Basic Physical Examination Basic Physical Examination in ENT – Head and Neckin ENT – Head and Neck

Department of Otolaryngology – Department of Otolaryngology – Head and Neck SurgeryHead and Neck Surgery

St. Luke’s Medical Center St. Luke’s Medical Center

EQUIPMENTEQUIPMENT

1.1. Chair with Head Chair with Head restrest

2.2. Light SourceLight Source

3.3. Instrument Instrument CabinetCabinet

EQUIPMENTEQUIPMENT

Head MirrorHead Mirror

““leaves both hands leaves both hands free for free for

examination”examination”

““positioned over the positioned over the left eye and close left eye and close to the examiner’s to the examiner’s

face” face”

EQUIPMENTEQUIPMENT

How to focus the head mirrorHow to focus the head mirror

The patient sits on the stool at the same level as the doctor.The patient sits on the stool at the same level as the doctor.

Patient's legs should be to one side of the examiner.Patient's legs should be to one side of the examiner.

The distance between the doctor and patient should not be The distance between the doctor and patient should not be more than 8 inches (Depending on the maximum focal length more than 8 inches (Depending on the maximum focal length of head mirror). of head mirror).

Fix the mirror on the left eye so that part of the mirror touches Fix the mirror on the left eye so that part of the mirror touches the nose. the nose.

Adjust the mirror so that you are seeing through the hole. Close Adjust the mirror so that you are seeing through the hole. Close the right eye and focus the mirror by rotating it. the right eye and focus the mirror by rotating it.

Open both the eyes. Open both the eyes.

EQUIPMENTEQUIPMENT

Basic InstrumentsBasic Instruments

1.1. Ear speculaEar specula2.2. Nasal SpeculaNasal Specula3.3. Tongue depressorsTongue depressors4.4. Indirect laryngoscopy mirrorsIndirect laryngoscopy mirrors5.5. Posterior Rhinoscopy mirrorsPosterior Rhinoscopy mirrors6.6. Nasal and aural forceps.Nasal and aural forceps.7.7. Tuning forks, 512 Hz, 1024 HzTuning forks, 512 Hz, 1024 Hz8.8. OtoscopeOtoscope

EAR EXAMEAR EXAM

EAR EXAMEAR EXAM

EAR EXAMEAR EXAM

“ “ begin with begin with inspection and inspection and palpation of the palpation of the pinna (auricle) and pinna (auricle) and structures structures surrounding the surrounding the ear…”ear…”

OTOSCOPYOTOSCOPY

Otoscopy is used to Otoscopy is used to visualize the ear visualize the ear canal/eardrum for canal/eardrum for the purpose of the purpose of detecting abnormal detecting abnormal conditions that conditions that might require might require further evaluation further evaluation or treatment.or treatment.

OTOSCOPYOTOSCOPY

““grasp and retract grasp and retract the pinna the pinna

backward and backward and upward in adults upward in adults

and downwards in and downwards in infants…”infants…”

OTOSCOPYOTOSCOPY• An -  annulus fibrosus An -  annulus fibrosus

• Lpi  (long process of incus) - Lpi  (long process of incus) - sometimes visible through a healthy sometimes visible through a healthy translucent drumtranslucent drum

• Um  (umbo) - the end of the malleus Um  (umbo) - the end of the malleus handle and the centre of the drumhandle and the centre of the drum

• Lr  (light reflex) - antero-inferiorlyLr  (light reflex) - antero-inferiorly

• Lp  (Lateral process of the malleus)Lp  (Lateral process of the malleus)

• At  (Attic) also known as pars At  (Attic) also known as pars flaccidaflaccida

• Hm  (handle of the malleus)Hm  (handle of the malleus)

PNEMATIC OTOSCOPYPNEMATIC OTOSCOPY

"allows the examiner to "allows the examiner to observe movement of the observe movement of the tympanic membrane tympanic membrane directly". "If the tympanic directly". "If the tympanic membrane does not move membrane does not move perceptibly with perceptibly with applications of slight applications of slight positive or negative positive or negative pressure, a middle ear pressure, a middle ear effusion is highly likely". effusion is highly likely". (Bluestone and Klein, (Bluestone and Klein,

