Chapter 13: Otorhinolaryngology and Ophthalmology
What is included in the throat and what is the provider looking for?
-larynx pharynx -enlarged adenoids (pharyngeal tonsils) and orifices of the eustachian tubes
What forms are ophthalmic medications available in? Where are they dispensed in the eye?
-liquid drops, eye ointments -drops into the eye, ointments in a ribbon directly into the bottom eyelid
error of refraction
Light rays are not being bent properly Are not focused on retina adequately Cause-defect in the shape of eyeball can be improved with corrective lenses
amblyopia
Reduction or dimness of vision with no apparent organic cause; often referred to as lazy eye syndrome.
The semicircular canals contain fluid (__________________) the filtration and excretion of which are controlled by the part of the canal called the ___________________ sac.
endolymph, endolymphatic sac
choroid
eye's vascular layer; contains blood vessels that supply nutrients to outer layers of the retina. brown pigment that absorbs excess light rays that could interfere with vision
strabismus
failure of the eyes to gaze in the same direction due to weakness in the muscles controlling the position of one eye. "lazy eye" or "crossed eyes"
ear irrigation
flushing of the ear canal with water or saline to dislodge foreign bodies or impacted cerumen (earwax)
Rinne Test
hearing acuity test performed with a vibrating tuning fork that is first placed on the mastoid process and then in front of the external auditory canal to test bone and air conduction. conductive hearing loss In normal hearing, sound is hear twice as long by air conduction as by boneconduction
presbycusis
hearing loss that affects aging people, caused by a reduction in number of receptor cells in organ of corti and is classified as sensorineural hearing loss
Symptoms of impacted cerumen
hearing loss, tinnnitus, conducive hearing loss, feeling of fullness, otalgia
A convex lens is used to treat _________________ while a concave lens is used to treat ________________
hyperopia, myopia
Common causes of conductive hearing loss
impacted cerumen, trauma to tympanic membrane, hemorrhage of fluid in middle ear, otosclerosis, chronic recurent ear infection
myringotomy
incision into the tympanic membrane to drain fluid of otitis media followed by insertion of a tympanostomy tube to continually drain middle ear of fluid.
glaucoma
increased intraocular pressure results in damage to the retina and optic nerve with loss of vision
What does the tympanic membrane look like during otitis?
inflamed and bulging, fluid or pus may be present
otitis media
inflammation of normally air filled middle ear that results in a collection of fluid behind the tympanic membrane. serous or purulent/suppurative
conjunctivitis
inflammation of the conjunctiva caused by irritation, allergy, or bacterial infection (most common)
keratitis
inflammation of the cornea that results in superficial ulcerations.
blepharitis
inflammation of the glands and eyelash follicles along the margin of the eyelids that may be caused by staphylococcal infection, allergies, or irritation
What parts of the eye does the primary care provider examine?
interior portion, eyelids, pupils
vitreous humor
jellylike substance found behind the lens in the posterior cavity of the eye that maintains its shape
astigmatism
light rays entering the eye are focused irregularly; cornea or lens is not a smooth sphere; light rays are unevenly scattered on the surface
Myopia (nearsighted)
light rays entering the eye focus in front of the retina causing objects at a distance to appear blurry and dull-- also called nearsightedness
lens
light refraction; focuses light after it passes through cornea
hordeolum (stye)
localized, purulent, inflammatory staphylococcal infection of a sebaceous gland in the eyelid
Audiometry measures...
lowest intensity of sound an individual can hear
function of the semicircular canals
maintain equilibrium
Where does the 8th cranial nerve transmit auditory impulses in the brain?
medulla oblongata, thalamus, auditory cortex
serous otitis media
occurs because of a buildup of clear fluid in the middle ear; patients complain of full feeling and some hearing loss
function of the eustachian tube
opens into middle ear cavity and connects to nasopharynx, equalize pressure
Typical diagnostic procedures for ears?
otoscope to view external auditory anal, palpates area around pinna, tuning fork tests, audiometric testing
The ear is divided into 3 sections:
outer ear, middle ear, inner ear
What parts does the outer ear consist of?
pinna/auricle, external auditory canal
Weber Test
Test done by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate in which ear the tone can be heard. Sensorineural hearing loss
Impacted cerumen
an accumulation of earwax that forms a solid mass by adhering to the walls of the external auditory canal
opticians
an individual who is trained to fill prescriptions written for corrective lenses by grinding lenses and dispensing eyewear
corneal abrasion
an injury, such as a scratch or irritation, to the outer layers of the cornea, corneal ulcer may form and become infected
How must solution be administered in ear irrigation?
