1. Examination of Ear, Nose, Head, Neck and Throat
Dr.Vijay M.D

2. Equipments Basic Instruments Ear specula Nasal Specula
Tongue depressors
Indirect laryngoscopy mirrors
Posterior Rhinoscopy mirrors
Nasal and aural forceps.
Tuning forks, 512 Hz, 1024 Hz
Otoscope

3. Be familiar with gear

4. Examination of Ear

5. Structures of Ear

7. Examination
“ begin with inspection and palpation of the pinna (auricle) and structures surrounding the ear…”

8. Examining the External Structures of The Ear - Observation
Helix
Tragus
Mastoid
Anti-Helix
External Canal
Lobe
Note: Picture on L normal external ear; picture on R swollen external canal, narrowed by inflammation

9. Canal Inspect pinna and concha Otoscopic examination
Pull upwards, outwards and backwards
Look for cavity,
Otitis externa
Osteomas
Mastoid cavity

10. TM
Look for malleus, incus
Record abnormalities

11. Normal Tympanic Membrane
NOSE
Long Process Malleus
Left Ear – Malleus points down and back
Incus
Short Process Malleus
Umbo
Cone of Light

12. Pars flaccida
Long process incus
Handle of malleus
Umbo
Pars tensa
Canal wall

13. Perforations
Central perforation
Marginal perforation

14. OTOSCOPY An - annulus fibrosus
Lpi  (long process of incus) - sometimes visible through a healthy translucent drum
Um  (umbo) - the end of the malleus handle and the centre of the drum
Lr  (light reflex) - antero-inferiorly
Lp  (Lateral process of the malleus)
At  (Attic) also known as pars flaccida
Hm  (handle of the malleus)

15. Otoscopy
“grasp and retract the pinna backward and upward in adults and downwards in infants…”

16. Using Your Otoscope Make sure battery’s charged!
Gently twist Otoscopic Head (clockwise) onto handle
Twist on disposable, medium sized speculum
Hold in R hand R ear, L hand L ear

17. Otosocopy Basics
Make sure patient seated comfortably & ask them not to move
Place tip speculum in external canal under direct vision
Gently pull back on top of ear
Advance scope slowly as look thru window – extend pinky to brace hand
Avoid fast, excessive movement – Stop if painful!

18. Great Moments In The History of Hearing

19. Indication: Differentiate type of Hearing Loss
Tuning Fork Test
Indication: Differentiate type of Hearing Loss
Sensorineural Hearing Loss
Conductive Hearing Loss

20. Preparation
Tuning fork should be 512 Hz to 1024 Hz

21. Weber Test Technique: Tuning Fork placed at midline forehead
Normal: Sound radiates to both ears equally
Abnormal: Sound lateralizes to one ear
Ipsilateral Conductive Hearing Loss OR
Contralateral Sensorineural Hearing Loss

22. Rinne Test Technique First: Bone Conduction Next: Air Conduction
Vibrating Tuning Fork held on Mastoid
Patient covers opposite ear with hand
Patient signals when sound ceases
Move the vibrating tuning fork over the ear canal (Near, but not touching the ear
Next: Air Conduction
Patient indicates when the sound ceases

23. Normal: Air Conduction is better than Bone Conduction
Air conduction usually persists twice as long as bone
Referred to as "positive test"
Abnormal: Bone conduction better than air conduction
Suggests Conductive Hearing Loss
Referred to as "negative test"

24. Nose

25. Examination The nose can be examined in three parts:
Examination of the external nose
Anterior Rhinoscopy
Posterior Rhinoscopy.

26. Symptoms Discharge Sinus pain Trauma
Frequent upper respiratory infections
Epistaxis
Allergies
Sense of smell

27. Inspect external nose:
symmetry, deformity, lesions
Test patency of each nostril
Inspect using nasal speculum:
Color and integrity of nasal mucosa
Septum- note any deviation,perforation, bleeding
Turbinates- Note color, exudate, swelling
Palpate sinuses, note tenderness

28. Paranasal Sinuses

29. Anterior Rhinoscopy Examination of the Vestibule Look for:
Boil or Abcess
Ulcerations and abrasions
Excoriation because of discharge.

