Examination of Examination of Oto-Rhino-Oto-Rhino-

Laryngology Laryngology PatientPatient

Ear-Nose and throat diseases will show disturbance of function which Ear-Nose and throat diseases will show disturbance of function which is very clear to the physician even before examination of patient.is very clear to the physician even before examination of patient.The general schedule for examination of patient is the same in all The general schedule for examination of patient is the same in all specialties, but the differences and additions are used by each sub specialties, but the differences and additions are used by each sub

specialty to reach provisional diagnosis and always we have to fined specialty to reach provisional diagnosis and always we have to fined any relation between the patient symptoms and diseases related to any relation between the patient symptoms and diseases related to

the organs that forms the physiological system of the diseased the organs that forms the physiological system of the diseased organ, as in ear diseases we have to examine the nose, throat, oral organ, as in ear diseases we have to examine the nose, throat, oral

cavity and nervous system.cavity and nervous system.

Otorhinolaryngology / HNS – What is it? 5- 6 years residency “Otto” – Ears “Rhiino” – Nose (+siinuses) “Laryngollogy” – Throatt (Aiirway) Head & Neck Surgery –Skullll base,,Salliivary gllands,, Face,, Neck

General scheme of patient General scheme of patient examinationexamination

Personal historyPersonal history Beside the general information Beside the general information

gained from the personal history in gained from the personal history in general for ear- nose and throat general for ear- nose and throat patient, special point should be patient, special point should be expressed:-expressed:-– At the beginning of the historyAt the beginning of the history – –

Looking to the patient Looking to the patient

Gait- Gait-

Spastic gait- cortico spinal lesion.Spastic gait- cortico spinal lesion. Stamping- sensory ataxia Stamping- sensory ataxia Drunken gait- cerebellar ataxiaDrunken gait- cerebellar ataxia Festinating gait- ParkinsonismFestinating gait- Parkinsonism Waddling gait – myopathy. Waddling gait – myopathy.

Tremors or abnormal movementsTremors or abnormal movements Obese- snoring and apneaObese- snoring and apnea

Pallor Pallor - Anemia- Anemia - Chronic toxemia- Chronic toxemia - Sever hemorrhage- Sever hemorrhage

MovementMovement - Paralysis- Paralysis - Twitches- Twitches

ScarsScars - Old trauma- Old trauma - Surgery- Surgery

Face –Face –

SwellingsSwellingsand orbital fissureand orbital fissure SwellingsSwellings

- Acute - abscess – trauma - Acute - abscess – trauma - Chronic – desmoids- Chronic – desmoids - lacrimal sac disease- lacrimal sac disease - Frontal sinus mucoceal - Frontal sinus mucoceal

Orbital fissure Orbital fissure

- Symmetrical or not - Symmetrical or not - Proptosis - Proptosis 1) Bilateral – thyroid, exophthalmus1) Bilateral – thyroid, exophthalmus 2) Unilateral 2) Unilateral - Orbital tumor - Orbital tumor - Sinus diseases - Sinus diseases - Unilateral pulsating prptosis with echymosis = covernus sinus - Unilateral pulsating prptosis with echymosis = covernus sinus

disease. disease. - epiphora - epiphora Bilateral – allergic or infective conjunctivitis.Bilateral – allergic or infective conjunctivitis. unilateral – lacrimal drainage blockage unilateral – lacrimal drainage blockage

Eyes in the central of face.Eyes in the central of face. Look for deviations, swellings, or scars.Look for deviations, swellings, or scars.

Auricle left and right symmetrical Auricle left and right symmetrical normal in shape and projection.normal in shape and projection.

Nose the upper lip and apex up Nose the upper lip and apex up between the two eyes. Congenital between the two eyes. Congenital deformity such as cleft, dermoids, deformity such as cleft, dermoids, heamangioma, sinuses and fistulasheamangioma, sinuses and fistulas. .

Talking to the patientTalking to the patient

Normal voice of the patientNormal voice of the patient Hoarseness of voice – laryngeal diseaseHoarseness of voice – laryngeal disease Breathy voice – chest diseaseBreathy voice – chest disease Nasal tone – nasal disease or naso Nasal tone – nasal disease or naso

pharyngeal diseasepharyngeal disease Aphonia – hysterical or after removal of Aphonia – hysterical or after removal of

larynxlarynx Articulation defect- pathology in lips, teeth, Articulation defect- pathology in lips, teeth,

palate or tonguepalate or tongue

Hearing evaluationHearing evaluation

Normal hearing patient hears the Normal hearing patient hears the normal conversation.normal conversation.

Weak hearing:-patient hears loud Weak hearing:-patient hears loud conversation.conversation.

Sever hearing loss: - patient can't hear Sever hearing loss: - patient can't hear very loud speech.very loud speech.

In conductive hearing loss the patient In conductive hearing loss the patient voice is low, but in sensory neural voice is low, but in sensory neural hearing loss the patient voice is high.hearing loss the patient voice is high.

Memory and orientation:-Memory and orientation:-

Normally the patient is oriented in Normally the patient is oriented in time and place and can tell his time and place and can tell his disease story very clearly. disease story very clearly.

Abnormal patient can't tell his Abnormal patient can't tell his disease story and if you ask him disease story and if you ask him about recent events of his daily life about recent events of his daily life he will not remember.he will not remember.

Occupation Occupation

Working in dust:- expect allergy, chronic Working in dust:- expect allergy, chronic rhinosinusitis, chest problems.rhinosinusitis, chest problems.

Wood dust:- cancer maxilla.Wood dust:- cancer maxilla. Fumes and chemicals:- allergy, asthma rhinosinusitis, Fumes and chemicals:- allergy, asthma rhinosinusitis,

laryngitis.laryngitis. Teachers and singers:- chronic laryngitis with Teachers and singers:- chronic laryngitis with

possible nodules.possible nodules. Drivers: - baro truma (otitis media, sinusitis), vertigo, Drivers: - baro truma (otitis media, sinusitis), vertigo,

due to rapture of round window membrane, due to rapture of round window membrane, perforation of tympanic membrane. perforation of tympanic membrane.

Mushroom pickers and birds farmers:- allergic rhinitis Mushroom pickers and birds farmers:- allergic rhinitis and asthma due to fungus.and asthma due to fungus.

