EENT Athletic Training at Iowa fundus

							Assessment Tests (Special Tests)

Visual Acuity – Used to determine vision. Most important part of an eye exam. Critical to
assess pre-participation and immediately after injury. Assessed while wearing glasses or
contacts for distance vision. Scored as a fraction of a standard for normal performance. Known
as a Snellen Visual Acuity from a chart placed 20ft away. The numerator is the distance a
normal person could read the same sized letters. Each eye is assessed independently by
occluding (covering) the other eye. Children and no-readers use picture charts. In the absence
of near vision cards (business cards, etc) can be used. When an injured player cannot see the
largest letters, hold up fingers. Documentation is # of fingers at ___ distance (ft). If they
cannot do that, wave the hand, documented as hand motion vision. If they cannot detect
motion, any bright light source can be used. Documented as light perception vision. NOTE:
Reduction in visual acuity in an injured eye is an ocular emergency.

Pupilary Responses – Used to determine normal neural, iris, and ciliary body function.
Pupilary reaction to light is normal. While the patient is looking into the distance, move a light
in toward the eye from the side and shine directly onto the pupil. The speed (briskness) of
contraction is noted. Examine each eye separately and compare. This is reactivity and
responsiveness. Swing a light from the good to the injured eye, if the injured eye appears to
dilate, this is known as afferent pupilary defect and may mean that a different amount of light
is being transmitted through the optic nerve – serious. Larger pupils or unreactive pupils or no
longer round pupils signals significant ocular trauma. A congenital large pupil on one side is
called ansicoria.

Eye Movement – Used to determine limitations of ocular movement from neural, muscular,
and possibly bony conditions. Also called ocular motility. An inability to move into cardinal
fields of gaze and indicates severe injury with possible bony or muscular pathology or
entrapment. Have the patient follow your finger tip up, down, left, right, and oblique for both
eyes together. Assess for smooth, uninterrupted movement. When the eyes do not move
synchronously, patients usually complain of double vision (diplopia).

Peripheral Vision – Used to determine neural or retinal detection of peripheral fields of
vision. To test the right eye, sit in front of the patient 3 ft. away. Occlude the left eye and have
them look at your left eye (examiner closes right eye). Hold up 1,2 or 3 fingers equidistant
between the patient and you. You must be able to see your own fingers. Do this peripheral
pattern in each cardinal field of vision.

Eye Inspection – Used to determine lacerations, hematomas, forein bodies, shape and
contours. Use a penlight (or normal flashlight). Retract the lower lid and have the patient look
up. Retract the upper lid and have them look down. Visualize the conjunctiva, sclera and
cornea. Visualize the fornices (posterior porti ons of the upper and lower conjunctiva where it
overlaps the sclera and joins together. Any obscuring of the structures behind the cornea (iris
or lens) is potentially a poor prognosis. If the eye is distorted or bleeding, discontinue
palpation. Penetration or rupture of the eyeball should eliminate palpation examination.

Ophthalmoscope – Used to determine red reflex and gross fundus examination. Turn on the
scope and select a wide aperture (large oval light shown on your hand or the wall). Darken the
room. Hold the handle of the scope in the right hand to examine the right eye. Put the index
finger or middle finger on the lens selector wheel. Use the left hand to open the lids. Hold the
scope against your right eye. Hold the scope against your right eye with the handle tilted
laterally. Instruct the patient to look over your shoulder. Start from about 15” away and
visualize a red-orange glow from inside the pupil (red reflex). Approach the eye from the lateral
side at an angle of about 15 d. Move in toward the patient to view the optic disc, arteries,
veins, and retina. To focus on various structures, turn the lens selector wheel. If the patient is
myopic, a minus (red) lens will be used. The fundus or retina will appear as a yellow or pink
background with blood vessels branching away from the optic disc. Follow vessels in four
directions.

