ENT Examination Technique

    Ear    Nose     Throat    Neck

Ear Examination

NB. As well as assessing the appearance of the ear, a complete examination of the ear also involves an assessment of hearing. This is done in greater detail in the audiology section but basic tests of hearing can be done in the clinic or bedside.

History

The classic symptoms of ear disease are:

• deafness
• tinnitus
• discharge (otorrhoea)
• pain (otlagia)
• vertigo

• previous ear surgery
• head injury
• systemic disease (e.g storke, multiple sclerosis, cardiovascular disease)
• otoxic drugs (antibiotics, diuretics, cytotoxics)
• exposure to noise at work or recreation (shooting)
• family history of deafness
• history of atopy and allergy in children

Inspection

Before examination with the otoscope / auroscope, the external ear should be inspected for any obvious abnormality including the following:

• Size and shape of the pinna

• Extra cartilage tags / pre-auricular sinuses or pits

• Evidence of trauma to the pinna

• Suspicious skin lesions on the pinna including neoplasia

• Skin conditions of the pinna and external canal

• Obvious infection of the external ear and canal with frank discharge

• Evidence of previous surgery (scars)

	The ear canal and drum itself are best examined with a modern electric otoscope / auroscope. It is essential that the batteries are in good condition as a dim light makes examination very difficult.
	The pinna should be grasped between fore-finger and thumb and pulled posteriorly and superiorly during examination.This has the effect of staightening out the canal which normally has a slight curve, and allows better inspection of the tympanic membrane (TM) or eardrum. Very small infants and neonates have slightly different anatomy and it is usally recommended that the pinna is pulled posteriorly but not superioirly for examiation.
	An appropriate sized end should be fitted on the otoscope.Although it is tempting to use a small end to make insertion easier, this severley restricts the image available, and the best view is acheived by using the largest end that will fit into the ear canal.
	Holding the otoscope near the eyepeice end makes it less likely that you will cause the patient discomfort by making sudden or exagerated movement.
	Holding the otoscope by it's end can lead to increased discomfort because movement of the hand is exaggerated in the ear

As well as the TM itself, make note of the condition of the the canal skin, the presence of any wax and any foreign body or discharge.

Tympanic Membrane

Although textbooks usually contain excellent pictures of the whole tympanic membrane, these are usually taken with wide angled endoscopes and using the otoscope, it is not always possible to see the whole drum in one single view. This is particulalry true where the anterioir wall is very prominent, and you will have to move the otoscope about to see the whole drum in several different views.

The drum is roughly circular and around 1cm in diameter. In a normal drum you should be able to identlify the following:

• Handle / lateral process of the malleus

• Light reflex / cone of light

• Pars tensa and pars flaccida (attic)

• Long process of incus

• chorda tympani

• eustachian opening

• promontory of the cochlea

• perforations

• tympanosclerosis

• Glue ear / middle ear effusion.

• Retractions of the drum

• Haemotympanum (blood in the middle ear)

If you are suspicious of any serious ear pathology, check the facial nerve function
 

Basic tests of hearing

Tuning fork tests.

These test hearing in both ears and can help distinguish between a sensorinueral and conductive hearing loss (for more details see section on types of deafness)
 

Ideally you should use a 512Hz tuning fork. If unavailable a 265Hz will suffice. Strike the tuning fork against your elbow or knee to make it vibrate. (this takes practice and may hurt if you get carried away...)

Striking it against a metal object can introduce unwanted harmonic vibrations into the sound signal.
DO NOT hit the patient on the head with it.

Tell the patient what you are doing and what you want them to do before you put the fok against their head. If you talk to them while you are doing the test it may confuse the result.

Weber Test

	Place the fork in the middle of the head (vertex). Ask the patient if he can hear the sound equally in both ears, or if it is louder on one side.
	If the patient cannot hear the sound at all, try striking the fork again, or pressing it against the nose
	......or even the upper teeth in the midline as this facilitates bone conduction

• A patient with normal hearing should hear the sound equally in both ears.

If a patient has a unilateral conductive loss, the Weber will localise to the affected ear. (try putting your finger in your ear to block it up and repeat the test). If a patient has a unilateral sensorineural loss, the Weber will localise to the opposite / unnafected ear.