1990)1990)

PNEUMATIC OTOSCOPYPNEUMATIC OTOSCOPY

TUNING FORK TESTTUNING FORK TEST

Indication: Differentiate type of Indication: Differentiate type of Hearing LossHearing Loss

SensorineuralSensorineural Hearing Loss Hearing Loss Conductive Hearing LossConductive Hearing Loss

TUNING FORK TESTTUNING FORK TEST

PreparationPreparation

Tuning fork should Tuning fork should be 512 Hz to 1024 be 512 Hz to 1024 HzHz

WEBER TESTWEBER TEST

Technique: Tuning Fork Technique: Tuning Fork placed at midline forehead placed at midline forehead

Normal: Sound radiates to Normal: Sound radiates to both ears equally both ears equally

Abnormal: Sound lateralizes Abnormal: Sound lateralizes to one ear to one ear • Ipsilateral Ipsilateral

Conductive Hearing LossConductive Hearing Loss OR OR • Contralateral Contralateral SensorineuralSensorineural

Hearing Loss Hearing Loss

RINNE TESTRINNE TESTTechnique Technique

•First: Bone Conduction First: Bone Conduction •Vibrating Tuning Fork held on Vibrating Tuning Fork held on Mastoid Mastoid •Patient covers opposite ear with Patient covers opposite ear with hand hand •Patient signals when sound ceases Patient signals when sound ceases •Move the vibrating tuning fork over Move the vibrating tuning fork over the ear canal (the ear canal (Near, but not Near, but not touching the ear)touching the ear)

•Next: Air Conduction Next: Air Conduction Patient indicates when the sound Patient indicates when the sound ceasesceases

RINNE TESTRINNE TESTNormal: Air Conduction is better than Normal: Air Conduction is better than

Bone Conduction Bone Conduction Air conduction usually persists twice as long as bone Air conduction usually persists twice as long as bone

Referred to as "positive test"Referred to as "positive test"

Abnormal: Bone conduction better than Abnormal: Bone conduction better than air conduction air conduction

Suggests Suggests Conductive Hearing LossConductive Hearing Loss

Referred to as "negative test"Referred to as "negative test"

Test for Eustachian Tube Test for Eustachian Tube FunctionFunction

1. Valsalva Maneuver: 1. Valsalva Maneuver:

Method: Method: After taking a deep breath, the patient pinches his nose After taking a deep breath, the patient pinches his nose

and closes his and closes his mouth in an attempt to blow air in his ears. mouth in an attempt to blow air in his ears. Otoscopy shows Otoscopy shows movement of the drum. movement of the drum.

Note: Failure of this test does not prove pathologic occlusion of Note: Failure of this test does not prove pathologic occlusion of the tube.the tube.

This maneuver in the presence of nasal and nasopharyngeal This 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.

2. Toynbee's test: 2. Toynbee's test:

It is safer and confirms normal tubal function.It is safer and confirms normal tubal function.

Method: The nose is closed and the patient swallows. There is in Method: The nose is closed and the patient swallows. There is in drawing of the tympanic membrane, confirmed by otoscopy.drawing of the tympanic membrane, confirmed by otoscopy.

NOSENOSE

EXAMINATION OF THE NOSEEXAMINATION OF THE NOSE

The nose can be examined in three The nose can be examined in three parts:parts:

1.1. Examination of the external noseExamination of the external nose

2.2. Anterior RhinoscopyAnterior Rhinoscopy

3.3. Posterior Rhinoscopy.Posterior Rhinoscopy.

EXAMINATION OF THE EXAMINATION OF THE EXTERNAL NOSEEXTERNAL NOSE

Inspection: Inspection: • Congenital deformities (Clefts)Congenital deformities (Clefts)• Acquired DeformitiesAcquired Deformities• Shape Shape • Swelling ( Inflammatory, cysts, tumors) Swelling ( Inflammatory, cysts, tumors) • Ulceration ( Trauma, neoplastic, infective)Ulceration ( Trauma, neoplastic, infective)

Palpation:Palpation:• TendernessTenderness• CrepitusCrepitus• DeformitiesDeformities

Anterior RhinoscopyAnterior Rhinoscopy

1.1. Examination of the VestibuleExamination of the Vestibule

Look for:Look for: Boil or AbcessBoil or Abcess Ulcerations and abrasionsUlcerations and abrasions Excoriation because of discharge. Excoriation because of discharge.

