Otolaryngologic examination             

EXAMINATION OF THE PATIENT

Light Source:

• Semi-mobile: Bull's lamp.
• Mobile: 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.

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• Revolving stools, both for the patient and the examiner.

Bull's lamp:

• 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.

Head Mirror

• 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.

• 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.
• 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 the nose.
• 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.

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Examination of the nose

The nose can be examined in three parts:

2. Anterior Rhinoscopy,

3. Posterior Rhinoscopy.

Inspection:

• Congenital deformities: Clefts, sinuses.
• Acquired Deformities,
• Shape,
• Swelling, ( Inflammatory, cysts, tumors)
• Ulceration ( Trauma, neoplastic, infective).

Palpation:

It is carried for;

• tenderness,
• crepitus, and
• deformities.

Tenderness over the tip is due to a boil. Over the dorsum is due to trauma.

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2. 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.

1]   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.

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2]  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.
• 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.

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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.

3. 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;

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.

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Method of Posterior Rhinoscopy:

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.

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.

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EXAMINATION OF THE THROAT

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.

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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.

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EXAMINATION OF THE LARYNX & HYPOPHARYNX

Hypopharynx consists of the:

• Posterior pharyngeal wall,
• Pyriform fossae, and
• Post cricoid area.

1. Indirect laryngoscopy,

4. X-rays.

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'.

  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.

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EXAMINATION OF THE EAR

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.

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OTOSCOPY:

Methods:

• Indirect illumination using a head mirror. Difficult.
• 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.

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Examination of the Pinna:

• Shape,
• Size,
• Symmetry,
• Signs of inflammation,
• Ulcers.

Examination of the External Auditory Meatus:

• 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)

• 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.

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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.

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.

iii]Politzer's test:

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.

iv]Tubal Catheterization

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.

Quantitative Methods:

1. Manometry

2. Sonomanometry,

3. Acoustic impedance, and

4. Tympanometry.

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Tests of Balance

Romberg test

Method:

- Unilateral peripheral lesion or a unilateral cerebellar lesion, the patient tends to sway towards the affected side.

- Quantitative assessment may be carried out using a Balance Platform.

Stepping on one spot with the eyes closed.

Peripheral lesions- rotation of the body axis to the side of the labyrinthine lesion.

Deviations of greater than 40 degree are significant.

Positional tests

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.

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2. Spontaneous tone reaction:

Method: 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.

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.

High Stepping Gait; Loss of proprioception as in tabes dorsalis or in sensory neuropathy.

Hemiplegic gait; Dragging of the leg and flexion of the affected arm.

Shuffling gait; Parkinsonism. Head bent.

Ataxic gait; Midline cerebellar dysfunction

TESTS FOR EYE MOVEMENTS:

Nystagmus 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)

Patient 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.

Result:

- Are noted on a Frenzel chart.

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.

Principle:

- 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 sec.

- 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.

Result:

- Reduced excitability; Partial loss of function

- Total absence of excitability; Complete loss of function.

- Directional Preponderance; Indicates a difference in spontaneous activity in the higher vestibular centers.

- Advantage: Each labyrinth can be examined separately.

Fistula test

Principle:

- 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 fistula).

- 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.

Technique:

*Tragal pressure.

* Politzer balloon with a perforated olive.

Result:

* Compression induces nystagmus towards the diseased ear.

* Aspiration towards the sound ear.

* 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 vestibule.

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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.

- 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).

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.

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.

Depends on comparison of the bone conduction of the patient with that of the examiner.

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.

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.

- 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.

Chimani-Moos test:

- 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.

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