Green houses and nurseryGreen houses and nursery: - : - allergy and asthma due allergy and asthma due to chemicals and fertilizers.to chemicals and fertilizers.

Special habitsSpecial habits

- Smoking: - chronic rhinosinusitis, - Smoking: - chronic rhinosinusitis, pharyngitis, laryngitis, bronchitis and pharyngitis, laryngitis, bronchitis and tumors.tumors.

- Drinking alcohol:- chronic - Drinking alcohol:- chronic laryngitis, hyperacidity and tumors.laryngitis, hyperacidity and tumors.

Complaint (C/O)Complaint (C/O):- :-

Should be written Should be written down in patient down in patient words.words.

Past historyPast history:-:-

Medical problems Medical problems - High blood pressure: - headache, bleeding, dizziness, - High blood pressure: - headache, bleeding, dizziness,

tinnitus. tinnitus. - Diabetes: - recurrent infections; necrotizing otitis externa, - Diabetes: - recurrent infections; necrotizing otitis externa,

sensory neural hearing loss, neuropathy, mucous sensory neural hearing loss, neuropathy, mucous membrane fungal infectionmembrane fungal infection

- Asthma: - with or without allergic rhinitis, chronic throat - Asthma: - with or without allergic rhinitis, chronic throat infections, breathy voice.infections, breathy voice.

- Renal disease: - sensory neural hearing loss.- Renal disease: - sensory neural hearing loss. - Rheumatic disease: - TMJ arthralgia, pain and headache.- Rheumatic disease: - TMJ arthralgia, pain and headache. - Hormonal imbalance: - thyroid exophthalmoses, hearing - Hormonal imbalance: - thyroid exophthalmoses, hearing

loss in hypothyroidism. loss in hypothyroidism. - Liver failure: - bleeding from mouth and nose. - Liver failure: - bleeding from mouth and nose.

Drug allergy or complications Drug allergy or complications - Aspirin allergy.- Aspirin allergy. - Oto-toxic drugs & Vestibule-toxic drugs- Oto-toxic drugs & Vestibule-toxic drugs - Nasal blockage with beta blockers.- Nasal blockage with beta blockers. - Nasal bleeding with anti- coagulants. - Nasal bleeding with anti- coagulants. Surgical problems:- previous surgery of the diseased organ Surgical problems:- previous surgery of the diseased organ

or complications of surgery or anesthesia.in generalor complications of surgery or anesthesia.in general Trauma:- Trauma:- - Noise – hearing loss.- Noise – hearing loss. - Chemical- chronic sinusitis, laryngitis, anosmia.- Chemical- chronic sinusitis, laryngitis, anosmia. - Accidental – organ loss or deformity - Accidental – organ loss or deformity Allergic syndrome:- allergy is a systemic disease, which Allergic syndrome:- allergy is a systemic disease, which

may give the following clinical diseases, rhinitis, may give the following clinical diseases, rhinitis, conjunctivitis, asthma, eczema, laryngitis.conjunctivitis, asthma, eczema, laryngitis.

History of psychic problems.History of psychic problems.

History of present illnessHistory of present illness

Onset – course of the disease – other Onset – course of the disease – other symptoms that may arise from the symptoms that may arise from the same organ.same organ.

- What increase or relieve the - What increase or relieve the symptoms? symptoms?

- History of same disease before. And - History of same disease before. And what medications given and what what medications given and what was the results of investigations? was the results of investigations?

General examinationsGeneral examinations

Examine the pulse, temperature, Examine the pulse, temperature, blood pressure (standing and laying blood pressure (standing and laying down in dizziness). down in dizziness).

Examine the cranial nerves and the Examine the cranial nerves and the nervous system. nervous system.

Examine the lymph nodes, liver and Examine the lymph nodes, liver and spleen when malignant tumor is spleen when malignant tumor is suspected.suspected.

Examine the chest and heart. Examine the chest and heart.

Local examination Local examination

Inspection. Inspection. Palpation. Palpation. Endoscopy. Endoscopy. Microscopy. Microscopy.

Nose examinationNose examination

NoseNose is a pyramidal structure is a pyramidal structure projecting in the midline of the face projecting in the midline of the face at the middle third, with the base at at the middle third, with the base at the upper lip and the apex between the upper lip and the apex between the orbits (root of the nose).the orbits (root of the nose).– External nose examination – External nose examination – inspect inspect

the skin for swellings, ulcers, deviations the skin for swellings, ulcers, deviations humb, scars and abnormal colouration. humb, scars and abnormal colouration. Palpate for tenderness on the bony nose Palpate for tenderness on the bony nose floor of frontal sinus and maxillary floor of frontal sinus and maxillary sinuses.sinuses.

Internal noseInternal nose

lateral walllateral wall

osteaostea

Medial wallMedial wall

– Internal nose examinationInternal nose examination-- rise the tip rise the tip with your finger and look inside the nose to with your finger and look inside the nose to see the skin of vestibule and part of nasal see the skin of vestibule and part of nasal mucosa, then with nasal speculum examine mucosa, then with nasal speculum examine the left and right nasal cavities, look for:- the left and right nasal cavities, look for:-

Colour of mucous membraneColour of mucous membrane– Normal- smooth glistening reddish white.Normal- smooth glistening reddish white.– Acute rhinitis- congested red smooth.Acute rhinitis- congested red smooth.– Chronic rhinitis- congested red non smooth.Chronic rhinitis- congested red non smooth.– Allergic rhinitis – bluish white/Allergic rhinitis – bluish white/

Amount, color and consistency of secretionsAmount, color and consistency of secretions– Normal- minimal amount of clear mucous.Normal- minimal amount of clear mucous.– Acute rhinitis – profuse amount.Acute rhinitis – profuse amount.– Chronic rhinitis- mucoperulent discharge.Chronic rhinitis- mucoperulent discharge.– Allergic rhinitis- profuse clear mucous discharge with Allergic rhinitis- profuse clear mucous discharge with

swelling.swelling.– Clear water discharge – CSF.Clear water discharge – CSF.– Bloody discharge tumor or grannuloma.Bloody discharge tumor or grannuloma.– Fresh blood epistaxis.Fresh blood epistaxis.

