Basic Physical Examination

Basic Physical Examination

in ENT Head and Neck
in ENT Head and Neck
Department of Otolaryngology
Department of Otolaryngology
Head and Neck Surgery
Head and Neck Surgery
St. Lukes Medical Center
St. Lukes Medical Center

EQUIPMENT
EQUIPMENT
1. 1.
Cair !it Head
Cair !it Head
rest
rest
". ".
Ligt Source
Ligt Source
#. #.
$nstrument
$nstrument
Ca%inet
Ca%inet

EQUIPMENT
EQUIPMENT
Head Mirror
Head Mirror
&
&
lea'es %ot ands
lea'es %ot ands
free for
free for
e(amination)
e(amination)
&
&
positioned o'er te
positioned o'er te
left eye and close
left eye and close
to te e(aminers
to te e(aminers
face)
face)

EQUIPMENT
EQUIPMENT
How to focus the head mirror How to focus the head mirror

*e patient sits on te stool at te same le'el as te doctor. *e patient sits on te stool at te same le'el as te doctor.

+atient,s legs sould %e to one side of te e(aminer. +atient,s legs sould %e to one side of te e(aminer.

*e distance %et!een te doctor and patient sould not %e *e distance %et!een te doctor and patient sould not %e
more tan - inces .Depending on te ma(imum focal lengt more tan - inces .Depending on te ma(imum focal lengt
of ead mirror/. of ead mirror/.

0i( te mirror on te left eye so tat part of te mirror touces 0i( te mirror on te left eye so tat part of te mirror touces
te nose. te nose.

1d2ust te mirror so tat you are seeing troug te ole. 1d2ust te mirror so tat you are seeing troug te ole.
Close te rigt eye and focus te mirror %y rotating it. Close te rigt eye and focus te mirror %y rotating it.

Open %ot te eyes. Open %ot te eyes.

EQUIPMENT
EQUIPMENT
Basic Instruments
Basic Instruments
#. #.
3ar specula
3ar specula
4. 4.
Nasal Specula
Nasal Specula
5. 5.
*ongue depressors
*ongue depressors
6. 6.
$ndirect laryngoscopy mirrors
$ndirect laryngoscopy mirrors
7. 7.
+osterior 8inoscopy mirrors
+osterior 8inoscopy mirrors
-. -.
Nasal and aural forceps.
Nasal and aural forceps.
9. 9.
*uning forks: 51" H;: 1<"4 H;
*uning forks: 51" H;: 1<"4 H;
1<. 1<.
Otoscope
Otoscope

EAR EXAM
EAR EXAM

EAR EXAM
EAR EXAM

EAR EXAM
EAR EXAM
&
&
%egin !it
%egin !it
inspection and
inspection and
palpation of te
palpation of te
pinna .auricle/ and
pinna .auricle/ and
structures
structures
surrounding te
surrounding te
ear=)
ear=)

OTO!OP"
OTO!OP"
Otoscopy is used to
Otoscopy is used to
'isuali;e te ear
'isuali;e te ear
canal>eardrum for
canal>eardrum for
te purpose of
te purpose of
detecting a%normal
detecting a%normal
conditions tat
conditions tat
migt re?uire
migt re?uire
furter e'aluation
furter e'aluation
or treatment.
or treatment.

OTO!OP"
OTO!OP"
&
&
grasp and retract
grasp and retract
te pinna %ack!ard
te pinna %ack!ard
and up!ard in
and up!ard in
adults and
adults and
do!n!ards in
do!n!ards in
infants=)
infants=)

OTO!OP"
OTO!OP"
@
1n A annulus fi%rosus 1n A annulus fi%rosus
@
Lpi .long process of incus/ A Lpi .long process of incus/ A
sometimes 'isi%le troug a ealty sometimes 'isi%le troug a ealty
translucent drum translucent drum
@
Cm .um%o/ A te end of te Cm .um%o/ A te end of te
malleus andle and te centre of te malleus andle and te centre of te
drum drum
@
Lr .ligt refle(/ A anteroAinferiorly Lr .ligt refle(/ A anteroAinferiorly
@
Lp .Lateral process of te malleus/ Lp .Lateral process of te malleus/
@
1t .1ttic/ also kno!n as pars 1t .1ttic/ also kno!n as pars
flaccida flaccida
@
Hm .andle of te malleus/ Hm .andle of te malleus/

PNEMATI! OTO!OP"
PNEMATI! OTO!OP"
Dallo!s te e(aminer to Dallo!s te e(aminer to
o%ser'e mo'ement of te o%ser'e mo'ement of te
tympanic mem%rane tympanic mem%rane
directlyD. D$f te tympanic directlyD. D$f te tympanic
mem%rane does not mo'e mem%rane does not mo'e
percepti%ly !it percepti%ly !it
applications of sligt applications of sligt
positi'e or negati'e positi'e or negati'e
pressure: a middle ear pressure: a middle ear
effusion is igly likelyD. effusion is igly likelyD.
.Eluestone and Flein: .Eluestone and Flein:
199</ 199</


