ENT Clinical methods ICM - 1

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.

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

Ear symptoms Pain Discharge Hearing loss Tinnitus Vertigo

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

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

Laryngeal symptoms Change of voice Cough Choking Stridor

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

Basic instruments

Source of light Torch Lamp & mirror Fiber-optic light

Otoscope

Tuning fork

Nasal specula

Tongue blades

Laryngeal mirror and postnasal mirror

Ear examination

Inspection Palpation Otoscopy Tests with tuning forks

Inspection of the auricle

Behind the auricle

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

Preliminary inspection of External Auditory Canal

Otoscopy

Normal tympanic membrane

Rinne’s Test

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.

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

Nose

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

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

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

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

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

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

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

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

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

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.

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

Posterior rhinoscopy

oro-pharyngeal Examination Mouth & oro-pharyngeal Examination

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

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

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.

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

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.

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

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

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

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

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

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.

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

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

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