ANTERIOR RHINOSCOPYANTERIOR RHINOSCOPY

2.2. Examination of Examination of the nasal cavity the nasal cavity using a nasal using a nasal speculum:speculum:

POSTERIOR RHINOSCOPYPOSTERIOR RHINOSCOPY

Post Nasal Mirror: Post Nasal Mirror:

It consists of a It consists of a handle on which a handle on which a small mirror is small mirror is attached to shaft attached to shaft at an angle of 110.at an angle of 110.

POSTERIOR RHINOSCOPYPOSTERIOR RHINOSCOPYTechnique Technique

1.1. Hold the mirror like a pen in the right hand. Hold the mirror like a pen in the right hand.

2.2. Warm the mirrorWarm the mirror

3.3. Ask the patient to open the mouth. Ask the patient to open the mouth.

4.4. Depress the anterior 2/3rds of the tongue Depress the anterior 2/3rds of the tongue

5.5. Feel the warmth of the mirror on the back of the wrist. It should Feel the warmth of the mirror on the back of the wrist. It should not be hot. not be hot.

6.6. Introduce the mirror from the angle of the mouth over the tongue Introduce the mirror from the angle of the mouth over the tongue depressor and slide it behind the uvula. Avoid touching the depressor and slide it behind the uvula. Avoid touching the posterior wall of the pharynx as it may trigger gagging. posterior wall of the pharynx as it may trigger gagging.

7.7. Instruct the patient to breath through the nose. Instruct the patient to breath through the nose.

1.1. Tilt the mirror in different direction tot see various structures of Tilt the mirror in different direction tot see various structures of the nasopharynx. the nasopharynx.

POSTERIOR RHINOSCOPYPOSTERIOR RHINOSCOPY

PARANASAL SINUSESPARANASAL SINUSES

TRANSILLUMINATION TESTTRANSILLUMINATION TEST• Dim the room lights. Dim the room lights.

• Place the lighted otoscopePlace the lighted otoscopedirectly on the infraorbital rim directly on the infraorbital rim (bone just below the eye).(bone just below the eye).

• Ask the patient to open theirAsk the patient to open their

mouth and look for lightmouth and look for lightglowing through the mucosaglowing through the mucosaof the upper mouth. of the upper mouth.

Principle: In the setting of Principle: In the setting of inflammation, the maxillary inflammation, the maxillary sinus becomes fluid filled and sinus becomes fluid filled and will not allow this will not allow this transillumination. transillumination.

ORAL CAVITYORAL CAVITY

ORAL CAVITYORAL CAVITYTongueTongue

Check for:Check for: Common and taste sensationsCommon and taste sensations Size: Macroglossia in acromegaly, Size: Macroglossia in acromegaly,

Down's syndromeDown's syndrome UlcersUlcers Movements: Restricted in Movements: Restricted in

hypoglossal palsies, tumor hypoglossal palsies, tumor infiltrationinfiltration

Fasciculation: Motor neuron diseaseFasciculation: Motor neuron disease Depapillation: Vitamin deficienciesDepapillation: Vitamin deficiencies Furrowing , as in geographic tongue Furrowing , as in geographic tongue Coating: Thrush, black hairy tongueCoating: Thrush, black hairy tongue

ORAL CAVITYORAL CAVITY

• Buccal Mucosa: Parotid duct opening Opposite Buccal Mucosa: Parotid duct opening Opposite upper 2nd molar), red or white patches, ulcers, upper 2nd molar), red or white patches, ulcers, moisturemoisture

• Hard Palate: Swelling, ulcer, perforations, clefts Hard Palate: Swelling, ulcer, perforations, clefts etc. etc.

