ENT Clinical skillENT Clinical skill dr. Reno Hardoyo kelan Sp dr. Reno Hardoyo kelan Sp

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EXAMINATION OF THE EXAMINATION OF THE PATIENTPATIENT

In order to In order to examine the ear, examine the ear, nose and throat of nose and throat of the patient one the patient one needs a good needs a good source of light and source of light and specialized specialized instruments.instruments.

Light Source: Light Source: Head light. Head light.

Instruments:Instruments: Ear specula,Ear specula, Nasal Specula,Nasal Specula, Tongue depressors,Tongue depressors, Indirect laryngoscopy mirrors,Indirect laryngoscopy mirrors, Posterior Rhinoscopy mirrors,Posterior Rhinoscopy mirrors, spirit lamp,spirit lamp, Jobson-Horne ear probes,Jobson-Horne ear probes, Nasal and aural forceps.Nasal and aural forceps. Barany's noise box,Barany's noise box, Seigle's speculum,Seigle's speculum, Tuning forks, 512 Hz, 1024 Hz,Tuning forks, 512 Hz, 1024 Hz, Otoscope.Otoscope.

Seat of patient: Seat of patient: Revolving stools, both for the patient Revolving stools, both for the patient

and the examiner.and the examiner. The patient sits on The patient sits on the stool at the same level as the doctor. the stool at the same level as the doctor.

Patient's legs should be to one side of Patient's legs should be to one side of the examiner. the examiner.

The distance between the doctor and The distance between the doctor and patient should not be more than 8 patient should not be more than 8 inches. inches.

EXAMINATION OF THE EXAMINATION OF THE EAREAR

Examination of the ear includes : Examination of the ear includes : 1. Pinna,1. Pinna, 2. External auditory meatus,2. External auditory meatus, 3. Tympanic membrane,3. Tympanic membrane, 4. Middle ear,4. Middle ear, 5. Tests for the function of Eustachian tube,5. Tests for the function of Eustachian tube, 6. Tests of hearing, 6. Tests of hearing, 7. Tests of balance,7. Tests of balance, 8. Eyes.8. Eyes. 9. Post aural area (Mastoid process), and 9. Post aural area (Mastoid process), and

lymph nodes.lymph nodes.

Examination of the Pinna:Examination of the Pinna:

Shape, Shape, Size, Size, Symmetry, Symmetry, Signs of Signs of

inflammation, inflammation, Ulcers. Ulcers.

Note the condition of the canal skin, Note the condition of the canal skin, and the presence of wax, foreign and the presence of wax, foreign tissue, or discharge. The mobility of tissue, or discharge. The mobility of the eardrum can be evaluated using the eardrum can be evaluated using a pneumatic speculum, which a pneumatic speculum, which attaches to the otoscope. The drum attaches to the otoscope. The drum should move on squeezing the should move on squeezing the balloon.balloon.

Pre aurikuler Pre aurikuler pit/sinuspit/sinus

Pre aurikuler tagPre aurikuler tag

Mikrotia Mikrotia Atresia liang Atresia liang

telingatelinga

MastoiditisMastoiditis

Fistel MastoidFistel Mastoid

SerumenSerumen

Otits eksternaOtits eksterna

Eksostosis liang telingaEksostosis liang telinga

OtomikosisOtomikosis

Benda asing liang Benda asing liang telingatelinga

OTOSCOPY:OTOSCOPY:

Methods:Methods: Electric Otoscope: It consists of Electric Otoscope: It consists of

a speculum, handle and a a speculum, handle and a magnifying attachment (1.5-2 magnifying attachment (1.5-2 x). x).

Technique:Technique: The pinna is pulled The pinna is pulled

upwards, backwards and upwards, backwards and outwards. outwards.

The speculum of The speculum of appropriate size is appropriate size is introduced along the axis of introduced along the axis of the meatus with a rotating the meatus with a rotating motion using the left hand motion using the left hand for the right ear and the for the right ear and the right hand for the left ear. right hand for the left ear. The wall of the bony meatus The wall of the bony meatus must not be irritated as it is must not be irritated as it is very sensitivevery sensitive. .

OTOSCOPY:OTOSCOPY:

One hand is left free for One hand is left free for instrumentation. instrumentation.

In infants and young In infants and young children the pinna is children the pinna is pulled downwards and pulled downwards and backwards to backwards to straighten the meatus. straighten the meatus.

