Nose ear throat examination ent head and neck

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1. EXAMINATION
OFEAR NOSE
&THROAT
BY,
VEDANTHA VINOD
ASSISTANT LECTURER
CCON-MYSORE

2. CONTENTS TO BE DISCUSSED:
•BASIC ANATOMY & PHYSIOLOGY OF
EAR,NOSE AND THROAT.
•HISTORY
•OTOSCOPIC EXAMINATION
•EXAMINATION OF EAR , NOSE AND
THROAT,

3. EXTERNAL
EAR
MIDDLE
EAR
INNER
EAR

5. EAR
EXTERNAL:
•AURICLE/PINNA
•EXTERNAL
AUDITORY
CANAL
MIDDLE:
•OSSICLES
•TYMPANIC
MEMBRANE
•EUSTACHIAN
TUBE
INNER:
•LABYRINTH
•VESTIBULE
•SEMICIRCULAR
CANAL
•COCHLEA

6. •Thevisibleportionthatis
commonlyreferredtoas
"theear"
•Helpslocalizesoundsources
•Directssoundintotheear
•Each individual's pinna
creates a distinctive imprint
on the acoustic wave
traveling into the auditory
canal

7. •Extends from the pinna to
the tympanicmembrane
–About 26 millimeters
(mm) in length and 7
mm in diameter in
adultear.
–Size and shape vary
amongindividuals.
–It contains hair,
sebaceous land,
ceruminouslands(wax)

8. •The purpose ofwax:
–Repelwater
–Trap dust, sand particles, micro-
organisms, and otherdebris
–Moisturize epithelium in ear
canal
–Odor discouragesinsects
–Antibiotic, antiviral, antifungal
properties
–Cleanse ear canal

9. •The eardrum separates the outer
ear from the middleear
•Creates a barrier that protects
the middle and inner areas from
foreignobjects
•Cone-shaped inappearance
–about 17.5 mm indiameter
•The eardrum vibrates in
response to sound pressure
waves.

10. •The eustachian tube (1MM WIDE 35 MM LONG)
connects the middle ear with thenasopharynx
•Theeustachiantubenormallyitisclosed,which
opens during swallowing andyawning
–Thisequalizesthepressureoneithersideofthe
eardrum, which is necessary for optimalhearing.

11. •Malleus
(hammer)
•Incus(anvil)
•Stapes
(stirrup)
smallest
bone ofthe
body

12. •The cochlea resembles a
snail shell and spirals for
about 2 3/4 turns around
a bonycolumn
•Within the cochlea are
threecanals:
–ScalaVestibuli
–ScalaTympani
–ScalaMedia

13. FUNCTIONS
•Hearing
•Balance &equilibrium

14. •History of presentillness
•General –onset, chronology, current situation,
location, radiation, quality, timing, factors,
associated symptoms, previoustreatments
•Cardinalsigns&symptoms:
EAR:Recentchangesinhearing,itching,
earache,discharge,tinnitus,vertigo,ear
trauma,Q-TIPUse

15. •NOSE&SINUSES: Rhinorrhea, epistaxis,
obstruction of airflow, sinus pain &
localised headache, itching, anosomia,
nasal trauma. Sneezing
•MOUTH& THROAT: Hoarseness, dental
chanes, oral lesions, bleeding gums, sore
throat, dysphagia
•NECK: Pain, swelling, enlargedglands
•OTHERS: Fever, malaise,N/V

16. •Medical conditions& surgeries
•Allergies(season)
•Medications
•Herbal preparations

17. MEDICAL HISTORY RELATED
TOENT
•Frequent ear or throat
infections
•Sinusitis
•Trauma to head,ENT
•ENTSurgery
•Seasonalallergies
•Asthma
•Hearingloss
•Meniere’sdisease
•ENTCancer

18. PERSONAL & SOCIAL
HISTORY
•Smoking
•Frequent exposure towater
•Use of foreign object toear
•Overcrowding
•Use of earprotection
•Recent airtravels
•Occupational exposure to toxins or
loud noises

19. •Inspection: auricle & surrounding tissue
should be inspected for deformities,
lesions & discharge
•Palpation:palpatetheauricle–ifpain
–A/CExternalotitis,tendernesson
mastoid–A/CMastoiditis

20. •Tympanic membrane is inspected with
otoscope
•Examinerholdtheotoscopeinright
hand in a pencil holdposition
•Use opposite hand to grasp and gently
pull back theauricle
•Speculumisslowlyinsertedintoear
canal,withexaminer’seyeheldcloseto
thelensofotoscopeandvisualisefor
discharge,inflammation&foreignbody
•AssesstheT.M–Pearlygrayandis
positionedobliquelyatthebaseof
canal–checkforfluid,airbubbles,
blood,massesinmiddleear

21. •Place the base of vibrating tunic fork on
mastoidprocess
•When sound is no longer heard, the fork is
placed just outside (2 Inch)theear
•Normal : 20 sec bone conduction, 30-40 sec
airconduction

22. •Vibrating tunic fork is placed in the
middle of forehead
•Patient is asked to report in which
ear sound is heard louder
•Normal : equal in bothears

23. HEARINGSTATUS WEBER
RINN
E
Normal Equal AC>BC
Conductive Sound is heard bestin
affected ear
Sound is heard aslong
or longer in affected
ear
Sensorineural Sound is heard bestin
normal hearingear
Air conduction is
audible longerthan
bone conduction in
affectedear

24. WHISPER
TEST
•Examiner cover the untested ear with
palm of thehand
•Then the examiner whispers softly
from a distance of 1 or 2 feet from
unoccluded ear and out of the
patientssight
•The patient with normal acuity repeat
what waswhispered.

