Year 2 MBChB

Clinical Skills Session

Ear (including Otoscopy) Nose and Throat

Reviewed & ratified by:

Dr V Taylor-Jones, Consultant Anaesthetist

Mr W Aucott, Consultant ENT Surgeon

Aug 2018

Learning objectives

To understand the anatomy and physiology of the ear

To be able to inspect the the external ear

To understand the basic use of an otoscope and be able to identify the structures in your partner's ear

To be able to recognise common abnormalities in the ear

Theory and Background

Indications for Otoscopy

There are a number of reasons for performing otoscopy, these include, but are not limited to, pain - otalgia,

vertigo, foreign body, tinnitus, swelling, deafness, trauma and discharge - otorrhoea.

Anatomy of the ear

The ear is divided anatomically and clinically into the external, middle and inner ear. The external ear consists of a

cartilaginous and a bony part (see diagram below).

Use the following diagram to identify the malleus, incus, stapes, cochlea, semi-circular canals, cochlear nerve and

auditory nerve.

Procedure

For examinations we think; inspection, palpation, percussion and auscultation.

With otoscopy we only carry out inspection and

palpation.

There is no set order, but remember that you need to

inspect the external and inner ear and the ear canal /

tympanic membrane and also palpate around the ear,

for areas of tenderness and for lymph nodes (especially

pre and post auricular nodes- see lymph node study

guide). Palpation can be carried out prior to using the

otoscope or at the end of inspection, as long as you

remember to do it. Inspect the size, shape and

symmetry of the pinna, comparing with the other ear.

Observe the ear and around the ear for any ulcers, lumps, scars or areas of tenderness or if the patient has hearing

aids. Remember to examine the posterior aspect of the ear, the sulcus (the grove behind the ear) and mastoid. On

inspection of the external meatus there may be evidence of discharge, which could be blood or pus indicating

possible trauma or infection. Additionally the area may be swollen or there may be notable masses present. Inspect

the ear canal, which you will be viewing through an appropriate sized speculum. You should use the largest sized

speculum that fits comfortably into the patient’s ear. Examine the canal wall and look for discharge / debris, note

any swelling or masses and if there is any wax present. Foreign bodies such as peas or Play Doh may be found in

children’s ears, whereas the tips of cotton buds may be found in adults ears.

To examine the ear with an otoscope, the patient should be positioned with their head flexed laterally away from

the examiner. The external auditory canal, which may have a bend in, normally restricts the examiners view of the

pinna, this needs to be gently pulled upwards and backwards to straighten the canal. This should be done with the

hand not holding the otoscope. If a patient has a painful ear or is

presenting with a history of otorrhoea, then examine the ‘good’ ear

first.

The otoscope is held in the same hand as the ear being examined and should be held, horizontally, like a pen (see

image below) as this provides a secure cradle for the instrument. The curled fingers can rest against the patient’s

cheek so the handle will not catch the shoulder (as it may if held vertically)

additionally this position will help protect against accidentally

going too deep if the patient moves.

Inspection of the tympanic membrane

Identify the normal structures of the tympanic membrane to see if there is any significant variation in appearance.

Observe the colour and shape checking for perforations or scars. Check the ossicles (if visible) and observe for the

presence of the light reflex (cone of light), a distortion of the cone of light could be a sign of increased inner ear

pressure. Finally check to see if there is any fluid behind the tympanic membrane, sometimes made more

noticeable due to the presence of air bubbles, a fluid line or ballooning of the membrane. Change the speculum

prior to inspecting the patient’s other ear.

Some inner ear abnormalities

Purulent otorrhoea

Purulent otorrhoea is an ear discharge draining from the ear. There are a number of possible causes of this

including water exposure, use of ear plugs, hearing aids or cotton buds. It may be difficult to view the tympanic

membrane due to the discharge.

Right Ear – you can determine which ear it is by the direction of the light reflex and lateral process, in this case they are both pointing to the right so it is the patients’ right ear.

Cone of Light (reflex)

Erythematous Tympanic Membrane

As the name suggests this is an inflamed ear drum. This can be caused by otitis media (middle ear infection).

Remember to document and report your findings in the patient records.

Finally, how did you get on working out the anatomy of the ear?

Nasal Examination

External Inspection

Nose

Shape - Look from the sides & above, is there any;

o Abnormal Nasal Creases

o Deviation

o Scars

o Discharge or crusting

o Redness or skin disease

o Offensive odour (from the patient)

Internal Inspection

Inspect the front of the nose first by tipping the nose up and

inspecting without a speculum.

