ENT Clinical skill

dr. Pulo R S Banjarnahor, Sp THT-KL

dr. Reno H Kelan, Sp.THT-KL
 EXAMINATION OF THE
PATIENT
 In order to examine the
ear, nose and throat of
the patient one needs a
good source of light and
specialized instruments.
 Light Source: Head light.
Instruments:

 Ear specula,
 Nasal Specula,
 Tongue depressors,
 Indirect laryngoscopy mirrors,
 Posterior Rhinoscopy mirrors,
 spirit lamp,
 Jobson-Horne ear probes,
 Nasal and aural forceps.
 Barany's noise box,
 Seigle's speculum,
 Tuning forks, 512 Hz, 1024 Hz,
 Otoscope.
 Seat of patient:
 Revolving stools, both for the patient and the
examiner. The patient sits on the stool at the
same level as the doctor.
 Patient's legs should be to one side of the
examiner.
 The distance between the doctor and patient
should not be more than 8 inches.
EXAMINATION OF THE EAR
 Examination of the ear includes :
 1. Pinna,
 2. External auditory meatus,
 3. Tympanic membrane,
 4. Middle ear,
 5. Tests for the function of Eustachian tube,
 6. Tests of hearing,
 7. Tests of balance,
 8. Eyes.
 9. Post aural area (Mastoid process), and lymph nodes.
 Examination of the Pinna:

 Shape,
 Size,
 Symmetry,
 Signs of inflammation,
 Ulcers.
 Note the condition of the canal skin, and the
presence of wax, foreign tissue, or discharge.
The mobility of the eardrum can be evaluated
using a pneumatic speculum, which attaches to
the otoscope. The drum should move on
squeezing the balloon.
 Pre aurikuler pit/sinus
 Pre aurikuler tag
 Mikrotia
 Atresia liang telinga
 Mastoiditis

 Fistel Mastoid
 Serumen
 Otits eksterna

 Eksostosis liang telinga

 Otomikosis

 Benda asing liang telinga

 OTOSCOPY:

 Methods:
 Electric Otoscope: It consists of a
speculum, handle and a magnifying
attachment (1.5-2 x).
 Technique:
 The pinna is pulled upwards,
backwards and outwards.
 The speculum of appropriate
size is introduced along the
axis of the meatus with a
rotating motion using the left
hand for the right ear and the
right hand for the left ear. The
wall of the bony meatus must
not be irritated as it is very
sensitive.
 OTOSCOPY:

 One hand is left free for

instrumentation.

 In infants and young children

the pinna is pulled downwards
and backwards to straighten
the meatus.

 Wax and other debris must be

removed for adequate
examination.
 Mistakes:
 A speculum that is too
narrow will penetrate the
bony EAM.
 A speculum that is too large
will not enter the
cartilaginous meatus.
 Unsatisfactory cleaning of
the debris will hinder view.
 Tympanic membrane: (Using naked eye, otoscope, and
otomicroscope)

 Position,
 Colour: Hemorrhage,
dullness, blue, bullae
 Ossicles
 Perforations: Marginal
and Central, site, size.
 Mobility: (Retractions) by
using a pneumatic
otoscope, or Siegle's
speculum.
 Middle ear:

 Can be examined
through a perforation.
Look at the colour of
mucosa, edema,
discharge, polyps,
promontory.
 Membran timpani normal
 Otitis media serosa
 Otitis media serosa dengan ventilating tube
 Timpano sklerosis

 kolesteatoma
 Glomus tumor telinga tengah
 Otitis media supuratif kronik (Omsk) benigna
(tenang)
 Otitis media supuratif kronik (Omsk) maligna
 Tests for Eustachian tube functions

 Qualitative Methods:
 i] Valsalva Maneuver:

 Principle: Demonstration of tubal

patency without external aids.

 Method: After taking a deep

breath, the patient pinches his nose
and closes his mouth in an attempt
to blow air in his ears. Otoscopy
shows movement of the drum.
Auscultation reveals crackling.
 Tests for Eustachian tube functions

 Qualitative Methods:
 i] Valsalva Maneuver:

 Note: Failure of this test does not

prove pathologic occlusion of the
tube.

