De La Salle Health Sciences Institute

Department of Otorhinolaryngology- Head and Neck Surgery

Basic
ear, nose
and throat
examination

William U. Billones MD, FPSOHNS, MOH

Basic ear,
nose and
throat exam

I Basic ENT
materials and
instruments

II Simple setup
for ENT exam

III Patient-
examiner position

IV The head
mirror

V The nasal
exam

VI The ear exam

VII The neck

exam

VIII The oral

cavity and
throat exam
A. Oral cavity
exam
B. Posterior
Rhinoscopy
C. Indirect
laryngoscopy
 Basic ENT
materials and instruments
Tongue
Head depressor
mirror

Otoscope Nasal
speculum

Examination
Laryngeal gloves
mirrors
Face mask
 Simple setup for an ENT exam

Lamp

Table
for
instruments
Patient’s
chair
(adjustable,
swivel)

Examiner’s chair
(adjustable, swivel)
 Patient-examiner position

Side-to-side
leg position
is preferred.

Both the examiner and patient should
sit up straight in a comfortable
position, slightly leaning toward
each other.
Examiners or patients
may feel uneasy in a
straggled leg position
particularly with
females.
 The
Head
Mirror
 How wear the head mirror
Place the head mirror as
close to the eye as possible.

Close one eye to make sure Both eyes should remain

that the other eye is peeping open when using
through the hole. the mirror.
 Adjusting the head mirror

Head mirror is placed on

Lamp is placed slightly
the side where the lamp
behind and at the
is positioned so that
side of the patient.
the patient does not
block the source of light.

Examiner
should
directly face
the
patient.

Adjust the mirror and/or the lamp to focus

the light on the patient.
 Adjusting the head mirror

Lamp is positioned behind the

patient and at the level
of the head mirror.

Adjust the mirror and/or the lamp to focus

the light on the patient.
 Adjusting the head mirror

Move closer to your patient to intensify the illumination.

Inspection using the head mirror
Once the ideal position
for light reflection is
achieved, it is better for
the examiner to maintain
that position. Simply
move the patient’s head
(or the succeeding parts
to be examined) onto the
illuminated zone.
The
Nasal
Exam
Nasal examination

1. Under proper lighting,

perform visual inspection
and palpation of the
external nose.
 Nasal examination

2. Carefully,
hyperextend the
neck to put the axis
of the nasal cavity
in a slightly
horizontal plane.

3. Hold the
speculum
on the side
opposite the
lamp so that
the examiner’s
hand does
not block the
light source.
 Nasal examination
How to hold the nasal Index finger
speculum over the
blade

Hold the
speculum
horizontally

Thumb over
the screw

Remaining digits How to

along handle hold the
nasal
speculum
 Nasal examination

4. Examine initially the nasal vestibule and observe

for any abnormalities or lesions that may interfere
with the insertion of the speculum . Gently introduce
the speculum, directed slightly towards the midline,
with care not to touch the turbinates.
 Nasal examination
5. Use your forefinger to press the ala
against the blade. Open the speculum as
wide as possible without causing
discomfort to the patient.

Use the 4th and 5th digits

to open the speculum
 Nasal examination

Inferior Septum Middle

turbinate turbinate

6. Inspect the nasal cavity. You may need to

decongest the turbinates to fully appreciate the
internal nasal anatomy.
Nasal examination

7. Gently withdraw the speculum

with the blades slightly opened
to prevent pulling the
nasal hair.
Nasal examination
Nasal patency testing
1. Occlude one
nostril with the
index finger. Place a
thin piece of cotton
or small mirror/
glass on the
unoccluded side.
Ask the patient to
breathe normally.
Observe movement
of the cotton or
formation of mist on
the mirror to
confirm air passage
through the nose.
Do the same on the
other side.
Nasal examination
Nasal patency testing

2. Draw the cheek laterally

while patient breathes
quietly. If airflow improves,
test (Cottle’s test) is positive
and indicates nasal valve
abnormality on the side
tested.
Nasal examination
Olfactory testing

