1. ENT Clinical methods ICM - 1

2. LEARNING OBJECTIVES To :
Gain understanding of basic components of the ear , nose and throat examination.
Learn about the basic tools that are used for the ear , nose and throat examination.

3. Patient encounter Hand hygiene & Introduce yourself to the patient
History taking:
Personal data
Patient complaint
Present history
Past history
Family history
Occupational history

4. Ear symptoms
Pain
Discharge
Hearing loss
Tinnitus
Vertigo

5. Nasal symptoms Nasal obstruction Nasal discharge Epistaxis Headache
Sneezing
Hyposmia / anosmia
Nasality problem

6. Oropharyngeal symptoms
Pain / soreness
Excess phlegm
Dysphagia
Lump feeling
Dry mouth
Bad odor
Bad taste
Snoring

7. Laryngeal symptoms
Change of voice
Cough
Choking
Stridor

8. Clinical examination Explain to the patient what you are going to do
Patient sits in a revolving chair facing doctor who also sits in a revolving chair

9. Basic instruments

10. Source of light
Torch
Lamp & mirror
Fiber-optic light

11. Otoscope

12. Tuning fork

13. Nasal specula

14. Tongue blades

15. Laryngeal mirror and postnasal mirror

16. Ear examination

17. Inspection
Palpation
Otoscopy
Tests with tuning forks

18. Inspection of the auricle

19. Behind the auricle

20. Mention the finds as per the name of the area of Pinna affected ; e. g
Mention the finds as per the name of the area of Pinna affected ; e.g., mass over lobule , ulcer over tragus etc

21. Preliminary inspection of External Auditory Canal

22. Otoscopy

23. Normal tympanic membrane

24. Rinne’s Test

26. Weber test
Wrap the tuning fork strongly on your palm and then press the butt of the instrument on the top of the patient's head in the midline and ask the patient where they hear the sound.

27. Normally, the sound is heard in the center of the head or equally in both ears.

28. Nose

30. Examination of the nose- inspection
Skin lesions
Swelling
Sinus
Bruising
Erythema
Ulceration

31. Examination of the nose- inspection
Frontal view
Side view
Basal view

32. Examination of the nose- inspection
Size in relation to the rest of the face
Deviation of bridge
Dorsum:
Convexity (hump)
Concavity (saddling) of the dorsum of the nose

33. Examination of the nose- inspection
Shape of the tip of nose
Pointed
bulbous

34. Shape of the columella and nostrils
short/ long columella
narrow/wide nostrils

35. Is septum midline or is there any deviation of the nasal septum?

36. Palpation of the nose
Press along the bridge of the nose with both index fingers feeling bony skeleton and skin thickness.
Press on the tip of the nose with one index finger to elicit tenderness

37. Inspection and palpation
Palpation of sinuses:
Frontal sinus: forehead and below eyebrow
Maxillary sinus: cheek ( canine fossa)
Ethmoids : in the inner canthus area

38. Nasal patency Ask the patient to exhale in front a shiny surface
(a cold metal tongue depressor)
Look for cloudiness due to condensation of water vapor

39. Anterior rhinoscopy
Hold the nasal speculum in the left hand in closed fashion and introduce it gently in skin lined nasal vestibule
Avoid contact with the sensitive septum and lateral nasal wall.

40. Anterior rhinoscopy Open the speculum gently in vestibule
Examine floor, medial wall and lateral wall.
Look for hyperemia/ discharge/ Little's area septal deviation/ perforation/ hypertrophic turbinates/ polyps
Roof of nose needs endoscopy

41. Posterior rhinoscopy

42. oro-pharyngeal Examination
Mouth
&
oro-pharyngeal Examination

43. Preparation
If patient is wearing artificial denture, give him paper towel to get it out so that gingival mucosa can be examined .

44. Inspection-Lips Note their color, any fissures, cracking, ulceration
or any mass.

45. Inspection-gums
Note color of gums (normally pink). There may be brown patches in dark races.
Look for black lines (in lead poisoning) and red swollen inter-dental papillae in gingivitis.

46. Inspection- oral vestibule
Make patient open his mouth.
Retract cheek mucosa with tongue depressor
Look for color, ulcers, white patches and nodules.

47. Inspection- oral vestibule
Look for opening of parotid duct (opposite crown of second upper molar).
Do massaging of the parotid gland and note flow of saliva from Stensen's duct.

48. Inspection-Roof of oral cavity
Look for any cleft, oro-nasal fistula, high arched palate, mass bony growth, or ulcer.

49. Inspection-Tongue
Ask patient to protrude his tongue out: inspect it for symmetry( a test for cranial nerve XII)
Note color and texture of dorsum of tongue

50. Inspection-Tongue
Note any white or reddened area, nodules or ulceration
Inspect sides, undersurface of tongue

51. Inspection-Floor of the mouth
Midline frenulum
Papillae of submandibular duct. Milk the gland and see the salivary flow

52. Palpation
Palpate any suspicious lesions especially in smokers and alcoholic individuals above 50 years of age.

53. Pharynx – inspection
Ask patient to open mouth without protruding the tongue.
Use a tongue depressor to get a good exposure of posterior pharyngeal wall - not so far that you induce gagging.

54. Pharynx- inspection
Inspect soft palate, anterior and posterior pillars, medial surface of tonsils.
Note congestion, exudates, swelling, ulceration and tonsillar enlargement/atrophy

55. Pharynx –inspection
Ask patient to say ah. Soft palate will rise which confirms intactness of vagus nerve.

56. Take-Home Points
Good lighting , right tools and Thorough exam is essential .