Ent Examination 1

8/11/2019 Ent Examination 1

1/13

Dr JALAL H

EAR EXAMI NATION

Introduction: -Good morning Sir / Madam

- My name is Dr.-May I examine your ear

-Is there any pain in or around your ear?

I nspection:

[Inspect the pre-auricular, pinna and post-auricular region]

- On inspection of the ear, there is no abnormality noted, pinna appears to be normal, there is no

Scar, no sinus noted. (Tag, deformity, low set ears)

-

Palpation:[Palpate the tragus, pinna, mastoid]

-

There is no pain on manipulation of the tragus, pinna and no mastoid tenderness

I would like to proceed with otoscopic examination.

[Explain to patient that Im going to insert a speculum into the ear canal]

- On otoscopic examination, the external canal is patent, skin appears to be normal, no scar seen

(endaural), no discharge, no mass or granulation tissue seen.

(Wax, pus discharge, bleeding, swollen EAC, anterior hump, polyp, granulation tissue, keratin, widen

EAC, any meatoplasty)If there is mastoid cavity: the mastoid cavity is present, facial ridge is high or low, the cavity is well

epithelized, no pus discharge, no keratin or granulation seen.

- The tympanic membrane appears intact, normal colour, not retracted, handle of malleus is in

normal position and cone of light is present.

(Attic retraction, scutum erosion, keratin)

(Tell examiner) I would like to proceed to examine the other ear

Then tell that I want to examine both ears under microscope.


2/13

Dr JALAL H

I would like to assess the hearing with Tuning fork and free field voice test .

- Explain to patient what Im going to do.

- Perform Rinnes test first: Strike the tuning fork {be gentle should not be so loud that examiner

also hears} and hear myself first then put in front (1.) of the ear then mastoid (2.). {Please support

patients head} Ask patient which one (1. or 2.) louder.

-

Then Weber test: Place on forehead and support head at the back. Ask right/ left or loud at centre.

I would like to proceed with Free field test

- Explain to patient, tragal rub for masking and branys noise box (90-110) for shout,

- Use 9CH, 64D

- Whisper at 2 feet normal

-

Whisper at 6 incharound 30dB loss

- Conversation speech at 2 feet50dB loss

- Conversation speech at 6 inch60dB loss

- Loud/shout at 2 feet 80-90 dB loss

- Loud/ shout at 6 inch> 90dB loss

And to complete my examination, I would like to do fistula test, examine for nystagmus and all the

cranial nerves especially facial nerve.

At last complete ENT examination nose, throat, and neck.

Thanks the patient before leaving the room

.

Siegelisation


3/13

Dr JALAL H

NOSE EXAMI NATION:


- My name is Dr.-May I examine your nose

-Is there any pain in or around your nose?I nspection:

From front, right and left side: no obvious swelling, scar, deformity or deviation seen.

From up: please lift hair and check for bicoronal flap

Look nose from upno scar, deformity (look for light reflection on nose)Look for proptosisLook for maxillary prominence

From down: look for deformity

Look for collumella scar

Please check for sinus tenderness (Frontal, ethmoidal, maxillary (on canine fossa is thinnest)

Cold spatula test:fogging is symmetrical from both side or unequal

(Explain to patient that u want to look for air vapor, pls breath normally)

On lifting the nasal tip:check for any collumella scar, comment on vestibule, any caudal dislocation,

any discharge

Anterior rhinoscopy: [inform examiner that u would like to proceed with antr rhinoscopy using killians

forceps then explain to patient that it wont hurt but let u know if there is any pain.]

Comment on- mucosa (pale or pink)

- size of IT (ITH or boggy),

- MT, middle meatusany discharge, any polyp, mass or crusting, concha bullosa

- floor of the nose,

- septum (any deviation, perforation, littles area)

- Any ulceration, mass lesion,

Cottles sign ask the patient to sniff and look for alar collapse (+ve)

Cottles testpull the cheek gently laterally ask the patient to breath, if better or improved test is +ve

Posterior rhinoscopy examn (ET, FOR, nasopharynx). I would like to conform my finding using rigid

nasal endoscope

Proceed with oral cavity examn: Please ask patient to remove denture. Any oroantral fistula, palate

pushed down, sensation of palate.Check buccogingival sulcuspalpate for any mass (nasal of

nasopharyngeal mass through ITF enter buccogingival sulcus. IDL, Ear and neck examn, cranial nerve

examn


4/13

Dr JALAL H

NECK EXAMI NATION


- My name is Dr.-May I examine your neck

-Is there any pain anywhere?