Fluoresein Dye Test – When a corneal abrasion is suspected, fluorescein dye can be used to
stain areas of the abrasion where the cornea and conjunctiva have lost epithelial surface layers.
First wet the tip of the fluorescein strip with sterile saline. Touch the test strip to the lower lid
conjunctiva (do not touch the eye globe). Have the patient blink to spread the dye. Darken the
room. Use a cobalt blue light to illuminate the eye. Observe for bright yellowish-green marks
that pinpoint the abrasion.

Eye Lid Visualization – When foreign body sensations are present and persistent, the upper
lid can be gently pulled away from the eyeball by grasping upper lid lashes and pull over the
lower lid lashes. This can act as a brush against the upper eyelid. When the sensation still
persists, the upper lid can be everted for direct inspection. Grasp the eyelid and have the
patient look down, placing a cotton swab against the upper lid crease and then rotate the
eyelid around the applicator to expose the upper lid conjunctival surface. A cotton-tipped
applicator, cotton sponge, or cotton ball can be used to remove visible foreign bodies by lifting
off the surface. Never touch the cornea and do not attempt to remove a foreign body from the
cornea. Inadvertent pressure may push the object further in an penetrate the cornea. If these
maneuvers fail, refer.

Ear Visualization – Inspect the auricle noting size, shape, and symmetry. Note deformities or
discoloration indicating trauma. Look for lesions or nodules. Observe for obvious discharge or
odor (straw-colored fluid following head injury could be CFS – CFS may be in blood as well).
Auricles and the mastoid area should be palpated for tenderness, swelling, and non-visible
nodules.

Hearing Exam – Gross detection of haring is determined by a patient’s responses to
questions or directions. To distinguish between sensorineural and conductive hearing loss,
Weber or Rine Tests are used. The Weber Test consists of holding a tuning fork at the base, tap
lightly against the palm to start a vibration. Place the tuning fork at the vertex of the skull, then
ask if sound is heard better on one or equally in both ears. Results are these: normal is equal
sound heard in both ears; Conductive Loss is sound heard best in the impaired ear;
Sensorineural Loss is sound only identified in the normal ear. For the Rine Test, hold the tuning
fork at the base; tap it against the palm to start the vibration. Place the stem against the
mastoid process, count the seconds to when sound is no longer heard, guickly place the sill
vibrating fork ½ - 1” away from the ear. Ask the patient to say when sound is no longer heard
and count the seconds. Compare the sounds with the other ear. Normal findings are these:
air-conducted sound is usually heard twice as long as bone-conducted. For a Conduction Loss,
the bone conducted sound is heard longer. For a Sensorineural Loss, the sound is reduced and
heard longer through the air.

Otoscope – Use the largest disposable speculum that comfortably fits. Usually the light in the
otoscope is turned on by rotating a dial at the top of the handle. The patient should tip the
head slightly to the opposite shoulder and avoid moving during the exam. Most of the time,
the canal slopes inferiorly and forward toward the eyes. Straighten the canal by pulling up and
back ob the pinna. Otitis externa is suspected if the patient experiences pain on this maneuver.
Insert the otoscope with the speculum in place directed slightly down and forward about ½ inch
into the canal. Use your little finger against the cheek to guard against inserting the speculum
too far. The canal is lubricated with cerumen and this wax can build up in the external canal,
sometimes impairing hearing and making the exam difficult. The skin in the canal should be
smooth and somewhat pink or fleshy. Take note of scaling, increased redness, discharge,
lesions, or foreign bodies. Reddened canals with discharge signifies inflammation or infection.
Slowly move the otoscope in a circular direction in toward the tympanic membrane. The
membrane should appear translucent and pearly gray in color. The malleus should be visible
through the membrane. The membrane is concave by the pull of the malleus at the center
(umbo). This allows a light reflex to be visible when observed through the otoscope. The
tympanic membrane should be free from holes or breaks and should not be bulging or bloody.
Redness of or around the tympanic membrane indicates infection in the middle ear, whereas
white color may indicate pus behind the membrane.

