Clinical features of Ear nose and throat

Clinical features of ENT
Clinical features of ENT

1. CLINICAL FEATURES AND EXAMINATION OF EAR & THROAT Dr.JUDE ANSELM SHYRAS PROF & HOD DEPT OF ENT KGMCH

2. MOST COMMON SYMPT OMS Ear discharge Side of the ear Onset: Acute, Chronic Duration: Acute < 3 months Chronic > 3 months Amount: Profuse - Tubotympanic CSOM - active stage Scanty - Atticoantral CSOM COLOUR Brown – Wax Yellow – Tubotympanic CSOM White – Candida infection Black - Otomycosis(Aspergillus niger) Golden yellow – Aspergillus fumigatus Green - Pseudomonas (pyocyanin) Red - Glomus tumour, Otitic Barotrauma

3. Blood stained EAC causes: Ear probing, Furunculosis, Keratosis obturans , Malignant otitis externa, EAC cholesteatoma, Myringitis bullosa/granulosa, Herpes zoster oticus , EAC malignancy Middle ear causes: ASOM, CSOM(AAD), Middle ear malignancy Smell/ odour Non foul smelling – Tubotympanic CSOM Foul smelling – Atticoantral CSOM Character Watery – CSF Otorrhoea , Early stage of Allergic otitis media Mucoid – Early stages of ASOM and CSOM, Allergic otitis media Mucopurulent – Tubotympanic CSOM Purulent EAC causes: Furunculosis, Keratosis obturans , Malignant otitis externa, EAC cholesteatoma, EAC malignancy Middle ear causes: CSOM(AAD), Middle ear malignancy Aggravating factors : Upper respiratory tract infections Relieving factors: Topical application of ear drops

4. Hard of hearing Side: Right or Left Onset: Sudden – Sudden sensorineural hearing loss, Acoustic trauma Insidious EAC causes: Impacted wax, Furunculosis, Keratosis obturans, EAC cholesteatoma, Malignant otitis externa, Osteoma of EAC, Exostosis of EAC Middle Ear causes: SOM, ASOM, CSOM, Otosclerosis, Otitic barotrauma Inner Ear causes: Meniere’s disease, Cochlear otosclerosis, Noise induced hearing loss, Ototoxicity, Presbycusis Duration Progression Degree of hearing loss for: Whispering, Normal conversations, Shouting Confirmed by Tuning Fork Tests

5. Earpain Side of the ear – Right or Left Onset Acute: Injury to the ear, Inflammatory Insidious: SOM Duration: Acute, Chronic Nature Throbbing - ASOM Dull aching - SOM Continuous Furunculosis Otitis externa Malignancy of EAC and Middle ear Intermittent: SOM Periodicity: ASOM Aggravating factors - Ear probing Relieving factorS - Medication Referred otalgia : Pain perceived in the ear but the primary pathology is elsewhere in the body.  V CN - TM joint and dental pathology  VII CN - Muscles of facial expression pathology  IX, X & XI CN - Pharyngeal & Laryngeal pathology  C1 & C2 cervical nerve involvement- Cervical spine pathology

6. Tinnitus Objective cause: Both the examiner and patient hears the sound Glomus tumour AV malformations Patulous Eustachian tube Subjective causes: Only the patient hear the sound, not the examiner External ear causes: Impacted wax, Osteoma, Exostosis, Keratosis obturans Middle ear cause: ASOM, SOM, CSOM, Otosclerosis, Haemotympanum Inner ear cause: Meniere’s disease, Labyrinthitis, Labyrinthine fistula, Acoustic neuroma Vertigo : Subjective imbalance of one’s own self or surroundings Causes: Vestibular neuronitis, Benign Positional Paroxysmal Vertigo, Meniere’s disease, Superior semicircular canal dehiscence, Migraine AUTOPHONY: Patient hears his own voice. e.g., Patulous Eustachian tube. PARACUSIS WILLISI: Patient hears better in noisy surroundings because the surrounding people raise their voice above the level of patient’s threshold of hearing. Eg. , Otosclerosis. HEADACHE AND PROJECTILE VOMITTING: Intracranial complication of otitis media.

7. EXAMINATION OF EAR Pre auricular region Pinna Post auricular region EAC TM Middle ear mucosa 3 finger test Facial nerve examination Tuning fork test Fistula test

8. PREAURICULAR REGION Sinus – pre auricular sinus Fistula Scar Swelling – cystic, lymphadenitis

9. EXAMINATION OF PINNA INSPECTION Size - anotia , microtia Shape - cauliflower ear, bat ear Colour - red (perichondritis)  Position - displacement of auricle forwards, laterally or inferiorly – mastoid abscess Swelling Scar Ulcer PALPATION Digital palpation of cartilage and soft tissue Soft tissue – mobility, thickening, swelling Raised temperature, tenderness Cartilage – defect or loss Tragal tenderness

10. POSTAURICULAR REGION INSPECTION Scar, dermatitis, swelling, fistula Change in mastoid contour PALPATION Skin – mobile Raised temperature Swelling – margins, cystic Iron out mastoid in coalescent mastoiditis

