Salute Vivamus 2023 | Central Philippine University | College of Medicine

Otolaryngology: S01L01

Head and Neck History and Physical Exam

Dr. Christien Marie T. Nufable | 09-10-2021 | F | 10:00-12:00 PM

OUTLINE
B. HISTORY
I. History taking IV. Nose Examination CHIEF COMPLAINT
A. Golden Rules in A. The Three Parts of • Ear?
History Taking Nose Examination
• Nose?
B. History B. Examination of the
• Throat?
C. Danger Signs in External Nose
ENT History C. Intranasal • Neck?
II. Basic Equipment and Examination
Technique D. Anterior Rhinoscopy HISTORY OF PRESENT ILLNESS
A. How to Focus the E. Posterior Rhinoscopy • Onset, frequency, duration
Head Mirror F. Nasal Mirror • Associated symptoms
B. Basic Instruments G. Poster Rhinoscopy • What has the patient already tried?
C. Physical techniques • Pertinent positives and negatives
Examination H. Abnormalities of the • If the patient presents with a neck mass always think: “Could
III. Ear Examination Nose this be related to underlying malignancy or something more
A. Ear Instruments V. Paranasal Sinuses serious?” especially in patients more than 40 years old.
B. Ear Examination Examination • Previous work-up, testing, imaging, or interventions: What
C. Abnormalities of A. Physical Examination has already been done or tried for this?
the External Ear VI. Other Methods of Nasal • Past Medical History: Allergies? Asthma? Neurologic or
D. Other and Sinus Examination Rheumatologic Disorders?
Abnormalities of VII. Oral Cavity • Past Surgical History: Head and Neck procedures?
the External Ear A. Patient History Especially in patients who had radiation exposure and
E. Abnormalities of B. Physical Exam developed an anterior head mass, this might be a thyroid
the External C. Oropharynx carcinoma
Auditory Canal D. Laryngoscopy • Allergies: Aspirin Sensitivity? These are seen in patients who
F. Otoscope E. Indirect have nasal polyps
G. Division of the Ear laryngoscopy → Samter’s Triad: Nasal polyposis, Bronchial Asthma, and
H. Landmarks of the VIII. Neck Aspirin Hypersensitivity
Tympanic A. Systematic Exam of → This will provide you a basis on how to prognosticate the
Membrane the Neck patient
I. Pneumatic B. Principles of ENT • Medication: Is this problem medication-related?
Otoscopy Examination
→ In patients with hearing loss, ask if he takes ototoxic drugs
J. Abnormalities of IX. References
like streptomycin
the Middle Ear
→ History of aminoglycoside (i.e. gentamicin) intake in
K. Tuning Fork
premature newborns predisposes them to a risk factor in
L. Physical
developing congenital hearing loss
Examination
→ Rhinitis medicamentosa: Drug-induced nasal congestion
usually secondary to topical decongestants taken more
I. HISTORY TAKING than 2 weeks
• Social History: Smoker? Alcohol use?
• A thorough assessment begins with the History → Smoking: Laryngeal Cancer
• 90% of the diagnosis comes from a thorough history taking • Environmental History:
• 10% will come from physical examination and diagnostic tests → Noise induced hearing loss: Patients who work in airports
or who live along highways
A. GOLDEN RULES IN HISTORY TAKING • Family History: Does this run in the patient’s family?
• Ask for the occupation of patient
1. The patient should always be encouraged to speak.
2. Patient’s narration should not be cut off prematurely. EARS
3. Leading questions should not be posed to the patient very
• Otorrhea: 2nd most common
early during history taking.
→ Ear discharge
4. Previous medical history taking should be elicited with great
• Hearing loss: Most common
care. Time should be spent doing this.
5. Importance should be given to the chronology of events as • Tinnitus: Subjective sensation of ringing in the ear
described by the patient. • Otalgia
6. Always check inaccuracies in the patient’s narrative without → Ear pain
accusation. • Autophony/Hyperacusis
7. Questions should be rephrased to check for → Autophony: Hearing your own voice echoes
contraindications. o Seen in patients with Eustachean tube dysfunction or
8. Always take into consideration failing memory of the patient. Middle Ear problems
→ Hyperacusis: Hypersensitive to high frequency sound
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• Otorrhagia NECK
→ Bloody ear discharge • Mass
• Associated symptoms seen with Otorrhea and usually been in • Pain
Chronic Otitis Media: • Associated symptoms/history of:
→ Nausea → Fever (inflammation)
→ Vomiting → Weight loss (secondary to malignancy)
→ Headache
→ Fever
→ Retro orbital pain: Inflammation in the petrous bone known C. DANGER SIGNS IN ENT HISTORY
as petrous apicitis
→ For Chronic/Complicated Otitis Media, patients may 1. Hoarseness for more than 3 weeks
have these following symptoms due to facial nerve 2. Foul smelling ear discharge
involvement: → Can be secondary to Cholesteatoma (chronic ear
o Inability to close the eye discharge) cause lysis of bone and intracranial
o Deviation of the angle of the mouth complications (brain abscess, meningitis)
→ Complicated otitis media with intracranial infection may 3. Unilateral, foul smelling nasal discharge in pediatric patients:
present with headache, ear discharge, hearing loss, Due to foreign bodies
vomiting, nausea.. 4. Epistaxis
→ Persistent or profuse
NOSE 5. Sudden, unilateral hearing loss: Must be detected less than 3
• Nasal Congestion: Most common months from onset. If not, this will not be reversed
• Rhinorrhea: Describe consistency and color 6. Persistent lump in the throat
→ Nasal discharge
• Sneezing
→ As seen in patients with allergic rhinitis or viral rhinitis II. BASIC EQUIPMENT AND TECHNIQUE
• Disturbances in smell
→ Seen in patients with Acute Sinusitis, Acute Rhinitis and
Chronic Rhinosinusitis
→ Acute presentation of any disturbances in smell may
indicate Covid-19
• Facial pain
→ Seen in patients with Sinusitis, Nasal
obstruction/congestion
• Snoring Figure 1. Head Mirror Figure 2. Light Source Figure 3. Proper positioning of the
patient
• Associated symptoms:
→ Headache 1. Head mirror: Round structure with a 3 ½ inch diameter with
→ Eye symptoms: Redness of the eye, eye pain, tearing of the a hole at the center approximately ½ inch. This is attached
eyes in allergic rhinitis to a head band to make the hands free.
→ Alteration of voice/Nasal twang → Concave mirror connected with a headband with a hole at
→ Snoring the center
→ Fever: In acute sinusitis → If not used, positioned towards above the eye and towards
the examiner
THROAT → Positioned on the left eye of examiner
• Odynophagia 2. Light source (illumination)
→ Pain in swallowing → Behind the patient (left side)
• Dysphagia → Wide base connected to goose lamp
→ Difficulty in swallowing 3. Position
→ Associated with swelling of face/neck, fever → Both the patient and the examiner should be within eye
• Hoarseness level and should be comfortable
• Cough → Upright, slightly leaning forward (Sniffing position)
• Snoring → Legs should be side by side
→ Seen in Hypertrophic tonsils o “Examiner should not straddle the patient”
• Trismus: Limitation of opening of the mouth; less than 2
fingerbreadths opening A. HOW TO FOCUS THE HEAD MIRROR
→ Normal opening of mouth is >2 fingerbreadths
→ Usually seen in patients with trauma, mandibular fracture, • The patient sits on the stool at the same level as the doctor
peritonsillar abscess, oropharynx/hypopharynx problems • Patient’s legs should be one to one side of the examiner
• Halitosis: bad breath • The distance between the doctor and patient should not be
→ Can be secondary to Upper Respiratory Tract Infection, more than 8 inches (depending on the maximum focal length
oropharyngeal infection such as tonsillitis or caries in the of the mirror)
oral cavity, or reflux problem • 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

