Practical ENT pdf - كتابة الطلاب

Fifth stage

ENT

ملي

كتابة الطالب

د.سعد

7/12/2015

ENT = Ear Nose Throat

ORL = otorhinolaryngology

1- The Ear:

Symptoms of the ear:



Pain:

o  Primary or secondary.
o  Otogenic (caused be otitis media for example).
o  Non-otogenic (cause be problems in the tooth, glossopharyngeal nerve, C2 and C3,

maxillary division of trigeminal nerve, temporomandibular joint, cervical spine).



Discharge:

o Mucus: due to perforated tympanic membrane.
o Serious: due to otitis externa or perforated tympanic membrane.



Hearing loss.



Tinnitus.



Vertigo.

Note: anything cause hearing loss could lead to tinnitus.

Examination of the ear:



Introduce yourself to the patient:

o Check hearing function, Any deafness?
o Communication



Position the patient:

o  At the same level
o  In chair
o  Can walk around patient



Inspect the pinna

o  Front and behind
o  Skin condition
o  Lesions
o  Scars
o  Pre-auricular area (common place for sinus)
o  Condition of cartilage

Findings in inspection of the pinna

Photos

Post auricular scar
Indications:
1-Tympanoplasty
2-mastoid surgery (mastoidectomy)
3-resection of benign parotid gland tumor

Benefit: cosmetic.

Discharging ear
Causes:
1-wax
2-otitis media
3-otits externa
4-mastoiditis
5-F.B. in the ear

Preauricular sinus
Cause: congenital.
Treatment: no treatment unless infected 
antibiotics or surgery.
Could convert to fistula (discharge) or
abscess (closed).

Auricular hematoma
Causes:
1-trauma
2-bleeding tendency
3-infection.
4-allergic skin diseases
Treatment: complete surgical evacuation of
the subperichondrial blood and prevent its
recurrence.
It need drainage  if not  deformity of
the ear.
Main complication: cauliflower ear.

Cauliflower ear
Due to repeated trauma and hematoma
Common in boxers.
Treatment: cosmetic surgery.

Auricular ulcer
Occur in squamous cell carcinoma

Acute mastoiditis
Causes: untreated acute otitis
media(commonest) + trauma
Medical treatment: long term antibiotics.
Surgical treatment:
1-tympanostomy tube.
2-mastoidectomy.
Complications:
1-subperiosteal abscess 2-skin fistula
3-hearing loss

4-facial palsy

5-meningitis 6-brain abscess

Right acute mastoiditis
The right pinna pushed forward and
downward.

Postauricular Hearing aid
or
behind the ear (BTE)

BAHA: Bone Anchored Hearing Aid



Palpation:

o Tragal tenderness: due to otitis externa.
o Tenderness on mastoid bone: due to acute

mastoiditis.



Inspect the external auditory meatus:

o  Pull pinna upwards, outwards and backwards
o  In infants downwards and backwards
o  In children pull backwards
o  See: Otorrhoea, otomycosis, Wax, Canal stenosis, Exostoses, osteomas.



There are three methods of inspection of external auditory meatus:

1- Aural (ear) speculum:

o  It is unaided eye method:
o  Use head light or mirror.
o  The pinna is pulled upward and backward.

Findings:

o  Wax.
o  Otitis externa: red, pain, pus.
o  Otomycosis: due to candida albicans (white) or aspergillus niger (dots)  both

called wet newspaper.

o Foreign body: very severe irritation / put light or esperto or oil.

Wax,

Conductive hearing

loss

Otomycosis

Otitis Externa

Foreign body in the ear

2- Otoscope:

o  It is aided eye method.
o  Examine right ear with right hand.
o  Pull the pinna upward, outward and backward.
o  The auroscope magnification is 1.5-2.0 times.

