Examination of Ear, Nose, Head, Neck and Throat Dr.Vijay M.D

Equipments Basic Instruments Ear specula Nasal Specula Tongue depressors Indirect laryngoscopy mirrors Posterior Rhinoscopy mirrors Nasal and aural forceps. Tuning forks, 512 Hz, 1024 Hz Otoscope

Be familiar with gear

Examination of Ear

Structures of Ear

Examination “ begin with inspection and palpation of the pinna (auricle) and structures surrounding the ear…”

Examining the External Structures of The Ear - Observation Helix Tragus Mastoid Anti-Helix External Canal Lobe Note: Picture on L normal external ear; picture on R swollen external canal, narrowed by inflammation

Canal Inspect pinna and concha Otoscopic examination Pull upwards, outwards and backwards Look for cavity, Otitis externa Osteomas Mastoid cavity

TM Look for malleus, incus Record abnormalities

Normal Tympanic Membrane NOSE Long Process Malleus Left Ear – Malleus points down and back Incus Short Process Malleus Umbo Cone of Light

Pars flaccida Long process incus Handle of malleus Umbo Pars tensa Canal wall

Perforations Central perforation Marginal perforation

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)

Otoscopy “grasp and retract the pinna backward and upward in adults and downwards in infants…”

Using Your Otoscope Make sure battery’s charged! Gently twist Otoscopic Head (clockwise) onto handle Twist on disposable, medium sized speculum Hold in R hand R ear, L hand L ear

Otosocopy Basics Make sure patient seated comfortably & ask them not to move Place tip speculum in external canal under direct vision Gently pull back on top of ear Advance scope slowly as look thru window – extend pinky to brace hand Avoid fast, excessive movement – Stop if painful!

Great Moments In The History of Hearing

Indication: Differentiate type of Hearing Loss Tuning Fork Test Indication: Differentiate type of Hearing Loss Sensorineural Hearing Loss Conductive Hearing Loss

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 Next: Air 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

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"

Nose

Examination The nose can be examined in three parts: Examination of the external nose Anterior Rhinoscopy Posterior Rhinoscopy.

Symptoms Discharge Sinus pain Trauma Frequent upper respiratory infections Epistaxis Allergies Sense of smell

Inspect external nose: symmetry, deformity, lesions Test patency of each nostril Inspect using nasal speculum: Color and integrity of nasal mucosa Septum- note any deviation,perforation, bleeding Turbinates- Note color, exudate, swelling Palpate sinuses, note tenderness

Paranasal Sinuses

Anterior Rhinoscopy Examination of the Vestibule Look for: Boil or Abcess Ulcerations and abrasions Excoriation because of discharge.

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 Technique Hold the mirror like a pen in the right hand. Warm the mirror Ask the patient to open the mouth. 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. I

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

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.

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. Tonsillar pillars: congestion, ulcers, patches. Tonsils: Presence, size, crypts, ulcers Posterior pharyngeal wall: Lymphoid follicles, ulcers.

Subjective Data Sores/lesions Sore throat Bleeding gums Toothache Dysphagia Altered taste Tobacco Self-care behaviors

Examination Inspect and palpate: Note condition gums, mucosa, teeth (caries? # of teeth malocclusion) Lips: (lumps, lesion, cracking,color) Tongue: color, moisture, surface characteristics. Check for white patches Wharton’s Duct: opening of submandibular glands Stensen’s Duct: opening of parotid salivary glands

Inspect uvula, palate, tonsils Uvula looks like hanging pendant (if split in two= bifid) Palate: anterior hard palate=whitish posterior soft palate = pinkish Tonsils- graded by enlargement: 1+ visible 2+ near uvula 3+ touching uvula 4+ touching together

ORAL CAVITY Tongue 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

Laryngoscope Definition Visual exam of the voice box (larynx) and the vocal cords. Laryngoscopy is also done to remove foreign objects stuck in the throat.