applicator tilted up, toward top of external canal so solution is not directed at the tympanic membrane
presbyopia
as people age, the lens of the eye becomes less flexible and ciliary muscles weaken, so changing the point of focus from distance to near becomes difficult
What are treatments for presbyopia?
bifocal lens, progressive lens correction, conductive keratoplasty
macular degeneration
breakdown or thinning of the tissues in the macula, resulting in partial or complete loss of central vision
exophthalmia
an abnormal condition characterized by a marked outward protrusion of the eyeballs
Why might otic medications be given?
soften impacted cerumen, relieve pain, antibiotic drop for infectious pathogen
Signs and symptoms of reractive errors
squinting, frequent rubbing of the eyes, headaches, blurred vision or fading or words at reading level
On the snellen chart, the last line the patient can read without ___________________ or _________________ and with no more than ________ mistakes is the line recorded in the patient's record for that eye.
squinting, straining, two
rods
structures in the retina of the eye that form the light sensitive elements
laser-assisted epithelium keratomileusis (LASEK)
surface epithelial cells of the eye are softened with an alcohol solution allowing epithelial layer to be rolled back and cornea to be exposed. Laser is used to reshape cornea and treat myopia, hyperopia and astigmatism
refraction
the ability of the lens to bend light rays so they focus on the retina
motion sickness/ motion sensitivity
the experience of nausea brought on by unnatural passive movement, as in a car or boat Caused by excessive stimulation in the brain from the semicircular canals
optic disc
the region at the back of the eye where the optic nerve meets the retina; it is considered the blind spot of the eye because it contains only nerve fibers and no rods or cones and thus is insensitive to light
ophthalmology
the science of the eye and its diosrders and diseases
otorhinolaryngology
the study of the ears, nose, and throat
sclera
the tough fibrous lining that protects then entire eyeball in the
One of the first signs of ototoxic drug complications is...?
tinnitus (ringing of ears)
Function of the oval window
transmits vibrations to the fluid in the cochlea
Why might medication be instilled in the eye?
treat infection, soothe eye irritation, anesthetize eye, dilate pupils
Treatments for otitis externa
treated with antibiotic or steroid ear drops, canal must be kept clean and dry,
Discomforts patients may experience during ear irrigation include?
vertigo, ear discomfort, coughing, tickle in back of throat
What is the inner ear sometimes called? Parts of the inner ear?
-labyrinth -semicircular canals, cochlea
Treatments of Meniere's disease
-Active periods of disease: treated symptomatically with nausea and vomiting medications, salt restricted diet, diuretics, antihistamines -surgical destruction of labyrinth (may cause permanent deafness)
What is most commonly used to test distance visual acuity? What must be kept in mind when administering this test?
-Snellen alphabetical chart -patient cannot study chart, 20 feet long hallway or distance, eye height chart and well lit
What does sensorineural hearing loss result from? What can cause it?
-abnormality of organ of Corti or auditory nerve -viral infection, trauma, ototoxic medications, prolonged exposure to loud noise
If sensorineural hearing loss cannot be improved by hearing aids, what is another option? How does it work?
-artificial cochlea -use electrical impulses to stimulate auditory nerve which carries current to brain to be interpreted as sound
What occurs to impair vision in chronic open angle glaucoma? How about acute closed angle glaucoma?
-channels that drain aqueous humor malfunction and over time, aqueous humor builds up, resulting in increased pressure which affects blood supply to retina and optic nerve -opening of drainage system narrows or closes completely, causing sudden increase in IOP
Function of the pinna/auricle and external auditory canal?
-collects sound waves and sends them down auditory canal -skin that lines canal contains hair follicles, nerve endings, ceruminous glands, etc.
Definition and Function of organ of Corti
-contains receptors for sound, in cochlea -hair like sensory cells surrounded by sensory nerve fibers that form the cochlear branch of the 8th cranial nerve -sound impulses cause hairs to bend and rub against nerve fibers which initiate stimuli to travel through cochlear nerve into brain for sound interpretation
How is the near visual acuity chart carried out?
-corrective lenses can be worn -well lit room, card held 14-16 inches away from the face -given for each eye then both -monitored for squinting or tearing -MA documents line at which patient had no more than 2 errors for each eye and two eyes together
When must surgical asepsis be practiced in otology? How must medications be handled?
-dressings changed and minor surgery performed -carefully, to prevent contamination
What are the eyelids examined for?