PNEUMATI! OTO!OP"
PNEUMATI! OTO!OP"

TUNIN# $OR% TET
TUNIN# $OR% TET
Indication: Differentiate type of
Indication: Differentiate type of
Hearing Loss
Hearing Loss

Sensorineural
Sensorineural
Hearing Loss
Hearing Loss

Conducti'e Hearing Loss

Conducti'e Hearing Loss


TUNIN# $OR% TET
TUNIN# $OR% TET
Preparation
Preparation

*uning fork sould
*uning fork sould
%e 51" H; to 1<"4
%e 51" H; to 1<"4
H;
H;

&EBER TET
&EBER TET
*ecni?ueG *uning 0ork
*ecni?ueG *uning 0ork
placed at midline foreead
placed at midline foreead
NormalG Sound radiates to
NormalG Sound radiates to
%ot ears e?ually
%ot ears e?ually
1%normalG Sound laterali;es
1%normalG Sound laterali;es
to one ear
to one ear
@ $psilateral $psilateral
Conducti'e Hearing Loss Conducti'e Hearing Loss O8 O8
@ Contralateral Contralateral Sensorineural Sensorineural
Hearing Loss Hearing Loss

RINNE TET
RINNE TET
*ecni?ue
*ecni?ue
@
0irstG Eone Conduction
0irstG Eone Conduction
@
Hi%rating *uning 0ork eld on Hi%rating *uning 0ork eld on
Mastoid Mastoid
@
+atient co'ers opposite ear !it +atient co'ers opposite ear !it
and and
@
+atient signals !en sound ceases +atient signals !en sound ceases
@
Mo'e te 'i%rating tuning fork o'er Mo'e te 'i%rating tuning fork o'er
te ear canal . te ear canal .Near: %ut not Near: %ut not
toucing te ear/ toucing te ear/
@
Ne(tG 1ir Conduction
Ne(tG 1ir Conduction
+atient indicates !en te sound +atient indicates !en te sound
ceases ceases

RINNE TET
RINNE TET
NormalG 1ir Conduction is %etter tan
NormalG 1ir Conduction is %etter tan
Eone Conduction
Eone Conduction
1ir conduction usually persists t!ice as long as
1ir conduction usually persists t!ice as long as
%one
%one
8eferred to as Dpositi'e testD
8eferred to as Dpositi'e testD

1%normalG Eone conduction %etter
1%normalG Eone conduction %etter
tan air conduction
tan air conduction
Suggests
Suggests
Conducti'e Hearing Loss
Conducti'e Hearing Loss

8eferred to as Dnegati'e testD
8eferred to as Dnegati'e testD


Test for Eustachian Tube
Test for Eustachian Tube
Function
Function
1. Valsalva aneuver: 1. Valsalva aneuver:
ethod: ethod:
!fter ta"ing a deep #reath$ the patient pinches his nose and !fter ta"ing a deep #reath$ the patient pinches his nose and
closes his closes his mouth in an attempt to #low air in his ears. %toscopy mouth in an attempt to #low air in his ears. %toscopy
shows shows movement of the drum. movement of the drum.

&ote: 'ailure of this test does not prove pathologic occlusion of &ote: 'ailure of this test does not prove pathologic occlusion of
the tu#e. the tu#e.

(his maneuver in the presence of nasal and nasopharyngeal (his maneuver in the presence of nasal and nasopharyngeal
infection carries the danger of transmission of infection to the infection carries the danger of transmission of infection to the
ear. ear.
). (oyn#ee*s test: ). (oyn#ee*s test:
It is safer and confirms normal tu#al function. It is safer and confirms normal tu#al function.

ethod: (he nose is closed and the patient swallows. (here is in ethod: (he nose is closed and the patient swallows. (here is in
drawing of the tympanic mem#rane$ confirmed #y otoscopy. drawing of the tympanic mem#rane$ confirmed #y otoscopy.

NOE
NOE

EXAMINATION O$ THE NOE
EXAMINATION O$ THE NOE
*e nose can %e e(amined in tree
*e nose can %e e(amined in tree
partsG
partsG
#. #.
3(amination of te e(ternal nose
3(amination of te e(ternal nose
4. 4.
1nterior 8inoscopy
1nterior 8inoscopy
5. 5.
+osterior 8inoscopy.
+osterior 8inoscopy.