Wax and other debris Wax and other debris must be removed for must be removed for adequate examination. adequate examination.

Mistakes:Mistakes: A speculum that is too A speculum that is too

narrow will penetrate narrow will penetrate the bony EAM.the bony EAM.

A speculum that is too A speculum that is too large will not enter large will not enter the cartilaginous the cartilaginous meatus.meatus.

Unsatisfactory Unsatisfactory cleaning of the debris cleaning of the debris will hinder view.will hinder view.

Tympanic membrane: (Using naked eye, Tympanic membrane: (Using naked eye, otoscope, and otomicroscope)otoscope, and otomicroscope)

Position, Position, Colour: Hemorrhage, Colour: Hemorrhage,

dullness, blue, bullae dullness, blue, bullae Ossicles Ossicles Perforations: Marginal Perforations: Marginal

and Central, site, size. and Central, site, size. Mobility: (Retractions) Mobility: (Retractions)

by using a pneumatic by using a pneumatic otoscope, or Siegle's otoscope, or Siegle's speculum. speculum.

Middle ear:Middle ear:

Can be examined Can be examined through a through a perforation. Look perforation. Look at the colour of at the colour of mucosa, edema, mucosa, edema, discharge, polyps, discharge, polyps, promontory. promontory.

Membran timpani normalMembran timpani normal

Otitis media serosaOtitis media serosa

Om serosa dg Om serosa dg ventilating tubeventilating tube

Timpano sklerosisTimpano sklerosis

kolesteatomakolesteatoma

Glomus tumor Glomus tumor telinga tengahtelinga tengah

Omsk benigna (tenang)Omsk benigna (tenang)

Omsk malignaOmsk maligna

Tests for Eustachian tube Tests for Eustachian tube functionsfunctions

Qualitative Methods:Qualitative Methods: i] Valsalva Maneuver: i] Valsalva Maneuver:

Principle:Principle: Demonstration Demonstration of tubal patency without of tubal patency without external aids.external aids.

Method:Method: After taking a After taking a deep breath, the patient deep breath, the patient pinches his nose and pinches his nose and closes his mouth in an closes his mouth in an attempt to blow air in his attempt to blow air in his ears. Otoscopy shows ears. Otoscopy shows movement of the drum. movement of the drum. Auscultation reveals Auscultation reveals crackling.crackling.

Tests for Eustachian tube Tests for Eustachian tube functionsfunctions

Qualitative Methods:Qualitative Methods: i] Valsalva Maneuver: i] Valsalva Maneuver:

Note:Note: Failure of this test Failure of this test does not prove pathologic does not prove pathologic occlusion of the tube.occlusion of the tube.

This maneuver in the This maneuver in the presence of nasal and presence of nasal and nasopharyngeal infection nasopharyngeal infection carries the danger of carries the danger of transmission of infection transmission of infection to the ear.to the ear.

Tests for Eustachian tube Tests for Eustachian tube functionsfunctions

ii]Toynbee's test: ii]Toynbee's test: Principle:Principle: It is safer It is safer

and confirms normal and confirms normal tubal function.tubal function.

Method:Method: The nose is The nose is closed and the patient closed and the patient swallows. There is in swallows. There is in drawing of the drawing of the tympanic membrane, tympanic membrane, confirmed by otoscopy confirmed by otoscopy and on auscultation and on auscultation when a noise is heard.when a noise is heard.

Quantitative Quantitative Methods:Methods:

Acoustic Acoustic impedance impedance Tympanometry.Tympanometry.

Tests of Hearing:Tests of Hearing:

- - This requires a quiet room of about 6 m This requires a quiet room of about 6 m long since noise and poor acoustic properties long since noise and poor acoustic properties such as a narrow room with smooth walls such as a narrow room with smooth walls produce echoes which falsify the results.produce echoes which falsify the results.

- Each ear is tested separately.- Each ear is tested separately. - The better ear is tested first.- The better ear is tested first. (for tunning fork test : The opposite ear is masked by a (for tunning fork test : The opposite ear is masked by a

moist plug of cotton pressed into the EAM moved in and moist plug of cotton pressed into the EAM moved in and out. (Wagener's vibration method of masking). In cases of out. (Wagener's vibration method of masking). In cases of severe unilateral deafness Barany's noise box has to be severe unilateral deafness Barany's noise box has to be used.)used.)