11. EXAMINATION OF EXTERNAL AUDITORY CANAL (EAC) Direct examination without speculum Size of meatus – atresia/wide/narrow Content of meatus – wax, discharge, FB, Polyp Digital examination Adults – pinna pulled upwards, backwards and laterally, tragus pulled forwards Children – pinna pulled downwards and laterally Look for furuncle, swelling & Rule out Fungal infections ( otomycosis ) Polyp => probe test – if able to all around arise from middle ear

12. Impacted wax – whole EAC occluded Tumours With speculum examination – Introduce in a slow rotatory fashion upto cartilage only Cough due to vagal irritation Sagging of posterior superior EAC – cholesteatoma , mastoid abscess, mastoiditis Absence of sensation in post sup EAC – Hitselberger’s sign – mass lesion in CP angle

13. EXAMINATION OF TYMPANIC MEMBRANE Colour Cone of light in the antero-inferior quadrant - Present/ Absent/ Distorted Handle of malleus- Normal or Foreshortened Lateral process of malleus- Normal or Prominent Anterior and posterior malleolar folds Retracted Mobility- with Valsalva manoeuvre or Toynbee, Siegel’s Pneumatic speculum, Pneumatic otoscope, EOT under microscope or endoscope.

14. Perforation - Site(AI, PI, AS, PS), shape, margins Condition of remaining TM - Congested or pale, Mobile or not Middle ear mucosa - congested, edematous, granulation tissue

15. MIDDLE EAR EXAMINATION Only through the perforation/ if TM thinned out/ semitransparent Middle ear mucosa – oedema / polyp Granulation tissue Ossicles , ET, round window, oval window FB/ Fistula EUSTACHIAN TUBE EXAMINATION Posterior rhinoscopy / Nasopharyngoscopy / DNE/ Through perforation Valsalva Maneuver ET catheterisation – check patency of ET TUNING FORK TESTS Rinne’s Weber ABC

16. TRAGAL SIGN Press tragus inward and outward Pain produced- tragal sign positive ( Eg . Otitis externa ) No tenderness – tragal sign negative FISTULA TEST Done with the use of tight fitting Siegel’s pneumatic speculum, by varying external auditory canal pressure, by alternate pressing and releasing of the speculum, look for nystagmus in the eyes Inference: The examiner looks for nystagmus when patient says vertigo. During the positive pressure, nystagmus towards the side of the lesion. During negative pressure, nystagmus towards the opposite side of the lesion

17. Po sitive fistula test -nystagmus present: Presence of fistula in the lateral semicircular canal Eg.1. CSOM-AAD . 2. Post-surgical - Fenestration surgery , Ty pe V tympanoplasty , Ac cidental injury of lateral se micircular canal during Mast oidectomy , Temporal bone fracture N egative fistula test: No fistula present False positive fistula test: Nystagmus present - fistula test positive without f istula . Eg : 1. Early Meniere’s disease – Enlargement of saccule pressing a gainst the foot plate of stapes ( Hennebert’s sign) 2. Abnormally mobile foot plate due to laxity of the annular l igament – Congenital Syphilis 3. TULLIO phenomenon – it is a noise induced vertigo False negative fistula test: Fistula test is negative inspite of the presence of fistula eg . Dead labyrinth

18. THREE FINGER TEST Middle finger – on cymba concha, tenderness seen in mastoid antrum infection I ndex finger - on posterior border of mastoid cortex tenderness seen in Mastoid emissary vein thrombosis due to l ateral sinus thrombophlebitis Thumb - o n mastoid tip tenderness positive in t ip cell infection

19. FACIAL NERVE EXAMINATION Look for: Wrinking of forehead/ closure of eyes/ loss of naso labial folds/ deviation of angle of mouth/ cant whistle or blow Changes in taste sensation and perception of hearing Inspect External auditory meatus for herpetic lesions

20. COMMON THROAT SYMPTOMS SORE THROAT Onset Duration Aggravating factors & Relieving factors THROAT PAIN Onset Duration Progressive or not Nature of pain Aggravating factors & Relieving factors Radiating or not ( Referred Otalgia ) DIFFICULTY IN SWALLOWING Onset Duration Progressive or not Type of food for which swallowing is difficult ODYNOPHAGIA Onset Duration Aggravating factors & Relievingfactors MOUTH BREATHING - Duration VOICE CHANGE Onset Duration Type of voice change (Hot potato, Hoarse or breathy) HALITOSIS - Duration FEVER RECURRENT URTI

21. EXAMINATION OF ORAL CAVITY INSPECTION Mouth opening Restricted - Trismus, dislocation, arthritis Lips - ulcer, colour change, swelling, scar Tongue - colour, cracks/fissures, swelling, ulcer, lingual thyroid, mobility (tongue tie, malignancy) Buccal mucosa Hard Palate Teeth Gums Floor of mouth PALPATION Cyst, swelling, thickening Malignant – hard, benign – firm Ulcer / Abscess Lymph nodes Bimanual palpation – floor of mouth

