TECHNIQUE

FINDINGS

EARS

Inspect auricles and mastoid area

Examine lateral and medial surfaces and surrounding tissue.

Size/shape/symmetry

EXPECTED:Familial variations. Auricles of equal size and similar appearance. Darwin tubercle.

UNEXPECTED:Unequal size or configuration. Cauliflower ear and other deformities.

Lesions

UNEXPECTED:Moles, cysts or other lesions, nodules, or tophi.

Color

EXPECTED:Same color as facial skin.

UNEXPECTED:Blueness, pallor, or excessive redness.

Position

Draw imaginary line between inner canthus and most prominent protuberance of occiput. Draw imaginary line perpendicular to first line and anterior to auricle.

EXPECTED:Top of auricle touching or above horizontal line. Vertical position.

UNEXPECTED:Auricle positioned below line (low-set); unequal alignment. Lateral posterior angle greater than 10 degrees.

Preauricular area

EXPECTED:Preauricular pits, skin tags, or smooth skin.

UNEXPECTED:Openings in preauricular area, discharge.

External auditory canal

EXPECTED:No discharge, no odor; canal walls pink.

UNEXPECTED:Serous, bloody, or purulent discharge; foul smell.

Palpate auricles and mastoid area

EXPECTED:Firm and mobile, readily recoils from folded position; no tenderness in postauricular or mastoid area.

UNEXPECTED:Tenderness, swelling, nodules. Pain when pulling on lobule.

Inspect auditory canal with otoscope

EXPECTED:Minimal cerumen in varying color and texture. Uniformly pink canal. Hairs in outer third of canal.

UNEXPECTED:Cerumen obscures tympanic membrane, odor, lesions, discharge, scaling, excessive redness, foreign body.

Inspect tympanic membrane

Landmarks

Vary light direction to observe entire membrane and annulus.

EXPECTED:Visible landmarks (umbo, handle of malleus, light reflex).

UNEXPECTED:Perforations, landmarks not visible.

Color

EXPECTED:Translucent, pearly gray.

UNEXPECTED:Amber, yellow, blue, deep red, chalky white, dull, white flecks, or dense white plaques; air bubbles or fluid level.

Tympanic membrane. From Barkauskas et al, 2001.

Contour

EXPECTED:Slightly conical with concavity at umbo.

UNEXPECTED:Bulging (more conical, usually with loss of bony landmarks and distorted light reflex) or retracted (more concave, usually with

accentuated bony landmarks and distorted light reflex).

Mobility

Seal canal with speculum, and gently apply positive (squeeze) and negative (release) pressure with pneumatic attachment.

EXPECTED:Movement in and out.

UNEXPECTED:No movement.

Assess hearing

Questions during history

EXPECTED:Responds to questions appropriately.

UNEXPECTED:Excessive requests for repetition. Speech with monotonous tone and erratic volume.

Whispered voice

Have patient mask hearing in one ear by inserting a finger in ear canal. Stand 1 to 2 feet from other ear and softly whisper three letter and number combinations (e.g., 3, T, 9 or 5, M, 2). Use a different letter number combination in other ear.

EXPECTED:Patient repeats numbers and letters correctly more than 50% of time.

UNEXPECTED:Patient unable to repeat whispered words.

Weber test

Place base of vibrating tuning fork on midline vertex of head. Repeat with one ear occluded.

EXPECTED:Sound heard equally in both ears (unoccluded). Sound heard better in occluded ear.

UNEXPECTED:See table on p. 84.

Weber test.

Interpretation of Tuning Fork Tests

Weber Test

Rinne Test

Expected findings

No lateralization but will lateralize to ear occluded by patient

Air conduction heard longer than bone conduction by 2 : 1 ratio (Rinne positive)

Conductive hearing loss

Lateralization to deaf ear unless sensorineural loss

Bone conduction heard longer than air conduction in affected ear (Rinne negative)

Sensorineural hearing loss

Lateralization to better-hearing ear unless conductive loss

Air conduction heard longer than bone conduction in affected ear, but less than 2 : 1 ratio

Rinne test

Place base of vibrating tuning fork against mastoid bone, note seconds until sound is no longer heard; then quickly move fork 1 to 2 cm ( to 1 inch) from auditory canal and note seconds until sound is no longer heard. Repeat with other ear.

EXPECTED:Measurement of air-conducted sound twice as long as measurement of bone- conducted sound.

UNEXPECTED:See table below.

Rinne test. A, Tuning fork against mastoid bone. B, Tuning fork near ear.

TECHNIQUE

FINDINGS

NOSE AND SINUSES

Inspect external nose

Shape/size

EXPECTED:Smooth. Columella directly midline, width is not greater than diameter of naris.

UNEXPECTED:Swelling or depression of nasal bridge. Transverse crease at junction of nose cartilage and bone.

Color

EXPECTED:Conforms to face color.