1. Inform the
patient that a test
for smell is to be
done. The patient
blocks the nose with
the index finger
(right finger for the
right nostril, left
finger for the left
nostril) and closes
the eyes.
 Nasal examination
Olfactory testing
2. Introduce the
substance to not more
than 2-3 cm from the
nostril. The patient
sniffs repeatedly and
tells when the odor is
sensed and identifies
it. The examiner
should be very careful
not to touch the
patient nor give any
auditory clues that the
substance is being
placed near the nose.
Use familiar, nonirritating substances Rest for a while before
(tobacco, coffee, lemon, vanilla, etc). Do
not use irritating substances (alcohol,
doing the same on the
camphor,etc) as they may stimulate the other side.
pain receptors of the trigeminal nerve and
would give a false result.
The
Ear
Exam
 Ear examination
How to hold the
otoscope

Like a
Like a hammer
pencil

The thumb, index and middle fingers hold the

otoscope while the 4th and 5th digits are
stretched out to touch the patient’s face for
anchoring the examiner’s hand.

Hold the otoscope on the right hand when examining the

right ear and on the left hand for the left ear.
Ear examination
1. Use the biggest speculum that
would fit the canal comfortably.
Too large a speculum may
cause discomfort or pain.
Too small, on the other hand,
will limit your
field of view.

Speculum sizes:

Adults - 4 to 5 mm
Children - 3 to 4 mm
Infants - 2.5 to 3 mm
Ear examination
2. Open the otoscope.
Inspect and palpate
the pinna and periauricular area.
 Ear examination
The ear canal curves
downward and forward.
You need to pull the pinna to
straighten the canal.

Downward
and
backward
in children

Outward, backward
and upward in adults
 Ear examination

2. Gently pull the pinna to

straighten the ear canal.
Observe for tenderness.
Ear examination
4. Using the tip of
the speculum,
gently push
the tragus
anteriorly to
widen
the opening
of the canal.
Observe the
entrance of the
canal for any
tenderness or
lesions that
may
interfere with
the insertion
of the
otoscope.
 Ear examination
5. Slowly insert the
otoscope following the
axis of the ear canal.
Always be conscious of
the patient’s reaction to
the amount of pressure
you are exerting and
adjust accordingly.
Extend your 4th and/or
5th digits to touch the
patient’s face. This
would cause your hand
to move in unison with
the patient’s head
should the patient
Anchor your suddenly flinch, thus
hand by
resting the 4th
preventing discomfort
or 5th digit on and injury to the
the patient’s patient.
face.
 Ear examination
Bony Cartilaginous
canal canal

6. Insert the speculum to a minimum

depth that will allow a clear view
of the canal and tympanic membrane.
Refrain from inserting it too deep into the
bony ear canal. Following the axis of the ear, the
otoscope should be directed downward and
forward (or towards the nose).
 Ear examination

7. Gently tilt the

otoscope at slight
angles to acquire a
complete picture of the
canal and tympanic
membrane.

Whenever possible, remove debris, cerumen or

discharge that may obstruct full view of the
canal and tympanic membrane.
 Ear examination
Tilt the otoscope at certain degrees to get a complete picture
of the tympanic membrane.
pars flaccida incus
LEFT
tympanic
membrane

malleus annulus

umbo pars tensa

cone of
light
 Ear examination

Toynbee
press the
nose and
swallow

Valsalva
pinch the
nose, close the
mouth then
exhale
forcefully

8. Try observing for movement of the tympanic membrane by

doing Valsalva and Toynbee maneuvers. These would cause
forceful entry of air into the middle ear, thus moving the
membrane.
Ear examination
Pneumatoscopy

Otoscope with
complete attachments
for pneumatoscopy

Special speculum with

soft, flexible tip to seal
off the ear canal
during the procedure
 Ear examination
Pneumatoscopy

The ear canal is sealed off with the special speculum and air is
insufflated into it. A normal and compliant tympanic membrane and
normally pressurized middle ear would produce discernible
movement of the membrane.
 Ear examination
Pneumatoscopy

Absence of movement of the tympanic membrane may result

from an ear drum perforation or middle ear fluid/pressure
changes due to eustachian tube dysfunction.
Ear examination
Tuning fork

The test must be done in a

very quite room.
Tine

A 512Hz tuning fork is

preferred. Make sure it has
Shoulder no damge or chips at the
tines.
Base

Stem

Footplate
 Ear examination
Tuning fork
Hold the tuning fork by its stem
between the thumb and
Strike zone
forefinger.