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• Open both the eyes • Otoscope with ear speculum
• Main drawback in using head mirror: → Ear speculum: funnel-shaped instruments that is used to
→ Requires some skill to use well examine the tympanic membrane and external auditory
→ Rarely seen outside ENT setting, thus being replaced with canal
penlights
• Now, young practitioners are switching to head lights
→ Head lights are easier to use because they don’t require the
training and experience the mirrors do.

B. BASIC INSTRUMENTS
Figure 5. Tuning fork Figure 6. Cerumen spatula Figure 7. Otoscope with
ear speculum
• Ear specula
• Nasal specula B. EAR EXAMINATION
• Tongue depressors
• Indirect Laryngoscopy mirrors • Can only assess the external and middle ear
• Posterior Rhinoscopy mirrors • The inner ear can only be examined by the tuning fork
• Nasal and aural forceps → Can be assessed through radiologic examination or
• Tuning forks: 512 Hz, 1024 Hz hearing test
• Otoscope: Gives you magnified view of tympanic membrane • Inspection: Take note of the position of upper helix in relation
and external auditory canal to the lateral canthus of the eye
→ The helix should be 1/3 above the lateral canthus of the eye
C. PHYSICAL EXAMINATION → Low set ears: Down Syndrome, Trisomy 21, Turner’s
Syndrome
o The upper 3rd is below the lateral canthus of the eye
• Palpation
• Helix: Curved structure
• Tragus: Anterior most part of the ear seen in the opening of
the ear canal
→ Tragal pain: Usually seen in the otitis externa
• Antitragus: Opposite of the tragus
• Triangular fossa: Depression found at the superior part of the
helix
• Lobule: Most inferior part of pinna; composed of Adipose
tissue
• Pinna: External ear; composed of fibrocartilage tissue

Figure 4. Anatomy of the ear.