[I] Whisper test:[I] Whisper test: Two syllable words are articulated at a Two syllable words are articulated at a

decreasing distance from the patient until these decreasing distance from the patient until these words can be clearly repeatedwords can be clearly repeated

[II] Tuning Fork tests:[II] Tuning Fork tests: (A C1 fork of 512 Hz is used).(A C1 fork of 512 Hz is used). i) Weber's test:i) Weber's test: Principle:Principle: It is dependent on binaural It is dependent on binaural

comparison of bone conduction.comparison of bone conduction. Method:Method: - The tuning fork is placed in the - The tuning fork is placed in the

center of skull at the hairline.center of skull at the hairline. - The patient with normal - The patient with normal

hearing will hear equally in both hearing will hear equally in both ears.ears.

- The patient with a unilateral - The patient with a unilateral conductive hearing loss localizes conductive hearing loss localizes the tone in the diseased ear.the tone in the diseased ear.

- The patient with a unilateral - The patient with a unilateral sensorineural loss will localize to sensorineural loss will localize to the healthy ear.the healthy ear.

ii) Rinne's test:ii) Rinne's test: Principle:Principle: This test rests on monaural This test rests on monaural

comparison to bone conduction.comparison to bone conduction. Method:Method: The patient can tested in two ways; The patient can tested in two ways;

i) Duration, ii) Intensity.i) Duration, ii) Intensity. The patient is asked whether the The patient is asked whether the

tuning fork placed in front of the tuning fork placed in front of the ear or behind the ear on the ear or behind the ear on the mastoid is heard better.mastoid is heard better.

Results:Results: - If air conduction is better than - If air conduction is better than

bone conduction, Rinne's test is bone conduction, Rinne's test is positive. This is the finding in positive. This is the finding in normal ear and in sensorineural normal ear and in sensorineural deafness.deafness.

- If bone conduction is better than - If bone conduction is better than air conduction, Rinne's test is air conduction, Rinne's test is negative. This is found in negative. This is found in conductive deafness.conductive deafness.

iii) Schwabach's test:iii) Schwabach's test: Depends on comparison of the bone Depends on comparison of the bone

conduction of the patient with that of the conduction of the patient with that of the examiner.examiner.

iv) Bing test:iv) Bing test: Increased loudness for Increased loudness for

bone conducted sound less bone conducted sound less than 2 kHz, occurs in the than 2 kHz, occurs in the normal or sensorineural normal or sensorineural deafness when the EAM is deafness when the EAM is occluded without occluded without increasing the pressure increasing the pressure ( As the masking effect of ( As the masking effect of air conducting sound is air conducting sound is removed). There is no removed). There is no change in conductive change in conductive deafness.deafness.

Tests for non-organic hearing loss:Tests for non-organic hearing loss:

Stenger test:Stenger test: Principle:Principle: If sounds of If sounds of identical frequency identical frequency but but different intensity different intensity are are

presented simultaneously to each ear, only louder sound will be presented simultaneously to each ear, only louder sound will be perceived.perceived.

The test can be performed with tuning forks or a n audiometer.The test can be performed with tuning forks or a n audiometer. Method:Method: - The examiner - The examiner stands behind stands behind the patient. the patient. - A tuning fork is struck and is held 20 cm from the good ear - the - A tuning fork is struck and is held 20 cm from the good ear - the

patient hears the sound.patient hears the sound. - The fork is then removed and placed 5 cm from the bad ear - patient - The fork is then removed and placed 5 cm from the bad ear - patient

'denies' hearing sound.'denies' hearing sound. - Another fork is the held 15 cm from the good ear without the patient - Another fork is the held 15 cm from the good ear without the patient

noticing.noticing. - If there is genuine hearing loss patient will the fork in the good ear.- If there is genuine hearing loss patient will the fork in the good ear. - But if there is non-organic loss the patient will be unable to hear the - But if there is non-organic loss the patient will be unable to hear the

fork in the good ear as the fork is closer in his 'bad' ear.fork in the good ear as the fork is closer in his 'bad' ear.

Tests for non-organic hearing loss:Tests for non-organic hearing loss:

Chimani-Moos test:Chimani-Moos test: - - Modification of Weber. When the fork is placed Modification of Weber. When the fork is placed

on the vertex, the patient indicates that he is on the vertex, the patient indicates that he is hearing the fork in the good ear and not in the hearing the fork in the good ear and not in the deaf ear.deaf ear.