Rinne Test

	Place the fork behind the ear, pressing on the mastoid process (firmly)
	and then hold the fork about three inches away from the ear .

In a normal ear, the patient should hear the tuning fork louder in front (air conduction) and quieter behind (bone conduction). This is called a Positive Rinne test. If the patient has a conductive hearing loss (usually of around 20dB or greater) then they will hear the bone conduction (behind the ear) louder than the iar condution and this is called a Negative Rinne test.
If a patient has a non-hearing ear on one side ('dead' ear), then they will still hear the bone conduction louder, becuase the sound will be transmitted around the skull and heard by the other cochlea. This is called a False Negative Rinne test.

Interpertation of Weber and Rinne Testing

(images)

Basic tests of hearing.

To make a basic assessment of a patients hearing, you need to mask the non test ear, say by inserting your finger into it, and then ask them to repeat random numbers (e.g 31, 45, 17, 64 etc) that you speak into the test ear. Start with a quiet whisper, then a 'stage' whisper, then quiet speech, loud speech and finally a shout, stop at the level at which the patient can accurately repeat the numbers you are giving them.

It is important that they cannot see your face as many deaf patients can lip read. Repeat this on the other side and you can get a rough measure of their hearing.

You could report this as (for example) "able to hear a quiet whisper at arms length on the right ear, but only able to hear a loud converationsal voice at arms length on the left"

Very roughly this might equate to the following level of hearing loss:
 

Able to understand following speech level at arms legth	Hearing loss equivalent
Quiet whisper	Normal
Loud whisper	20-30dB
Quiet voice	30-45dB
Loud voice	45-60dB
Shout	60-80dB

Hearing levels are objectively and accurately assessed by pure tone audiometery. (see Audiology section)
 
 

Ear   Nose     Throat   Neck
 
 

Examination of the Nose
 

• Examination of the nose also involves assessment of function: airway resistance and occasionally sense of smell. Examination of the nose is incomplete without looking into the mouth and pharynx.

History

The main symptoms of nasal disease are:

• airway obstruction
• runny nose (rhinorrhoea)
• sneezing
• loss of smell (anosmia)
• facial pain due to sinusitis
• snoring associated with nasal obstruction

• Allergies / atopic disease
• Smoking
• Pets at home
• Occupation
• History of previous surgery
• History of trauma
• General medical history
• Seasonal or daily variation in symptoms

Inspection

Look at the external nose and face before you look into it. Ask the patient to take off any glasses they may be wearing. Look at the nose from the side as well as in front. A deviated nose is often best looked at by looking from above. Look for any of the following:

• Obviously bend, deformity or swelling
• Scars or abnormal creases across the nose
• Redness or evidence of skin disease
• Discharge or crusting
• Offensive smell

	To inspect the nose, fist look into the very front of the nose (anterior nares) by tipping the tip of the nose up with a finger and looking inside without a speculum.
	After this you may choose to use a speculum with a torch or head mirror.
	Probably the best way of examining the nose for undergraduates and general pratitioners is to use an otoscope with a very wide end on it. The head mirror is excellent for this purpose, but it take a while to get used to and if you only have two weeks, it may not be worth your while. Otolaryngologists use either a head mirror or illuminated spectacles.
	The Thudicum speculum is used to open up the nose, this take practice to use correctly but is very useful if you wish to instument the nose for any reason. You will need to be shown how to hold this correctly.

Inside the nose you should be able to identify the nasal septum medially and the turbinates laterally. It should nearly always be possible to see the inferior turbinate, the middle turbinate may be more difficult. The superior turbinate is of little importance in examination and is very small.

Try to assess if there is any inflammation (rhinitis) and if the septum is straight or deviated to one side.
If you see what you think is a polyp, it is useful to see if it is sensitive. Swollen turbinates are often mistaken for polyps: a polyp is insensitive whereas a turbinate is quite tender to touch. Try touching it gently with a blunt probe to measure this. Polyps tend to have a slightly grey / yellow colour whereas turbinates or more commonly pink.