Nasal septum deviation.Nasal septum deviation. Inferior and Middle turbinate.Inferior and Middle turbinate. Floor of the nose.Floor of the nose. Inferior and middle meatus. Inferior and middle meatus. Presence of abnormal growthPresence of abnormal growth

Clinical aspects of nasal Clinical aspects of nasal diseasedisease

– Nasal obstruction.Nasal obstruction. Nasal dischargeNasal discharge Fetor Fetor Epistaxis Epistaxis Smell disturbance Smell disturbance Facial painFacial pain Facial deformityFacial deformity

Specific diagnostic methodsSpecific diagnostic methods

a) Nasal endoscopya) Nasal endoscopy b) Biochemical and immunologic investigation of b) Biochemical and immunologic investigation of

the secretionsthe secretions c) Cytology and bacteriologyc) Cytology and bacteriology d) Allergic investigationd) Allergic investigation e) Biopsye) Biopsy To complete examination of the nose, the naso To complete examination of the nose, the naso

pharynx should be examined with endoscopy pharynx should be examined with endoscopy through the nose or with mirror through the through the nose or with mirror through the mouth.mouth.– X-Ray X-Ray conventional for sinuses and nasal bones in case conventional for sinuses and nasal bones in case

of trauma, but C.T. is much more diagnostic.of trauma, but C.T. is much more diagnostic.

Ear examinationEar examination

– Inspect the auricles for shape,Inspect the auricles for shape,– redness, swelling,redness, swelling,– ulceration, tumors, ulceration, tumors, – fistula, andfistula, and– retroauricular skin.retroauricular skin.– Palpate the auricles forPalpate the auricles for– tenderness and pre ortenderness and pre or– post auricular swelling orpost auricular swelling or– tenderness. tenderness.

Inspect external canal Pull the Inspect external canal Pull the auricle upward backward in adult auricle upward backward in adult or backward downward in infants or backward downward in infants and young children to see the and young children to see the external canal, which is S external canal, which is S shaped, by this movement you shaped, by this movement you find out if there is tenderness or find out if there is tenderness or not. Tenderness means otitis not. Tenderness means otitis extenaextena ..

The length of external canal 25mm, the The length of external canal 25mm, the outer third is cartilaginous lined with hairy outer third is cartilaginous lined with hairy skin and cerumen glands, and the inner skin and cerumen glands, and the inner tow thirds is bony. Normally the skin is tow thirds is bony. Normally the skin is smooth with some soft cerumen, the smooth with some soft cerumen, the bottom of the canal is closed by the bottom of the canal is closed by the tympanic membrane, which is oval, gryish tympanic membrane, which is oval, gryish white, glistening, mobile membrane. It is white, glistening, mobile membrane. It is oblique and concave. It shows the handle oblique and concave. It shows the handle of malleus hanging downwards backwards of malleus hanging downwards backwards and cone of light in the antro inferior and cone of light in the antro inferior sector. Examination to be done at this sector. Examination to be done at this stage with otoscope or microscope. stage with otoscope or microscope.

TYMPAMIC MEMBRANE -NORMALTYMPAMIC MEMBRANE -NORMAL

AOM-bulging,no land AOM-bulging,no land marks,pus behind TMmarks,pus behind TM

CHRONIC PERFERATIONCHRONIC PERFERATION

Chronic O.M.Chronic O.M.

Traumatic perferation

– . Tympanic membrane may be :-. Tympanic membrane may be :- Red congested…. Acute otitis mediaRed congested…. Acute otitis media Atrophic retrscted with prominent handle of Atrophic retrscted with prominent handle of

malleus in long standing negative pressure- malleus in long standing negative pressure- Secretory or adhesive otitis media. Secretory or adhesive otitis media.

Thick with calcification white in color …. Thick with calcification white in color …. Tymanosclerosis.Tymanosclerosis.

Perforated – central ….. marginalPerforated – central ….. marginal

e) Ear discharge e) Ear discharge Brown mass – waxBrown mass – wax Moist keratin debri – otitis externaMoist keratin debri – otitis externa Moist dirty mass- fungus.Moist dirty mass- fungus. Mucoid or mucoperulent discharge- chronic or Mucoid or mucoperulent discharge- chronic or

acute otitis media.acute otitis media. Scanty offensive perulent discharges – Scanty offensive perulent discharges –

cholesteatoma/cholesteatoma/ Clear fluid – C.S.F.Clear fluid – C.S.F. Bleeding – trauma, tumor.Bleeding – trauma, tumor. Serosangious discharge- polyp, viral otitis Serosangious discharge- polyp, viral otitis

media, and traumatic rapture of tympanic media, and traumatic rapture of tympanic membrane.membrane.

Special testSpecial test– Tuning fork testTuning fork test

Weber's test Weber's test – place the fork 512Hz in the midline on the – place the fork 512Hz in the midline on the for head or upper central incisors. The patient may hear- for head or upper central incisors. The patient may hear- – Equal in both ears= normal.Equal in both ears= normal.– Better in the diseased ear- conductive hearing loss.Better in the diseased ear- conductive hearing loss.– Better in the normal ear- sensory neural hearing loss.Better in the normal ear- sensory neural hearing loss.

Rinne's testRinne's test – the fork is placed one inch opposite the – the fork is placed one inch opposite the external canal, tell the patient stop hearing, then the fork is external canal, tell the patient stop hearing, then the fork is moved to the mastoid bone behind the ear- moved to the mastoid bone behind the ear-

R.N…R.N… positive- the air conduction is better than bone positive- the air conduction is better than bone conduction= normal hearing or sensory hearing loss. conduction= normal hearing or sensory hearing loss.

R.N.. R.N.. negative- the bone conduction is better than air negative- the bone conduction is better than air conduction = conductive hearing loss.conduction = conductive hearing loss.

Audiometry Audiometry Pure tone audiometryPure tone audiometry TympanometryTympanometry A.B.R. [ Auditory Brain Response ]A.B.R. [ Auditory Brain Response ]

– X-rayX-ray Covential x-ray mastoidsCovential x-ray mastoids C.T. brain and skull base with or without contrastC.T. brain and skull base with or without contrast M.R.I.M.R.I. Functional assessment of the Eustachian Tube.Functional assessment of the Eustachian Tube. - - Valsalva's testValsalva's test - Tympanometry –- Tympanometry – for both intact membrane or for both intact membrane or

dry perforation.dry perforation.

