Transcript Basic Physical Examination in ENT – Head and Neck

Basic Physical Examination
in ENT – Head and Neck
Department of Otolaryngology –
Head and Neck Surgery
St. Luke’s Medical Center
EQUIPMENT
1.
2.
3.
Chair with Head
rest
Light Source
Instrument
Cabinet
EQUIPMENT
Head Mirror
“leaves both hands
free for
examination”
“positioned over the
left eye and close
to the examiner’s
face”
EQUIPMENT
How to focus the head mirror

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 (Depending on the maximum focal length
of head mirror).

Fix the mirror on the left eye so that part of the mirror touches
the nose.

Adjust the mirror so that you are seeing through the hole.
Close the right eye and focus the mirror by rotating it.

Open both the eyes.
EQUIPMENT
Basic Instruments
1.
2.
3.
4.
5.
6.
7.
8.
Ear specula
Nasal Specula
Tongue depressors
Indirect laryngoscopy mirrors
Posterior Rhinoscopy mirrors
Nasal and aural forceps.
Tuning forks, 512 Hz, 1024 Hz
Otoscope
EAR EXAM
EAR EXAM
EAR EXAM
“ begin with
inspection and
palpation of the
pinna (auricle) and
structures
surrounding the
ear…”
OTOSCOPY
Otoscopy is used to
visualize the ear
canal/eardrum for
the purpose of
detecting abnormal
conditions that
might require
further evaluation
or treatment.
OTOSCOPY
“grasp and retract
the pinna
backward and
upward in adults
and downwards in
infants…”
OTOSCOPY
•
•
•
An - annulus fibrosus
Lpi (long process of incus) sometimes visible through a healthy
translucent drum
Um (umbo) - the end of the malleus
handle and the centre of the drum
•
Lr (light reflex) - antero-inferiorly
•
Lp (Lateral process of the malleus)
•
•
At (Attic) also known as pars
flaccida
Hm (handle of the malleus)
PNEMATIC OTOSCOPY
"allows the examiner to
observe movement of the
tympanic membrane
directly". "If the tympanic
membrane does not move
perceptibly with
applications of slight
positive or negative
pressure, a middle ear
effusion is highly likely".
(Bluestone and Klein,
1990)
PNEUMATIC OTOSCOPY
TUNING FORK TEST
Indication: Differentiate type of
Hearing Loss
Sensorineural Hearing Loss
 Conductive Hearing Loss

TUNING FORK TEST
Preparation
Tuning fork should
be 512 Hz to 1024
Hz
WEBER TEST
Technique: Tuning Fork
placed at midline forehead
Normal: Sound radiates to
both ears equally
Abnormal: Sound lateralizes
to one ear
• Ipsilateral Conductive
Hearing Loss OR
• Contralateral Sensorineural
Hearing Loss
RINNE TEST
Technique
•First: Bone Conduction
Vibrating Tuning Fork held on
Mastoid
•Patient covers opposite ear with
hand
•Patient signals when sound ceases
•Move the vibrating tuning fork over
the ear canal (Near, but not
•
touching the ear)
•Next: Air Conduction
Patient indicates when the sound
ceases
RINNE TEST
Normal: Air Conduction is better than
Bone Conduction
Air conduction usually persists twice as long as
bone
Referred to as "positive test"
Abnormal: Bone conduction better
than air conduction
Suggests Conductive Hearing Loss
Referred to as "negative test"
Test for Eustachian Tube
Function
1. Valsalva Maneuver:
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.


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.
2. Toynbee's test:
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.
NOSE
EXAMINATION OF THE NOSE
The nose can be examined in three
parts:
1.
2.
3.
Examination of the external nose
Anterior Rhinoscopy
Posterior Rhinoscopy.
EXAMINATION OF THE
EXTERNAL NOSE
Inspection:
•
•
•
•
•
Congenital deformities (Clefts)
Acquired Deformities
Shape
Swelling ( Inflammatory, cysts, tumors)
Ulceration ( Trauma, neoplastic, infective)
Palpation:
•
•
•
Tenderness
Crepitus
Deformities
Anterior Rhinoscopy
1.
Examination of the Vestibule
Look for:

Boil or Abcess

Ulcerations and abrasions

Excoriation because of discharge.
ANTERIOR RHINOSCOPY
2.
Examination of
the nasal cavity
using a nasal
speculum:
POSTERIOR RHINOSCOPY
Post Nasal Mirror:
It consists of a
handle on which a
small mirror is
attached to shaft
at an angle of 110.
POSTERIOR RHINOSCOPY
1.
Technique
Hold the mirror like a pen in the right hand.
2.
Warm the mirror
3.
Ask the patient to open the mouth.
4.
Depress the anterior 2/3rds of the tongue
5.
6.
7.
1.
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.
POSTERIOR RHINOSCOPY
PARANASAL SINUSES
TRANSILLUMINATION TEST
•
•
•
Dim the room lights.
Place the lighted otoscope
directly on the infraorbital rim
(bone just below the eye).
Ask the patient to open their
mouth and look for light
glowing through the mucosa
of the upper mouth.
Principle: In the setting of
inflammation, the maxillary
sinus becomes fluid filled and
will not allow this
transillumination.
ORAL CAVITY
ORAL CAVITY
Tongue
Check for:
 Common and taste sensations
 Size: Macroglossia in acromegaly,
Down's syndrome
 Ulcers
 Movements: Restricted in
hypoglossal palsies, tumor
infiltration
 Fasciculation: Motor neuron disease
 Depapillation: Vitamin deficiencies
 Furrowing , as in geographic tongue
 Coating: Thrush, black hairy tongue
ORAL CAVITY
• Buccal Mucosa: Parotid duct opening Opposite
upper 2nd molar), red or white patches,
ulcers, moisture
• Hard Palate: Swelling, ulcer, perforations,
clefts etc.
• Uvula: Position, deviations (Towards the
normal side in palsies), ulcers
• Floor of mouth: Wharton duct openings,
ulcers, and bimanual palpation
• Teeth and occlusion
•
•
•
•
•
OROPHARYNX
Soft Palate: Swelling, ulcer,
movement, perforations,
clefts etc.
Uvula: Position, deviations
(Towards the normal side in
palsies), ulcers
Tonsillar pillars: congestion,
ulcers, patches.
Tonsils: Presence, size,
crypts, ulcers
Posterior pharyngeal wall:
Lymphoid follicles, ulcers.
LARYNGOSCOPY
Definition
Visual exam of the voice box (larynx)
and the vocal cords.
Laryngoscopy is also done to remove
foreign objects stuck in the throat.
LARYNGOSCOPY
There are two main kinds:
1.Indirect laryngoscopy - uses mirrors
to examine the larynx and
hypopharynx
2.Direct laryngoscopy - uses a special
instrument (flexible or rigid scope)
INDIRECT LARYNGOSCOPY
Technique
1.
2.
3.
4.
5.
6.
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'.
INDIRECT LARYNGOSCOPY
HEAD AND NECK
NECK
LYMPH NODE LEVELS
I--Submental and
submandibular nodes
II--Upper jugulodigastric
group
III--Middle jugular nodes
draining the naso- and
oropharynx, oral cavity,
hypopharynx, larynx.
IV--Inferior jugular nodes
draining the hypopharynx,
subglottic larynx, thyroid, and
esophagus.
V-- Posterior triangle group
VI--Anterior compartment
group
CERVICAL LYMPH NODES
THYROID AND PARATHYROID
GLANDS
SALIVARY GLANDS
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