- The meatus of the good ear is then blocked .- The meatus of the good ear is then blocked . - A genuine deaf patient will still lateralize the - A genuine deaf patient will still lateralize the

sound to the good ear, the malingerer will sound to the good ear, the malingerer will usually deny hearing any sound at all.usually deny hearing any sound at all.

Hearing testsHearing tests

Hearing testsHearing tests Whispered speech test. Whispered speech test. Your GP will whisper a combination of Your GP will whisper a combination of

numbers and letters behind you and check if you can hear anything numbers and letters behind you and check if you can hear anything by asking you to repeat the combination. Your GP will probably move by asking you to repeat the combination. Your GP will probably move further away from you each time to test the range of your hearing. further away from you each time to test the range of your hearing.

Tuning fork testTuning fork test. Different tuning forks can be used to test your . Different tuning forks can be used to test your hearing at a variety of frequencies. They can also help determine the hearing at a variety of frequencies. They can also help determine the type of hearing loss. type of hearing loss.

Pure tone audiometryPure tone audiometry. An audiometer produces sounds of different . An audiometer produces sounds of different volumes and frequencies. During the test, you're asked to indicate volumes and frequencies. During the test, you're asked to indicate when you hear a sound in the headphones. The level at which you when you hear a sound in the headphones. The level at which you can't hear a sound of a certain frequency is known as your threshold. can't hear a sound of a certain frequency is known as your threshold.

If your hearing loss has a sensorineural cause, a number of tests can If your hearing loss has a sensorineural cause, a number of tests can be performed to pinpoint where the problem lies. be performed to pinpoint where the problem lies.

Otoacoustic emissionsOtoacoustic emissions. This is used to measure your cochlear . This is used to measure your cochlear function by recording signals produced by the hair cells. function by recording signals produced by the hair cells.

Auditory brainstem responseAuditory brainstem response. This measures the activity of the . This measures the activity of the cochlea, auditory nerve and brain when a sound is heard. cochlea, auditory nerve and brain when a sound is heard.

Tests of BalanceTests of Balance Romberg testRomberg test Method:Method: - Patient stands upright - Patient stands upright

with the feet parallel and with the feet parallel and close together, eyes closed close together, eyes closed ,and the arms folded in ,and the arms folded in front of the chest or front of the chest or outstretched.outstretched.

Results:Results: - Unilateral peripheral - Unilateral peripheral

lesion or a unilateral lesion or a unilateral cerebellar lesion, the cerebellar lesion, the patient tends to sway patient tends to sway towards the affected side.towards the affected side.

- Central lesions give - Central lesions give irregular pattern of sway.irregular pattern of sway.

Unterberger's Stepping Unterberger's Stepping testtest

Method:Method: Stepping on one spot with Stepping on one spot with

the eyes closed.the eyes closed. Result:Result: Peripheral lesions- rotation Peripheral lesions- rotation

of the body axis to the side of the body axis to the side of the labyrinthine lesion.of the labyrinthine lesion.

Central disorders- the Central disorders- the deviation is irregular.deviation is irregular.

Deviations of greater than Deviations of greater than 40 degree are significant40 degree are significant

Finger-nose Finger-nose pointing test:pointing test:

Method:Method: The index finger The index finger of the outstretched hand of the outstretched hand is brought to the point o is brought to the point o the nose with the eyes the nose with the eyes closed.closed.

ResultResult: Ataxia and : Ataxia and disorders of coordination disorders of coordination indicate an ipsilateral indicate an ipsilateral cerebellar lesion or a cerebellar lesion or a disorder of positional disorder of positional sense.sense.

Positional testing ( Dix - Positional testing ( Dix - Halpike method).Halpike method).

Principle: Principle: - Screening test for - Screening test for

Positional nystagmus.Positional nystagmus. - Nystagmus induced or - Nystagmus induced or

aggravated by this test is aggravated by this test is attributable to cervical attributable to cervical proprioceptors and proprioceptors and vertebral artery vertebral artery compression.compression.

Positional testing ( Dix - Positional testing ( Dix - Halpike method).Halpike method).

Method: Method: (With the head in different (With the head in different

positions).positions). - The head is firmly grasped - The head is firmly grasped

with the patient sitting on a with the patient sitting on a couch.couch.