You can insert a big otoscope speculum as

far as the nasal hairs go or use a Thudichum

or Kilian speculum and a light. Don’t touch

the septum; it’s very sensitive.

You should be able to identify the septum

medially and the inferior turbinates laterally.

Internal Inspection contd.

Picture attributed to Dr A. Tomlinson, California

Sinus Centers,

https://www.youtube.com/watch?v=aP2oYudd

4Qk

Accessed March 2018

Internal inspection should also cover;

o Mucosa: is there any swelling, redness or oedema (rhinitis)

o Septum: straight or deviated.

o Masses (or foreign bodies in a child.)

o Mouth: polyps (abnormal growth of tissue projecting from a mucous membrane) or tumours may hang into

the pharynx or grow through the palate.

o Polyps are grey / yellow whereas turbinates are normally pink

o Oedematous turbinates can look like polyps (e.g. in hay fever when inflamed) but polyps are not sensitive

to touch whereas turbinates are exquisitely so.

Permission kindly granted by Surgical Holdings UK to use above

images 2018

Polyps

Palpation

Gently palpate as appropriate;

o As stated above turbinates are sensitive to touch.

Nasal Airway Assessment

o Cover one nostril and ask the patient to sniff. This gives a reasonable idea of nasal airway and sounds wet if

there is discharge.

o Airway patency is very subjective; even flow meter readings often don’t match patient scoring.

Throat Examination

Take a clear history;

o Enquire on general history

- Sore throat, food sticking, visible lesions +/- causing pain.

o Ask about alcohol & tobacco habits.

o Ask about their dental history.

Throat Symptoms

What symptoms does the patient have?;

o Sore throat / spots on tonsils (i.e. pus in crypts. Crypts serve to increase the surface area of the tonsils &

are part of the immune system.)

o Food sticking or regurgitation.

o Masses or ulcers and are these painful?

o Voice changes

o Ask about alcohol & tobacco habits.

o N.B. Dental history eg; facial swelling or glands in the neck.

Inspection

o Inspect the lips. Note pallor, angular stomatitis and asymmetry

vermillion border

maxillary labial frenum

gingivae

mucogingival line

o Retract the lips with the teeth partly closed. Examine the gums (with and without any dentures) note

gingivitis (inflammation of the gums), ulcers (eroded patches of tissue), missing teeth, dental carries.

o Note the buccal mucosa of the cheeks. The Parotid duct

opens behind the 2nd molar.

o Ask the patient to lift their tongue. If the tip can touch the

roof of the mouth and the vermillion border (outer edge of

lips) there is no tongue tie. (Ankyloglosia.)

o Inspect the floor of the mouth to beyond the last molar;

use a speculum against the cheek & one to hold the tongue

across.

o Note oral hydration, halitosis,

o Note ulcers or masses

o Use a bright light. With the tongue out: inspect the tonsils,

uvula and soft palate. Ask for head up to inspect the palate.

o Only use a tongue depressor if the view isn’t adequate.

Children often show their epiglottis!

o Any further examination of the larynx requires specialised equipment.

Consider neurological examination:

o Lips; VII – stroke, ear disease, parotid

o Tongue XI – motor neurone disease, malignant otitis externa

o Sensation – V, IX, Cauda Equina

Palpation

Palpate associated lymph nodes.

Document

Document all findings clearly and ensure all abnormalities reported to your supervisor.

Glossary

o Angular stomatitis- inflammation at the angles of mouth, with possible cracking or scaling, causes

are multi-factorial.

o Ankyloglosia – Tongue tie

o Anosmia – loss of smell

o Leucoplakia – white patches on tongue

o Ossicles – Incus, Stapes and malleolus

o Otalgia – pain in ear

o Otorrhoea – discharge in ear

o Polyp – small growth, often benign, originating in mucous membrane

o Post nasal discharge – catarrh

o Rhinitis – Inflammation of the mucous membrane inside the nose, also known as coryza.

o Rhinorrhoea – runny nose

o Septum – a partition separating 2 chambers, such as between the nostrils.

o Speculum – latin word for “mirror” a medical device inserted into a body passage to facilitate

visualisation or inspection.

o Sternutation – sneezing

o Tinnitus – ringing or buzzing in the ears

o Turbinate – shell shaped network of bones, vessels and tissue in the nasal passageway.