• Uvula: Position, deviations (Towards the Uvula: Position, deviations (Towards the normal side in palsies), ulcersnormal side in palsies), ulcers

• Floor of mouth: Wharton duct openings, ulcers, Floor of mouth: Wharton duct openings, ulcers, and bimanual palpationand bimanual palpation

• Teeth and occlusionTeeth and occlusion

OROPHARYNXOROPHARYNX• Soft Palate: Swelling, ulcer, Soft Palate: Swelling, ulcer,

movement, perforations, movement, perforations, clefts etc. clefts etc.

• Uvula: Position, deviations Uvula: Position, deviations (Towards the normal side in (Towards the normal side in palsies), ulcerspalsies), ulcers

• Tonsillar pillars: congestion, Tonsillar pillars: congestion,

ulcers, patches. ulcers, patches.

• Tonsils: Presence, size, Tonsils: Presence, size, crypts, ulcerscrypts, ulcers

• Posterior pharyngeal wall: Posterior pharyngeal wall: Lymphoid follicles, ulcers. Lymphoid follicles, ulcers.

LARYNGOSCOPYLARYNGOSCOPY

DefinitionDefinition

Visual exam of the voice box (larynx) Visual exam of the voice box (larynx) and the vocal cords. and the vocal cords.

Laryngoscopy is also done to remove Laryngoscopy is also done to remove foreign objects stuck in the throat. foreign objects stuck in the throat.

LARYNGOSCOPYLARYNGOSCOPY

There are two main kinds: There are two main kinds:

1.Indirect laryngoscopy - uses mirrors 1.Indirect laryngoscopy - uses mirrors to examine the larynx and to examine the larynx and hypopharynxhypopharynx

2.Direct laryngoscopy - uses a special 2.Direct laryngoscopy - uses a special instrument (flexible or rigid scope)instrument (flexible or rigid scope)

INDIRECT LARYNGOSCOPYINDIRECT LARYNGOSCOPY

TechniqueTechnique

1.1. Mirror is held like a pen in the right hand with the glass Mirror is held like a pen in the right hand with the glass pointing downwards. pointing downwards.

2.2. Warm the mirror and test the temperature on the back of Warm the mirror and test the temperature on the back of the hand. the hand.

3.3. The patient is asked to stick out the tongue which is held The patient is asked to stick out the tongue which is held with a piece of gauze. with a piece of gauze.

4.4. The patient is asked to breath through the mouth. The patient is asked to breath through the mouth.

5.5. The mirror is introduced into the mouth to the uvula which The mirror is introduced into the mouth to the uvula which is gently pushed back to get a view of the larynx and the is gently pushed back to get a view of the larynx and the pyriform fossae. pyriform fossae.

6.6. The patient is asked to say 'Aaa' and 'Eee'. The patient is asked to say 'Aaa' and 'Eee'.

INDIRECT LARYNGOSCOPYINDIRECT LARYNGOSCOPY

HEAD AND NECKHEAD AND NECK

NECKNECK

LYMPH NODE LEVELSLYMPH NODE LEVELSI--Submental and I--Submental and

submandibular nodessubmandibular nodes II--Upper jugulodigastric II--Upper jugulodigastric

groupgroup

III--Middle jugular nodes III--Middle jugular nodes draining the naso- and draining the naso- and oropharynx, oral cavity, oropharynx, oral cavity, hypopharynx, larynx. hypopharynx, larynx.

IV--Inferior jugular nodes IV--Inferior jugular nodes draining the hypopharynx, draining the hypopharynx, subglottic larynx, thyroid, and subglottic larynx, thyroid, and esophagus. esophagus.

V-- Posterior triangle groupV-- Posterior triangle group

VI--Anterior compartment VI--Anterior compartment groupgroup

CERVICAL LYMPH NODESCERVICAL LYMPH NODES

THYROID AND PARATHYROID THYROID AND PARATHYROID GLANDSGLANDS

SALIVARY GLANDSSALIVARY GLANDS

THANK YOUTHANK YOU