Basic Physical Examination

in ENT – Head and Neck

Department of Otolaryngology –
Head and Neck Surgery
St. Luke’s Medical Center
 EQUIPMENT
1. Chair with Head
rest
2. Light Source
3. 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

3. Ear specula
4. Nasal Specula

5. Tongue depressors

6. Indirect laryngoscopy mirrors

7. Posterior Rhinoscopy mirrors

8. Nasal and aural forceps.

9. Tuning forks, 512 Hz, 1024 Hz

10. 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:

3. Examination of the external nose

4. Anterior Rhinoscopy
5. 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
Technique
2. Hold the mirror like a pen in the right hand.

4. Warm the mirror

6. Ask the patient to open the mouth.

8. Depress the anterior 2/3rds of the tongue

10. Feel the warmth of the mirror on the back of the wrist. It should
not be hot.

12. 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.

14. Instruct the patient to breath through the nose.

16. 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

3. Mirror is held like a pen in the right hand with the glass
pointing downwards.

5. Warm the mirror and test the temperature on the back of

the hand.

7. The patient is asked to stick out the tongue which is held

with a piece of gauze.

9. The patient is asked to breath through the mouth.

11. 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.
12. 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
THANK YOU