3- Microscope:

o  It is aided eye method.
o  Its magnification is 6-20 times.
o  Uses:
o  1-detailed examination of the ear (magnified up

to 6-20 times)

o  2-certain surgical operations
o  3-biopsy
o  4-cleaning



Examination of the tympanic membrane:

o  Oval – pearly gray color.
o  There is handle of malleus.
o  There is cone of light  shatter  اختفاءthe cone

of light when the tympanic membrane is pulled
or pushed.

o Divided by two lines into 4 quadrants.



Tympanic membrane perforations:

o Causes :

1-trauma
2-infection
3-iatrogenic (medical mistakes)

Normal

tympanic

membrane

Congested tympanic membrane with loss of cone of light, redness and
pulging of the membrane

Dx: acute otitis media

Pain occur at night because there is no swallowing (eustachian tube is open)

o Types of perforation:

1- Safe (Central)  the perforation is surrounded by part of the tympanic
membrane.
2- Unsafe (Marginal and Attic perforations).

cholesteatoma

Otitis media with effusion 
Eustachian tube dysfunction is
the commonest cause

Myringotomy with insertion of Grommet
ventilation tube

-indication

1-CHRONIC O.M. with effusion (commonest in
child)

2-recuurent O.M.

3-Eustachian tube dysfunction with recurrent s and
s (commonest in adult)

4-recuurent episodes of barotrauma

Complication: blockage , otorrhea , chloesteatoma ,
tympanosclerosis

Tympanosclerosis

Precipitation of ca carbonate
after healing of repeated
perforation or myringotomy

Perforation of the tympanic membrane



Assessment of tympanic membrane mobility

o  Valsava manover (close mouth and nose and swallow)
o  Seigle pneumatic speculum (also used for magnification)
o  Politzerization (balloon in the nose and drink water)
o  Causes of fixed tympanic membrane  fluid behind the membrane (otitis media),

fibrosis, calcifications (tymeno-sclerosis), perforation.



Assessment of Hearing

o While assessing the auditory function it is important to find out:

  Type of hearing loss ( CHL, SNHL or mixed )
  Degree of hearing loss.
  Site of lesion.
  Cause of hearing loss.

o Causes of conductive hearing loss:

  Sclerosis of bone.
  Calcification of oval window.
  Fluid behind the membrane.

o Clinical tests of hearing:

  Finger friction test: rubbing the thumb and finger close to the ear.
  Watch test: by clicking watch.
  Speech (voice) test: conversation voice, distance of 6 meters.
  Tuning fork tests.

o Tuning fork tests:

  Traditionally 512Hz (   )االهتزاز أطول لهذا التردد
  Rinne and Weber (they were both German)
  Help differentiate between conductive and sensorineual

hearing loss

o Rinne`s test:

  Compare Air and Bone conduction in the same ear
  Normal subject = AC > BC (Rinne +ve)
  CHL = BC > AC (Rinne -ve)
  SNHL = AC > BC (Rinne +ve) and often the BC is not heard.
  False negative Rinne  in very severe SNHL.

o Weber test:

 In normal subjects the sound is heard in the midline or in both ears equally.

 In CHL the sound is heard in the affected ear (absence of environmental noise),

i.e.; lateralized toward the affected ear

 In SNHL the sound is heard in the non-affected ears.



Assessment of Balance ( Labyrinthine function)



Cranial nerves examination

=================================================================

2- The Nose:

Symptoms of the nose:



Discharge (rhinorrhea).



Epistaxis.



Obstruction or block  causes of nasal obstruction:

o  Vestibule: big boil.
o  Nasal cavity: turbinate hypertrophy, septal deviation, sinusitis, polyp.
o  Post-nasal space: tumor, adenoid hypertrophy (it is the most common cause of

nasal obstruction in children)



Nasal fetor:

o Unilateral offensive nasal discharge in children  foreign body.
o Unilateral offensive nasal discharge in adult  rhinolith, tumor, chronic infection.

Examination of the nose:



Introduce yourself

o Any hyponasal speech (rhinolalia clausa )?



Position the patient

o Head-mirror or headlight?



