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Examination of the Ears, Nose, Examination of the Ears, Nose, Throat, and NeckThroat, and Neck
Dr Stephen O'Hanlon MA(Oxon) Dr Stephen O'Hanlon MA(Oxon) MBBChir(Cantab) MRCS DOHNS MSc MBBChir(Cantab) MRCS DOHNS MSc
Examination of the Ears, Nose, and Examination of the Ears, Nose, and ThroatThroat
Curriculum statement 15.4 ENT and Facial Curriculum statement 15.4 ENT and Facial ProblemsProblems
Examination of the EarExamination of the Ear
1) Introduction1) Introduction
2) Position the patient2) Position the patient
3) Start with the better ear3) Start with the better ear
4) 4) InspectInspect the pinna the pinna
5) Inspect the mastoid5) Inspect the mastoid
6) Inspect the external 6) Inspect the external auditory meatusauditory meatus
7) Otoscopic examination7) Otoscopic examination
8) Fistula test8) Fistula test
9) Free field testing9) Free field testing
10) Tuning fork tests10) Tuning fork tests
11) Facial nerve11) Facial nerve
12) Post nasal space12) Post nasal space
Examination of the EarExamination of the Ear
1) Introduce yourself to the patient1) Introduce yourself to the patient Any deafness?Any deafness? CommunicationCommunication
Examination of the EarExamination of the Ear
2) Position the patient2) Position the patient Away from the wallAway from the wall In chairIn chair Can walk around patientCan walk around patient
Examination of the EarExamination of the Ear
3) Start with the better side3) Start with the better side Start with the dry sideStart with the dry side Remove hearing aidsRemove hearing aids
Examination of the EarExamination of the Ear
4) Inspect the pinna4) Inspect the pinna Front and behindFront and behind Skin conditionSkin condition LesionsLesions ScarsScars Pre-auricular area (common place for sinus)Pre-auricular area (common place for sinus) Condition of cartilageCondition of cartilage
Examination of the EarExamination of the Ear
5) Inspect the mastoid5) Inspect the mastoid Mastoiditis is very, very rareMastoiditis is very, very rare Post auricular lymph nodesPost auricular lymph nodes ScarsScars BAHAs and Cochlear implantsBAHAs and Cochlear implants
Examination of the EarExamination of the Ear
6) Inspect the external auditory meatus6) Inspect the external auditory meatus Pull pinna upwards, outwards and backwardsPull pinna upwards, outwards and backwards In infants downwards and backwardsIn infants downwards and backwards In children pull backwardsIn children pull backwards Otorrhoea and otomycosisOtorrhoea and otomycosis Canal stenosisCanal stenosis Exostoses and osteomasExostoses and osteomas
Examination of the EarExamination of the Ear
7) Otoscopic examination7) Otoscopic examination The lateral process and handle of the malleus lie The lateral process and handle of the malleus lie
towards the centre of the tympanic membranetowards the centre of the tympanic membrane Four quadrantsFour quadrants PerforationPerforation
Central or marginalCentral or marginal What can be seen through itWhat can be seen through it
Mastoid cavityMastoid cavity DryDry Wet, inflamedWet, inflamed
Examination of the EarExamination of the Ear
8) Fistula test8) Fistula test A test for ENT doctors!A test for ENT doctors! Warn the patientWarn the patient A cholesteatoma has erroded part of a semi-circular A cholesteatoma has erroded part of a semi-circular
canalcanal Pressure in the EAM causes conjugate deviation of Pressure in the EAM causes conjugate deviation of
the eyesthe eyes
Examination of the EarExamination of the Ear
9) Free field testing9) Free field testing Start with the better earStart with the better ear Use masking, such as a tragal rubUse masking, such as a tragal rub Whispered voice, conversation voice, and shouted Whispered voice, conversation voice, and shouted
voice at 60cmvoice at 60cm Use double number fingers or bisyllable wordsUse double number fingers or bisyllable words
Examination of the EarExamination of the Ear
10) Tuning fork tests10) Tuning fork tests Traditionally 512Hz (256Hz may be better)Traditionally 512Hz (256Hz may be better) Rinne and Weber (they were both German)Rinne and Weber (they were both German) Help differentiate between conductive and Help differentiate between conductive and
