Practical ENT

Examination of the Ears, Nose, Throat, and Neck

Dr. Saad Y. Sulaiman

Examination of the Ear

1) Introduction 2) Position the patient 3) Inspection 4) Palpation 5) Otoscopic examination 6) Microscopic examination 7) Assessment of tympanic membrane mobility 7) Tuning fork tests 8) Assessment of balance and examination of cranial nerves

Examination of the Ear

1) Introduce yourself to the patient Any deafness? Communication 2) Position the patient At the same level In chair Can walk around patient

Examination of the Ear

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

Post auricular scar INDICATION: 1-Tympanoplasty 2-mastoid surgery 3-resection of benign parotid gland tuomr. Benefit : cosmetic.
Discharging ear Cuases: 1-wax 2-otitis media 3-otits externa 4-mastoiditis 5-F.B. in the ear

Preauricular sinus Cause:congenital Tx:no Tx unless infected(AB, surgery)

Auricular haematoma Causes: 1-trauma 2-bleeding tendency 3-infection. 4-allergic skin diseases Tx:complete surgical evacuation of the subperichondrial blood and prevent its recurrance MAIN complication : cauliflower ear

Cauliflower ear Due to repeated trauma and haematoma Tx : COSMETIC SURGERY

Auricular ulcer – squamous cell CA

Acute mastoiditis Causes: untreated acute otitis media(commonest) + trauma Tx : Medical:long term Ab. Surgical : 1-tympanostomy tube . 2-mastoidectomy Complications : 1-subperiosteal abscess 2-skin fistula 3-hearing loss 4- 7 palsy 5-meningitis 6-brain abscess

Rt. Acute mastoiditis: the Rt. pinna pushed foreword and downward

Postauricular Hearing aid or behind the ear ( BTE )

BAHA: Bone Anchored Hearing Aid

Palpation 1. palpation of the pinna ( tragal tenderness) 2. Lymph nodes( Preauricular, postauricular and upper deep cervical) 3. Palpation of mastoid process


Examination of the Ear
Inspect the external auditory meatus Pull pinna upwards, outwards and backwards In infants downwards and backwards In children pull backwards Otorrhoea and otomycosis Wax Canal stenosis Exostoses and osteomas


Examination of the external ear by use of aural speculum and head light or mirror ( the pinna is pulled upward and backward)

Wax Conductive hearing loss

Otomycosis Just 2 organisms cause it : 1-candida albicans 2-aspergillus nigra

Otitis Externa

Foreign body in the ear

Examination of the Ear

Otoscopic examination The lateral process and handle of the malleus lie towards the centre of the tympanic membrane Four quadrants Perforation Central or marginal Attic perforation What can be seen through it



Otoscope ( Auroscope)
The device was first described and illustrated in France in 1363 by Guy de Chauliac

The auroscope magnification is 1.5-2.0 times

Sometimes we use microscope to examine the ear ( its magnification is 6-20 times) Uses: 1-detailed examination of the ear(magnified up to 6-20 times) 2-certain surgical operations 3-biopsy

Normal Tympanic membrane: Colour Mobile Anatomical land marks

Congested tympanic membrane with loss of cone of light Dx: acute otitis media

Congested tympanic membrane with loss of cone of light Dx: acute otitis media

Tympanic membrane perforations
Causes : 1-trauma 2-infection 3-iatrogenic(medical mistakes) Safe (Central) Unsafe (Marginal and Attic perforations)
Central Perforation



Traumatic Perforation

cholesteatoma

Otitis media with effusion Eustachian tube dysfunction(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

Examination of the Ear

Assessment of tympanic membrane mobility Valsava manover Seigle pneumatic speculum Politzerization
Causes of fixed tympanic membrane: fluid behind the membrane , fibrosis and perforation

Examination of the Ear

Assessment of Hearing 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.