- The patients head is rotated - The patients head is rotated 45 to one side and then the 45 to one side and then the other while he is made to other while he is made to assume the supine position assume the supine position with the head hanging 30 with the head hanging 30 below the edge of the table. below the edge of the table. The head is kept in this The head is kept in this position for some time.position for some time.

- The eyes should be - The eyes should be observed for nystagmus.observed for nystagmus.

Examination of the noseExamination of the nose

The nose can be The nose can be examined in three examined in three parts:parts:

1. Examination of 1. Examination of the external nose,the external nose,

2. Anterior 2. Anterior Rhinoscopy,Rhinoscopy,

3. Posterior 3. Posterior Rhinoscopy.Rhinoscopy.

Examination of the External Examination of the External Nose: Nose:

Inspection: Inspection: Congenital Congenital

deformities: Clefts, deformities: Clefts, sinuses. sinuses.

Acquired Deformities, Acquired Deformities, Shape, Shape, Swelling, Swelling,

( Inflammatory, cysts, ( Inflammatory, cysts, tumors) tumors)

Ulceration ( Trauma, Ulceration ( Trauma, neoplastic, infective). neoplastic, infective).

Palpation:Palpation: It is carried for; It is carried for; tenderness, tenderness, crepitus, and crepitus, and deformities. deformities. Tenderness over the Tenderness over the

tip is due to a boil. tip is due to a boil. Over the dorsum is Over the dorsum is due to trauma.due to trauma.

Loss of smell (anosmia) Loss of smell (anosmia) is a relatively is a relatively common problem, though often undiagnosed. In common problem, though often undiagnosed. In patients who make mention of this problem, patients who make mention of this problem, olfaction can be crudely assessed using an olfaction can be crudely assessed using an alcohol pad sniff test as follows:alcohol pad sniff test as follows: Ask the patient to close their eyes so that they Ask the patient to close their eyes so that they

don't get any visual cues. don't get any visual cues. Occlude each nostril seqeuentially, making Occlude each nostril seqeuentially, making

sure that they can move air adequately thru sure that they can move air adequately thru both. both.

Occlude one nostril and then present an Occlude one nostril and then present an alcohol pad to the other side, asking the alcohol pad to the other side, asking the patient to inform you when they are able to patient to inform you when they are able to detect its smell. detect its smell.

to detect the odor of the alcohol pad at a to detect the odor of the alcohol pad at a distance of 10 cm. Alcohol is used for distance of 10 cm. Alcohol is used for convenience, as most exam rooms have convenience, as most exam rooms have these pads. More sophisticated testing these pads. More sophisticated testing can be done using vials containing very can be done using vials containing very distinctive odors (e.g. coffee grounds 0distinctive odors (e.g. coffee grounds 0

The NoseThe Nose First check to see if the patient is able to First check to see if the patient is able to

breathe through either nostril effectively. breathe through either nostril effectively. Push on one nostril until it is occluded and Push on one nostril until it is occluded and

have them inhale. Then repeat on the other have them inhale. Then repeat on the other side. Air should move equally well through side. Air should move equally well through each nares. each nares.

To look in the nose, have the patient tilt their To look in the nose, have the patient tilt their head back. Push up slightly on the tip of the head back. Push up slightly on the tip of the nose with the thumb of your left hand. Place nose with the thumb of your left hand. Place the end of the speculum into the nares under the end of the speculum into the nares under direct vision. Now look through the viewing direct vision. Now look through the viewing windowwindow

Anterior RhinoscopyAnterior Rhinoscopy:: It consists of the following steps:It consists of the following steps: 1. Examination of the vestibule (Skin lined 1. Examination of the vestibule (Skin lined

part of the nares),part of the nares), 2. Examination of the nasal cavity using 2. Examination of the nasal cavity using

the Thudichum's speculum,the Thudichum's speculum, 3. Patency tests,3. Patency tests, 4. Probe test,4. Probe test, 5. Examination after vasoconstriction.5. Examination after vasoconstriction.

Examination of the vestibule:Examination of the vestibule: This is carried out by tilting the tip of This is carried out by tilting the tip of The lining which is skin and has all the The lining which is skin and has all the

dermal appendages (Hair, sebaceous dermal appendages (Hair, sebaceous glands etc.). All the diseases affecting glands etc.). All the diseases affecting these adnexa can occur in the vestibule. these adnexa can occur in the vestibule.