Examination of mouth and Examination of mouth and pharynxpharynx

Oral cavity is bounded anteriorly by the Oral cavity is bounded anteriorly by the lips, and posteriorly by the anterior faucial lips, and posteriorly by the anterior faucial archs, inferiorly by the floor of the mouth, archs, inferiorly by the floor of the mouth, and superiorly by the hard and soft palates. It and superiorly by the hard and soft palates. It is divided into regions and areas for clinical is divided into regions and areas for clinical examination:-examination:-

Mouth vestibule – stars from lips deeply Mouth vestibule – stars from lips deeply outside the dental arches. The Stensen's duct outside the dental arches. The Stensen's duct of parotid open opposite the second upper of parotid open opposite the second upper molar teeth.molar teeth.

Dental arches with buccal gums and lingual Dental arches with buccal gums and lingual gums gums

Mandible interfaces with skull base Mandible interfaces with skull base via the TMJ and is held in position by via the TMJ and is held in position by the muscles of masticationthe muscles of mastication

Divided into components with Divided into components with weakest sites being the third molar weakest sites being the third molar area, socket of the canine tooth, and area, socket of the canine tooth, and the condyle.the condyle.

Fracture FrequencyFracture Frequency

Oral cavity proper –Oral cavity proper –

– Tongue – the tip, the margins, the body, the base, the Tongue – the tip, the margins, the body, the base, the dorsum, and the ventral surface. The upper surface is dorsum, and the ventral surface. The upper surface is covered by modified epithelium containing the filiform covered by modified epithelium containing the filiform papillae and the taste buds. The V shaped terminal papillae and the taste buds. The V shaped terminal sulcus separates the body from the base of the tongue. sulcus separates the body from the base of the tongue. The central point is the foramen cecum, the remnant of The central point is the foramen cecum, the remnant of the thyroglossal duct.the thyroglossal duct.

Floor of the mouth: - it is below the lower surface Floor of the mouth: - it is below the lower surface of the tongue, the anterior part shows the of the tongue, the anterior part shows the openings of Wharton's ducts of submandibular openings of Wharton's ducts of submandibular glands and Bartholin's ducts of sublingual glands glands and Bartholin's ducts of sublingual glands on both sides of lingual frenulum. The epithelial on both sides of lingual frenulum. The epithelial lining of the oral cavity consists of nonkeratinzed lining of the oral cavity consists of nonkeratinzed stratified squamous epithelium with subepithelial stratified squamous epithelium with subepithelial collections of minor salivary glands collections of minor salivary glands

PharynxPharynx

it is long muscular tube about 12cm it is long muscular tube about 12cm in length, extends from base of the in length, extends from base of the skull down to level of cervical spine skull down to level of cervical spine No.6. it is lined with mucosa and it No.6. it is lined with mucosa and it is divided into three parts:- is divided into three parts:-

Nasopharynx: -Nasopharynx: - extends from the extends from the base of skull down to the level of base of skull down to the level of palate. Anteriorly open in the nose, palate. Anteriorly open in the nose, inferiorly open in the oropharynx, inferiorly open in the oropharynx, laterally the Eustachian tube open laterally the Eustachian tube open on ether side. The epithelial lining is on ether side. The epithelial lining is respiratory ciliated and stratified respiratory ciliated and stratified squamous epithelium, with squamous epithelium, with transitional epithelium area.transitional epithelium area.

Oropharynx:Oropharynx: - extends from the level of - extends from the level of soft palate down to the upper edge of the soft palate down to the upper edge of the epiglottis. It is continuous with the oral epiglottis. It is continuous with the oral cavity through the faucial isthmus. It has cavity through the faucial isthmus. It has posterior wall in front second and third posterior wall in front second and third cervical vertebrae, the lateral wall cervical vertebrae, the lateral wall containing the palatine tonsil with anterior containing the palatine tonsil with anterior and posterior faucial pillars. The epithelial and posterior faucial pillars. The epithelial lining consists of nonkeratinizing stratified lining consists of nonkeratinizing stratified squamous epithelium.squamous epithelium.

Hypopharynx:Hypopharynx:- extends from the - extends from the upper edge of the epiglottis superiorly upper edge of the epiglottis superiorly to the lower edge of cricoid cartilage it to the lower edge of cricoid cartilage it opens anteriorly into the larynx and on opens anteriorly into the larynx and on each side of the larynx lie the funnel-each side of the larynx lie the funnel-shaped piriform sinuses inferiorly its shaped piriform sinuses inferiorly its continues with esophagus the continues with esophagus the epithelial lining consist of epithelial lining consist of nonkeratinized stratified nonkeratinized stratified squamusepithelium .squamusepithelium .

Clinical aspects of diseases Clinical aspects of diseases of the mouth and pharynx:of the mouth and pharynx:

– Pain on eating, chewing or swallowing.Pain on eating, chewing or swallowing.– Dysphagia.Dysphagia.– Pain the neck.Pain the neck.– Globus symptoms.Globus symptoms.– Burning of the tongue.Burning of the tongue.– Blood in the sputum.Blood in the sputum.– Catarrh.Catarrh.– Oral fetor.Oral fetor.– Disorder of salivary secretion.Disorder of salivary secretion.– Disorders of taste.Disorders of taste.– Respiratory obstruction.Respiratory obstruction.– Disorders of speech.Disorders of speech.– Swellings of the neck,floor of mouth and of the lymph Swellings of the neck,floor of mouth and of the lymph

nodes at the angle of jaw and below the mandible.nodes at the angle of jaw and below the mandible.

Methods of Methods of investigation:investigation:

PalpationPalpation: of lips, dental arches, floor of the : of lips, dental arches, floor of the mouth for swellings ,submandibular area, mouth for swellings ,submandibular area, submental, TMJssubmental, TMJs

InspectionInspection: by using tongue depressor, : by using tongue depressor, mirror, flexible rigid endoscopymirror, flexible rigid endoscopy

Look for: Look for: The color, symmetrical mobility of the lips, skin The color, symmetrical mobility of the lips, skin

of the lips, mucosa of lips and mouth vestibule.of the lips, mucosa of lips and mouth vestibule. The arrangement of the teeth, occlusion, The arrangement of the teeth, occlusion,

dental caries, temporomandibular joint dental caries, temporomandibular joint mobility.mobility.

The shape and mobility of the tongue, the upper The shape and mobility of the tongue, the upper surface and inferior surface.surface and inferior surface.