 This maneuver in the presence of

nasal and nasopharyngeal infection
carries the danger of transmission
of infection to the ear.
 Tests for Eustachian tube functions

 ii]Toynbee's test:
 Principle: It is safer and
confirms normal tubal
function.
 Method: The nose is closed
and the patient swallows.
There is in drawing of the
tympanic membrane,
confirmed by otoscopy and
on auscultation when a noise
is heard.
 Quantitative Methods:
 Acoustic impedance Tympanometry.
 Tuning Fork tests: (A C1 fork of 512 Hz is used).
i) Weber's test:

 Principle:
It is dependent on binaural comparison of bone
conduction.
 Method:
- The tuning fork is placed in the center of skull at the
hairline.
- The patient with normal hearing will hear equally in
both ears.
- The patient with a unilateral conductive hearing loss
localizes the tone in the diseased ear.
- The patient with a unilateral sensorineural loss will
localize to the healthy ear.
ii) Rinne's test:
Principle:
This test rests on monaural comparison to bone
conduction.
Method:
-The patient can tested in two ways; i) Duration, ii)
Intensity.
-The patient is asked whether the tuning fork placed
in front of the ear or behind the ear on the mastoid
is heard better.
Results:
- If air conduction is better than bone conduction,
Rinne's test is positive. This is the finding in normal
ear and in sensorineural deafness.
- If bone conduction is better than air conduction,
Rinne's test is negative. This is found in conductive
deafness.
iii) Schwabach's test:
Depends on comparison of the bone conduction of the
patient with that of the examiner.
iv) Bing test:
Increased loudness for bone
conducted sound less than 2 kHz,
occurs in the normal or sensorineural
deafness when the EAM is occluded
without increasing the pressure ( As
the masking effect of air conducting
sound is removed). There is no change
in conductive deafness.
 Tests for non-organic hearing loss:

Stenger test:
Principle:
-If sounds of identical frequency but different intensity are presented simultaneously
to each ear, only louder sound will be perceived.
-The test can be performed with tuning forks or an audiometer.

Method:
- The examiner stands behind the patient.
- A tuning fork is struck and is held 20 cm from the good ear - the patient hears the sound.
- The fork is then removed and placed 5 cm from the bad ear - patient 'denies' hearing
sound.
- Another fork is the held 15 cm from the good ear without the patient noticing.
- If there is genuine hearing loss patient will the fork in the good ear.
- But if there is non-organic loss the patient will be unable to hear the fork in the good ear
as the fork is closer in his 'bad' ear.
 Tests of Balance

Romberg test
Method:
- Patient stands upright with the feet
parallel and close together, eyes closed
,and the arms folded in front of the
chest or outstretched.
Results:
- Unilateral peripheral lesion or a
unilateral cerebellar lesion, the patient
tends to sway towards the affected
side.
- Central lesions give irregular pattern
of sway.
Unterberger's Stepping test

Method:

Stepping on one spot with the eyes closed.

Result:

-Peripheral lesions- rotation of the body axis

to the side of the labyrinthine lesion.
-Central disorders- the deviation is irregular.
-Deviations of greater than 40 degree are
significant
Finger-nose pointing test:

Method:

-The index finger of the outstretched

hand is brought to the point o the
nose with the eyes closed.
Result:

-Ataxia and disorders of coordination

indicate an ipsilateral cerebellar lesion
or a disorder of positional sense.
Positional testing ( Dix - Halpike
method).