In children, a foreign body may occasionally be seen inside the nose, this is usually accompanied by an offensive, unilateral nasal discharge.

Look inside the mouth as well, occasionaly large nasal polyps and tumours may be visible arising from behind the soft palate. It is not normally possible to view the nasopharynx on routine examination, and this is either done using a mirror and headlight or an endoscope. Undergraduates will not be expected do be able to undertake this examination.

To assess the nasal airway there are a variety of bedside techniques:

	1. Hold a cold metal tongue depressor under the nose while the patient exhales. If there is reasonable airflow, there should be some condensation under both nostrils.
	2. Occlude one nostril with a thumb and ask the patient to sniff. This gives a reasonable idea of the patency of the airway.

Of course, the nasal airway changes with posture, time of day and a variety of other factors, so it is very difficult to measure the nasal resistance accurately in a way which reflects the patients' actual perception of nasal obstruction. A variety of instruments are in use to attempt to do this (rhinomanometery) but their use is largely as a research tool.

The smell is not routinely assessed in nasal examination as this can be very subjective. On occasions where there is a need to assess smell, this is done using a series of bottles containing specific odours. Usually asking specifically about sense of smell in the history is enough.
 

 Nasal Obstruction and Rhinitis section               Facial Pain and Sinusitis section
 

Ear    Nose     Throat   Neck
 
 

Throat Examination
 

• The throat examination includes a thorough examination of the oral cavity.

History

As the mouth and throat can have a variety of different clinical problems it is more difficult to generalise about history taking.
It is always important to ask about a history of tobacco or alchohol usage and if the mouth is involved, if there is any relevant dental history. A number of systemic diseases may present with oral syptoms and signs - a reasonable medical history is often required.

Examination

Pressing the tongue down with a wooden spatula and peering in with a dim torch is often the extent of the majority of medical examinations of the mouth, it is however, insufficient. The mouth contains a number of recesses and sites which are not routinely examined such as the floor of the mouth, and these may contain occult malignancies or other pathology. The mouth should be examined systematically.
 

Use the brightest torch you can. Start by examining the mouth without a tongue depressor and note the condition of the tongue. Pressing down on the tongue with a tongue depressor wil allow you to examine the back of the tongue and tonsils (see diagram). You should also be able to inspect the uvula and soft palate.
To inspect the hard palate ask the patient to tip their head back, until you can see the whole hard palate all the way to the front teeth.
Next examine the buccal region and the gingivolabial / gingivobuccal sulcus - the space between the cheek and the gums, all the way from the front to the back where the cheek meets the ascending ramus of the mandible at the so called retro-molar trigone.
Ask the patient to stick their tongue upwards and now examine the floor of the mouth.

Examination of the nasopharynx and larynx are done by using mirrors or flexible fibre-optic nasendoscopes. You will not be required to do this as undergraduate.

remember that to adequaltely examine the mouth you should inspect:
 

• tongue
• hard and soft palate
• tonsillar fossa
• gingivolabial / gingivobuccal sulci
• floor of mouth / undersurface of tongue

Ear   Nose     Throat   Neck
 

Neck Examination
 
 

• Neck examination should be systematic and thorough. If there is a parotid lesion, check facial nerve function and look in the mouth.

The neck should be examined in a sytematic manner, and as you are palpating the neck, think about what normal structures are underneath your fingers.

Make sure that the patient has their whole neck exposed, if they have collars done up, ask them to unbutton them sufficiently.

The neck should be examined with the fingers flat, and the palpation done with the undersurface of the fingers rather than the palm of the hand as they are more sensitive.

There is no correct order in which to examine the neck, as long as all of the following areas are covered.
 

• Parotid region
• Midline from chin to sternal notch
• Anterior triangle including submandibular triangle
• Anterior jugular chain
• Posterior triangle

Now examine the posterior triangle. Because the angle can be awkward, try doing this one side at a time and standing slightly to one side, so that your hand is still flat against the neck.
If you feel any abnormality in the parotid region, check the facial nerve function.

For more information  refer to the section on neck masses
 

Ear   Nose     Throat   Neck
 
 Special thanks to Richard Sim FRCS and Darren Pinder FRCS for volunteering to be photographed for this page!