Inspect the external nose

o  Compare nose to rest of face
o  Size
o  Skin
o  Swelling, bruising, ulcers
o  Rhinophyma:

 Due to untreated rosacea (heavy alcohol aggravate it)
 Treatment: carbon dioxide laser or complete excision with skin graft)

o Shape 

  Banana nose=deviated nose  trauma, septal deviation.
  High arched nose=roman nose=prominent nose  Congenital, Trauma.
  Saddle nose  HOT SALT (septal haematoma

_operation_trauma_syphilis_septal abscess_leprosy_TB)



Examine the nasal tip, vestibule, and assess the nasal airways

o  Nasal tip  elevation of nasal tip to see the vestibule.
o  Nostrils and air flow
o  Mist test  For airway patency



Palpation and Percussion

Deviated nose

Saddle nose

Prominent nose

Ulcer

Rhinophyma

Elevation of nasal tip

Septal hematoma

Mist Test



Anterior rhinoscopy:

o Thudichum’s speculum, Killian speculum, otoscope?

  Obvious lesions
  Mucosa
  Septum
  Turbinates (and osteomeatal complex)

o Thudichum’s nasal speculum

 Used to examine the nasal cavity.
 See  septum, floor of nose, middle and inferior turbinate, middle meatus.

Polyp



Post nasal space examination:

o  With mirror ( nasopharyngeal mirror) (also use tongue depressor)
o  Rigid endoscope
o  Flexible endoscope

=================================================================

3- The Throat:

Symptoms of the throat:



Horsiness (don’t horsiness of the voice, but only horsiness).



Sore throat.



Dysphagia and odynophagia.



Cough.



Strider.

Examination of the throat:



Introduce yourself



Position the patient:

o Headlamp, mirror or other light source
o Seated in chair with space to examine from all sides



Assess speech:

o  Stridor
o  Hoarseness
o  Any other dysphonia



Oral examination

o  Lips, perioral lesions
o  1 or 2 tongue depressors
o  Inspect tongue, buccal mucosa and oropharynx
o  Salivary duct orifaces
o  Say ‘Ahhh’ (movement of soft palate) // Say 'Eeee' (movement of vocal cords)
o  Finger examination of floor of mouth, cheeks

Tongue depressor

Used for examination of oral cavity and oropharynx

Can use with nasopharyngeal mirror r to examine posterior
nasal space.

Herpes labialis

Peri-oral eczema

Angular stomatitis:



Iron d. anemia



Vit. B. deficiency



Bacterial



Fungal



Contact dermatitis

The orifice of sublingual duct of Brtholine



Indirect laryngoscopy

o With mirror or nasendoscope
o Can assess the base of the tongue, vallecula,

Epiglottis, false and true vocal cords.

o Look for abnormality in the mucosa ( e.g.

congestion , mass, vocal cord nodule>>>)

o Check vocal cord mobility by asking the patient

to say (EEE)

o The mirror is warmed before examination to

avoid fogging



Examination of neck

o Head and neck cancers metastasise to neck nodes and to the lungs
o Tonsillar infections are the commonest cause of enlarged lymph nodes

o  Skin  Skin lesions, Ulceration, Scars and wounds, Stoma, Obvious large masses.
o  Swallow  Larynx should rise, a goitre may rise, too.
o  Examine from behind  Let patient know what you are doing, Tender areas,

Gentle, One side at a time.

o  Lymph nodes in the anterior and posterior triangle
o  Thyroid gland
o  Laryngeal skeleton
o  Position of trachea

Parotid gland orifice

Using gauze to dry

the area and

watching the flow
by pressing above

Stenson’s duct is a

good indicator of

salivary flow.

Antrochoanal polyp

Acute follicular tonsilitis

Membranous tonsilitis

DDx:



Diphtheria



Fungi



IMN



Vincent angina

Mention 2 Ix:



WBC count



throat swab

Post-tonsillectomy

Peritonsillar abscess