-edema, ptosis (blepharoptosis)
What are the semicircular canals responsible for? Structure of them?
-evaluating position of head in relation to pull of gravity -3 canals positioned at right angles to each other on different planes
What parts of the eye does an ophthalmologist observe or procedures they carry out?
-exams with a slit lamp biomicroscope -exophthalmometer for patients with exophthalmia
Path of tears in the eye to keep it moist:
-eye blinks 2-3 seconds causing lacriminal gland to secrete tears -tears move across eyes then drain into lacriminal canals in medial corner of the eye -then drain into nasal cavity into nasolacriminal duct
Risk factors for otitis media
-gender (male) -age (6 to 18 mos) -premature birth -family history -siblings with infections -seasonal factors (cold/flu season) allergies -underlying disease (cleft palate, down syndrome, asthma, allergies) -ethnicity (Native American and Alaskan Inuit because of shape of eustachian tubes) -exposure to large group child care settings -exposure to secondhand smoke -child not held upright during bottle feeding -use of pacifiers beyond 6 months -not washing hands frequently -Child unimmunized with prevnar and flu vaccines
How are throat specimens taken?
-gently swabbing back of throat and surfaces of tonsils with sterile swab -mouth and tongue avoided to prevent contaminations of swab with normal flora of mouth
How do the semicircular canals help maintain balance?
-head turns rapidly, fluid filled canals must adjust and send stimulated change into the CNS which interprets info and initiates desired response to maintain balance. With excessive stimulation people can become nauseous
People with conductive hearing loss receive the greatest benefit from what treatment? What about if hearing loss is caused by a malfunction or congenital abnormality of ossicles?
-hearing aids -surgical procedure to replace damaged ossicles with manufactured models
What is the procedure that must be followed for eye irrigation?
-inspection: patient looks in all directions, look down while provider everts upper eyelid and materials can be rinsed away -if unsuccessful, cover both eyes with gauze and notify supervisor immediately
Diagnosis of corneal abrasion is confirmed using? Treatments for corneal abrasions?
-instillation of fluorescein stain (then cobalt blue light to view abrasions which appear green) -patching affected eye, nonsteroidal antiinflammatory ophthalmic drops, topical antibiotics for secondary infection, etc.
Function of the eyebrows, eyelids, and eyelashes
-keeps irritants out of the eyes -protect eye from trauma -line margins of eyelids and trap foreign particles
Names and functions of the auditory ossicles
-malleus (next to tympanic membrane) -stapes (next to oval window) -incus -pick up vibrations from tympanic membrane and change from air conducted sound waves to bone conducted sound waves
Treatments for open angle glaucoma? Closed angle glaucoma?
-miotic and beta blocker eye drops, oral medicaitons, laser surgery, -medications to lower IOP (medical emergency)
How is the throat viewed in inspections? What is often taken in the provider's office to assist in diagnosis of strep throat infection?
-mirror and either tongue depressor or gauze square -throat specimens
dry macular degeneration
-most cases, painless and develops slowly -breakdown of light sensitive cells in region of macula -age related condition, no cure but antioxidants help
Why is the nasal cavity inspected? What are main causes of change in the mucosa? What might the provider use to visualize the nostrils and nasal sinuses?
-mucuous membrane of the nostrils -common cold and allergies -nasal speculum; palpation and transillumination
What is near visual acuity tested with? What conditions does this test screen for?
-near visual acuity chart -presbyopia, hyperopia
Signs and symptoms of chronic glaucoma? Acute glaucoma? What type (acute closed angle or chronic open angle), can a person become completely blind in a matter of days with?
-need to change eyeglass prescriptions frequently, tunnel vision, mild headaches, impaired adaptation to the dark -severe pain, headaches, inflammation, photophobia, halos around lights (more obvious symptoms) -acute
Two common types of otitis:
-otitis externa (swimmer's ear), otitis media
How is impacted cerumen discovered? How is it treated?
-otoscopic examination -removed by softening wax with oily drops and irrigating ear with warm water until plug is removed
Describe the path of a visual impulse
-passage of light through cornea through aqueous humor through pupil through lens -ciliary muscle adjusts curvature of lens to refract light so it passes into retina -light energy is converted to an electrical impulse which is sent through optic nerve to the visual cortex of the occipital lobe of the brain
How is the tuning fork activated?