Nares

EXPECTED:Oval. Symmetrically positioned

UNEXPECTED:Asymmetry, narrowing, discharge, nasal flaring on inspiration.

Palpate ridge and soft tissues of nose

Place one finger on each side of nasal arch and gently palpate from nasal bridge to tip.

EXPECTED:Firm and stable structures.

UNEXPECTED:Displacement of bone and cartilage, tenderness, or masses.

Evaluate patency of nares

Occlude one naris with finger on side of nose, ask patient to breathe through nose. Repeat with other naris.

EXPECTED:Noiseless, easy breathing.

UNEXPECTED:Noisy breathing; occlusion.

Inspect nasal mucosa and nasal septum

Tilt patient’s head toward opposite shoulder. Gently insert speculum without overdilating naris.

Color

EXPECTED:Mucosa and turbinates deep pink and glistening.

UNEXPECTED:Increased redness of mucosa or localized redness and swelling in vestibule. Turbinates bluish gray or pale pink.

Shape

EXPECTED:Septum close to midline and fairly straight, thicker anteriorly than posteriorly. Inferior and middle turbinates visible.

UNEXPECTED:Asymmetry of posterior nasal cavities, septal deviation.

Condition

EXPECTED:Possibly film of clear discharge on septum. Possibly hairs in vestibule. Turbinates firm consistency.

UNEXPECTED:Discharge, bleeding, crusting, masses, or lesions. Swollen, boggy turbinates. Perforated septum. Polyps.

SENSE OF SMELL

See Chapter 18.

Inspect frontal and maxillary sinus area

UNEXPECTED:Swelling.

Sinuses.

TECHNIQUE

FINDINGS

Palpate frontal and maxillary sinuses

Press thumbs up under bony brow on each side of nose. Palpate with thumbs or index and middle fingers under zygomatic processes.

EXPECTED:Nontender on palpation.

UNEXPECTED:Tenderness or pain, swelling.

MOUTH

Inspect and palpate lips with mouth closed

Have patient remove lipstick (if applicable).

Symmetry

EXPECTED:Symmetric vertically and horizontally at rest and while moving.

UNEXPECTED:Asymmetric.

Color

EXPECTED:Pink in whites, bluish in individuals of darker skin, distinct border between lips and facial skin.

UNEXPECTED:Pallor, circumoral pallor, bluish purple, or cherry red.

Condition

EXPECTED:Smooth.

UNEXPECTED:Dry, cracked; deep fissues in mouth corners, swelling; lesions; plaques; vesicles; nodules, ulcerations; or round, oval, or irregular bluish gray macules.

Inspect teeth

Occlusion

Have patient clench teeth and smile with lips spread.

EXPECTED:Upper molars interdigitate with groove on lower molars. Premolars and canines interdigitate fully. Upper incisors slightly override lower incisors.

UNEXPECTED:Malocclusion. Protrusion of lower incisors. Problems with bite.

Teeth occlusion line. From Miyasaki-Ching, 1997.

Color

EXPECTED:Ivory, stained yellow or brown.

UNEXPECTED:Discolorations on crown may indicate caries.

Condition

EXPECTED:32 teeth, firmly anchored.

UNEXPECTED:Caries and loose or missing teeth.

Inspect buccal mucosa

Have patient remove any dental appliances and then partially open mouth. Use tongue blade and bright light to assess.

Color

EXPECTED:Pinkish red, patchy pigmented mucosa in individuals with dark skin.

UNEXPECTED:Deeply pigmented. Whitish or pinkish scars.

Condition

EXPECTED:Smooth and moist. Whitish yellow or whitish pink Stensen duct. Fordyce spots.

UNEXPECTED:Adherent thickened white patch; white, round, or oval ulcerative lesions; red spot at opening of Stensen duct; stones or exudate from Stensen duct.

Inspect and palpate gingiva

Use gloves to palpate.

Color

EXPECTED:Slightly stippled and pink, may be more hyperpigmented in individuals with dark skin.

UNEXPECTED:Blue-black line about 1 mm from gum margin.

Condition

EXPECTED:Clearly defined, tight margin at each tooth. Gingival enlargement with pregnancy and puberty.

UNEXPECTED:Inflammation, swelling, bleeding, or lesions under dentures or on gingiva; induration, thickening, masses, or tenderness. Enlarged crevices between teeth and gum margins. Pockets containing debris at tooth margins.

Inspect tongue

Size/symmetry

Ask patient to extend tongue.

EXPECTED:Midline, no fasciculations.

UNEXPECTED:Atrophied, deviation to one side.

Color

EXPECTED:Dull red.

Dorsum surface

Have patient extend tongue and hold extended.

EXPECTED:Moist and glistening. Anterior: Smooth yet roughened surface with papillae and small fissures. Posterior: Smooth, slightly uneven or rugated surface with thinner mucosa than anterior. Possibly geographic.

