyoid muscles contract, elevating
sinus headache. the hyoid bone and larynx thus the
opening the hypopharynx
The Pharynx • Intrinsic laryngeal muscles contract in
• Common passageway between the a sphincter-like fashion to prevent
respiratory and digestive tracts aspiration
• Located behind the oral and nasal • A strong motion of tongue posterior,rly
cavities plunges the food inferiorly through the
oropharynx , a movement aided by the • Procedures
contraction of the superior and middle - Indirect Laryngoscopy
pharyngeal constrictors - Endoscopy
• Peristalsis, assisted by gravity, moves • Radiographic
the food down the esophagus and into - X-ray
the stomach - CT scan
Anatomy of the Larynx
Composed of 9 cartilages: 3 single, 3  HISTORY
paired - Drug use
• Thyroid- Adam’s apple - Allergies
• Cricoid-below the thyroid cartilage; - Frequent URTI
contains vocal cords
• Arytenoid- attach at the back end of • Occupational history
the vocal cords, for vocal cord - Teachers
movement - Salesman
• Epiglottis- lead-shaped elastic cartilage - TV and radio anchor
guarding the glottis
• Corniculate • Demographic Data
• Cuneiform • Family History and Genetic Risk
- Cancers
Two pairs of vocal cords - Maternal exposure to teratogenous or
• False disease
• True • Personal History
- Smoking history
Physiology of the Larynx
• Protection of the airway Current Health Problems
• Respiration • Common complaints
• Phonation - Sore throat
- Adducted true vocal cords serve as a - Discharge in the throat
passive reed that vibrates when air is - Sense of lump, fullness or swelling
forced through them - Difficulty in swallowing
- Changes in shape, mass and tension of
the true vocal cords produces different
- Loudness of voice proportional to the Physical examination
pressure in the subglottic airstream -Perform PE in an adequately lighted
- Whispering due to escape of air area
between the abduction sphenoid -have patient sit upright and leaning
without vibration of the tru vocal cords Slightly forward as if pushing the chin
towards the examiner
Assessment of the Throat
• History -Equipment
• Physical Examination Lights
- Inspection
- Palpation
 Inspection -Pharyngitis is an inflammation of the
Observe for palate and uvula Pharynx that frequently results in a sore
- Color throat
- Symmetry - It may be caused by a variety of
- Evidence of discharge (postnasal) microorganisms.
- Edema or ulceration
- Tonsil enlargement and inflammation
Observe neck
- Symmetry
- Alignment
- Masses

 Palpation
Gently palpate the neck
- Position of the trachea
- Massess
- Lymph nodes

 Indirect Laryngoscopy
• Requires a mirror to view the larynx
and hypopharynx
• Assess function of vocal cords or to
obtain tissue for biopsy
• The mirror is placed against the soft
• May make patient anxious and

Nursing Interventions
- NPO several hours before procedure
- Assess client for allergies to iodine,
contrast media, or local anesthetics
- Administer pretest medications
- Assess client for fear
- After the procedure NPO until gag
- Encourage coughing
- Assess VS q 15 min atleast 2 hr
- After procedure and then q2 x 24 h
- Assess client for bleeding
- After procedure, administer lozenges
or gargles as prescribed.