Mucosa of mouth, cheeks are examined for Mucosa of mouth, cheeks are examined for sensation, ulceration, dryness, tumors.sensation, ulceration, dryness, tumors.

The condition of hard and soft palate; smooth The condition of hard and soft palate; smooth mucosa, mobility of soft palate, swellings, ulcers.mucosa, mobility of soft palate, swellings, ulcers.

Examine the parotid duct in the cheek opposite Examine the parotid duct in the cheek opposite the upper second molar tooth and the opening of the upper second molar tooth and the opening of submandibular gland in the floor of the mouth on submandibular gland in the floor of the mouth on either side of frinulum.either side of frinulum.

Examine the palatine tonsils:- size, crypts, cysts, Examine the palatine tonsils:- size, crypts, cysts, ulcers or tumor.ulcers or tumor.

Radiography: Radiography: Lateral view of the skull:- nasopharynx.Lateral view of the skull:- nasopharynx. Panorama of jaws:- dental cyst.Panorama of jaws:- dental cyst. Lateral view of the neck and upper thoracic Lateral view of the neck and upper thoracic

region:- for hypopharynx and cervical esophagus region:- for hypopharynx and cervical esophagus to show foreign bodies.to show foreign bodies.

Contrast medium:- to show pharyngeal pouch, Contrast medium:- to show pharyngeal pouch, stenoses and swallowing disorders. stenoses and swallowing disorders.

CT-SCAN for skull base larynx.CT-SCAN for skull base larynx. Carotid angiography for the highly vascular Carotid angiography for the highly vascular

tumors and incases of bleeding for possible tumors and incases of bleeding for possible embolization of external carotid branche,embolization of external carotid branche,

Microbiology:Microbiology: Culture for bacteriologic, Mycological Culture for bacteriologic, Mycological

andand virology examinationvirology examination.. Biopsy: Biopsy: From any swelling which is not From any swelling which is not

acutely inflamed or suspected highly acutely inflamed or suspected highly Vascular.Vascular.

LARYNX: LARYNX:

Embryology:Embryology: The larynx develops from a two-part The larynx develops from a two-part

anlage: the supraglottis develops from a anlage: the supraglottis develops from a buccopharyngeal bud, the glottis and subglottis buccopharyngeal bud, the glottis and subglottis from a tracheobronchial bud. This fact has clinical from a tracheobronchial bud. This fact has clinical significance in the postnatal period.significance in the postnatal period.

Anatomy:Anatomy: The laryngeal skeleton consists of the thyroid. The laryngeal skeleton consists of the thyroid.

Cricoid, and arytenoids cartilages, ehich are Cricoid, and arytenoids cartilages, ehich are hyaline cartilage, the epiglottis, which is fibrous hyaline cartilage, the epiglottis, which is fibrous cartilage and the fibroelastic accessory cartilages cartilage and the fibroelastic accessory cartilages of Santorini and Wrisburg, which have no of Santorini and Wrisburg, which have no function.function.

The laryngeal cavity is The laryngeal cavity is divided for clinical divided for clinical

purposes into:-purposes into:- Supraglottis.Supraglottis. Glottis.Glottis. Subglottis.Subglottis. The vocal cords length is 0.7 cm. in the newborn, The vocal cords length is 0.7 cm. in the newborn,

1.6 to 2 cm. in women, 2 to 2.4 in men.1.6 to 2 cm. in women, 2 to 2.4 in men. Functions of the laryngeal musculature:Functions of the laryngeal musculature: Opening of the glottis, abduction of the vocal Opening of the glottis, abduction of the vocal

cords-Posterior cricoarytenoid muscle(posticus cords-Posterior cricoarytenoid muscle(posticus muscle)muscle)

Closure of the glottis adduction of V.C-Lateral Closure of the glottis adduction of V.C-Lateral cricoarytenoid, transverse arytenoids, cricoarytenoid, transverse arytenoids, thyroarytenoid, lateral part.thyroarytenoid, lateral part.

Tension of the vocal cords-Cricothyroid muscle, Tension of the vocal cords-Cricothyroid muscle, thyroarytenoid muscle, medial part ( vocalis).thyroarytenoid muscle, medial part ( vocalis).

The nerve supply:The nerve supply: 1) Superior laryngeal nerve:1) Superior laryngeal nerve: a) Sensory internal branch supplies a) Sensory internal branch supplies

sensation down to the glottis. sensation down to the glottis. b) External branch the motor supply to the b) External branch the motor supply to the

external cricothyroid muscle. external cricothyroid muscle. 2) The recurrent laryngeal nerves left and 2) The recurrent laryngeal nerves left and

right gives motor supply to the internal right gives motor supply to the internal laryngeal muscles and sensation to the laryngeal muscles and sensation to the laryngeal mucosa below the glottis.laryngeal mucosa below the glottis.

Lymph drainage:Lymph drainage: No lymphatic capillaries in the vocal No lymphatic capillaries in the vocal

cord.cord. Supraglottic drain in the superior Supraglottic drain in the superior

cervical lymph nodes.cervical lymph nodes. Subglottic dran in inferior cervical Subglottic dran in inferior cervical

lymph nodes, prelaryngeal, lymph nodes, prelaryngeal, pretracheal nodes.pretracheal nodes.

Functions of the larynx:Functions of the larynx:

Phonation.Phonation. Respiration.Respiration. Protection of the lower airway:Protection of the lower airway:

– Closure of the aditus.Closure of the aditus.– Closure of the glottis.Closure of the glottis.– Reflex respiratory arrest.Reflex respiratory arrest.– Cough reflex.Cough reflex.

Fixation of the thorax aided by glottic Fixation of the thorax aided by glottic closure.closure.

Symptoms of laryngeal Symptoms of laryngeal diseasedisease

– HoarsenessHoarseness– Stridor:- inspiratory type.Stridor:- inspiratory type.– Irritative cough Irritative cough – Dysphagia Dysphagia

Pain in the neck, which may radiate Pain in the neck, which may radiate to the ears to the ears

Examinations of the larynxExaminations of the larynx

Inspection of the larynx Inspection of the larynx Normally, the throid prominence can only Normally, the throid prominence can only

be seen in men. It moves upward on be seen in men. It moves upward on swallowing; absence of this movement swallowing; absence of this movement indicates fixation of the larynx by infection indicates fixation of the larynx by infection or tumor.or tumor.