Ulceration may be neoplastic, infective. Ulceration may be neoplastic, infective. Excoriation because of discharge. Excoriation because of discharge.

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

Nasal speculum:Nasal speculum: It is an inverted 'U' shaped instrument. It It is an inverted 'U' shaped instrument. It

has two blades at the lower end.has two blades at the lower end.

Method of holding the instrument:Method of holding the instrument: Hold it in the left hand keeping the right hand Hold it in the left hand keeping the right hand

free for other instruments. free for other instruments. Pick the instrument with the thumb and the index Pick the instrument with the thumb and the index

finger of the L hand with the blades directed finger of the L hand with the blades directed towards the elbow. towards the elbow.

The loop is directed downwards. The loop is directed downwards. Pronate the forearm and flex the wrist there by Pronate the forearm and flex the wrist there by

aligning the blades with the nares. aligning the blades with the nares. The legs of the speculum are controlled by the The legs of the speculum are controlled by the

middle and the ring fingers. middle and the ring fingers.

Use of the speculum:Use of the speculum: The axis of the anterior nares is upwards The axis of the anterior nares is upwards

and backwards, whereas that of the and backwards, whereas that of the posterior nares is horizontally backwards. posterior nares is horizontally backwards. Lift the tip of the nose with the blades so Lift the tip of the nose with the blades so that the two axes are in straight line that the two axes are in straight line

Introduce the speculum with the blades Introduce the speculum with the blades closed.. closed..

Introduce the speculum in an upwards and Introduce the speculum in an upwards and backwards direction. backwards direction.

Once inside the nose, gradually open the Once inside the nose, gradually open the blades avoiding discomfort to the patient. blades avoiding discomfort to the patient.

Look at roof, floor, lateral and medial Look at roof, floor, lateral and medial walls of the nose. walls of the nose.

Septum: Position, spurs, deviation, colour Septum: Position, spurs, deviation, colour of mucosa, ulcers, crusting, vessels, and of mucosa, ulcers, crusting, vessels, and perforations. perforations.

Lateral wall: Inferior and middle Lateral wall: Inferior and middle turbinates, size ,colour, shape. turbinates, size ,colour, shape.

noting:noting: The color of the mucosa. It The color of the mucosa. It

can become quite reddened can become quite reddened in the setting of infection. in the setting of infection.

The presence of any The presence of any discharge as well as its color discharge as well as its color (clear with allergic (clear with allergic reactions; yellowish with reactions; yellowish with infection). infection).

The middle and inferior The middle and inferior turbinates, which are shelf-turbinates, which are shelf-like projections along the like projections along the lateral wall. Any polypoid lateral wall. Any polypoid growths, which may be growths, which may be associated with allergies and associated with allergies and obstructive symptoms? obstructive symptoms?

The other nostril is examined The other nostril is examined in a similar manner. in a similar manner.

Meatii for pus and discharge, and polyps. Meatii for pus and discharge, and polyps. Middle meatus is situated higher up so tilt Middle meatus is situated higher up so tilt

the head backwards at an angle of 45. If the head backwards at an angle of 45. If any growth or polyp is suspected confirm any growth or polyp is suspected confirm by the probe test. by the probe test.

Probe test: Probe test: It is carried out by spraying the nose with It is carried out by spraying the nose with

4% Lignocaine with 1:100000 adrenaline 4% Lignocaine with 1:100000 adrenaline or 10% cocaine. or 10% cocaine.

The lesion or area is palpated to The lesion or area is palpated to determine its character and mobility. determine its character and mobility.

Patency test: Patency test: By placing a cold tongue depressor or a By placing a cold tongue depressor or a

wick of cotton below the nostril, nasal wick of cotton below the nostril, nasal patency can be assessed. patency can be assessed.

Compare the two sides alwaysCompare the two sides always. .

Anterior Rhinoscopy with Anterior Rhinoscopy with endoscopeendoscope

Posterior Rhinoscopy:Posterior Rhinoscopy: It is carried out to examine the post nasal space It is carried out to examine the post nasal space

(nasopharynx). It is a difficult space to examine (nasopharynx). It is a difficult space to examine so the disease may be hidden for quite a long so the disease may be hidden for quite a long time. Different methods of examining the area time. Different methods of examining the area are;are;

i. Post nasal mirror.i. Post nasal mirror. ii. Nasopharyngoscope.ii. Nasopharyngoscope. iii. Examination under anaesthesia after palatal iii. Examination under anaesthesia after palatal

retraction.retraction. iv. Digital palpation.iv. Digital palpation. v. Radiological examination.v. Radiological examination.