UNEXPECTED:Smooth, red, slick; hairy; swollen; coated; ulcerated; fasciculations; or limitation of movement.

Ventral surface and floor of mouth

Have patient touch tip of tongue to palate behind upper incisors.

EXPECTED:Ventral surface pink and smooth with large veins between frenulum and fimbriated folds. Wharton ducts apparent on each side of frenulum.

UNEXPECTED:Difficulty touching hard palate. Swelling, Varicosities, ranula (mucocele).

Lateral borders

Wrap tongue with gauze and pull to each side. Scrape white or red margins to remove food particles.

UNEXPECTED:Any fixed white or red margins. Leukoplakia, ulceration, induration.

Inspecting lateral border of tongue.

Palpate tongue and floor of mouth

EXPECTED:Smooth and even texture.

UNEXPECTED:Lumps, nodules, induration, ulcerations, or thickened white patches.

Inspect palate and uvula

Have patient tilt head back.

Color and landmarks

EXPECTED:Hard palate (whitish and dome shaped with transverse rugae) contiguous with pinker soft palate. Uvula at midline. Bony protuberance of hard palate at midline (torus palatinus).

UNEXPECTED:Nodule on palate, not at midline.

Movement

Ask patient to say “ah” while observing soft palate. (Depress tongue if necessary.)

EXPECTED:Soft palate rises symmetrically, with uvula remaining in midline.

UNEXPECTED:Failure of soft palate to rise bilaterally. Uvula deviation. Bifid uvula.

Inspect oropharynx

Depress tongue with tongue blade.

Tonsils

Inspect the tonsillar pillars and size of tonsils.

EXPECTED:Tonsils, if present, blend into pink color of pharynx. Possible crypts in tonsils where cellular debris and food particles collect.

UNEXPECTED:Tonsils projecting beyond limits of tonsillar pillars. Tonsils red, enlarged, covered with exudate.

Posterior wall of pharynx

EXPECTED:Smooth, glistening, pink mucosa with some small, irregular spots of lymphatic tissue and small blood vessels.

UNEXPECTED:Red bulge adjacent to tonsil extending beyond midline. Yellowish mucoid film in pharynx.

Elicit gag reflex

Prepare patient and touch posterior wall of pharynx on each side.

EXPECTED:Bilateral response.

UNEXPECTED:Unequal response or no response.

TECHNIQUE

FINDINGS

EARS

Inspect tympanic membrane

In infants, pull auricle downward and back to straighten canal.

EXPECTED:Tympanic membrane may be red from crying. If red from crying, it will be mobile.

Assess hearing

Evaluate response to auditory stimuli (bell, clapped hands, tissue paper)

EXPECTED:For infants, see table on p. 95. Young children should turn toward sound consistently.

Age

Response

Birth to 3 months

Startles, wakes, or cries when hearing a loud sound; quiets to parent’s voice; makes vowel sounds “oh” and “ah.”

4 to 6 months

Turns head toward interesting sound; moves eyes in direction of sound but may not always recognize location of sound; responds to parent’s voice; enjoys sound-producing toys; starts babbling with many speech sounds

7 to 12 months

Responds to own name, telephone ringing, and person’s voice, even if not loud; begins localizing sounds above and below; turns eyes and head toward sound; babbles with short and long strings of sounds; begins to imitate speech sounds; correctly uses mama and dada.

TECHNIQUE

FINDINGS

NOSE AND SINUSES

Evaluate patency of nares With infant’s mouth closed or with infant sucking on bottle or pacifier, occlude one naris and then the other. Observe respiratory pattern.

EXPECTED:Breathes easily; obligatory nose breathing until 2 to 3 months of age.

Pediatric sinuses.

MOUTH

Inspect and palpate lips with mouth closed

EXPECTED:Drooling in infants ages 6 weeks to 6 months, sucking calluses in newborns.

UNEXPECTED:Drooling persistent after age 6 months not associated with teething.

Inspect teeth

Color

EXPECTED:0 to 20 teeth until age 6 years. Permanent teeth start erupting around age 6 years.

UNEXPECTED:Natal teeth.

Inspect buccal mucosa

Condition

EXPECTED:In infants, nonadherent white patches (milk).

UNEXPECTED:In infants, adherent white patches.

Inspect and palpate gingiva

Condition

EXPECTED:In infants up to 2 months, pearl-like retention cysts.

Inspect and palpate hard palate

Condition

EXPECTED:Strong suck and Epstein pearls in young infants.

UNEXPECTED:No cleft of hard or soft palate.

ABNORMALITY

DESCRIPTION

Cleft lip and palate

Subjective Data:Difficulty sucking, failure to gain weight.

Objective Data:Unilateral or bilateral fissure or cleft in lip, hard palate, or soft palate that extends into the nasal cavity.