EXAMINATION O$ THE
EXAMINATION O$ THE
EXTERNA' NOE
EXTERNA' NOE
$nspectionG
$nspectionG
@
Congenital deformities .Clefts/
Congenital deformities .Clefts/
@
1c?uired Deformities
1c?uired Deformities
@
Sape
Sape
@
S!elling . $nflammatory: cysts: tumors/
S!elling . $nflammatory: cysts: tumors/
@
Clceration . *rauma: neoplastic: infecti'e/
Clceration . *rauma: neoplastic: infecti'e/
+alpationG
+alpationG
@
*enderness
*enderness
@
Crepitus
Crepitus
@
Deformities
Deformities

Ante(io( Rhinosco)y
Ante(io( Rhinosco)y
1. 1.
3(amination of te Hesti%ule
3(amination of te Hesti%ule
Look forG
Look forG

Eoil or 1%cess
Eoil or 1%cess

Clcerations and a%rasions

Clcerations and a%rasions

3(coriation %ecause of discarge.

3(coriation %ecause of discarge.

ANTERIOR RHINO!OP"
ANTERIOR RHINO!OP"
). ).
+,amination of
+,amination of
the nasal cavity
the nasal cavity
using a nasal
using a nasal
speculum:
speculum:

POTERIOR RHINO!OP"
POTERIOR RHINO!OP"
+ost Nasal MirrorG
+ost Nasal MirrorG
$t consists of a
$t consists of a
andle on !ic a
andle on !ic a
small mirror is
small mirror is
attaced to saft
attaced to saft
at an angle of 11<.
at an angle of 11<.

POTERIOR RHINO!OP"
POTERIOR RHINO!OP"
*ecni?ue *ecni?ue
". ". Hold te mirror like a pen in te rigt and. Hold te mirror like a pen in te rigt and.
4. 4. Iarm te mirror Iarm te mirror
6. 6. 1sk te patient to open te mout. 1sk te patient to open te mout.
-. -. Depress te anterior ">#rds of te tongue Depress te anterior ">#rds of te tongue
1<. 1<. 0eel te !armt of te mirror on te %ack of te !rist. $t sould 0eel te !armt of te mirror on te %ack of te !rist. $t sould
not %e ot. not %e ot.
1". 1". $ntroduce te mirror from te angle of te mout o'er te $ntroduce te mirror from te angle of te mout o'er te
tongue depressor and slide it %eind te u'ula. 1'oid toucing tongue depressor and slide it %eind te u'ula. 1'oid toucing
te posterior !all of te paryn( as it may trigger gagging. te posterior !all of te paryn( as it may trigger gagging.
14. 14. $nstruct te patient to %reat troug te nose. $nstruct te patient to %reat troug te nose.
16. 16. *ilt te mirror in different direction tot see 'arious structures of *ilt te mirror in different direction tot see 'arious structures of
te nasoparyn(. te nasoparyn(.

POTERIOR RHINO!OP"
POTERIOR RHINO!OP"

PARANAA' INUE
PARANAA' INUE

TRANI''UMINATION TET
TRANI''UMINATION TET
@
Dim te room ligts. Dim te room ligts.
@
+lace te ligted otoscope +lace te ligted otoscope
directly on te infraor%ital rim directly on te infraor%ital rim
.%one 2ust %elo! te eye/. .%one 2ust %elo! te eye/.

@
1sk te patient to open teir 1sk te patient to open teir
mout and look for ligt mout and look for ligt
glo!ing troug te mucosa glo!ing troug te mucosa
of te upper mout. of te upper mout.
+rincipleG $n te setting of +rincipleG $n te setting of
inflammation: te ma(illary inflammation: te ma(illary
sinus %ecomes fluid filled and sinus %ecomes fluid filled and
!ill not allo! tis !ill not allo! tis
transillumination. transillumination.

ORA' !A*IT"
ORA' !A*IT"

ORA' !A*IT"
ORA' !A*IT"
*ongue
*ongue
Ceck forG
Ceck forG

Common and taste sensations

Common and taste sensations

Si;eG Macroglossia in acromegaly:

Si;eG Macroglossia in acromegaly:
Do!n,s syndrome
Do!n,s syndrome

Clcers
Clcers

Mo'ementsG 8estricted in
Mo'ementsG 8estricted in
ypoglossal palsies: tumor
ypoglossal palsies: tumor
infiltration
infiltration

0asciculationG Motor neuron disease

0asciculationG Motor neuron disease

DepapillationG Hitamin deficiencies

DepapillationG Hitamin deficiencies

0urro!ing : as in geograpic tongue

0urro!ing : as in geograpic tongue

CoatingG *rus: %lack airy tongue

CoatingG *rus: %lack airy tongue

ORA' !A*IT"
ORA' !A*IT"
@
Euccal MucosaG +arotid duct opening Opposite
Euccal MucosaG +arotid duct opening Opposite
upper "nd molar/: red or !ite patces: ulcers:
upper "nd molar/: red or !ite patces: ulcers:
moisture
moisture
@
Hard +alateG S!elling: ulcer: perforations:
Hard +alateG S!elling: ulcer: perforations:
clefts etc.
clefts etc.
@
C'ulaG +osition: de'iations .*o!ards te
C'ulaG +osition: de'iations .*o!ards te
normal side in palsies/: ulcers
normal side in palsies/: ulcers
@
0loor of moutG Iarton duct openings: ulcers:
0loor of moutG Iarton duct openings: ulcers:
and %imanual palpation
and %imanual palpation