Two Types: 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 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

Inspect posterior pharynx , onsils, mucosa, teeth, gums, tongue – use tongue depressor & light – otoscope works as flashlight Can grasp tongue w/a gauze pad & move it side to side for better visualization Palpate abnormalities

Selected Pathology of Oropharynx L CN 9 palsy – uvula pulled to R L peri-tonsilar abscess – uvula pushed to R L CN 12 palsy – tongue deviates L

Function: CNs 9 (glosopharyngeal), 10 (vagus) & 12 (hypoglossal) Uvula midline - CN 9 Stick out tongue, say “Ahh” Use tongue depressor if can’t see Palate/uvula rise -CN 9, 10 Gag Reflex – Provoked w/tongue blade or q tip - CN 9, 10 Tongue midline :CN 12 Check strength

What about the Dental? Dental health has big implications: Nutrition (ability to eat) Appearance Self esteem Employability Social acceptance Systemic diseaseendocarditis, ? other Local problems: Pain, infection Profound lack of access to care

Neck, Throat, Thyroid

Neck

Salivary Glands

Inspection and Palpation Inspection face & neck: Does anything appear out of ordinary in Head & Neck? Bumps/lumps, asymmetry, swelling, discoloration, bruising/trauma? anything hidden by hair? Inspection & palpation of Scalp, hair Note right sided neck/jaw area swelling • and R v L asymmetry

Lymph nodes 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

Lymphadenopathy– Major Causes Enlarged if inflammation or malignancy Infection: Acute, tender, warm Primary region drained also involved (e.g neck nodes w/strep throat) Sometimes get diffuse enlargement in response to generalized infection or systemic inflammatory process (.e.g TB, HIV, Mono) Malignancy: Slowly progressive, firm, multiple nodes involved, stuck together & to underlying structures. Primary site malignancy could be nodes (e.g. lymphoma) or adjacent region (e.g. intra-oral squamous cell ca)

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Lymph Node Examination Gently walk fingers along general regions – comparing R to L

Function CN 7 – Facial Nerve Facial Symmetry & Expression - Precise Pattern of Inervation L UMN R UMN R LMN - Forehead L LMN - Forehead R LMN – Face L LMN -Face

CN 7 – Exam Observe facial symmetry Wrinkle Forehead Keep eyes closed against resistance Smile, puff out cheeks Cute.. and symmetric!

Bell’s Palsy Patient can’t close L eye, wrinkle L forehead or raise L corner mouthL CN 7 Peripheral (i.e. LMN) Dysfunction Central (i.e. UMN) CN 7 dysfunction (e.g. stroke) - not shown: Can wrinkle forehead bilaterally; loss of lower facial movement on side opposite stroke.

CN 5 - Trigeminal Sensation: Motor: 3 regions of face: Ophthalmic, Maxillary & Mandibular Motor: Temporalis & Masseter muscles

Function of CN 5 – Trigeminal Motor Sensory Ophthalmic(V1) Temporalis (clench teeth) Maxillary (V2) Masseter (move jaw side-side) Mandibular (V3) Corneal Reflex: Blink when cornea touched - Sensory CN 5, Motor CN 7

Testing CN 5 - Trigeminal Sensory: Ask pt to close eyes Touch Motor: Palpate temporalis & mandibular areas as patient clenches and grinds teeth Corneal Reflex: Tease out bit of cotton from q-tip - Sensory CN 5, Motor CN 7 Blink when touch cornea with cotton wisp

Thyroid Anatomy

Observe (obvious abnormalities, trachea) From front or behind Identify landmarks (touch and vision) Palpate as patient swallows (drinking water helps) ? Focal or symmetric enlargement, nodules.

(CN 11 – Spinal Accessory) Neck Movement (CN 11 – Spinal Accessory) Turn head to L into R hand function of R Sternocleidomastoid (SCM) Turn head to R into L hand (L SCM) Shrug shoulders into your hands