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.
- Semi-mobile: Bull's lamp.
- Mobile: Head light.
Indirect laryngoscopy mirrors,
Posterior Rhinoscopy mirrors,
Jobson-Horne ear probes,
Nasal and aural forceps.
Barany's noise box,
Tuning forks, 512 Hz, 1024 Hz,
Revolving stools, both for the patient and the
Semi mobile source, with a bulb of 70-100 Watts, and
a plano-convex lens.
Lamp is place 6 inches above and behind the left
shoulder of the patient at the level of the ear of the patient.
|It has got three parts.
- Mirror: Hole in center. Concave. Focal length of 7-10 inches,
therefore maximum illumination is at the same distance.
- Lever with 2 ball and socket joints: The 2 joints should be at right
angles to each other.
- Plastic Head bands.
How to focus the 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
Put on the mirror with the notch downwards, and the joints all in one
line and at right angles.
Fix the mirror on the right eye so that part of the mirror touches
Adjust the mirror so that you
are seeing through the hole. Close the left eye and
focus the mirror by rotating it. Open both the eyes.
Examination of the
|The nose can be examined in three parts:
1. Examination of the external nose,
2. Anterior Rhinoscopy,
3. Posterior Rhinoscopy.
|1.Examination of the External Nose:Inspection:Congenital deformities: Clefts, sinuses.
Swelling, ( Inflammatory, cysts, tumors)
Ulceration ( Trauma, neoplastic, infective).
Tenderness over the tip is due to a boil. Over the
dorsum is due to trauma.
consists of the following steps:
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.
- Boil causes swelling in the roof and lateral wall.
- Ulceration may be neoplastic, infective.
- Excoriation because of discharge.
2] Examination of the nasal
cavity using a 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
- Lateral wall: Inferior and middle turbinates, size ,colour, shape.
- 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.
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.
By placing a cold tongue depressor or a wick of
cotton below the nostril, nasal patency can be assessed.
3. Posterior Rhinoscopy:
- Compare the two sides always.
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.
iii. Examination under anaesthesia after palatal retraction.
iv. Digital palpation.
v. Radiological examination.
lesions of the nasopharynx:
- Post nasal drip
- Bleeding. Should be taken seriously as it may be due to a tumor.
- Aural symptoms of deafness, discharge, and blockage.
Method of Posterior
Post Nasal Mirror:
t 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.
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
- Ask the patient to open the mouth.
- Take the tongue depressor in the left hand and depress the anterior 2/3rds of the
- 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
- 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:
Hard and soft palates,
It includes the following structures:
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,
- Soft palate,
- Anterior and posterior tonsillar pillars,
- Posterior pharyngeal wall.
- posterior 1/3rd,
- dorsum and
- the margins.
common and taste sensations,
size: Macroglossia in acromegaly, Down's syndrome.
ulcers: Traumatic, dental, apthous, malignant, tuberculous,
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
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),
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
Teeth and occlusion
The upper and lower vestibule of the cheek.
EXAMINATION OF THE LARYNX & HYPOPHARYNX
|Hypopharynx consists of the:
Posterior pharyngeal wall,
Pyriform fossae, and
Post cricoid area.
Examination can be carried out by:
1. Indirect laryngoscopy,
2. Flexible or rigid endoscopes,
3. Direct 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'.Top
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.
|Examination of the ear includes :
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,
9. Cranial nerves
10. Post aural area (Mastoid process), and lymph nodes.
- Indirect illumination using a head mirror. Difficult.
- Electric Otoscope: It consists of a speculum, handle and a magnifying
attachment (1.5-2 x).
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
Wax and other debris must be removed for adequate examination.
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.
Examination of the
Examination of the
External Auditory Meatus:
- Signs of inflammation,
- Patency: Atresia, stenosis
- Swelling: Inflammatory, neoplastic.
- Discharge: Wax, mucoid, purulent, haemorrhagic, watery.
- Tragal tenderness.
- Sagging of the postero-superior meatal wall.
Tympanic membrane: (Using naked
eye, otoscope, and otomicroscope)
- Colour: Hemorrhage, dullness, blue, bullae
- Perforations: Marginal and Central, site, size.
- Mobility: (Retractions) by using a pneumatic otoscope, or
- Can be examined through a perforation. Look at the colour of
mucosa, edema, discharge, polyps, promontory.
Tests for Eustachian tube functions
i] Valsalva Maneuver:
Principle: Demonstration of tubal patency without external aids.
Principle: It is safer
and confirms normal tubal function.
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.
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.
Principle: When the soft palate is elevated the pressure in the
nasopharynx is increased which opens the tube.
Method: The doctor occludes one of the patient's nostrils
with the olive of a rubber balloon and pinches the other nostril tightly. The patient
elevates the palate by swallowing or saying "Kay, Kay". At the same time air
pressure in the closed nasal cavity is increased by pressing the Politzer's bag. The
doctor can hear the rush of air into the middle ear by auscultation using a tube. Optical
assessment can also be used.
Principle: It is to artificially blow air through the tubal opening.
Method: A silver catheter with an angulated tip is passed
through the nose to engage the tubal opening. Air is forced into the ear by connecting the
catheter to a balloon.
