ENT Clinical skill

dr. Reno Hardoyo kelan Sp THT

 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. Cranial nerves
 10. 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.
 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
 Om serosa dg
 ventilating tube
 Timpano sklerosis

 kolesteatoma
 Glomus tumor
telinga tengah
 Omsk benigna (tenang)
 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.
 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.
 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
 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.
 - The patient deviates towards the
side of the lesion, in gross lesions.
 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.
 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.
 Tests of Hearing:

 - This requires a quiet room of about 6 m long since noise

and poor acoustic properties such as a narrow room with
smooth walls produce echoes which falsify the results.
 - Each ear is tested separately.
 - The better ear is tested first.
(for tunning fork test : The opposite ear is masked by a moist plug of cotton
pressed into the EAM moved in and out. (Wagener's vibration method of
masking). In cases of severe unilateral deafness Barany's noise box has to be
used.)
 [I] Whisper test:
 Two syllable words are articulated at a decreasing distance from
the patient until these words can be clearly repeated
 [II] 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 a n 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.
 Hearing tests

 Hearing tests
 Whispered speech test. Your GP will whisper a combination of numbers and letters
behind you and check if you can hear anything by asking you to repeat the
combination. Your GP will probably move further away from you each time to test the
range of your hearing.
 Tuning fork test. Different tuning forks can be used to test your hearing at a variety of
frequencies. They can also help determine the type of hearing loss.
 Pure tone audiometry. An audiometer produces sounds of different volumes and
frequencies. During the test, you're asked to indicate when you hear a sound in the
headphones. The level at which you can't hear a sound of a certain frequency is known
as your threshold.
 If your hearing loss has a sensorineural cause, a number of tests can be performed to
pinpoint where the problem lies.
 Otoacoustic emissions. This is used to measure your cochlear function by recording
signals produced by the hair cells.
 Auditory brainstem response. This measures the activity of the cochlea, auditory nerve
and brain when a sound is heard.
 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
cysts, tumors) is 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 0
 The Nose

 First check to see if the patient is able to breathe

through either nostril effectively.
 Push on one nostril until it is occluded and have
them inhale. Then repeat on the other side. Air
should move equally well through each nares.
 To look in the nose, have the patient tilt their head
back. Push up slightly on the tip of the nose with
the thumb of your left hand. Place the end of the
speculum into the nares under direct vision. Now
look through the viewing window
 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
 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:
 It is 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.
Anterior Rhinoscopy with endoscope
 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. Different
methods of examining the area are;
 i. Post nasal mirror.
 ii. Nasopharyngoscope.
 iii. Examination under anaesthesia after palatal
retraction.
 iv. Digital palpation.
 v. Radiological examination.
 Symptomatology of lesions of the nasopharynx:

 Nasal obstruction
 Post nasal drip
 Bleeding. Should be taken seriously as it may be due to
a tumor.
 Pain
 Aural symptoms of deafness, discharge, and blockage.
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.
Digital palpation
Posterior Rhinoscopy with
endoscope
 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'.
Direct laryngoscopy
 Examination of the Neck forms an integral part of
examination of the larynx.

 Inspection: Position, shape, thyroid angle,

movement with swallowing, retraction of the
suprasternal notch on inspiration.
 Palpation: Cartilages for irregularity, scars,
tenderness, subcutaneous emphysema, laryngeal
crepitus.