25. AUDIOMETRY :
•(music tone&speech)
•Frequency –20-20,000Hz
•Pitch –low 100 Hz –High
10,000 Hz Intensity:
•0-15 dB –
normal 15-25 dB-
slight H.L 25-
40dB –mildH.L
•40-55 dB-moderateH.L
•55-70dB –Moderate to severe
H.L

26. •Measure middle ear muscle reflex to sound
stimulation and compliance of tympanic
membrane by changing air pressure in a
sealed earcanal

27. •Electrodes are placed on the patients scalp &
an each ear lobe –connected tocomputer
•They record brain wave activity in response to
sounds you hear throughearphones.

28. •Measurementofgraphicrecordingofthechangesin
electricalpotentialcreatedbyeyemovementsduring
spontaneous,positionals(nystagmus)
•Itisusedtoassesstheocculomotorandvestibular
systemandtheircorrespondinginteractions

29. •Used to assess the vestibulo occular system by
analysing compensatory eye movements in
response to clockwise and counter clock wise
rotation ofchair

30. PRINCIPAL NASALSYMPTOMS
Airwayobstruction
Runnynose (rhinorrhoea)
Sneezing
Lossof smell (anosmia)
Facialpain due to sinusitis
Snoringassociated with nasal
obstruction

31. INSPECTION
Shape -Deviation. Look from the sides&
fromabove.
–Abnormal NasalCreasesDeformities
Scars
Discharge orcrusting
Redness or evidence
of skindisease
Offensive odour (From thePatient)
Rhinorrhoea

32. INSPECTION

•Inspect the front of the nose first
by tipping the nose up and
inspecting without aspeculum.

33. •Insert a Thudicum speculuminto the
appropriate nostril. A light source is
required to visualise the internal
structures.
ThudicumSpeculum

34. •You should be able to identify the
septum medially, the turbinates
laterally. The inferior turbinates
should be easy to visualise.

35. INSPECTION
Inspect for inflammation
(Rhinitis)
Comment on the
septum. Is it straight or
deviated.
Look in the mouth.
Occasionally large
polyps or tumoursmay
be visible from arising
behind the softpalate.
Polyp rightnostril
TURBINATE
SEPTUM

36. PALPATION
•If you see what you believe is a polyp
then it is useful to assess sensitivity.
•Polypsare not sensitive to touch
whereas turbinates are tender totouch.
•Polyps are grey / yellow whereas
turbinates arepink.

37. NASAL AIRWAYASSESSMENT
Holdacoldmetaltonguedepressorunderthe
patient’snosewhilsttheybreathinandout
throughtheirnose.Condensationshouldbe
visibleasairpassesoverthemetal.
Toassessnasalairwayefficiency.Occludeone
nostrilandaskthepatienttosniff.Thisgivesa
reasonableideaonnasalairwayefficiency.

38. THROATEXAMINATION
Enquire on generalhistory.
Sore throat, feeling run down, visible lesions & causingpain.
Ask about alcohol & tobaccohabits.
Ask about their general dentalhistory.

39. INSPECTION1
Ask the patient to remove anydentures.
Inspect the lips. Note the Vermillion border
& the corners of the mouth for anydeviation.
Retract the upper lip with the front teeth
closed together. Note the maxillary labial
frenum,gingivae, mucogingival line with
teeth.

40. Vermillionborder
maxillary labialfrenum
mucogingivalline
gingivae
INSPECTION2

41. INSPECTION3
Note oralhydration
Halitosis?
Note anyvaricosities,
missing teeth, dental
carries, ulceration or
haemangiomas.
Use a bright light & a tongue
depressor, inspect the tonsils,
uvula and the soft palate. Ask
the patient to tilt their head
upwardsto inspect the hard
palate.

42. INSPECTION4
Notethemucosalliningofthecheeks,noting
Stensen’sglands.Locatedbehindthe2
nd
molar.It
carriessalivafromtheParotidgland.
Anyblockagecanrenderthemouthdry.
Note the frenum. Note any ulceration /discharge.
Ask the patient to lift their tongue upwards to
inspect the floor of the mouth. Note if the tip of
the tongue can touch the roof of the mouth.
Failure to do so may indicated tongue tie.
(Ankyloglosia.)

43. PAROTID
The parotid salivary gland is
located over the mandibular
ramus, anteriorly and
inferiorly to theears.
Inspection of stensen’sduct
may require inspectionif the
mouth is dry or if any parotid
swelling is detected upon
externalpalpation.

44. PAROTIDPALPATION
Palpatedbilaterally
Start palpating
anterior to the ears
and move towards
the cheek and
then inferiorly
towards the angle
of the mandible.

45. INSPECTION4
Any further examination of the
larynx requires specialised
equipment.
Inspection of the oral cavity may also
have a neurological element. C.N’s
7.9&12

46. ANY DOUBTS?