I would like to expose the neck from chin until upper chest for proper examination

I nspection

Look front, sidescomment on scar, mass, etc then describe the mass

Swallow, protrude tongue: any mass moving

Palpationplease explain to patient and ask if there is any pain

-

Get behind the patient

- Start from 1a, 1b, 2, 3, 4, 5a, 5b, preauricular, post auricular and occipital.

If any mass obvious please examine the mass first then proceed with other neck level

Mass:

Inspection: site (right or left), location (level), size, surface, any pulsation, scar, sinus, margin, movement

on swallowing or deglutition if central. Please check whether superficial or deep to fascia and muscle.

Palpation: inspectory findings are confirmed. Any tenderness, consistency, movement vertically or

horizontally. Whether pulsatile. Mobile or fixed to underlying structures.

If thyroidalso check for eye signs, pulse, tremor, and warmth of skin, IDL or FNPLS for vocal cord

movement.

Check for bruit for vascular tumours, Check for laryngeal crepitus

Inform that I would like to do complete ENT examination and cranial nerves examination.

Neck swelling usually will be thyroid, branchial cyst or lymph node, li poma.


5/13

Dr JALAL H

LARYNX EXAM INATION


- My name is Dr.-May I examine you?

-Is there any pain anywhere?

Adequate neck exposure

Inspection of neck: from front, sidesany scar, deformity.

- Ask patient to tell his name and addressto assess the voice, good voice -vocal cord meeting, no

hoarseness

- Ask patient to take deep breathand lean nearer to hear stridor

-

Request patient to count 1-10 in a single breathif canno air leakvocal cord meeting (goodapproximation of glottis)

-

Request patient to coughgood coughable to produce good sub-glottic pressure

- Please check for laryngeal crepitus

IDL:

- Explain procedure to patient

- Need to open mouth, protrude tongue, breath using your mouth

-

Request patient to open mouth and assess the oral cavity big cavitycan use bigger mirror

- Try to use bigger mirrorbetter view

- Please use proper IDL mirror - dip in cetrimide (if using heatcheck on your hand whether too

hot before placing inside the mouth.

- Request patient to protrude tongue

- Hold at centre of tongue not the tip of tongue

-

Hold with thumb down, index finger at centre of tongue, middle finger lift the upper lip

- Introduce IDL mirrordo not touch PPWpt will cough

- Comment on mucosa of larynx, vocal cord movement, epiglottis, pyriform sinus, aryepiglottic

fold, vallecula, base of tongue

- If gag or unable to visualize well, ask for flexible or 70 degree scope.


6/13

Dr JALAL H

CRANIAL NERVE EXAMI NATION:

Introduce yourself

I.Olfactory: if testing close one nose and test the other.

Coffee, vinegar, ammonia (trigeminal nerve)

II.Optic:

- visual acuityask patient read your name in name tag, snellen chart, or ask to read poster in the

clinic room

- visual fieldask patient to look straight, from the side bring a red pin and ask patient whether can

see the object

III, IV, VI:

-

follow light left, right, up, downcheck eye movementH direction

- with lightcheck for divergence and convergence

-

papillary reflex- 2 and 3 nerve

V: Trigeminal nerve

Sensory component: Corneal reflex

Papillary reflex

Sensation of face (ophthalmic, maxillary, mandibular) ask to close the eye andis sensation felt and equal

Hard palate sensation

Motor component: Clench teethpalpate masseter m

Ask to open against resistance, palpate the pterygoid m

VII: Facial nerve

Check all five branches

Lift the eyebrows, frown - test for temporal branch

Close the eyes tight and open against resistance - test for zygomatic branchBlow the cheeks and dont let air leak - test fir buccal branch

Show the teeth - test marginal mandibular branch

Ask to contract the platysma muscle - test for cervical branch


7/13

Dr JALAL H

Please comment on 4 aspects:

i) patient has got left or right facial nerve palsy

ii) UMN or LMN

iii)

Partial or complete

iv)

HB grading

If the patient has got VII nerve palsy please tell examiner or straight away examine 4 areas:

1) Mastoidlook for scar, post op developed facial nerve palsy

2) EarEAC, retraction pocket, cholesteatoma, tumour

3) Oral cavityparapharyngeal tumour causing the VII nerve palsy and medialising lateral

pharyngeal wall.