Complications: Tubal otitis media, rupture of an atrophic
drum, nasal bleeding, damage to tubal ostium.
3. Acoustic impedance, and
Tests of Balance
Patient stands upright with the feet parallel and close together, eyes closed ,and the
arms folded in front of the chest or outstretched.
- Blindfold gait and walking a straight
peripheral lesion or a unilateral cerebellar lesion, the patient tends to sway towards the
- Central lesions give irregular pattern of sway.
- The patient deviates towards the side of the lesion, in gross
- Quantitative assessment may be carried out using a Balance Platform.
Unterberger's Stepping test
Stepping on one spot with the eyes closed.
Peripheral lesions- rotation of the body axis to the side of the labyrinthine
Central disorders- the deviation is irregular.
Deviations of greater than 40 degree are
1. Spontaneous deviation
Method: The arms are held horizontal in the
supine position with the patient sitting.
Result: Both arms are deviated in
parallel to the side of the lesion.
2. Spontaneous tone reaction:
With the patient sitting and the arms stretched in front of him.
Result: The arm on the side of cerebellar lesion sinks as a
result of loss of tone of the muscles.
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.
Stepping Gait; Loss of proprioception as in tabes dorsalis or in sensory neuropathy.
gait; Dragging of the leg and flexion of the
gait; Midline cerebellar
TESTS FOR EYE
should be sought with the head in the :
i. primary position.
ii. when flexed, extended, laterally inclined and rotated. These
constitute the cervical postural tests (Barany Halpike).
Method: ( With the head in neutral position)
looking to the front. Observer viewing from the side. Visual fixation is obtained by
placing a finger central to the eyes and at least 45 cm from the nose. The presence or
absence of nystagmus is noted, and then the finger is moved 30° to either side asking the
patient to follow the finger without moving the head.
- Observation with and without Frenzel's glasses.
- Examined in a dark room with + 15 diopter lenses which almost
completely suppress optical fixation.
- Examine with and without fixation for a Fixation nystagmus.
- Are noted on a Frenzel chart.
Positional testing ( Dix -
Screening test for Positional nystagmus.
- Nystagmus induced or aggravated by this test is attributable to
cervical proprioceptors and vertebral artery compression.
(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.
Caloric Labyrinthine Testing:
- The LSCC is brought into a vertical position in the supine patient by
elevating the head 30° .
- The volume of endolymph is changed by cooling or
warming the labyrinthine capsule by irrigation with water at 30° and 44° C for 30-40
- This produce changes in volume of the endolymph
(previous concept was of currents) which deflects the cupula.
- In cases where tympanic membrane is perforated Air
Caloric test is carried out.
- Reduced excitability;
Partial loss of function
- Total absence of excitability; Complete loss of
- Directional Preponderance; Indicates a difference
in spontaneous activity in the higher vestibular centers.
- Advantage: Each labyrinth can be examined
- In the presence of a fistula in the LSCC, or stapes or elsewhere in the
labyrinthine capsule caused by trauma, cholesteatoma, or lytic process, a sudden increase
in pressure in the EAM produces vertigo, nystagmus.
- The same symptom can occur in case of adhesions
between the membranous labyrinth and the stapes footplate. (Fistula test without a
- Tullio's phenomenon:
A large defect in the tympanic membrane or in mastoid cavity, aspiration of
air leads to cooling of the LSCC producing a caloric labyrinthine reaction and thus
nystagmus. This always beats towards the sound ear for both compression and aspiration.
* Politzer balloon with a perforated olive.
* Compression induces nystagmus towards the diseased ear.
* Aspiration towards the sound ear.
Tests of Hearing:
* Hennebert' sign:
Is a positive fistula test in the presence of a
normal tympanic membrane and no evidence of middle ear disease. Present in Congenital or
tertiary syphilis, Endolymphatic hydrops, third window due to osteitis, and adhesions in
- 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
- Each ear is tested separately.
- The better ear is tested first.
- 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
[I] Whisper test:
Two syllable words are
articulated at a decreasing distance from the patient until these words can be clearly
[II] Tuning Fork tests:
(A C1 fork of 512 Hz is used).
i) Weber's test:
dependent on binaural comparison of bone conduction.
- 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.
This test rests on monaural comparison to bone conduction.
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.
- If air conduction is better than
bone conduction, Rinne's test is positive. This is the finding in normal ear and in
- If bone conduction is better than air
conduction, Rinne's test is negative. This is found in conductive deafness.
on comparison of the bone conduction of the patient with that of the examiner.
The air pressure in the EAM is altered by a Siegle's speculum
leading to increased stiffness of the ossicular chain. In the normal patient or in
sensorineural deafness bone conducted sound appears to be decreased in intensity. Whereas
in stapes fixation no alteration occurs.
v) 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:
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.
- The examiner stands behind the patient.
- A tuning fork is struck and is held 20 cm from the good ear - the patient hears the
- The fork is then removed and placed 5 cm from the bad ear - patient 'denies' hearing
- 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.
- Modification of Weber. When the fork is
placed on the vertex, the patient indicates that he is hearing the fork in the good ear
and not in the deaf ear.
- The meatus of the good ear is then blocked .
- A genuine deaf p[patient will still lateralize the sound to the
good ear, the malingerer will usually deny hearing any sound at all.