Nose Exam – Major non-traumatic conditions related to the nose are: nasal obstruction,
drainage, facial pain or headache, epistaxis, and change in smell or taste. Thorough Hx is key to
the exam. Always ask about the onset and duration of sx. For nasal obstruction, trauma or
insidious onset; bilateral or unilateral; constant or intermittent is determined. As sessment of
inspiratory and expiratory air flow are done by occluding one nostril at a time. Unilateral
obstruction, may indicate an anatomical problem (deviated septum or polyp), whereas bilateral
obstruction may be from a cold. If drainage is present, determine its characteristics (unilateral
or bilateral; clear or discolored – clear indicates rhinitis either allergic or non-allergic; whereas
yellow, green, or brown suggests bacterial or viral; straw-colored drainage following a head
injury is associated with CSF; wear gloves). Facial pain and headache are associated with nasal
or sinus disorders (differentiate from other causes – migraines, tension headaches, TMJ, dental
disorders). For pain and swelling over the sinuses accompanied by purulent draina ge, suspect
sinusitis. Examine the external nose, noting size, shape, and color. Ask the patient about
changes in appearance or function. Look at the nose and face from behind and top to visualize
linear or curved bone lines as well as depressions. The nares should be examined for discharge
and unilateral flaring or narrowing. Palpation should be done for tenderness, swelling, masses,
and displacement of bone or cartilage. Squeeze the nares together for a patency exam.
Palpate the facial bones and sinuses (maxillary and frontal) – these are not usually tender and if
so often indicate inflammation from infection or allergy.

Trans-illumination – Sinuses may pass light through it walls. Use a penlite or otoscope in a
darkened room. For the frontal sinuses, press the light medially against the supraorbital rim
and look for a slight red glow just above the eye brow. For the maxillary sinus, press the light
lateral to the nose beneath the medial aspect of the eye and have the patient open the mouth.
The hard palate should be illuminated. When secretions are present, transmission is less or
absent.

Nasal Speculum Exam – To view the septum and turbinates, tilt the patient’s head slightly
backward. The septum is normally pink, glistening, and thicker anteriorly. Look for
discoloration, perforation, bleeding, crusting, and note differences such as polyps, holes,
swelling, and abnormal coloring. The septum should be straight and close to the midline. The
vestibule and turbinates are visualized with the patient’s head erect. The turbinates should be
pink, moist, and free from lesions or discoloration.

Mouth and Throat Exam – Always start with a visual inspection of the face, head and neck,
noting symmetry and skin changes. Palpate lymph nodes bilaterally to detect enlargement and
tenderness: anterior triangle neck chain, posterior triangle chain, subungal, periauricular,
parotid, posterior auricular, facial, submandibular, and submental. Evaluate the lips with the
mouth open and closed, noting texture, color and surface abnormalities. Ask the patient to
open the mouth to visually examine the labial muscosa (inside lips and gums) as well as
maxillary and mandibular vestibules, noting color, texture, and swelling of mucosa and gingivae.
The buccal mucosa is observed from the labial commisure to the tonsilar pillar. Use a tongue
depressor or gloved finger to pul the cheek away from the teeth, noting pigmentation, color,
texture, mobility and other abnormalities. Cracking of the lips is indicative of dehydration.
Inspect the mucosa for white or dark pigmented areas. Stensen’s duct looks like a small dimple
opposite the second molar. Inspect the tongue for swelling, ulceration, coating, or variation in
size, color, or texture. Ask the patient to stick out the tongue (CN XII), noting abnormal mobility
or positioning. Grasp the tip of the tongue with sterile gauze and pull out more to visualize the
lateral borders of the tongue. Then examine the ventral surface of the tongue and floor of the
mouth. Ask the patient to tilt their head back, mouth open wide, and depress the tongue at the
base with a tongue blade. Examine the hard and soft palate and oropharyngeal tissues.
Movement of the soft palate is evaluate by asking the patient to say “ahhh” (CN IX, X).
Continue inspecting the oropharynx: tonsilar pillars should be pink and blend in with the
retropharyngeal wall. Hypertrophied or reddened tonsils that may be covered with exudate
indicate a viral or bacterial infection. The posterior wall is normally pink and smooth. A
yellowish film may indicate post-nasal drip. A gag reflex can be done to assess CN IX, X.