30. Examination of the nasal cavity using a nasal speculum:

31. POSTERIOR RHINOSCOPY Post Nasal Mirror:
It consists of a handle on which a small mirror is attached to shaft at an angle of 110.

32. Posterior Rhinoscopy Technique
Hold the mirror like a pen in the right hand.
Warm the mirror
Ask the patient to open the mouth.
Depress the anterior 2/3rds of the tongue
Feel the warmth of the mirror on the back of the wrist. It should not be hot. I

33. Introduce the mirror from the angle of the mouth over the tongue depressor and slide it behind the uvula.
Avoid touching the posterior wall of the pharynx as it may trigger gagging.
Instruct the patient to breath through the nose.
Tilt the mirror in different direction tot see various structures of the nasopharynx.

34. POSTERIOR RHINOSCOPY

35. Transillumination Test
Dim the room lights.
Place the lighted otoscope
directly on the infraorbital rim (bone just below the eye).
Ask the patient to open their
mouth and look for light
glowing through the mucosa
of the upper mouth.

36. Oral Cavity

37. Buccal Mucosa: Parotid duct opening Opposite upper 2nd molar), red or white patches, ulcers, moisture
Hard Palate: Swelling, ulcer, perforations, clefts etc.
Uvula: Position, deviations (Towards the normal side in palsies), ulcers
Floor of mouth: Wharton duct openings, ulcers, and bimanual palpation
Teeth and occlusion

38. Oropharynx
Soft Palate: Swelling, ulcer, movement, perforations, clefts etc.
Tonsillar pillars: congestion, ulcers, patches.
Tonsils: Presence, size, crypts, ulcers
Posterior pharyngeal wall: Lymphoid follicles, ulcers.

39. Subjective Data Sores/lesions Sore throat Bleeding gums Toothache
Dysphagia
Altered taste
Tobacco
Self-care behaviors

40. Examination Inspect and palpate:
Note condition gums, mucosa, teeth (caries? # of teeth malocclusion)
Lips: (lumps, lesion, cracking,color)
Tongue: color, moisture, surface characteristics. Check for white patches
Wharton’s Duct: opening of submandibular glands
Stensen’s Duct: opening of parotid salivary glands

41. Inspect uvula, palate, tonsils
Uvula looks like hanging pendant (if split in two= bifid)
Palate:
anterior hard palate=whitish
posterior soft palate = pinkish
Tonsils- graded by enlargement:
1+ visible near uvula
3+ touching uvula touching together

42. ORAL CAVITY Tongue Common and taste sensations
Size: Macroglossia in acromegaly, Down's syndrome
Ulcers
Movements: Restricted in hypoglossal palsies, tumor infiltration
Fasciculation: Motor neuron disease
Depapillation: Vitamin deficiencies
Furrowing , as in geographic tongue
Coating: Thrush, black hairy tongue

43. Laryngoscope Definition
Visual exam of the voice box (larynx) and the vocal cords.
Laryngoscopy is also done to remove foreign objects stuck in the throat.

44. Two Types:
1.Indirect laryngoscopy - uses mirrors to examine the larynx and hypopharynx
2.Direct laryngoscopy - uses a special instrument (flexible or rigid scope)

45. Indirect Laryngoscopy
Technique
Mirror is held like a pen in the right hand with the glass pointing downwards.
Warm the mirror and test the temperature on the back of the hand.
The patient is asked to stick out the tongue which is held with a piece of gauze.
The patient is asked to breath through the mouth.
The mirror is introduced into the mouth to the uvula which is gently pushed back to get a view of the larynx and the pyriform fossae.
The patient is asked to say 'Aaa' and 'Eee'.