Symptomatology of lesions of the Symptomatology of lesions of the nasopharynxnasopharynx::

Nasal obstruction Nasal obstruction Post nasal drip Post nasal drip Bleeding. Should be taken seriously as it Bleeding. Should be taken seriously as it

may be due to a tumor. may be due to a tumor. Pain Pain Aural symptoms of deafness, discharge, Aural symptoms of deafness, discharge,

and blockage. and blockage.

Method of Posterior Method of Posterior RhinoscopyRhinoscopy

Post Nasal Mirror: Post Nasal Mirror: it consists of a handle on which a it consists of a handle on which a

small mirror is attached to shaft at small mirror is attached to shaft at an angle of 110. There is another an angle of 110. There is another angulation in the shaft.angulation in the shaft.

Technique: Technique: Hold the mirror like a pen in the right hand. Hold the mirror like a pen in the right hand. Warm the mirror slightly on the flame of the Warm the mirror slightly on the flame of the

spirit lamp to avoid condensation from the spirit lamp to avoid condensation from the expired air. expired air.

Ask the patient to open the mouth. Ask the patient to open the mouth. Take the tongue depressor in the left hand Take the tongue depressor in the left hand

and depress the anterior 2/3rds of the tongue. and depress the anterior 2/3rds of the tongue. Feel the warmth of the mirror on the back of Feel the warmth of the mirror on the back of

the wrist. It should not be hot. the wrist. It should not be hot.

Introduce the mirror Introduce the mirror from the angle of the from the angle of the mouth over the tongue mouth over the tongue depressor and slide it depressor and slide it behind the uvula. Avoid behind the uvula. Avoid touching the posterior touching the posterior wall of the pharynx as wall of the pharynx as it may trigger gagging. it may trigger gagging.

Instruct the patient to Instruct the patient to breath through the breath through the nose. nose.

Tilt the mirror in Tilt the mirror in different direction tot different direction tot see various structures see various structures of the nasopharynx. of the nasopharynx.

Digital palpationDigital palpation

Posterior Rhinoscopy with Posterior Rhinoscopy with endoscopeendoscope

EXAMINATION OF THE EXAMINATION OF THE THROATTHROAT

The throat consists of the ; oral The throat consists of the ; oral cavity ,and the oropharynxcavity ,and the oropharynx

ORAL CAVITYORAL CAVITY It includes the It includes the

following structures: following structures: Lips Lips Teeth Teeth Gums Gums Tongue Tongue Hard and soft palates, Hard and soft palates, Floor, Floor, Cheeks. Cheeks.

OROPHARYNXOROPHARYNX It includes the It includes the

following structures:following structures: Uvula, Uvula, Soft palate, Soft palate, Anterior and posterior Anterior and posterior

tonsillar pillars, tonsillar pillars, Tonsils, Tonsils, Posterior pharyngeal Posterior pharyngeal

wallwall..

Lips: Common site for Lips: Common site for carcinoma, herpes and carcinoma, herpes and primary syphilis. primary syphilis.

Teeth and gums: Bleeding Teeth and gums: Bleeding from gums, state of from gums, state of dentition, foul discharge dentition, foul discharge from a tooth, sensations. from a tooth, sensations.

Tongue: It includes the Tongue: It includes the anterior 2/3rds, anterior 2/3rds, posterior 1/3rd, posterior 1/3rd, tip. tip. dorsum and dorsum and the margins. the margins.

Check for:Check for: Tongue:Tongue: common and taste common and taste

sensations, sensations, size: Macroglossia in size: Macroglossia in

acromegaly, Down's acromegaly, Down's syndrome. syndrome.

ulcers: Traumatic, ulcers: Traumatic, dental, apthous, dental, apthous, malignant, malignant, tuberculous, syphilitic. tuberculous, syphilitic.

movements: Restricted in hypoglossal movements: Restricted in hypoglossal palsies, tumor infiltration. palsies, tumor infiltration.

fasciculation: Motor neuron disease, fasciculation: Motor neuron disease, depapillation: Vitamin deficiencies, depapillation: Vitamin deficiencies, furrowing , as in geographic tongue furrowing , as in geographic tongue coating: Thrush, black hairy tongue. coating: Thrush, black hairy tongue. Hypoglossal palsy: Tongue deviates Hypoglossal palsy: Tongue deviates

towards the lesion. towards the lesion.