22. EXAMINATION OF OROPHARYNX Base of tongue, vallecula Anterior & Posterior pillars Tonsil Palpation – hard ( tonsillolith , malignancy), on squeezing – pus (acute), cheesy material (chronic) Post Pharyngeal wall – congestion, discharge, ulcer, bulge (Abscess) Soft Palate – congestion, ulcer, movement Bimanual palpation - styloid Look for Pulsations – ICA anuerysm Uvula – bifid X CN palsy – deviation of soft palate and uvula to healthy side

23. INDIRECT LARYNGOSCOPY Structures visualised: Posterior one third of tongue Lingual tonsils Vallecula Glossoepiglottic folds Epiglottis True and False vocal cords Arytenoids Rings of trachea Movement of vocal cords

24. Laryngopharynx Pyriform Fossa – on either side of aryepiglottic folds Pooling of saliva – obstruction to swallowing at level of upper oesophagus Post cricoid malignancy Ulcer, swelling

25. Examination of Ulcer Inspection Site Size and shape Number Position and extent Edge – tubercular (undermined), carcinoma (everted), inflamed in spreading ulcer, bluish in healing ulcer Floor Surrounding area PALPATION Tenderness Margins ( between normal epithelium and ulcer) Edge (between margin and floor) Hardness (induration), thickening (chronic) Base, Floor & Depth of ulcer Bleeding Relation with deeper structures (Fixed – malignancy)

26. Examination of Neck SWELLING Inspection Site Number Size Extent – ant to post, med to lat , sup to inf Colour (blue- ranula ) Surface (irregular – malignancy, smooth – cyst) Skin over swelling – colour , ulcer, scar Edge – smooth(benign), irregular – malignancy) PALPATION Surface – smooth, irregular Fixation of skin – malignancy, seb cyst Edge – irregular, smooth and well defined Pulsations – vascular tumours ( CB, aneurysms) Temperature, Tenderness Consistency – soft, hard Reducibility & Compressibility Relation to Sternocleidomastoid- superficial, deep Translucency Mobility

27. Impulse on coughing – if swelling in continuity with cranial or spinal cavity – meningocele Movement on deglutition – if fixed to larynx or trachea – thyroid Movement on protrusion of tongue – thyroglossal cyst Percussion – Laryngocele Auscultation – bruits and murmurs

28. EXTERNAL EXAMINATION Examination of Neck Inspection - Tracheal position, visible scars & sinuses, movement on deglutition and breathing Palpation - Laryngeal crepitus, tenderness ( perichondritis ), Scars, Neck nodes Auscultation – vascular swelling, stridor Examination of Lymphnodes Location Laterality Number Consistency – hard, rubbery, soft, Discrete or matted Tender Fixation to skin, deeper structures Mobility (both transverse and vertical planes) Surface

29. IMPORTANT SIGNS IN ENT AQUINO'S SIGN: Glomus tumors blanching of the tympanic mass with gentle pressure on the carotid artery BATTLE SIGN: Bruising behind ear at mastoid region seen in petrous temporal bone fracture (middle fossa #) BEZOLD'S SIGN: Inflammatory edema at the tip of the mastoid process seen in mastoiditis BROWNE'S SIGN: Glomus tumor blanching noted when applying positive pressure with Siegel's speculum DELTA SIGN: Lateral sinus thrombosis CT or MRI with contrast shows an empty triangle appearance of the thrombosed sinus surrounded by contrast enhanced dura (empty triangle sign) GRIESINGER'S SIGN: lateral sinus thrombosis -Erythema and oedema posterior to the mastoid process resulting from septic thrombosis of the mastoid emissary vein HALO SIGN/ HANDKERCHIEF SIGN: CSF rhinorrhea CSF will separate from blood when the mixture is placed on filter paper resulting in a central area of blood with an outer ring or halo

30. HENNEBERT'S SIGN: false positive fistula test fistula of horizontal semicircular canal meniere's disease or congenital syphilis IRWIN MOORE’S SIGN: chronic tonsillitis LIGHT HOUSE SIGN: Acute suppurative otitis media small pin hole perforation with a pulsatile ear discharge OMEGA SIGN: seen in laryngomalacia PHELP’S SIGN: glomus jugulare loss of crest of bone between carotid canal and jugular canal RISING SUN SIGN: red vascular hue seen behind the intact tympanic membrane in glomus tumour SCHWARTZ SIGN: Seen in active phase of otosclerosis(otospongiosis) due to increased vascularity in submucous layer of promontory aka flamingo flush sign STEEPLE SIGN: Seen in Acute laryngotracheobronchitis - presence of edema in the trachea, which results in elevation of the tracheal mucosa TEAR DROP SIGN: Seen in Orbital floor fracture, a tear drop shaped opacification seen hanging from the roof of the maxillary sinus on water's view THUMB SIGN: Due to enlarged epiglottis seen in Epiglottitis