Indrawing of the suprasternal notch on Indrawing of the suprasternal notch on inspiration combined with inspiratory stridor inspiration combined with inspiratory stridor -points to laryngotracheal obstruction by -points to laryngotracheal obstruction by foreign body, tumor, odema, etc.foreign body, tumor, odema, etc.

Palpation Palpation The laryngeal skeleton and neighboring structures are The laryngeal skeleton and neighboring structures are

palpated during respiration and swallowing, paying palpated during respiration and swallowing, paying attention to the following:- attention to the following:-

– The thyroid cartilage.The thyroid cartilage.– The cricothyroid membrane and the cricoid cartilage.The cricothyroid membrane and the cricoid cartilage.– The carotid artery with the carotid bulb which must not be The carotid artery with the carotid bulb which must not be

confused with neighboring cervical lymph nods; the confused with neighboring cervical lymph nods; the palpating picks up pulsations.palpating picks up pulsations.

– The simultaneous movement of the larynx and thyroid gland The simultaneous movement of the larynx and thyroid gland on swallowing.on swallowing.

Laryngeal click: - normally it is present and you feel click Laryngeal click: - normally it is present and you feel click sensation by moving the larynx side to side. But when sensation by moving the larynx side to side. But when lost it means there is increase in the thickness of pre- lost it means there is increase in the thickness of pre- vertebral soft tissue. This is present in post cricoid vertebral soft tissue. This is present in post cricoid carcinoma or odema. carcinoma or odema.

LaryngoscopyLaryngoscopy Indirect laryngoscopy: - inspection by means of mirror or Indirect laryngoscopy: - inspection by means of mirror or

telescopic system 90 degree. telescopic system 90 degree. Direct laryngoscopy:- Rigid - FlexableDirect laryngoscopy:- Rigid - Flexable

By all the above methods examine the following By all the above methods examine the following areas:- areas:-

Base of the tongue, both valleculae, lingual Base of the tongue, both valleculae, lingual surface of the epiglottis, piriform sinus, surface of the epiglottis, piriform sinus, glossoepiglottic and aryepiglottic folds, glossoepiglottic and aryepiglottic folds, epiglottis, vestibular folds, vocal cords, anterior epiglottis, vestibular folds, vocal cords, anterior and posterior commissures. The normal colour of and posterior commissures. The normal colour of vocal cords is whitish, service is smooth, and vocal cords is whitish, service is smooth, and closed in the mid line when patient say's closed in the mid line when patient say's eeeeeeeeeeeee eeeeeeeeeeeee

RadiographyRadiography Plain views in the sagittal or lateral Plain views in the sagittal or lateral

plane for foreign body. C.T. scan, plane for foreign body. C.T. scan, then laryngography, then then laryngography, then stroboscopy, then biopsy. stroboscopy, then biopsy.

NeckNeck

The upper border of the neck runs along the inferior border The upper border of the neck runs along the inferior border of the mandible through the apex of the mastoid process to of the mandible through the apex of the mastoid process to the external occipital protuberance. Inferiorly, the neck the external occipital protuberance. Inferiorly, the neck ends in a plane formed by the suprasternal notch, the ends in a plane formed by the suprasternal notch, the clavicles, and the spinous process of the seventh cervical clavicles, and the spinous process of the seventh cervical vertebra.vertebra.

To examine the neck the following should be remembered:To examine the neck the following should be remembered: Topographic anatomy of neck triangles and their contents.Topographic anatomy of neck triangles and their contents. Deep neck spaces and compartements and fascial plains.Deep neck spaces and compartements and fascial plains. Lymph node groups and from which organs or regions their Lymph node groups and from which organs or regions their

afferent comes afferent comes

Triangles of neckTriangles of neck

– Postesior triangle Postesior triangle Between posterior border of sternomstoid muscle Between posterior border of sternomstoid muscle

and anterior border of trapezius muscle, the and anterior border of trapezius muscle, the apexis at surperior nuchal ,line and base is apexis at surperior nuchal ,line and base is formed by intermediate third of clavicle .formed by intermediate third of clavicle .

– Anterior triangle of neck Anterior triangle of neck Anteriorly bounded by midline of neck posteriorly Anteriorly bounded by midline of neck posteriorly

bouded by anterior border of stesnomastoid,bouded by anterior border of stesnomastoid, Superiorly :-the lower borders of mandible.Superiorly :-the lower borders of mandible. Apex:-at the saprasternal notes it is subdivided to Apex:-at the saprasternal notes it is subdivided to

more smaller more smaller Triangles:-Triangles:-

Submental triangle .Submental triangle .

Bounded by anterior belly of Bounded by anterior belly of diagastric muscle on either side and diagastric muscle on either side and base is thee body of hyoid bone apex base is thee body of hyoid bone apex is the mondiabular diagastric fossa is the mondiabular diagastric fossa

- Look for lymph nodes.- Look for lymph nodes. - Lipoma.- Lipoma. - Cystic swellings.- Cystic swellings.

Submandibular triangle .Submandibular triangle .

Bounded by anterior belly of Bounded by anterior belly of diagastric muscle and posterior diagastric muscle and posterior bellies and base is thee body of bellies and base is thee body of hyoid boneq apex is the mandiabular hyoid boneq apex is the mandiabular diagastric fossa diagastric fossa

- Look for lymph nodes.- Look for lymph nodes. - Lipoma.- Lipoma. - Cystic swellings.- Cystic swellings.

Carotid triangleBorders Carotid triangleBorders - Posterior:anterior border of - Posterior:anterior border of

sternomastoid muscle sternomastoid muscle - Inferior:superior belly of omohyoid - Inferior:superior belly of omohyoid

muscle muscle - Superiorly:posterior belly of diagastric - Superiorly:posterior belly of diagastric

muscle muscle Look for:Look for: - Lymph nodes - Lymph nodes - Chemodectomas - Chemodectomas - Branchial cysts - Branchial cysts - Parotid tail enlargment- Parotid tail enlargment

Muscular triangle Borders Muscular triangle Borders - Superiorly:superior belly of omohyoid- Superiorly:superior belly of omohyoid - Posteriorly:anterior border of sternomastoid - Posteriorly:anterior border of sternomastoid

musclemuscle - Anteriorly:medline of neck - Anteriorly:medline of neck In this triangle, there are many important organs;In this triangle, there are many important organs; Lareynx:with the thyroid cartilage projecting as Lareynx:with the thyroid cartilage projecting as

adam,s apple in the midline adam,s apple in the midline Thyroid gland, trachea Thyroid gland, trachea So on examing this triangle think about laryngeal, So on examing this triangle think about laryngeal,

thyroidal, tracheal diseases and then for lymph thyroidal, tracheal diseases and then for lymph nodes, carotid body tumors, cysts, thymus nodes, carotid body tumors, cysts, thymus disease.disease.

