ENT ExaminationENT Examination

Dr Sudhakar VaidyaDr Sudhakar Vaidya

Common SymptomsCommon Symptoms

Otalgia – ear painOtalgia – ear pain Ottorhoea – dischargeOttorhoea – discharge Hearing lossHearing loss TinnitusTinnitus Vertigo Vertigo

OtalgiaOtalgia

From ear:From ear:• TraumaTrauma• TumourTumour• Acute otitis externa / mediaAcute otitis externa / media• Herpes Zoster infection (Ramsey-Hunt syndrome)Herpes Zoster infection (Ramsey-Hunt syndrome)

Referred pain:Referred pain:• NoseNose• SinusesSinuses• MouthMouth• TMJTMJ• Pre/post auriculat LNsPre/post auriculat LNs• C-spineC-spine

OtorrhoeaOtorrhoea

3 types of discharge3 types of discharge MucopurulentMucopurulent

• Perforation of TM & infection from middle earPerforation of TM & infection from middle ear SerousSerous

• CSF (trauma of temporal bone)CSF (trauma of temporal bone) BloodyBloody

• TraumaTrauma• MalignancyMalignancy

Hearing lossHearing loss

2 types2 types ConductiveConductive

• Problem in outer / middle earProblem in outer / middle ear• Speech retainedSpeech retained• Improves with amplification of sound Improves with amplification of sound

SensorineuralSensorineural• Problem in inner ear / CNVIII (vestibulocochlear)Problem in inner ear / CNVIII (vestibulocochlear)• Speech impairedSpeech impaired• ‘‘recruitment’ – small degrees of amplification may cause recruitment’ – small degrees of amplification may cause

unpleasant distortion due to damage of hair cells of cochleaunpleasant distortion due to damage of hair cells of cochlea PresbyacusisPresbyacusis Progressive gradual hearing loss related to ageingProgressive gradual hearing loss related to ageing

VertigoVertigo

IntermittentIntermittent• Vestibular originVestibular origin• Associated with nausea & vomitingAssociated with nausea & vomiting

ConstantConstant• Central originCentral origin

Examination of the earExamination of the ear

Wash handsWash hands Introduce yourselfIntroduce yourself Confirm pt name / ageConfirm pt name / age Explain what you would like to doExplain what you would like to do Obtain consentObtain consent

QuestionsQuestions

Have you had any change in your hearing Have you had any change in your hearing recently?recently?

Do you hear any funny noises?Do you hear any funny noises? Have you had any discharge?Have you had any discharge? Have you got any pain in your ear?Have you got any pain in your ear? Have you had any problems with balancing Have you had any problems with balancing

/ do you ever feel the room is spinning / do you ever feel the room is spinning around?around?

InspectionInspection PinnaPinna

• ShapeShape• SizeSize• DeformityDeformity• Compare with other sideCompare with other side

Behind earBehind ear• ScarsScars• Hearing aid – ask to removeHearing aid – ask to remove

MeatusMeatus• Size – if very wide suggests previous mastoid surgerySize – if very wide suggests previous mastoid surgery• DischargeDischarge• Colour change of skinColour change of skin

PalpationPalpation

Gently pull on pinnaGently pull on pinna If tender may indicate EAM infectionIf tender may indicate EAM infection

AuriscopyAuriscopy

Use largest speculum that will fit in EAMUse largest speculum that will fit in EAM• Make sure you change speculum at start of Make sure you change speculum at start of

station & between examining L & R earsstation & between examining L & R ears• Explain what you’d like to doExplain what you’d like to do• Use the ‘pen grip’Use the ‘pen grip’• R hand & R ear / L hand & L earR hand & R ear / L hand & L ear• Pull pinna up & back (straightens EAM)Pull pinna up & back (straightens EAM)

The normal viewThe normal view

Annulus fibrosus

UmboL-R

Handle of malleus

Pars flaccida (attic)

Comment on:Comment on: Tympanic membraneTympanic membrane

• Cone of Light (light reflex)Cone of Light (light reflex)• EffusionEffusion• Redness of TMRedness of TM• Perforation Perforation

EAMEAM• WaxWax• Foreign bodiesForeign bodies• InfectionInfection

Testing hearingTesting hearing Whispered voice testWhispered voice test

• Explain what you are going to do & assess if they can Explain what you are going to do & assess if they can hear youhear you

• 15cm away from pt15cm away from pt• Rub tragus of opposite earRub tragus of opposite ear• Whisper a number & ask pt what it wasWhisper a number & ask pt what it was

Weber’s testWeber’s test• Place a vibrating 512Hz tuning fork on pt foreheadPlace a vibrating 512Hz tuning fork on pt forehead• Ask if sound is heard in the middle or to one sideAsk if sound is heard in the middle or to one side• If heard louder on LHS than RHS indicates conductive If heard louder on LHS than RHS indicates conductive

hearing loss on LHS hearing loss on LHS

Rinne’s testRinne’s test• Place vibrating 512Hz tuning fork against Place vibrating 512Hz tuning fork against

mastoid process then in front of ear mastoid process then in front of ear • Ask which is louderAsk which is louder• Rinne’s +ve when AC>BC i.e. normal / Rinne’s +ve when AC>BC i.e. normal /

complete sensorineural deafnesscomplete sensorineural deafness

Dix Hallpike’s positional test - Dix Hallpike’s positional test - vestibular functionvestibular function

Used in benign positional vertigoUsed in benign positional vertigo Explain procedure & to expect dizzinessExplain procedure & to expect dizziness

• Sit near to edge of couchSit near to edge of couch• Turn head to 45Turn head to 45° to left° to left• Lower head to 30° below horizontalLower head to 30° below horizontal• Ask pt to keep eyes open & report vertigoAsk pt to keep eyes open & report vertigo• Look for nystagmusLook for nystagmus

Repeat for right earRepeat for right ear

D-H cont…D-H cont…

In BPVIn BPV• 20sec latency before vertigo & nystagmus 20sec latency before vertigo & nystagmus • AdaptationAdaptation

↓ ↓ response if repeated immediatelyresponse if repeated immediately In central pathology:In central pathology:

• No latent period before nystagmusNo latent period before nystagmus• No adaptationNo adaptation• May not have vertigoMay not have vertigo

Test cerebellar function (say you would)Test cerebellar function (say you would)

To finish…To finish…

Thank the ptThank the pt Summarise your findingsSummarise your findings

Questions???Questions???