Principle:
- Screening test for Positional
nystagmus.
- Nystagmus induced or aggravated by
this test is attributable to cervical
proprioceptors and vertebral artery
compression.
Positional testing ( Dix - Halpike
method).
Method:
-(With the head in different positions).
- The head is firmly grasped with the
patient sitting on a couch.
- The patients head is rotated 45 to
one side and then the other while he is
made to assume the supine position
with the head hanging 30 below the
edge of the table. The head is kept in
this position for some time.
- The eyes should be observed for
nystagmus.
 Examination of the nose

The nose can be examined

in three parts:
1. Examination of the
external nose,
2. Anterior Rhinoscopy,
3. Posterior Rhinoscopy.
 Examination of the External Nose:
Inspection: Palpation:
Congenital deformities: It is carried for;
Clefts, sinuses. tenderness,
Acquired Deformities, crepitus, and
Shape, deformities.
Swelling, ( Inflammatory, Tenderness over the tip is
cysts, tumors) due to a boil. Over the
Ulceration ( Trauma, dorsum is due to trauma.
neoplastic, infective).
 Loss of smell (anosmia) is a relatively common
problem, though often undiagnosed. In patients who
make mention of this problem, olfaction can be crudely
assessed using an alcohol pad sniff test as follows:
 Ask the patient to close their eyes so that they don't
get any visual cues.
 Occlude each nostril seqeuentially, making sure that
they can move air adequately thru both.
 Occlude one nostril and then present an alcohol pad
to the other side, asking the patient to inform you
when they are able to detect its smell.
 to detect the odor of the alcohol pad at a distance of 10
cm. Alcohol is used for convenience, as most exam
rooms have these pads. More sophisticated testing can
be done using vials containing very distinctive odors
(e.g. coffee grounds)
 Anterior Rhinoscopy:
It consists of the following steps:
1. Examination of the vestibule (Skin lined part of the nares)
2. Examination of the nasal cavity using the Thudichum's
speculum
3. Patency tests
4. Probe test
5. Examination after vasoconstriction.
 Examination of the vestibule:
 This is carried out by tilting the tip of nose
 The lining which is skin and has all the dermal
appendages (Hair, sebaceous glands etc.). All the
diseases affecting these adnexa can occur in the
vestibule.
 Ulceration may be neoplastic, infective.
 Excoriation because of discharge.
Examination of the nasal cavity using a speculum:
Nasal speculum:

It is an inverted 'U' shaped instrument. It has two blades

at the lower end.
 Method of holding the instrument:
-Hold it in the left hand keeping the right hand free for
other instruments.
-Pick the instrument with the thumb and the index finger
of the L hand with the blades directed towards the
elbow.
-The loop is directed downwards.
-Pronate the forearm and flex the wrist there by aligning
the blades with the nares.
-The legs of the speculum are controlled by the middle
and the ring fingers.
Use of the speculum:

-The axis of the anterior nares is upwards and backwards,

whereas that of the posterior nares is horizontally
backwards. Lift the tip of the nose with the blades so that
the two axes are in straight line
-Introduce the speculum with the blades closed..
-Introduce the speculum in an upwards and backwards
direction.
-Once inside the nose, gradually open the blades avoiding
discomfort to the patient.
-Look at roof, floor, lateral and medial walls of the nose.
-Septum: Position, spurs, deviation, colour of mucosa,
ulcers, crusting, vessels, and perforations.
-Lateral wall: Inferior and middle turbinates, size ,colour,
shape.
noting:
The color of the mucosa. It can
become quite reddened in the setting
of infection.
The presence of any discharge as well
as its color (clear with allergic
reactions; yellowish with infection).
The middle and inferior turbinates,
which are shelf-like projections along
the lateral wall. Any polypoid growths,
which may be associated with allergies
and obstructive symptoms?
The other nostril is examined in a
similar manner.
 Meatii for pus and discharge, and polyps.
 Middle meatus is situated higher up so tilt the head
backwards at an angle of 45. If any growth or polyp is
suspected confirm by the probe test.
Probe test:

Itis carried out by spraying the nose with 4% Lignocaine

with 1:100000 adrenaline or 10% cocaine.
The lesion or area is palpated to determine its character
and mobility.
Patency test:
By placing a cold tongue depressor or a wick of cotton
below the nostril, nasal patency can be assessed.
Compare the two sides always.
transiluminasi
 Posterior Rhinoscopy:
 It is carried out to examine the post nasal space
(nasopharynx). It is a difficult space to examine so the
disease may be hidden for quite a long time
 Post nasal mirror.
Method of Posterior Rhinoscopy
 Post Nasal Mirror:
 it consists of a handle on which a small mirror is
attached to shaft at an angle of 110. There is
another angulation in the shaft.
Technique:
Hold the mirror like a pen in the right hand.