4)

Examine parotidtumour causing facial nerve palsy

VIII: Vestibulocochlear nerve - Tuning fork, Free field

IX Glossopharyngeal- - Gag reflex, Soft palate sensation

X:Vagus - - VC movement (need to do IDL), cough, count 1-10, gag reflex

XI: Accessory nerve - - Shoulder movement, SCM and trapezius

XII:Hypoglossal nerve - Tongue movement


8/13

Dr JALAL H

LONGCASEPRESENTATION

Mr. /Mrs. --------------- -------- years old M/C/I gentlemen / lady

HISTORY:

Presented with C/C -

PERSONAL HISTORY: smoker, alcoholic,

PAST MEDICAL HISTORY: DM, HTN, Asthma, Cardiac disease

Drug history, allergy

FAMIL HISTORY:cancer,


9/13

Dr JALAL H

O/E:

Patient is sitting comfortable, no pallor, no jaundice,

1.

Voice 4. Facial asymmetry2.

Cough 5. No drooling of saliva, able to close the eye completely

3.

Count 1-10

EARS:

Rt Lt

Inspection 1. Abnormality, same2. Scar, no sinus

Palpation pain 1.tragus,2. Pinna same3. Mastoid tenderness

Otoscopy examination

EAC: 1.patency2. Skin same3. Scar seen (endaural),4. Discharge, mass or granulation tissue5. Mastoid cavity

TM: appears intact, normal colour, not retracted, sameTM movement is normal,

Handle of malleus is in normal position and

Cone of light is present.

[Mastoid cavity is present, facial ridge is high or low, the cavity is well epithelized, no pus discharge, no keratin or granulation]

Tuning fork - Rt Lt

Rinnes + +

Webers ------------------

Free field voice test: Patient able to hear whisper at 2 feet indication normal hearing

Fistula test- Negative / Positive


10/13

Dr JALAL H

NOSE:

Inspection:

1> Front: breathing with mouth closed, No obvious swelling, scar, deformity or deviation seen

2>Top: No bicoronal scar, no deformity [light reflection on nose]No proptosis

Maxillary prominence appears normal

3> Below:No deformity, No collumella scar

Palpation:

1.

Sinus: No sinus tenderness

2. Cold spatula test: Equal and adequate airflow on both side

3. On lifting the nasal tip: No collumella scar,

Vestibule is normal,

No caudal dislocation,

No discharge

4. Cottles test

5. Numbness:

Anterior Rhinoscopy:

1. Mucosa: pale or pink

2. IT: ITH or boggy

3. MT, middle meatus: No discharge, polyp, mass or crusting, concha bullosa

4. Floor of the nose:

5. Septum:No deviation, perforation, littles area

Posterior rhinoscopy:(ET, FOR, nasopharynx)


11/13

Dr JALAL H

ORAL CAVITY:

1. Mouth opening

2. Denture:

3.

Lips:

4. Buccogingival sulcus:

5. Oral hygiene/ Teeth:

6. Retromolar region:

7. Floor of oral cavity:

8. Tongue: - ulcer - movement

9.

Palate:

10.Parotid duct opening:

Palpation: tongue, mass

OROPHARYNX:

1. Tonsil:

2.

Posterior pharyngeal wall:

3. Gag reflex:

IDL:

1. Base of tongue

2. Vallecula

3. Epiglottis

4.

Piriform fossa

5. Arytenoids

6. Vocal cord

7. Post cricoid area


12/13

Dr JALAL H

NECK:

Inspection:

1.

Scar , swelling, engorged veins

2.

Swallowing / protrusion of tongue

Palpation:

1.

Trachea

2. Laryngeal crepitus

3.

Lymph node level

CRANIAL NERVE:


13/13

Dr JALAL H

SWELLING

Inspection

1. Site

2.

Size cm * cm

3. Skin overlying, - redness -scar -sinus

4. Relation to surrounding area

5.

Pulsation

Palpation

1.

Confirm size, site

2. Multiple/single

3. Tenderness

4. Consistency

5. Mobile/ fixed

6.

Edges

7.

Skin overlying -Attached - warm

8. Relation to muscle -superficial -deep

9. Auscultation

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Ent Examination 1