Clinical tests of hearing: Finger friction test; rubbing the thumb and finger close to the ear.2) Watch test;.. by clicking watch …..3) Speech ( voice ) test;… conversation voice ,,,,distance of 6 meters.4) Tuning fork tests

Tuning fork test

Examination of the Ear
Tuning fork tests Traditionally 512Hz Rinne and Weber (they were both German) Help differentiate between conductive and sensorineual hearing loss

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.

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

Examination of the nose
1) Introduce yourself 2) Position patient 3) Inspect the external nose 4) Inspect the nasal tip, vestibule, and nasal airways 5) Palpation and Percussion
6) Anterior rhinoscopy 7) Post nasal space examination



Examination of the nose
1) Introduce yourself Any hyponasal speech (rhinolalia clausa )?

Examination of the nose

2) Position the patient Head-mirror or headlight?

Examination of the nose

3) Inspect the external nose Compare nose to rest of face Size and shape Skin Swelling, bruising, ulcers

الصورة الاولىBanana nose=deviated nose :1-trauma2-septal deviationالصورة الثانيةSaddle nose :HOT SALT(septal haematoma _operation_trauma_syphilis_septal abscess_leprosy_TB)الصورة الثالثةHigh arched nose=roman nose: CongenitalTrauma

Ulcer

Ulcer

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

Examination of the nose

4) Examine the nasal tip, vestibule, and assess the nasal airways Nasal tip Nostrils and air flow Mist test

Elevation of nasal tip

Septal haematoma

Mist Test For airway patency

Palpation and Percussion

Examination of the nose

5) Anterior rhinoscopyThudichum’s speculum, Killian speculum, otoscope?Obvious lesionsMucosaSeptumTurbinates (and osteomeatal complex)

Handling of Thudichum’s nasal speculum

Polyp

Examination of the nose

7) Post nasal space examination With mirror ( nasopharyngeal mirror) Rigid endoscope Flexible endoscope

Examination of the throat

1) Introduce yourself 2) Position the patient 3) Assess speech 4) Oral examination
5) Indirect laryngoscopy 6) Examine the neck

Examination of the throat

1) Introduce yourself 2) Position the patient Headlamp, mirror or other light source Seated in chair with space to examine from all sides 3) Assess speech Stridor Hoarseness Any other dysphonia

Examination of the throat

4) Oral examinationLips, perioral lesions1 or 2 tongue depressors Inspect tongue, buccal mucosa and oropharynxSalivary duct orifacesSay ‘Ahhh’Finger examination of floor of mouth, cheeks

Peri-oral eczema

Angular stomatitis: Iron d. anemia Vit. B. deficiency Bacterial Fungal Contact dermatitis
Herpes labialis
حسب موقع الصور السابقة

The orifice of sublingual duct of Brtholine

Using gauze to dry the area and watching the flow by pressing above Stenson’s duct is a good indicator of salivary flow. Parotid gland orifice



Antrochoanal polyp

Acute follicular tonsilitis

Membranous tonsilitis Ddx: Diphtheria Fungi IMN Vincent angina Mention 2 Ix: 1-WBC count 2-throat swab

Post-tonsillectomy

Peritonsillar abscess

Examination of the throat

6) Indirect laryngoscopy With mirror or nasendoscope Can assess the base of the tongue, vallecula, Epiglottis, false and true vocal cords. Look for abnormality in the mucosa ( e.g. congestion , mass, vocal cord nodule>>>) Check vocal cord mobility by asking the patient to say (EEE)

The mirror is warmed before examination to avoid fogging

Examination of the throat
7) Examination of neck Head and neck cancers metastasise to neck nodes and to the lungs Tonsillar infections are the commonest cause of enlarged lymph nodes

Examination of the neck

1) Skin 2) Swallow 3) Examine from behind #Lymph nodes in the anterior and posterior triangle #Thyroid gland # Laryngeal skeleton #Position of trachea

Examination of the neck

1) Skin Skin lesions Ulceration Scars and wounds Stoma Obvious large masses

Examination of the neck

2) Swallow Larynx should rise A goitre may rise, too

Examination of the neck

3) Examine from behind Let patient know what you are doing Tender areas Gentle One side at a time

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