INITIAL EXAM
• Examination should begin with inspection and palpation of
pinna and tissues around the ear
• First: Start by looking at the skin of the face
• Look for scars, any concerning lesions
• Check for symmetry: Is there muscle weakness? In patients
presenting ear discharge
• Does the patient have tell-tale signs?
→ Mouth breathers
→ Low set ears
→ Nasal crease in allergies?
→ Noisy nasal breathing? Figure 8. Assess external anatomy of the ear for Inspection and Palpation
• Listen to the patient’s voice as they give the history/answer
questions. Ask if this is his/her normal voice C. ABNORMALITIES OF THE EXTERNAL EAR
• Is it breathy? Nasal? Does the patient have stridor?
• Be observant PRE-AURICAL SINUS
• Congenital Anomaly
III. EAR EXAMINATION • If not infected, leave it
• Do surgical reconstruction if there is
A. EAR INSTRUMENTS recurrent infection

• Tuning fork
• Cerumen spatula and cotton applicator Figure 9. Pre-aurical sinus
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BAT EAR OR MICKEY MOUSE CAULIFLOWER EAR
EAR • Irreversible due to lysis of the cartilage
• Too much cartilage • Due to failure in treating auricular
hematoma
• Can be due to trauma, infection, insect
bite
• Immediately incise and drain

Figure 14. Cauliflower Ear

Figure 10. Bat ear or micky

mouse ear PERICHONDRITIS
• Inflammation of pinna
SKIN TAG → Secondary to insect bite, trauma
• Excess skin • If there is erythema & swelling, start
• Indication for surgical intervention: oral/IV antibiotics
Aesthetic reasons • If there is accumulation of pus,
immediately do incision and drainage

Figure 15. Perichondritis

KELOID
Figure 11. Skin Tag
• Hypertrophied scar
• Common in ear piercing
D. OTHER ABNORMALITIES OF THE EXTERNAL EAR • Treatment: Incision, remove

MICROTIA
• Abnormalities in pinna
• Type 1: Smaller than normal, but the ear has mostly normal
anatomy; (any changes in the shape of pinna, open auditory Figure 16. Keloid

meatus patent)
• Type 2: Part of the ear looks normal, usually the lower half. The MALIGNANCY
canal may be normal, small or completely closed; (small • Can be squamous cell or basal cell
auditory meatus) carcinoma
• Type 3: Just a small remnant of “peanut-shaped” skin and • Any tumors or lesion can develop in the
cartilage. There is no canal, which is call aural atresia; (stenotic pinna especially when they are exposed
auditory meatus) to the sun
• Type 4: Complete absence of both the external and the ear
canal, also called “anotia”
Figure 17. Malignancy

E. ABNORMALITIES OF THE EXTERNAL AUDITORY

CANAL

OSTEOMA
• Bony overgrowth, whitish (different
Figure 12. Microtia
from polyps: polyps are translucent
or reddish)
AURICULAR HEMATOMA • Can be secondary to inflammatory
• Accumulation of blood between the skin process
and the cartilage of pinna due to trauma • Can be seen during otoscopy
• Usually seen in boxers • Common in swimmers
• Too much cartilage • Seen in deep sea divers Figure 18. Osteoma
• If untreated, can lead to cauliflower ear
• ENT Emergency OTITIS EXTERNA: “SWIMMERS EAR”
• Incise, drain, and put pressure • Small opening
dressing to prevent accumulation of • Inflammation of external auditory canal
blood • Secondary to frequent manipulation or
Figure 13. Auricular Hematoma swimming
• May be localize
• May involve the entire ear canal
(Diffuse Otitis Externa): Start oral
antibiotics and to prevent
closure/stenosis of auditory meatus
start with systemic antibiotics Figure 19. Otitis Externa

