Examination of the Ears, Nose, Throat, and Neck
Dr. Saad Y. SulaimanExamination of the Ear
1) Introduction 2) Position the patient 3) Inspection 4) Palpation 5) Otoscopic examination 6) Microscopic examination 7) Assessment of tympanic membrane mobility 7) Tuning fork tests 8) Assessment of balance and examination of cranial nervesExamination of the Ear
1) Introduce yourself to the patient Any deafness? Communication 2) Position the patient At the same level In chair Can walk around patientExamination of the Ear
Inspection Inspect the pinna Front and behind Skin condition Lesions Scars Pre-auricular area (common place for sinus) Condition of cartilagePost auricular scar
Discharging earPreauricular sinus
Auricular haematoma
Cauliflower earAuricular ulcer – squamous cell CA
Acute mastoiditisRt. Acute mastoiditis: the Rt. pinna pushed foreword and downward
Postauricular Hearing aid or behind the ear ( BTE )BAHA: Bone Anchored Hearing Aid
Palpation 1. palpation of the pinna ( tragal tenderness) 2. Lymph nodes( Preauricular, postauricular and upper deep cervical) 3. Palpation of mastoid process
Examination of the Ear
Inspect the external auditory meatus Pull pinna upwards, outwards and backwards In infants downwards and backwards In children pull backwards Otorrhoea and otomycosis Wax Canal stenosis Exostoses and osteomasExamination of the external ear by use of aural speculum and head light or mirror ( the pinna is pulled upward and backward)
Wax
Otomycosis
Otitis ExternaForeign body in the ear
Examination of the EarOtoscopic examination The lateral process and handle of the malleus lie towards the centre of the tympanic membrane Four quadrants Perforation Central or marginal Attic perforation What can be seen through it
Otoscope ( Auroscope)
The device was first described and illustrated in France in 1363 by Guy de ChauliacThe auroscope magnification is 1.5-2.0 times
Sometimes we use microscope to examine the ear ( its magnification is 6-20 times)Normal Tympanic membrane: Colour: Pearly grey Mobile Anatomical land marks
Tympanic membrane perforationsSafe (Central) Unsafe (Marginal and Attic perforations)
Central Perforation
Traumatic Perforation
Otitis media with effusionMyringotomy with insertion of Grommet ventilation tube
TympanosclerosisExamination of the Ear
Assessment of tympanic membrane mobility Valsava manover Seigle pneumatic speculum PolitzerizationExamination of the Ear
Assessment of Hearing While assessing the auditory function it is important to find out: Type of hearing loss ( CHL, SNHL or mixed ) Degree of hearing loss. Site of lesion. Cause of hearing loss.Clinical tests of hearing: Finger friction test; rubbing the thumb and finger close to the ear.2) Watch test;.. by clicking watch …..3) Speech ( voice ) test;… conversation voice ,,,,distance of 6 meters.4) Tuning fork tests
Tuning fork test
Examination of the EarTuning fork tests Traditionally 512Hz Rinne and Weber (they were both German) Help differentiate between conductive and sensorineual hearing loss
Rinne`s test
Compare Air and Bone conduction in the same ear Normal subject = AC > BC (Rinne +ve) CHL = BC > AC (Rinne -ve) SNHL = AC > BC(Rinne +ve) and often the BC is not heard.
Weber test;
In normal subjects the sound is heard in the midline or in both ears equally. In CHL the sound is heard in the affected ear (absence of environmental noise), i.e.; lateralized toward the affected ear In SNHL the sound is heard in the non-affected ears.Assessment of Balance ( Labyrinthine function) Cranial nerves examination
Examination of the nose1) Introduce yourself 2) Position patient 3) Inspect the external nose 4) Inspect the nasal tip, vestibule, and nasal airways 5) Palpation and Percussion
6) Anterior rhinoscopy 7) Post nasal space examination
Examination of the nose
1) Introduce yourself Any hyponasal speech (rhinolalia clausa )?Examination of the nose
2) Position the patient Head-mirror or headlight?Examination of the nose
3) Inspect the external nose Compare nose to rest of face Size and shape Skin Swelling, bruising, ulcersRhinophyma
Examination of the nose4) Examine the nasal tip, vestibule, and assess the nasal airways Nasal tip Nostrils and air flow Mist test
Elevation of nasal tip
Septal haematomaMist Test
Palpation and PercussionExamination of the nose
5) Anterior rhinoscopyThudichum’s speculum, Killian speculum, otoscope?Obvious lesionsMucosaSeptumTurbinates (and osteomeatal complex)Handling of Thudichum’s nasal speculum
Examination of the nose
7) Post nasal space examination With mirror ( nasopharyngeal mirror) Rigid endoscope Flexible endoscopeExamination of the throat
1) Introduce yourself 2) Position the patient 3) Assess speech 4) Oral examination5) Indirect laryngoscopy 6) Examine the neck
Examination of the throat
1) Introduce yourself 2) Position the patient Headlamp, mirror or other light source Seated in chair with space to examine from all sides 3) Assess speech Stridor Hoarseness Any other dysphoniaExamination of the throat
4) Oral examinationLips, perioral lesions1 or 2 tongue depressors Inspect tongue, buccal mucosa and oropharynxSalivary duct orifacesSay ‘Ahhh’Finger examination of floor of mouth, cheeksThe orifice of sublingual duct of Brtholine
Using gauze to dry the area and watching the flow by pressing above Stenson’s duct is a good indicator of salivary flow. Parotid gland orificeAntrochoanal polyp
Post-tonsillectomyExamination of the throat
6) Indirect laryngoscopy With mirror or nasendoscope Can assess the base of the tongue, vallecula, Epiglottis, false and true vocal cords. Look for abnormality in the mucosa ( e.g. congestion , mass, vocal cord nodule>>>) Check vocal cord mobility by asking the patient to say (EEE)The mirror is warmed before examination to avoid fogging
Examination of the throat7) Examination of neck Head and neck cancers metastasise to neck nodes and to the lungs Tonsillar infections are the commonest cause of enlarged lymph nodes