Warm the mirror slightly on the flame of the spirit lamp

to avoid condensation from the expired air.
Ask the patient to open the mouth.

Take the tongue depressor in the left hand and depress

the anterior 2/3rds of the tongue.
Feel the warmth of the mirror on the back of the wrist.
It should not be hot.
 Introduce the mirror from
the angle of the mouth over
the tongue depressor and
slide it behind the uvula.
Avoid touching the posterior
wall of the pharynx as it may
trigger gagging.
 Instruct the patient to breath
through the nose.
 Tilt the mirror in different
direction tot see various
structures of the
nasopharynx.
 EXAMINATION OF THE
THROAT
 The throat consists of the ; oral cavity ,and the
oropharynx
ORAL CAVITY
It includes the following
structures:
Lips

Teeth

Gums

Tongue

Hard and soft palates,

Floor,

Cheeks.
OROPHARYNX
It includes the following
structures:
Uvula,
Soft palate,
Anterior and posterior tonsillar
pillars,
Tonsils,

Posterior pharyngeal wall.

 Lips: Common site for carcinoma,
herpes and primary syphilis.
 Teeth and gums: Bleeding from
gums, state of dentition, foul
discharge from a tooth, sensations.
 Tongue: It includes the anterior
2/3rds,
 posterior 1/3rd,

 tip.

 dorsum and

 the margins.
Check for: Tongue:
 common and taste
sensations,
 size: Macroglossia in
acromegaly, Down's
syndrome.
 ulcers: Traumatic, dental,
apthous, malignant,
tuberculous, syphilitic.
 movements: Restricted in hypoglossal palsies,
tumor infiltration.
 fasciculation: Motor neuron disease,
 depapillation: Vitamin deficiencies,
 furrowing , as in geographic tongue
 coating: Thrush, black hairy tongue.
 Hypoglossal palsy: Tongue deviates towards the
lesion.
 Cheeks: Parotid duct opening
Opposite upper 2nd molar),
red or white patches, ulcers,
moisture.
 Palate: Swelling, ulcer,
movement, perforations,
clefts etc.
 Uvula: Position, deviations
(Towards the normal side in
palsies), ulcers.
 Tonsillar pillars: Linear congestion, ulcers, patches.
 Tonsils: Presence, size, crypts, ulcers, express the contents of the
crypts by pressing on the pillars to see whether purulent.
 Posterior pharyngeal wall: Lymphoid follicles, ulcers.
 Floor of mouth: Wharton duct openings, ulcers, and bimanual
palpation.
 Teeth and occlusion
 The upper and lower vestibule of the cheek.
 Tonsillar grading
 T0 = sdh dilakukan tonsilektomi
 T1 = tonsil sdh melewati pillar anterior
 T2 = tonsil sdh melewati pillar anterior dan
posterior
 T3 = tonsil sdh mendekati/mencapai garis
tengah

o T0 = tonsil masih dalam fossa tonsiler

o T1 = tonsil <dr 25% jarak uvula-pillar anterior
o T2 = tonsil 25%-50% jarak uvula-pillar
anterior
o T3 = tonsil 50%-75% jarak uvula-pillar
anterior
o T4 = tonsil >75% jarak uvula-pillar anterior
INDIRECT LARYNGOSCOPY:
The mirror is plane, on a straight handle.

Mirror is held like a pen in the right hand

with the glass pointing downwards.
Warm the mirror and test the temperature
on the back of the hand.
The patient is asked to stick out the

tongue which is held with a piece of gauze.

 The patient is asked to
breath through the
mouth.
 The mirror is introduced
into the mouth to the
uvula which is gently
pushed back to get a
view of the larynx and
the pyriform fossae.
 The patient is asked to
say 'Aaa' and 'Eee'.
Neck examination
Terima kasih