-provider holds stem of fork and strikes the tine softly on palm of hands
wet macular degeneration
-rarer, acute onset and rapid progression -new blood vessels behind retina form and leak blood and fluid into the macula -age related condition, no cure but antioxidants help
What are pupils fo the eye examined for?
-round and equal -normal pupils constrict rapidly in response to light (using a pen light) -adjust and focus on objects at different distances in reasonable amount of time
How does a cataract impair vision? Treatments for cataracts?
-scatters light as it passes through lens. preventing a sharply defined image from reaching the retina resulting in blurred and dimmed vision -slit lamp procedure, eye glasses, bright lighting, hold objects closer to eyes, advanced cases: surgical removal of lens and replacement with IOL.
The eyeball consists of three layers: (1) the outermost layer is made up of the _____________ and the _____________ (2) the middle layer of the eye is made up of the ____________________ in the posterior portion and the ___________ and ____________ in the anterior portion. (3) The inner layer of the eye contains the _____________ in the posterior portion and the ______________ in the anterior portion
-sclera, cornea -choroid, iris, ciliary body -retina, lens
How is screening for glaucoma conducted?
-tonometer with slit lamp to measure IOP or gonioscopy, or ophthalmoscopic exam to identify cupping of optic disk
The development of drug-resistant strains of bacteria as a result of overprescription of antibiotics is a growing concern. The American Academy of Pediatrics recommends the following for treatment of otitis media:
-treatment with antibiotics should be delayed, giving the child's immune system a chance to fight the infection by itself. 24 hours in kids 6-24 mos, 72 hours older children. If child's condition does not improve, appropriate antibiotic can be prescribed -child typically improves in about 48 to 72 hours but parent should understand how important it is to complete the antibiotic medication as ordered to prevent the infection from occurring -provider may decide to treat otitis media with short course of antibiotics but at a higher dose. May include amoxicillin, azithromycin, cefuroxime -Antibiotics will not help otitis if caused by a a virus
What can mixed hearing loss result from?
-tumors, toxic levels of medication, hereditary factors, stroke
What is the middle ear sometimes called? Main parts of the middle ear?
-tympanic cavity -auditory ossicles, eustachian tube, tympanic membrane (ear drum), oval window
What must be recorded after the Snellen eye chart is used?
-whether patient used corrective lenses -results of each eye separately and in fractions -results of both eyes -squinting or straining noted at all
hyperopia
A condition in which visual images come to a focus behind the retina of the eye and vision is better for distant than for near objects -- called also farsightedness.
ototoxic
A medicine or substance capable of damaging cranial nerve VIII or the organs of hearing and balance.
gonioscopy
A procedure in which a mirrored optical instrument is used to visualize the filtration angle of the anterior chamber of the eye; the procedure is used to diagnose glaucoma.
fovea centralis
A small pit in the center of the retina that is considered the center of clearest vision.
conductive keratoplasty (CK)
A solid-state infrared laser refractive surgical procedure employed to create heat shrinkage of the peripheral corneal stroma, thereby steepening the central cornea and reducing hyperopia.
mydriatic
A topical ophthalmic medication that dilates the pupil; it is used in diagnostic procedures of the eye and as treatment for glaucoma.
psoriasis
A usually chronic, recurrent skin disease marked by bright red patches covered with silvery scales.
Meniere's disease
Abnormal condition within the labyrinth of the inner ear that can lead to a progressive loss of hearing. The symptoms are dizziness or vertigo, hearing loss, and tinnitus (ringing in the ears). Causes swelling and edema in the endolymphatic sac, along with an overproduction of endolymph
audiologist
Allied healthcare professional who specializes in evaluation of hearing function, detection of hearing impairment, and determination of the anatomic site of impairment.
audiometric evaluation
An evaluation done by an audiologist including a variety of tests that assess level of hearing impairment and providing valuable info as to how patient may be helped -first test is speech comprehension and assesses patient's ability to follow verbal directions -patient in soundproof booth with earphones, audiologist speaks to patient and conducts all testing through earphones
seborrhea
An excessive discharge of sebum from the sebaceous glands, forming greasy scales or cheesy plugs on the body.
tonometer
An instrument used to measure intraocular pressure.
miotic
Any substance or medication that causes constriction of the pupil.
accommodation
adjustment of the eye that allows a person to see various sizes of objects at different distances
nystagmus
Constant involuntary back and forth, up and down, or rotary movement of the eyeball. accompanied by blurred vision; caused by abnormal function in part of the brain that controls eye movements, no cure
audiometry testing
Each ear is tested by delivering a single frequency at a specific intensity, starting at low frequency tones and going up. Patient is asked to signal when he/she hears sound/ Adult with normal hearing can hear below 25 decibels and child below 15 decibels
otosclerosis
The formation of spongy bone in the labyrinth of the ear, which often causes the auditory ossicles to become fixed and unable to vibrate when sound enters the ears.
hertz
The unit of measurement used in hearing examinations; a wave frequency equal to 1 cycle per second.
evert
To turn the eyelid inside out; this typically is done by the provider to inspect the area for foreign bodies.
