ENT EXAMINATION

Equipment for ENT examination

Essential instruments

Bulls eye lamp

Provides

powerful source of light Can be tilted, rotated, raised, or lowered according to needs

Head mirror
Concave

mirror used to reflect light from Bulls eye lamp onto the part being examined Focal lenghth of approximately 25cm

Tongue depressors

 Thudicum

and Vienna types Size of nasal speculum is selected according to age of patient and size of nostril

Laryngeal mirrors
Used to examine larynx and laryngopharynx Size available from 6 to 30mm To prevent fogging, always warm over a spirit lamp or dipping it in hot water then tested it on back of hand before insertion into mouth

Postnasal mirrors
Used

to examine nasopharynx and posterior part of nasal cavity Also warmed and tested on back of hand before use

Ear specula
Various

sizes available to suit different sizes of ear canal The largest speculum which can be conveniently inserted into ear canal should be used

Siegels speculum
Essential

in examination of tympanic membrane It gives magnified view of the membrane and helps to test its mobility

Tuning forks
Commonly

used tuning fork has a frequency of 512Hz

Jobson-Hornes probe
One

end of the probe is used to form a cotton bud to clean the ear of discharge and other end (with curette) is used to remove the wax

Blunt probe
Used

for palpation in nasal cavity or ear canal

Tilleys or Hartmans forceps

Used

in packing of ear canal or nasal cavity

Eustachians catheter
Used

to test patency of Eustachian tube Can also be used to remove foreign body from the nose

Otoscope
Electric

or battery operated device with a magnifying glass Useful for detailed examination or ear

Spirit lamp
Used

to warm the postnasal and laryngeal mirror

NOSE

Inspection

Mouth breathing suggest nasal airway obstruction Shape nasal deviation Nasal base
Patients

head tilted back Test stability of nasal alae; if too soft, indrawn even during unforced inspiration

Skin changes erythema or swelling

The anatomically important cartilaginous structures are projected onto the nasal base.

The nasal septum is subluxed toward the left side, partially obstructing the nasal airway

Palpation

Most useful to detect bony discontinuities Suspected neuralgia patient

Tenderness

over supraorbital, infraorbital or mental foramina disclose any mobility or crepitus suggesting fracture of nasal pyramid

Recent trauma history

To

Accuracy limited by soft tissue swelling

Anterior rhinoscopy

To evaluate nasal vestibule and anterior portion of nasal cavity Carried out with Thudichums speculum

Insert speculum into nose with blades the closed Use the other hand to position patients head and gently open speculum to spread open the nostril to inspect nasal cavity Tilt head forward to evaluate nasal floor, inferior turbinate, anterior portions of septum

The appearance of the normal nose showing the inferior turbinate attached to the lateral

Tilt head backward to obtain limited view of middle meatus and middle turbinate cannot be adequately assesed Carefully withdraw speculum with blades slightly open to avoid avulsing hairs from nasal vestibule

Posterior rhinoscopy

Patient sits facing examiner Examiner depresses the tongue with tongue depressor and introduces posterior rhinoscopic mirror which has been warmed first

Nasal endoscopy

Provides close-up views of small intranasal areas Rigid endoscopes

Available in 4mm and 2.7mm diameters and assorted viewing angles (eg; 0, 30, 120)

Flexible endoscopes
Available for inspecting nose and nasopharynx and exploring all of pharynx and larynx in one sitting Weaker light intensity and poorer image resolutions compared to rigid scopes

Positions of the patient and examiner.

Examiner advances the endoscope into nasopharynx Inspect eustachian tube orifices, torus tubarius, posterior pharyngeal wall, and roof of nasopharynx

Nasal endoscope shown in an anatomic specimen (sagittal section). The tip of the scope is in the nasopharynx.

Transnasal endoscopic appearance of the nasopharynx.

Normal appearance of the middle meatus, with the middle turbinate and uncinate process. The asterisk marks the narrow passage through which the endoscope can be advanced into the ostiomeatal unit (using narrow gauge scope)

EAR

Inpection

Thorough inspection of auricle and its surrounding. Attention should be given to:

Changes in shape of auricle and ear canal Surgical scars Crusting in external ear canal and discharge: cerumen, mucus, pus, blood, cerebrospinal fluid

Redness and swelling of auricles or surrounding

Palpation

Raised temperature Thickness of tissue Fluctuation tenderness

Otoscopy

Performed with a handheld otoscope Auricle is rotated gently backward and upward to straighten the external ear canal and bring the lateral cartilaginous part of the canal in line medial bony part Diameter of ear speculum should conform to anatomic constraints Broad speculum provides

Tympanic membrane

Examine for:

Color

Red and congested Bluish Chalky plaque Retracting Bulging Vesicles or bullae Perforation Siegels speculum

Position

Surface

Mobility

The normal tympanic membrane has a light reflex indicating a smooth surface and displays various anatomic landmarks. Its transparency and colour are variable. The figure illustrates right tympanic membrane.