sensorineual hearing losssensorineual hearing loss Limited reliability (around 80%)Limited reliability (around 80%) For Weber, incisors > vertex > foreheadFor Weber, incisors > vertex > forehead
Examination of the EarExamination of the Ear
11) Facial nerve11) Facial nerve Otoneurological conditions affect the cranial nerves Otoneurological conditions affect the cranial nerves
closest to the vestibulocochlear nerveclosest to the vestibulocochlear nerve CholesteatomaCholesteatoma Malignant otitis externa (osteomyelitis)Malignant otitis externa (osteomyelitis) Vestibular Schwannoma (formerly acoustic neuroma)Vestibular Schwannoma (formerly acoustic neuroma) Other skull-base tumoursOther skull-base tumours
Examination of the EarExamination of the Ear
12) Post nasal space12) Post nasal space Conditions affecting the middle ear can sometimes Conditions affecting the middle ear can sometimes
affect the post nasal spaceaffect the post nasal space Hopkins rod, flexible endoscope, or angled mirror Hopkins rod, flexible endoscope, or angled mirror
usually neededusually needed Massive lesions can sometimes be seen through Massive lesions can sometimes be seen through
the nose, or behind the soft palatethe nose, or behind the soft palate
Examination of the noseExamination of the nose
11) Introduce yourself) Introduce yourself
2) Position patient2) Position patient
3) Inspect the external nose3) Inspect the external nose
4) Inspect the nasal tip, 4) Inspect the nasal tip, vestibule, and nasal vestibule, and nasal airwaysairways
5) Anterior rhinoscopy5) Anterior rhinoscopy
6) Oral examination6) Oral examination
7) Post nasal space 7) Post nasal space examinationexamination
8) Neck examination8) Neck examination
Examination of the noseExamination of the nose
1) Introduce yourself1) Introduce yourself AnyAny hyponasal speech? hyponasal speech?
Examination of the noseExamination of the nose
2) Position the patient2) Position the patient Head-mirror or headlight?Head-mirror or headlight?
Examination of the noseExamination of the nose
3) Inspect the external nose3) Inspect the external nose Compare nose to rest of faceCompare nose to rest of face Size and shapeSize and shape SkinSkin Swelling, bruising, ulcersSwelling, bruising, ulcers ProfileProfile
Examination of the noseExamination of the nose
4) Examine the nasal tip, vestibule, and assess 4) Examine the nasal tip, vestibule, and assess the nasal airwaysthe nasal airways Nasal tipNasal tip Nostrils and air flowNostrils and air flow Mist testMist test Condition of mucosa inside vestibuleCondition of mucosa inside vestibule
Examination of the noseExamination of the nose
5) Anterior rhinoscopy5) Anterior rhinoscopy Thudichum’s speculum vs otoscopeThudichum’s speculum vs otoscope Obvious lesionsObvious lesions MucosaMucosa SeptumSeptum Turbinates (and osteomeatal complex)Turbinates (and osteomeatal complex)
Examination of the noseExamination of the nose
6) Oral examination6) Oral examination Rotten teethRotten teeth Alveolar process of the maxillaAlveolar process of the maxilla Palate and uvulaPalate and uvula
Examination of the noseExamination of the nose
7) Post nasal space examination7) Post nasal space examination With mirror, Hopkins rod, or nasendoscopeWith mirror, Hopkins rod, or nasendoscope Not easy outside of ENT clinicNot easy outside of ENT clinic Large masses, such as an antrochoanal polypLarge masses, such as an antrochoanal polyp
Examination of the noseExamination of the nose
8) Neck examination8) Neck examination Anterior nose drains to submandibular regionAnterior nose drains to submandibular region Posterior drains to middle deep cervicalPosterior drains to middle deep cervical
Examination of the throatExamination of the throat
1) Introduce yourself1) Introduce yourself
2) Position the patient2) Position the patient
3) Assess speech3) Assess speech
4) Oral examination4) Oral examination
5) Nasopharynx5) Nasopharynx
6) Indirect laryngoscopy6) Indirect laryngoscopy
7) Examine the neck7) Examine the neck
Examination of the throatExamination of the throat
1) Introduce yourself1) Introduce yourself
Examination of the throatExamination of the throat