Fascia:Fascia:

The cervical muscles, viscera, and The cervical muscles, viscera, and carotid sheath are enclosed in fascia which is carotid sheath are enclosed in fascia which is partly tight, partly loose, and partly partly tight, partly loose, and partly incomplete.incomplete.– The superficial cervical fascia lies under the The superficial cervical fascia lies under the

platysma, encloses the sternocleidomastoid and platysma, encloses the sternocleidomastoid and tapezius muscles, insered onto the hyoid bone, tapezius muscles, insered onto the hyoid bone, and extends superiorly to the lower border of the and extends superiorly to the lower border of the mandible and inferiorly to the superior border of mandible and inferiorly to the superior border of the sternum and the clavicles.the sternum and the clavicles.

– The medial cervical fascia is multilocular system The medial cervical fascia is multilocular system enclosing the entire cervical viscera, the thyroid enclosing the entire cervical viscera, the thyroid gland, the esophagus, the trachea, the pharynx, gland, the esophagus, the trachea, the pharynx, the hyoid, the clavicle, the upper part of the the hyoid, the clavicle, the upper part of the sternum, and the scapula.sternum, and the scapula.

Superfacial layer of Superfacial layer of

The middleThe middle

– The deep cervical fascia forms a tight tube around The deep cervical fascia forms a tight tube around the deep cervical muscles arising from the spinous the deep cervical muscles arising from the spinous processes of the bodies of the cervical spine. The processes of the bodies of the cervical spine. The prevertebral layer is part of the fascial system prevertebral layer is part of the fascial system running continuously from the base of the skull to running continuously from the base of the skull to the inferior end of the spinal column.the inferior end of the spinal column.

The deep cervical fascia is divided into the The deep cervical fascia is divided into the alar fascia and prevertebral part lying alar fascia and prevertebral part lying directly on bone. The prevertebral fascial directly on bone. The prevertebral fascial space is thus divided into two to form the space is thus divided into two to form the “danger space” Infection can spread directly “danger space” Infection can spread directly within it into the posterior mediastinum.within it into the posterior mediastinum.

The deepThe deep

Note:Note: the space between the superficial and the space between the superficial and

middle cervical fascia is closed inferiorly middle cervical fascia is closed inferiorly as a sac because of their common as a sac because of their common insertion to the sternum and clavicle. This insertion to the sternum and clavicle. This prevents inferior extension of infection. In prevents inferior extension of infection. In contrast, the space between the middle contrast, the space between the middle and deep cervical fascia communicates and deep cervical fascia communicates freely below with the mediastinum. This freely below with the mediastinum. This allows abscesses to track downward and allows abscesses to track downward and allows infection due to esophageal injuries allows infection due to esophageal injuries or surgical emphysema to spread to or surgical emphysema to spread to mediastinum.mediastinum.

Spaces:Spaces:

The visceral space of the neck allows gliding movements. It The visceral space of the neck allows gliding movements. It lies anterior and lateral to the middle cervical fascia and lies anterior and lateral to the middle cervical fascia and posterior to the pharynx but anterior to the deeper cervical posterior to the pharynx but anterior to the deeper cervical fascia.fascia.

The parapharyngeal space contains the neurovascular The parapharyngeal space contains the neurovascular bundle and has areas of contact with the Eustachian tube bundle and has areas of contact with the Eustachian tube and the tonsil.and the tonsil.

The submandibular space with submandibular glan is in The submandibular space with submandibular glan is in contact with the dental alveoli.contact with the dental alveoli.

The sublingual space encloses the sublingual gland and is The sublingual space encloses the sublingual gland and is the site of abscesses of the floor of the mouth.the site of abscesses of the floor of the mouth.

The submental space is important in Ludwig’s angina.The submental space is important in Ludwig’s angina. The parotid space-contain parotid glands, Veins, Facial The parotid space-contain parotid glands, Veins, Facial

nerve, Terminal branches of external carotid artery. nerve, Terminal branches of external carotid artery.

Cervical Lymphatic System:There are about 200 lymph nodes located in the human neck.

The cervical lymphatic system is a component of the reticuloendothellial system

Superficial lymph nodes.Submental-submandibular.

Facial.Parotid-auricular.

Mastoid.Occipital.

Deep lymph nodes groupsDeep lymph nodes groups

– ..

Along the internal jugular vein.Along the internal jugular vein. Along the accessory nerve.Along the accessory nerve. Laryngotracheothyroid.Laryngotracheothyroid. Bronchomediastinal.Bronchomediastinal.

Method of the Method of the investigation:investigation:

Inspection is oriented on those structures of the neck that Inspection is oriented on those structures of the neck that contribute to the profile and seeks lesion of the contribute to the profile and seeks lesion of the

overlying skin(vascular signs, venous congestion, overlying skin(vascular signs, venous congestion, radiodermatitis, pigmented nevi, and melanoma), radiodermatitis, pigmented nevi, and melanoma),

as well as fistulous openings in branchiogenic fistula, as well as fistulous openings in branchiogenic fistula, swellingswelling

or indurations ( lymphadenopathy, tumors, abscesses).or indurations ( lymphadenopathy, tumors, abscesses).

The position and mobility of the head are examined looking The position and mobility of the head are examined looking for spasm of the neck muscles, e.g. in abscesses, for spasm of the neck muscles, e.g. in abscesses, thyroiditis, and torticollis..thyroiditis, and torticollis..

Palpation:Palpation: Palpation is carried out either Palpation is carried out either

from in front or behind, and both sides are from in front or behind, and both sides are palpated and compared. The head should palpated and compared. The head should be tilted forward to relax the soft tissues.be tilted forward to relax the soft tissues.