@
*eet and occlusion
*eet and occlusion

OROPHAR"NX
OROPHAR"NX
@
Soft +alateG S!elling: ulcer: Soft +alateG S!elling: ulcer:
mo'ement: perforations: mo'ement: perforations:
clefts etc. clefts etc.
@
C'ulaG +osition: de'iations C'ulaG +osition: de'iations
.*o!ards te normal side in .*o!ards te normal side in
palsies/: ulcers palsies/: ulcers

@
*onsillar pillarsG congestion: *onsillar pillarsG congestion:
ulcers: patces. ulcers: patces.
@
*onsilsG +resence: si;e: *onsilsG +resence: si;e:
crypts: ulcers crypts: ulcers
@
+osterior paryngeal !allG +osterior paryngeal !allG
Lympoid follicles: ulcers. Lympoid follicles: ulcers.

'AR"N#O!OP"
'AR"N#O!OP"
Definition
Definition
Hisual e(am of te 'oice %o( .laryn(/
Hisual e(am of te 'oice %o( .laryn(/
and te 'ocal cords.
and te 'ocal cords.
Laryngoscopy is also done to remo'e
Laryngoscopy is also done to remo'e
foreign o%2ects stuck in te troat.
foreign o%2ects stuck in te troat.

'AR"N#O!OP"
'AR"N#O!OP"
*ere are t!o main kindsG
*ere are t!o main kindsG
1.$ndirect laryngoscopy A uses mirrors
1.$ndirect laryngoscopy A uses mirrors
to e(amine te laryn( and
to e(amine te laryn( and
ypoparyn(
ypoparyn(
".Direct laryngoscopy A uses a special
".Direct laryngoscopy A uses a special
instrument .fle(i%le or rigid scope/
instrument .fle(i%le or rigid scope/

IN+IRE!T 'AR"N#O!OP"
IN+IRE!T 'AR"N#O!OP"
*ecni?ue *ecni?ue
#. #. Mirror is eld like a pen in te rigt and !it te glass Mirror is eld like a pen in te rigt and !it te glass
pointing do!n!ards. pointing do!n!ards.
5. 5. Iarm te mirror and test te temperature on te %ack of Iarm te mirror and test te temperature on te %ack of
te and. te and.
7. 7. *e patient is asked to stick out te tongue !ic is eld *e patient is asked to stick out te tongue !ic is eld
!it a piece of gau;e. !it a piece of gau;e.
9. 9. *e patient is asked to %reat troug te mout. *e patient is asked to %reat troug te mout.
11. 11. *e mirror is introduced into te mout to te u'ula !ic *e mirror is introduced into te mout to te u'ula !ic
is gently pused %ack to get a 'ie! of te laryn( and te is gently pused %ack to get a 'ie! of te laryn( and te
pyriform fossae. pyriform fossae.
1". 1". *e patient is asked to say ,1aa, and ,3ee,. *e patient is asked to say ,1aa, and ,3ee,.

IN+IRE!T 'AR"N#O!OP"
IN+IRE!T 'AR"N#O!OP"

HEA+ AN+ NE!%
HEA+ AN+ NE!%

NE!%
NE!%

'"MPH NO+E 'E*E'
'"MPH NO+E 'E*E'
I--.u#mental and I--.u#mental and
su#mandi#ular nodes su#mandi#ular nodes

II--/pper 0ugulodigastric II--/pper 0ugulodigastric
group group
III--iddle 0ugular nodes III--iddle 0ugular nodes
draining te nasoA and draining te nasoA and
oroparyn(: oral ca'ity: oroparyn(: oral ca'ity:
ypoparyn(: laryn(. ypoparyn(: laryn(.
IV--Inferior 0ugular nodes IV--Inferior 0ugular nodes
draining te ypoparyn(: draining te ypoparyn(:
su%glottic laryn(: tyroid: and su%glottic laryn(: tyroid: and
esopagus. esopagus.
V-- Posterior triangle group V-- Posterior triangle group
VI--!nterior compartment VI--!nterior compartment
group group

!ER*I!A' '"MPH NO+E
!ER*I!A' '"MPH NO+E

TH"ROI+ AN+ PARATH"ROI+
TH"ROI+ AN+ PARATH"ROI+
#'AN+
#'AN+

A'I*AR" #'AN+
A'I*AR" #'AN+

THAN% "OU
THAN% "OU