Tuning fork tests

To differentiate between conductive and sensorineural hearing loss. Two tests are adequate for this purpose:
the

Weber test and the Rinne test

Conductive hearing loss

Caused

by diseases of external auditory canal or middle ear its cause in cochlea or neural structures of auditory system

Sensorineural hearing loss

has

Weber test

Tuning fork (512 Hz) is placed in the midline of the skull, usually on the vertex of forhead Vibrations are transmitted by bone conduction to cochlea Interpretation:

Normal hearing: vibrations are perceived as equally loud on both sides Sensorineural hearing loss: tuning fork is lateralized to the better-hearing ear Conductive hearing loss: tuning fork is lateralized to the affected ear because there is less masking from the ambient sounds, so more vibrational energy is present in normal functioning cochlea and sound is perceived as louder

a) When hearing is symmetrical, the sound is perceived with equal loudness in or between both ears. b) With unilateral sensorineural hearing loss, the sound is lateralized to the better ear. c) With conductive hearing loss, the sound os lateralized to the affected side.

Rinne test

Compares level of air and bone conduction in the same ear Air conduction (AC) is tested by holding the tuning fork just outside the ear canal without touching it Bone conduction (BC) is tested by pressing the tuning fork firmly against the mastoid

Patient is told to compare the loudness in the first condition (AC) with that in second condition (BC) If patient is unsure which is louder, AC and BC can be compared by testing for threshold:
Tuning

fork is struck and pressed to the mastoid, and patient tells the examiner when the sound becomes inaudible. Then the tuning fork is shifted to the position just outside the ear canal.

Interpretation:
In

a normal (positive) Rinne test, air-conducted sound is perceived as louder than the boneconducted sound and lasts at least 15s longer In conductive hearing loss is present, sound is perceived as louder on the mastoid than outside the ear canal. The Rinne test is negative.

a) In the absence of conductive hearing loss, air conduction is perceived as being louder and/or longer duration than bone conduction b) When conductive hearing loss is present, bone conduction is perceived as being louder and/or more prolonged than air conduction.

Speech test

This is done by having the patient listen to and repeat spoken numbers Simple screening test used to detect a threshold difference between right and left ear Formerly degree of hearing loss was tested by determining the range at which the patient could hear spoken or whispered numbers
Imprecised

and today the quantitative degree of hearing loss should be assesed only by audiometric testing

Hearing for spoken numbers is tested separately on each side as simple screening test. a) Examiner masks the nontest ear with one hand and shields the patients view with the other hand b) Examiner whispers numbers while turned away from the patient, or whispers them closer to the test ear when hearing loss is present

To test hearing range, an assistant masks the nontest ear while shielding the patients view. The patient turns the test ear toward examiner, who whispers number toward the patient from a distance of 6 meters. If patient does not understand the numbers, examiner moves closer and determines the range at which the number become intelligible.

Interpretation: Hearing loss can be stated in terms of the distance at which the numbers are still intelligible.
In a normal test, subject can understand 2-digit numbers whispered from approximately 6 meters away. If numbers are unintelligible or are understood only when whispered just outside the ear canal, the patient is considered to have severe hearing loss If numbers are unintelligible when spoken close to the ear at a normal or even loud level, patient is considered to have functional deafness for speech in that ear

Throat examination

Oral cavity

Lips Buccal mucosa

Change

in colour Change in surface appearance

Gums and teeth Hard palate Tongue Floor of mouth

Oropharynx

Tonsils
Presence Size Symmetry Membrane Ulcer Mass

Soft palate
Redness Swelling

Posterior pharyngeal wall

Lymphoid

nodules Purulent discharge Hypertrophy

Laryngopharynx

Indirect laryngoscopy
Patient sit opposite the examiner Ask patient to protrude tongue, wrap in gauze and held with left hand with thumb and middle finger Keep the upper lip and moustache out of way using index finger

Neck and head

Neck nodes are palpated while standing at the back of the patient Neck is slightly flexed to achieve relaxation of muscles When nodes are palpable, look for:
Location

of nodes Number of nodes Size