2) Position the patient2) Position the patient Headlamp, mirror or other light sourceHeadlamp, mirror or other light source Seated in chair with space to examine from all sidesSeated in chair with space to examine from all sides
Examination of the throatExamination of the throat
3) Assess speech3) Assess speech StridorStridor HoarsenessHoarseness Hot potatoHot potato Any other dysphoniaAny other dysphonia
Examination of the throatExamination of the throat
4) Oral examination4) Oral examination Lips, perioral lesionsLips, perioral lesions 1 or 2 tongue depressors (or finger)1 or 2 tongue depressors (or finger) Inspect tongue, buccal mucosa and oropharynxInspect tongue, buccal mucosa and oropharynx Salivary duct orifacesSalivary duct orifaces Say ‘Ahhh’Say ‘Ahhh’ Finger examination of tongue, floor of mouth, cheeks Finger examination of tongue, floor of mouth, cheeks
and back of throatand back of throat
Examination of the throatExamination of the throat
5) Nasopharynx5) Nasopharynx Unless large lesion, will need mirror, Hopkins rod or Unless large lesion, will need mirror, Hopkins rod or
nasendoscopenasendoscope
Examination of the throatExamination of the throat
6) Indirect laryngoscopy6) Indirect laryngoscopy With mirror or nasendoscopeWith mirror or nasendoscope Can assess nasal cavity, nasopharynx, oropharynx, Can assess nasal cavity, nasopharynx, oropharynx,
hypopharynx and larynxhypopharynx and larynx Can assess movement of cords, especially with Can assess movement of cords, especially with
strobestrobe
Examination of the throatExamination of the throat
7) Examination of neck7) Examination of neck Head and neck cancers metastasise to neck nodes Head and neck cancers metastasise to neck nodes
and to the lungsand to the lungs Tonsillar infections are the commonest cause of Tonsillar infections are the commonest cause of
enlarged lymph nodesenlarged lymph nodes
Examination of the neckExamination of the neck
1) Skin1) Skin
2) Swallow2) Swallow
3) Voice3) Voice
4) Examine from behind4) Examine from behind
5) Anterior triangle5) Anterior triangle
6) Airway6) Airway
7) Thyroid7) Thyroid
8) Posterior triangle8) Posterior triangle
9) Sternocleidomastoid9) Sternocleidomastoid
Examination of the neckExamination of the neck
1) Skin1) Skin Skin lesionsSkin lesions UlcerationUlceration Scars and woundsScars and wounds StomaStoma Obvious large massesObvious large masses
Examination of the neckExamination of the neck
2) Swallow2) Swallow Larynx should riseLarynx should rise A goitre may rise, tooA goitre may rise, too
Examination of the neckExamination of the neck
3) Voice3) Voice As before. “Count to ten”.As before. “Count to ten”.
Examination of the neckExamination of the neck
4) Examine from behind4) Examine from behind Let patient know what you are doingLet patient know what you are doing Tender areasTender areas GentleGentle One side at a timeOne side at a time
Examination of the neckExamination of the neck
5) Anterior Triangle5) Anterior Triangle MastoidMastoid Mental processMental process Sternal notchSternal notch Ramus and border of Ramus and border of
mandiblemandible MidlineMidline Upper edge of SCMUpper edge of SCM
Examination of the neckExamination of the neck
6) Airway6) Airway TracheaTrachea LarynxLarynx Trotter’s signTrotter’s sign Hyoid boneHyoid bone Thyroglossal cyst (around half move with tongue Thyroglossal cyst (around half move with tongue
protrusion)protrusion)
Examination of the neckExamination of the neck
7) Thyroid7) Thyroid Moves on swallowingMoves on swallowing Two lobesTwo lobes Describe any lumpsDescribe any lumps Percuss the sternumPercuss the sternum
Examination of the neckExamination of the neck
8) Posterior Triangle8) Posterior Triangle MastoidMastoid Medial end of clavicleMedial end of clavicle Junction of trapezius Junction of trapezius
and clavicleand clavicle Lower edge of SCMLower edge of SCM Border of trapeziusBorder of trapezius ClavicleClavicle
Examination of the neckExamination of the neck
9) Sternocleidomastoid 9) Sternocleidomastoid As well as traditional As well as traditional
names of nodes, can be names of nodes, can be described as I to VIdescribed as I to VI
Easier to remember, and Easier to remember, and more relevant to more relevant to metastatic spreadmetastatic spread