Cheeks: Parotid duct Cheeks: Parotid duct opening Opposite opening Opposite upper 2nd molar), red upper 2nd molar), red or white patches, or white patches, ulcers, moisture. ulcers, moisture.

Palate: Swelling, ulcer, Palate: Swelling, ulcer, movement, movement, perforations, clefts etc. perforations, clefts etc.

Uvula: Position, Uvula: Position, deviations (Towards deviations (Towards the normal side in the normal side in palsies), ulcers. palsies), ulcers.

Tonsillar pillars: Linear congestion, ulcers, Tonsillar pillars: Linear congestion, ulcers, patches. patches.

Tonsils: Presence, size, crypts, ulcers, express Tonsils: Presence, size, crypts, ulcers, express the contents of the crypts by pressing on the the contents of the crypts by pressing on the pillars to see whether purulent. pillars to see whether purulent.

Posterior pharyngeal wall: Lymphoid follicles, Posterior pharyngeal wall: Lymphoid follicles, ulcers. ulcers.

Floor of mouth: Wharton duct openings, ulcers, Floor of mouth: Wharton duct openings, ulcers, and bimanual palpation. and bimanual palpation.

Teeth and occlusion Teeth and occlusion The upper and lower vestibule of the cheek. The upper and lower vestibule of the cheek.

Tonsillar gradingTonsillar grading T0 = sdh dilakukan tonsilektomiT0 = sdh dilakukan tonsilektomi T1 = tonsil sdh melewati pillar T1 = tonsil sdh melewati pillar

anterioranterior T2 = tonsil sdh melewati pillar T2 = tonsil sdh melewati pillar

anterior dan posterioranterior dan posterior T3 = tonsil sdh T3 = tonsil sdh

mendekati/mencapai garis tengahmendekati/mencapai garis tengaho T0 = tonsil masih dalam fossa T0 = tonsil masih dalam fossa

tonsilertonsilero T1 = tonsil <dr 25% jarak uvula-T1 = tonsil <dr 25% jarak uvula-

pillar anteriorpillar anterioro T2 = tonsil 25%-50% jarak uvula-T2 = tonsil 25%-50% jarak uvula-

pillar anteriorpillar anterioro T3 = tonsil 50%-75% jarak uvula-T3 = tonsil 50%-75% jarak uvula-

pillar anterior pillar anterior o T4 = tonsil >75% jarak uvula-T4 = tonsil >75% jarak uvula-

pillar anterior pillar anterior

INDIRECT INDIRECT LARYNGOSCOPY:LARYNGOSCOPY:

The mirror is plane, on a The mirror is plane, on a straight handle. straight handle.

Mirror is held like a pen in Mirror is held like a pen in the right hand with the the right hand with the glass pointing downwards. glass pointing downwards.

Warm the mirror and test Warm the mirror and test the temperature on the the temperature on the back of the hand. back of the hand.

The patient is asked to stick The patient is asked to stick out the tongue which is out the tongue which is held with a piece of gauzeheld with a piece of gauze. .

The patient is asked to The patient is asked to breath through the breath through the mouth. mouth.

The mirror is The mirror is introduced into the introduced into the mouth to the uvula mouth to the uvula which is gently which is gently pushed back to get a pushed back to get a view of the larynx and view of the larynx and the pyriform fossae. the pyriform fossae.

The patient is asked to The patient is asked to say 'Aaa' and 'Eee'.say 'Aaa' and 'Eee'.

Direct laryngoscopyDirect laryngoscopy

Examination of the Neck forms an Examination of the Neck forms an integral part of examination of the integral part of examination of the

larynx.larynx. Inspection:Inspection: Position, shape, thyroid Position, shape, thyroid

angle, movement with swallowing, angle, movement with swallowing, retraction of the suprasternal notch retraction of the suprasternal notch on inspiration.on inspiration.

Palpation:Palpation: Cartilages for Cartilages for irregularity, scars, tenderness, irregularity, scars, tenderness, subcutaneous emphysema, laryngeal subcutaneous emphysema, laryngeal crepitus.crepitus.

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