Examination of Ear, Nose, Head, Neck and Throat

Dr.Vijay M.D

EquipmentsBasic Instruments

Ear specula

Nasal Specula

Tongue depressors

Indirect laryngoscopy mirrors

Posterior Rhinoscopy mirrors

Nasal and aural forceps.

Tuning forks, 512 Hz, 1024 Hz

Otoscope

Be familiar with gear

Examination of Ear

Structures of Ear

Examination “ begin with inspection and

palpation of the pinna (auricle) and structures surrounding the ear…”

Examining the External Structures of The Ear - Observation

Helix

Tragus

External Canal

Anti-Helix

Lobe

Mastoid

Note: Picture on L normal external ear; picture on R swollen external canal, narrowed by inflammation

Canal• Inspect pinna and concha

• Otoscopic examination

• Pull upwards, outwards and backwards

• Look for cavity,

Otitis externaOsteomasMastoid cavity

TM

•Look for malleus, incus

•Record abnormalities

Normal Tympanic Membrane

Umbo

Cone of Light

Short Process Malleus

Long Process Malleus Incus

NOSE Left Ear – Malleus points down and back

Pars flaccida

Long process incus

Handle of malleus

Umbo

Pars tensa

Canal wall

Perforations

Central perforation Marginal perforation

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)

Otoscopy

“grasp and retract the pinna backward and upward in adults and

downwards in infants…”

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

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!

Great Moments In The History of Hearing

Tuning Fork Test

Indication: Differentiate type of Hearing Loss

•Sensorineural Hearing Loss •Conductive Hearing Loss

Preparation

Tuning fork should be 512 Hz to 1024 Hz

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

Rinne TestTechnique

▫First: Bone 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

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"

Nose

Examination The nose can be examined in three parts:

Examination of the external nose

Anterior Rhinoscopy

Posterior Rhinoscopy.

Symptoms

Discharge

Sinus pain

Trauma

Frequent upper respiratory infections

Epistaxis

Allergies

Sense of smell

• 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

Paranasal Sinuses

Anterior Rhinoscopy1. Examination of the Vestibule

Look for:• Boil or Abcess• Ulcerations and abrasions• Excoriation because of discharge.

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

POSTERIOR RHINOSCOPY

Post Nasal Mirror:

It consists of a handle on which a small mirror is attached to shaft at an angle of 110.

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

• 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.

POSTERIOR RHINOSCOPY

Transillumination Test

• Dim the room lights.

• Place the lighted otoscopedirectly on the infraorbital rim (bone just below the eye).

• Ask the patient to open theirmouth and look for lightglowing through the mucosaof the upper mouth.

Oral Cavity

▫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

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.

Subjective Data

•Sores/lesions

•Sore throat

•Bleeding gums

•Toothache

•Dysphagia

•Altered taste

•Tobacco

•Self-care behaviors

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

Inspect uvula, palate, tonsils

Uvula looks like hanging pendant (if split in two= bifid)

Palate:anterior hard palate=whitishposterior soft palate = pinkish

Tonsils- graded by enlargement:1+ visible 2+ near uvula 3+ touching uvula 4+ touching together

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

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.

Two Types:

1.Indirect laryngoscopy - uses mirrors to examine the larynx and hypopharynx

2.Direct laryngoscopy - uses a special instrument (flexible or rigid scope)

Indirect LaryngoscopyTechnique

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

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

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

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

5. 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.

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

Indirect Laryngoscopy

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

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

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

What about the Dental?• Dental health has big implications:

– Nutrition (ability to eat)– Appearance

• Self esteem• Employability• Social acceptance

– Systemic diseaseendocarditis, ? other– Local problems:

• Pain, infection

• Profound lack of access to care

Neck, Throat, Thyroid

Neck

Salivary Glands

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

Lymph nodesI--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

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)

http://www.utdol.com/online/content/image.do?imageKey=onco_pix/lymph_8.htm&title=Lymph%20nodes%20head%20and%20neck

Lymph Node Examination

• Gently walk fingers along general regions– comparing R to L

Function CN 7 – Facial Nerve Facial Symmetry & Expression -

Precise Pattern of InervationL UMN

R UMN

R LMN -Forehead

R LMN – Face

L LMN -Forehead

L LMN -Face

CN 7 – Exam Observe facial symmetry

Wrinkle Forehead

Keep eyes closed against resistance

Smile, puff out cheeks Cute.. and symmetric!

Bell’s Palsy

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.

Patient can’t close L eye, wrinkle L forehead or raise L corner mouthL CN 7 Peripheral (i.e. LMN) Dysfunction

CN 5 - Trigeminal Sensation:

3 regions of face: Ophthalmic, Maxillary & Mandibular

Motor:Temporalis & Masseter muscles

Function of CN 5 – Trigeminal

Ophthalmic(V1)

Maxillary (V2)

Mandibular (V3)

Temporalis (clench teeth)

Masseter (move jaw side-side)

SensoryMotor

Corneal Reflex: Blink when cornea touched - Sensory CN 5, Motor CN 7

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

Thyroid Anatomy

• 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.

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