Function of the tympanic membrane
Transducing sounds (vibrates) waves from outer ear to inner ear, vibrates when ear is hit.
Causes of otitis media
URI allergies influenza
Tuning fork tests measure hearing by ___ and _____ conduction. Most commonly used fork is?
air, bone -512 hertz
cataract
a cloudy or opaque area in the normally clear lens of the eye tat blocks passage of light into retina, causing impaired vision. May result from injury to eye, extreme heat or radiation, inherited factors, and old age
chalazion
a nodule or cyst, usually on the upper eyelid, caused by obstruction in a sebaceous gland
optometrist
a person skilled in testing for defects of vision in order to prescribe corrective glasses; not an MD
ophthalmologist
a physician who specializes in diagnosing and treating diseases and disorders of the eyes and vision -licensed medical doctor
Ishihara color vision test
a test using configurations of multicolored disks with embedded symbols; the symbols can be seen by people with normal color vision but not by people with particular color vision deficiencies
conjunctiva
a thin mucous membrane folded like an envelope between the eyelids and the eyeball. Keeps the eye moist
photophobia
abnormal sensitivity to light
What does treatment for strabismus involve in children (specifically with amblyopia)?
child wear a patch over unaffected eye so muscles of "lazy" eye are strengthened or administration of atropine eye drosp to unaffected eye to medically decrease visual acuity in good eye, forcing other eye to cooperate
iris
colored portion of the eye; contains muscles that regulate the size of the pupil according to the intensity of light
Two problems result in hearing loss:
conduction, sensorineural
Major concern of ophthalmic procedures?
contamination of eye medication applicators -solutions must be sterile for every person
Never attempt to remove a foreign body from the cornea using a ___________________________________________. Scratches to the cornea may result, causing scar formation and impaired vision.
cotton tipped applicator
cornea
covers the exposed 1/6 of the eyeball; allows light to enter eye and refracts direction of light rays after they enter the eye
optic nerve
cranial nerve II which carries impulses for the sense of sight
Causes of otitis externa
dermatologic conditions, trauma to canal, continuous use of earplugs or earphones, water collecting in ears and mixing with cerumen to form culture medium for bacteria and fungus
Main symptom of strabismus and amblyopia in all age groups is...?
diplopia (double vision)
Two types of macular degeneration:
dry and wet
The semicircular canals of the inner ear, in coordination with the ____________ cranial nerve, control ___________ and give a sense of how the body is positioned.
eighth, balance
Conductive hearing loss is caused by...
problem originating in the external or middle ear that prevents sound vibrations from passing through external auditory canal, limits vibration of tympanic membrane or interferes with passage of bone conducted sound in the middle ear
photorefractive keratectomy (PRK)
procedure for the treatment of astigmatism, hyperopia, and myopia in which an excimer laser is used to reshape (flatten) the corneal surface by removing a portion of the cornea
laser-assisted in situ keratomileusis (LASIK)
procedure that uses a laser to create a corneal flap and reshape the corneal tissue; used to correct vision problems such as myopia, hyperopia, and astigmatism
Who is more prone to impacted cerumen?
psoriasis, abnormally narrow ear canals, excessive hair growth in ear canals
PERLA
pupils equal, round, reactive to light and accommodation
suppurative otitis media
purulent fluid is present in middle ear, patient has fever pain, hearing loss
tympanogram
record of middle ear function (presented in graph form) -done to determine the air pressure of middle ear and mobility of the tympanic membrane -normal is a spike around 0 mm H20
Why is eye irrigation performed?
relieve inflammation, remove drainage, dilute chemicals, wash away foreign bodies
Function of cochlea
responsible for the sense of hearing
cones
retinal receptor cells that are concentrated near the center of the retina and that function in daylight or in well-lit conditions. The cones detect fine detail and give rise to color sensations.
ciliary body
secretion of vitreous fluid, helps change the shape of lens
otitis externa
severe pain and inflammation and swelling of external auditory canal, hearing loss, possible purulent or serous drainage