Strike one side of the tines (one-

third from the free end of the
tine) on a firm, elastic surface
or on the examiner’s elbow or
ball of hand.

Do not strike it on a hard

surface as it may damage the
instrument.

Inspect the ear canal

initially. It may need to be
cleaned prior to the
procedure.
 Ear examination
Weber tuning fork test
This is a test of lateralization and establishes in
which ear the tone is perceived.

Strike the tuning fork and place

it anywhere along the midline.
Hold it in place for several
seconds. Inquire where the
patient heard it loudest (left,
right or equally on both).

Report finding as:

Weber lateralized to left ear or
right ear or no lateralization.
 Ear examination
Rinne tuning fork test
This test is a comparison of loudness of perceived air
conduction to bone conduction in one ear at a time.

Strike the tuning

fork and place it
about 2,5 cm from
the opening of the
ear with the tines
parallel to the axis
of the canal. Start
with the ear where
Weber was
lateralized to. This
tests the air
conduction of the
ear.
Ear examination
Rinne tuning fork test
Once the patient stops
hearing the sound from
the air conduction,
immediately place the
tuning fork firmly against
the mastoid process. This
tests the bone conduction.
Ask if the patient still
hears the sound. Make
sure no hair is caught
between the tuning fork
and mastoid.

Report finding as:

Positive Rinne - air conduction
longer then bone conduction
Negative Rinne - bone
conduction longer than air
conduction
 Ear examination
Schwabach tuning fork test
This test is a comparison of perceived bone conduction
between the examiner and the patient. It is imperative that
the examiner has a normal hearing acuity to perform the test.

Strike the tuning fork and place it

alternately against the mastoid process of
the patient and of the examiner. Each
time the fork is pressed against the
patient’s head, ask the patient if the tone
is heard. When the patient no longer
hears the tone, the fork is immediately
placed on the examiner’s mastoid to
check if the tone is still audible.

Report finding as:

Schwabach : examiner equal/
longer /shorter than patient
The
Neck
Exam
 Neck examination

1. Under proper lighting, carefully hyperextend the neck and

perform a systematic visual inspection using the imaginary
triangles of the neck. Look for masses, lesions, visible
pulsations and other abnormalities. Ask the patient to
swallow and observe for any perceptible movement of the
thyroid gland.
Neck examination
Triangles of the neck
Submandibular

Submental
Anterior
Carotid

Muscular

Occipital
Posterior
Supraclavicular
Neck examination

2. Gently flex
the neck
towards the
side being
examined to
relax the
muscles.
Perform light
and deep
palpation along
the
different
triangles of the
neck.
 Neck examination

3. Systematically palpate lymph nodes from

levels I to VII. The presence of palpable nodes
at a certain level warrants a thorough
evaluation of the specific section of the
head and neck which drains into those nodes.
 Neck examination

4. Hyperextend the neck and palpate for the

laryngeal cartilages, trachea, thyroid
gland and great vessels. Ask the patient to
swallow while palpating these structures.
Neck examination

4. Using the bell of the

stethoscope, auscultate the
carotid artery over the carotid
triangle for bruit. The patient
breathes deeply and holds his
breath for 15 to 30 seconds.
Simultaneously palpate the
contralateral carotid for
timing purposes.
 Neck examination

5. Using the bell of

the stethoscope,
auscultate along the
supraclavicular
triangle for venous
hum. If present, it
can be intensified by
deep inspiration.
Likewise, it may be
obliterated by a
Valsalva maneuver or
by lightly
compressing the
jugular vein cephalad
to the auscultation
site.
 The
Oral
Cavity
and
Throat
Exam
Oral cavity examination

A systematic and
detailed
examination of the
oral cavity is
essential due to the
numerous
structures located
therein.
 Oral cavity examination