For every swelling – the following points For every swelling – the following points should be memorized (remembered):- should be memorized (remembered):-

Neck SwellingSiteNeck SwellingSiteTopographic Topographic descriptiondescription

Form and SizeForm and SizeSize in centimeters.Size in centimeters. MobilityMobilityVertically or horizontally mobile, Vertically or horizontally mobile,

fixed or adherent to the overlying skin.fixed or adherent to the overlying skin.

Consistency Consistency Soft, elastic, fluctuant, Soft, elastic, fluctuant, firm or hard.firm or hard.

Pulsation, Pulsation, skin temperature,skin temperature, color.color.Comparison to the surrounding Comparison to the surrounding

tissuestissues ..TendernessTenderness  

Deep neck lymph nodesDeep neck lymph nodes Level I:Level I: Lymph node groups – submental and submandibular Lymph node groups – submental and submandibular Level Ia*Level Ia*: Submental triangle: Submental triangle Boundaries – anterior bellies of the digastric muscle and the Boundaries – anterior bellies of the digastric muscle and the

hyoid hyoid bonebone Level Ib*Level Ib*: Submandibular triangle : Submandibular triangle Boundaries – body of the mandible, anterior and Boundaries – body of the mandible, anterior and posterior belly of the digastric muscleposterior belly of the digastric muscle Note: includes the submandibular gland, pre- and Note: includes the submandibular gland, pre- and

postglandular postglandular lymph nodes and pre- and postvascular lymph nodes and pre- and postvascular

(relative to facial vein (relative to facial vein and artery) lymph nodesand artery) lymph nodes Note: does not include perifacial lymph nodesNote: does not include perifacial lymph nodes

Level II:Level II: Lymph node groups – upper jugular Lymph node groups – upper jugular Boundaries – 1) anterior – lateral border Boundaries – 1) anterior – lateral border

of the sternohyoid muscleof the sternohyoid muscle 2) posterior – posterior border 2) posterior – posterior border

of the sternocleidomastoid muscleof the sternocleidomastoid muscle 3) superior – skull base3) superior – skull base 4) inferior – level of the hyoid 4) inferior – level of the hyoid

bone (clinical landmark) or carotid bone (clinical landmark) or carotid bifurcation (surgical landmark)bifurcation (surgical landmark) Level IIa*Level IIa* and and IIb*IIb* are arbitrarily designated are arbitrarily designated

anatomically by splitting level II with the anatomically by splitting level II with the spinal accessory nerve.spinal accessory nerve.

Level III:Level III: Lymph node groups – middle Lymph node groups – middle jugularjugular

Boundaries – 1) anterior – lateral Boundaries – 1) anterior – lateral border of the sternohyoid muscleborder of the sternohyoid muscle

2) posterior – posterior 2) posterior – posterior border of the sternocleidomastoid muscleborder of the sternocleidomastoid muscle

3) superior – hyoid bone 3) superior – hyoid bone (clinical landmark) or carotid (clinical landmark) or carotid

bifurcation (surgical landmark)bifurcation (surgical landmark) 4) inferior – cricothyroid 4) inferior – cricothyroid

notch (clinical landmark) or omohyoid notch (clinical landmark) or omohyoid muscle (surgical landmark)muscle (surgical landmark)

Level IV:Level IV: Lymph node groups – lower jugular Lymph node groups – lower jugular Boundaries – 1) anterior – lateral border of the Boundaries – 1) anterior – lateral border of the

sternohyoid musclesternohyoid muscle 2) posterior – posterior border of the 2) posterior – posterior border of the

sternocleidomastoid musclesternocleidomastoid muscle 3) superior – cricothyroid notch 3) superior – cricothyroid notch

(clinical landmark) or omohyoid (clinical landmark) or omohyoid muscle (surgical landmark)muscle (surgical landmark) 4) inferior – clavicle4) inferior – clavicle Level IVa*Level IVa* denotes the lymph nodes that lie along the denotes the lymph nodes that lie along the

internal jugular vein but immediately deep to the sternal internal jugular vein but immediately deep to the sternal head of the SCM. head of the SCM. Level IVb*Level IVb* denotes the lymph nodes denotes the lymph nodes that lie deep to the clavicular head of the SCMthat lie deep to the clavicular head of the SCM

Level V:Level V: Lymph node groups – posterior triangle Lymph node groups – posterior triangle Boundaries – 1) anterior – posterior Boundaries – 1) anterior – posterior

border of the sternocleidomastoid muscleborder of the sternocleidomastoid muscle 2) posterior – anterior border 2) posterior – anterior border

of the trapezius muscleof the trapezius muscle 3) inferior - clavicle3) inferior - clavicle Level Va*Level Va* denotes those lymphatic denotes those lymphatic

structures in the upper part of level V that follow structures in the upper part of level V that follow the spinal accessory nerve. the spinal accessory nerve. Level Vb*Level Vb* refers to refers to those nodes that lie along the transverse cervical those nodes that lie along the transverse cervical artery. Anatomically, the division between these artery. Anatomically, the division between these to subzones is the inferior belly of the omohyoid to subzones is the inferior belly of the omohyoid muscle. muscle.

Level VI:Level VI: Lymph node groups – Lymph node groups – [prelaryngeal (Delphian), pretracheal, [prelaryngeal (Delphian), pretracheal, paratracheal, andparatracheal, and

precricoid (Delphian) lymph nodes] - also precricoid (Delphian) lymph nodes] - also known as the anterior compartmentknown as the anterior compartment

Boundaries – 1) lateral – carotid Boundaries – 1) lateral – carotid sheathsheath

2) superior – hyoid bone2) superior – hyoid bone 3) inferior – suprasternal 3) inferior – suprasternal

notchnotch

Level VII:Level VII: Lymph node groups – Lymph node groups – Upper mediastinalUpper mediastinal

Boundaries – 1) lateral – Boundaries – 1) lateral – carotid arteriescarotid arteries

2) superior – 2) superior – suprasternal notchsuprasternal notch

3) inferior – aortic 3) inferior – aortic archarch

Supraclavicular zone or fossaSupraclavicular zone or fossa: : relevant to nasopharyngeal carcinomarelevant to nasopharyngeal carcinoma

Boundaries – 1) superior Boundaries – 1) superior margin of the sternal end of the margin of the sternal end of the clavicleclavicle

2) superior margin of 2) superior margin of the lateral end of the claviclethe lateral end of the clavicle

3) the point where the 3) the point where the neck meets the shoulderneck meets the shoulder