46. Indirect Laryngoscopy

47. Inspect posterior pharynx , onsils, mucosa, teeth, gums, tongue – use
tongue depressor & light
– otoscope works as flashlight
Can grasp tongue w/a gauze pad & move it side to side for better visualization
Palpate abnormalities

48. Selected Pathology of Oropharynx
L CN 9 palsy – uvula pulled to R
L peri-tonsilar abscess – uvula pushed to R
L CN 12 palsy – tongue deviates L

49. Function: CNs 9 (glosopharyngeal), 10 (vagus) & 12 (hypoglossal)
Uvula midline - CN 9
Stick out tongue, say “Ahh”
Use tongue depressor if can’t see
Palate/uvula rise -CN 9, 10
Gag Reflex –
Provoked w/tongue blade or q tip - CN 9, 10
Tongue midline :CN 12
Check strength

50. What about the Dental? Dental health has big implications:
Nutrition (ability to eat)
Appearance
Self esteem
Employability
Social acceptance
Systemic diseaseendocarditis, ? other
Local problems:
Pain, infection
Profound lack of access to care

51. Neck, Throat, Thyroid

52. Neck

54. Salivary Glands

55. Inspection and Palpation
Inspection face & neck:
Does anything appear out of ordinary in Head & Neck?
Bumps/lumps, asymmetry, swelling, discoloration, bruising/trauma?
anything hidden by hair?
Inspection & palpation of Scalp, hair
Note right sided neck/jaw area swelling •
and R v L asymmetry

56. Lymph nodes I--Submental and submandibular nodes
II--Upper jugulodigastric group
III--Middle jugular nodes draining the naso- and oropharynx, oral cavity, hypopharynx, larynx.
IV--Inferior jugular nodes draining the hypopharynx, subglottic larynx, thyroid, and esophagus.
V-- Posterior triangle group
VI--Anterior compartment group

57. Lymphadenopathy– Major Causes
Enlarged if inflammation or malignancy
Infection: Acute, tender, warm
Primary region drained also involved (e.g neck nodes w/strep throat)
Sometimes get diffuse enlargement in response to generalized infection or systemic inflammatory process (.e.g TB, HIV, Mono)
Malignancy:
Slowly progressive, firm, multiple nodes involved, stuck together & to underlying structures.
Primary site malignancy could be nodes (e.g. lymphoma) or adjacent region (e.g. intra-oral squamous cell ca)

58. http://www. utdol. com/online/content/image. do

59. Lymph Node Examination
Gently walk fingers along general regions
– comparing R to L

60. Function CN 7 – Facial Nerve Facial Symmetry & Expression - Precise Pattern of Inervation
L UMN
R UMN
R LMN -
Forehead
L LMN -
Forehead
R LMN – Face
L LMN -Face

62. CN 7 – Exam Observe facial symmetry Wrinkle Forehead
Keep eyes closed against resistance
Smile, puff out cheeks
Cute.. and symmetric!

63. Bell’s Palsy
Patient can’t close L eye, wrinkle L forehead or raise L corner mouthL CN 7 Peripheral (i.e. LMN) Dysfunction
Central (i.e. UMN) CN 7 dysfunction (e.g. stroke) - not shown:
Can wrinkle forehead bilaterally;
loss of lower facial movement on side opposite stroke.

64. CN 5 - Trigeminal Sensation: Motor:
3 regions of face: Ophthalmic, Maxillary & Mandibular
Motor:
Temporalis & Masseter muscles

65. Function of CN 5 – Trigeminal
Motor
Sensory
Ophthalmic(V1)
Temporalis (clench teeth)
Maxillary (V2)
Masseter (move jaw side-side)
Mandibular (V3)
Corneal Reflex: Blink when cornea touched - Sensory CN 5, Motor CN 7

66. Testing CN 5 - Trigeminal
Sensory:
Ask pt to close eyes
Touch
Motor:
Palpate temporalis & mandibular areas as patient clenches and grinds teeth
Corneal Reflex:
Tease out bit of cotton from q-tip - Sensory CN 5, Motor CN 7
Blink when touch cornea with cotton wisp

67. Thyroid Anatomy

68. Observe (obvious abnormalities, trachea)
From front or behind Identify landmarks (touch and vision)
Palpate as patient swallows (drinking water helps)
? Focal or symmetric enlargement, nodules.

69. (CN 11 – Spinal Accessory)
Neck Movement
(CN 11 – Spinal Accessory)
Turn head to L into R hand function of R Sternocleidomastoid (SCM)
Turn head to R into L hand (L SCM)
Shrug shoulders into your hands