1. Using a tongue
depressor, start
anteriorly with Permanent
dentition
the examination
of the lips, gums Universal
and teeth. Numbering
Primary System
dentition
 Oral cavity examination

(Stensen’s duct)

(Ducts of Rivinus,
Duct of Bartholin)

(Wharton’s duct)

2. Proceed inferiorly to the floor of the mouth, then

laterally to the buccal areas. Inspect the oral mucosa and
openings of the salivary glands.
Oral cavity examination

3. Superiorly, examine the

hard and soft palates .
Observe for clefts and
abnormalities of the uvula.

premaxillary suture

alveolar ridge

median raphe
 Oral cavity examination

4. Inspect the ventral,

dorsal and lateral aspects
of the tongue. Observe its
mobility.
Oral cavity examination
5. Proceed
posteriorly to
examine the
oropharynx.
With the tongue
relaxed and
resting on the
floor of mouth,
firmly depress
along its
anterior two-
thirds using a
tongue
depressor. Ask
the patient to
say “aaah” to
elevate the soft
palate.
Oral cavity examination

6. Examine the tonsils,

tonsillar pillars,
poaterior third of the
tongue and
orophayngeal walls.
 Oral cavity examination

7. With gloves on, perform a bimanual

palpation of the tongue, buccal areas and
floor of the mouth.
 Posterior rhinoscopy

1. Hyperextend the neck. With the tongue at rest, depress

its anterior two-thirds with a tongue depressor and ask the
patient to breathe through the nose.
 Posterior rhinoscopy
2. Select an appropriately sized
mirror (sizes 00-4). Too small a
mirror would limit your field of
view. Hold it like a pencil and
introduce it through the side of the
mouth.
Number Diameter
(mm)
0-0 8

0 10

1 12

2 14

3 16

4 18

5 20

6 22

7 24

8 26

To prevent mist from forming on the mirror, immerse it in

warm water or rub its surface along the buccal mucosa to
moisten it with the patient’s saliva.
Posterior rhinoscopy

3. Gently insert the

mirror. Additional
pressure on the tongue
may be required to
increase the space of
the oropharynx and
effectively position the
mirror behind the soft
palate. Try to prevent
the mirror from
touching the posterior
third of the tongue as it
may induce gag.

You may need to spray the oral

cavity with a local anesthetic to
minimize the gag reflex.
Posterior rhinoscopy

4. Focus your light

on the mirror to
reflect the light on
the nasopharynx
and brighten the
area.
Posterior rhinoscopy

5, Rotate the
mirror at
different angles
to get a
complete
picture of the
nasopharynx
and posterior
choana.
 Indirect laryngoscopy

Larynx

Widened
view of the
larynx

The head needs to be hyperextended and the

tongue pulled out for this procedure.
 Indirect laryngoscopy

1. Wrap the
tongue with
gauze to
prevent
contact with
the teeth. Pull
the tongue
anteriorly and
not
downward.

Teeth
 Indirect laryngoscopy
2. Select an appropriately
sized mirror (sizes 5-8).
Too small a mirror would
limit your field of view.
Hold it like a pencil and
Number Diameter
(mm)
0-0 8

0 10
introduce it through the
1 12 side of the mouth.
2 14

3 16

4 18

5 20

6 22

7 24

8 26

To prevent mist forming on the mirror, immerse it in

warm water or rub its surface along the buccal mucosa
to moisten it with the patient’s saliva. Topical
anesthetic may also be sprayed to reduce the gag reflex.
 Indirect laryngoscopy

You may need to

bend the mirror
slightly to modify
3. Push the uvula gently and insert the angle of the
the mirror behind the tongue. mirror to the
larynx, thereby
improving your
view.
Indirect laryngoscopy

4. Focus your light

on the mirror to
reflect the light on
the larynx and
brighten the area.
Indirect laryngoscopy

epiglottis

false vocal
fold

true vocal
fold

arytenoid

pyriform
sinus

5. Tilt the mirror at different angles to get

a full picture of the larynx. Ask the patient
to breath deeply through the nose and say
“eeee.” Observe the movement of the vocal
folds.