Nose & Sinus Nose & Sinus ExaminationExamination

Common SymptomsCommon Symptoms

Nasal obstructionNasal obstruction Nasal dischargeNasal discharge SneezingSneezing Disturbance of smellDisturbance of smell Nasal deformityNasal deformity Nasal painNasal pain

IntroductionIntroduction

Wash handsWash hands Introduce yourselfIntroduce yourself Confirm pt name / DOBConfirm pt name / DOB Explain what you would like to doExplain what you would like to do Obtain consentObtain consent

Questions to askQuestions to ask

Have you noticed any change in your Have you noticed any change in your sense of smell recently?sense of smell recently?

Have you had a discharge from your nose?Have you had a discharge from your nose? Have you got a blocked nose?Have you got a blocked nose? Have you got any pain in your nose?Have you got any pain in your nose?

InspectionInspection

NoseNose• DeformityDeformity• Skin changesSkin changes• Anterior naresAnterior nares

In children – press on tip of noseIn children – press on tip of nose In adults – use nasal speculumIn adults – use nasal speculum Discharge / bleeding / polypsDischarge / bleeding / polyps

• Nasal septumNasal septum Anterior end of inferior turbinate (on lateral wall of Anterior end of inferior turbinate (on lateral wall of

septum)septum) SinusesSinuses Periorbital swelling (sinus infection)Periorbital swelling (sinus infection)

PalpationPalpation

Nasal bonesNasal bones• Distinguish cartilagenous / bony deformityDistinguish cartilagenous / bony deformity

Block each nostril in turn & ask pt to Block each nostril in turn & ask pt to breathe in:breathe in:• Assess nasal obstructionAssess nasal obstruction

Press on sinusesPress on sinuses• Frontal – above eyebrowsFrontal – above eyebrows• Ethmoid – corner of eyesEthmoid – corner of eyes• Maxillary – cheek boneMaxillary – cheek bone

To finish…To finish…

For a more detailed examination:For a more detailed examination:• Endoscopy of nasal cavity & nasopharynxEndoscopy of nasal cavity & nasopharynx• Posterior rhinoscopy (posterior nasal space)Posterior rhinoscopy (posterior nasal space)

Thank patientThank patient Summarise findings to examinerSummarise findings to examiner

Questions???Questions???

Examination of the Examination of the Mouth & ThroatMouth & Throat

Common SymptomsCommon Symptoms

Mouth painMouth pain DysphoniaDysphonia DysphagiaDysphagia Odynophagia Odynophagia

• Pain on swallowingPain on swallowing Stridor Stridor

• Noise from narrowing of upper airwayNoise from narrowing of upper airway• Do not examine throat if stridor present – may induce Do not examine throat if stridor present – may induce

laryngospasm & total airway obstructionlaryngospasm & total airway obstruction LumpsLumps HallitosisHallitosis

• Bad breathBad breath

IntroductionIntroduction

Wash handsWash hands Introduce yourselfIntroduce yourself Confirm pt name / DOBConfirm pt name / DOB Explain what you would like to doExplain what you would like to do Obtain consentObtain consent

Questions to ask…Questions to ask…

Have you had difficulty swallowing?Have you had difficulty swallowing? Have you had any pain on swallowing?Have you had any pain on swallowing? Have you had a sore mouth / throat?Have you had a sore mouth / throat? Have you noticed a change in your voice Have you noticed a change in your voice

recently?recently?

InspectionInspection

Face & neckFace & neck• ScarsScars• LumpsLumps• Skin changesSkin changes• TraumaTrauma• DeformityDeformity

LipsLips MouthMouth

• Buccal mucosaBuccal mucosa• GumsGums• Teeth (take dentures out offer a pot)Teeth (take dentures out offer a pot)

TongueTongue• Inside mouth – anteior aspectInside mouth – anteior aspect• Ask pt to stick tongue outAsk pt to stick tongue out

Tests CNXII (hypoglossal)Tests CNXII (hypoglossal) Look at posterior & lateral aspect (common site for Look at posterior & lateral aspect (common site for

CA)CA)

• Ask pt to touch roof of mouth with tongueAsk pt to touch roof of mouth with tongue Look at inferior tongue & floor of mouthLook at inferior tongue & floor of mouth

Hard palateHard palate• CleftCleft• High arch e.g. Marfan’s syndromeHigh arch e.g. Marfan’s syndrome• telengectasiatelengectasia

Posterior oral cavityPosterior oral cavity• Ask pt to say ‘ahhh’ – use tongue depressorAsk pt to say ‘ahhh’ – use tongue depressor• Look at uvula – should rise (CNIX – Look at uvula – should rise (CNIX –

glossopharyngeal)glossopharyngeal)• Soft palateSoft palate

TonsilsTonsils

PalpationPalpation

If lesion presentIf lesion present• Put on glovesPut on gloves• 1 finger in mouth1 finger in mouth• 1 hand on cheek / jaw1 hand on cheek / jaw

Cervical lymph nodesCervical lymph nodes

To finish…To finish…

Thank ptThank pt Summarise findings Summarise findings

Questions???Questions???