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IMPACTED CERUMEN
• Can be mistaken as foreign body
• most common problem
• Due to over accumulation of earwax
• Problems in patients who frequently
cleans their ear
FOREIGN BODY
• Can be animate or inanimate foreign
body
• For animate foreign bodies: drown with
baby oil in order to stop the insect from
going further inside the ear
→ Advise the patients not to poke their
ears with Q-tips
→ Remove the insect by flushing or
suction
OTOMYCOSES
• Spores or fungal growth
• Cotton appearance
• Seen in immunocompromised diabetic
patients, and those who clean their ears
other than cotton buds
• Start with antifungals
F. OTOSCOPE
• It comes with an ear speculum with
different sizes which will give you a
magnified view
• When you examine the right ear,
hold the otoscope with your right
hand and hold the patient’s ear with
you left hand
• Choose the largest speculum that
can comfortably fit the patient’s ear
canal
• Grasp and retract the pinna
backward and upward in adults
→ To straighten the ear canal
• Downward and backward in infants
G. DIVISION OF THE EAR
OUTER EAR
• Auditory Canal
• Pinna
MIDDLE EAR
• Tympanic membrane
• Ossicles
• Middle ear space
INNER EAR
• Cannot assess Eustachian tube by otoscopy (in inspection,
start with the most external)
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Figure 20. Impacted Cerumen
Figure 21. Foreign body
Figure 22. Otomycoses
Figure 23. Otoscope
H. LANDMARKS OF TYMPANIC MEMBRANE
Figure 24. Anatomy of the middle
ear.
1. An (Annulus Fibrosus)
→ Margin of tympanic membrane
→ Part of your External Auditory canal that attaches to the
tympanic membrane
2. Lpi (Long process of Incus)
→ Sometimes visible through a healthy translucent drum
3. Um (Umbo)
→ End of malleus handle and the center of the drum
4. Lr (Light reflex)
5. Lp (Lateral process of the Malleus)
→ Forms the boundaries of the annulus fibrosus, pars tensa
and pars flaccida
6. At (Attic): Where the pars flaccida is located
→ When a perforation is located at the pars flaccida, usually it
is a dangerous ear because chances of having
cholesteatoma is great
→ It is flaccid because it only has 2 layers compared to pars
tensa which has a middle layer
7. Hm (Handle of the malleus)
→ Tympanic membrane is divided into 4 quadrants through
the umbo
→ From the umbo you make a horizontal imaginary line then
from the handle of the malleus you try to make a vertical
line
→ Laterality of the ear can be determined through the
presence of cone light
o Cone of light at 4 or 5 o’clock position: RIGHT ear
o Cone of light at 7 or 8 o’clock position: LEFT ear
NICE TO KNOW!
Your cone of light is always located in the anteroinferior
portion of your tympanic membrane.
→ Anterior – towards the face
→ Posterior- away from the face
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I. PNEUMATIC OTOSCOPY PERFORATED EAR WITH A
YELLOWISH DISCHARGE
• An instrument that allows the • Involves the pars densa
examiner to observe movement • Perforation can be central or marginal
of the tympanic membrane
directly, applying positive and
negative pressure
→ If it does not move:
Presence of tympanic
membrane pathology Figure 31. Perforated Ear
→ Limited movement:
Retracted or Middle ear CHRONIC OTITIS
problem Figure 26. Pneumatic otoscopy MEDIA/INACTIVE
→ No movement: Perforation • Central perforation, pale mucosa, dry
• Bulbous/Aural speculum: To completely seal off ear canal ear.
when applying pressure • Advise the patient to avoid water
• Middle Ear Effusion is highly likely if the tympanic membrane getting inside the ear
does not move perceptibly with applications of slight positive or
negative pressure

Figure 32. Chronic Otitis Media

J. ABNORMALITIES OF THE MIDDLE EAR K. TUNING FORK

NORMAL • Assessment of hearing loss
• Pearly gray and structure can be easily • Should be 512 Hz to 1024 Hz
identified • Riverbank 512 cycle fork: Best single fork
→ Ideal: 1024 Hz
→ Based on doc’s recording:
o >1024 Hz: We don’t use high frequency >1024 Hz
because the duration is very short and cannot give a good
result
Figure 27. Normal appearance of
tympanic membrane o <512 : Can be vibratory
→ Based on doc’s explanation: (ViVa Trans)
ACUTE OTITIS MEDIA o <512 Hz: Not used because duration is shorter. It will be
• The tympanic membrane is bulging difficult to assess if there is a hearing problem
and hyperemic, and yellow purulent o >1024 Hz: Can be vibratory
fluid is seen in the middle ear space → According to Boise:
→ Bulbous swelling of tympanic o Higher frequency tuning forks can’t sustain long enough
membrane seen in viral otitis to allow adequate testing
media o Lower frequency tuning fork stimulate vibratory sensation
in bone which is sometimes difficult to distinguish from low
tone hearing
Figure 28. Acute Otitis Media
→ Done in a quiet room

AIR BUBBLES L. PHYSICAL EXAMINATION

• Can be viral or early stage of acute
otitis media WEBER’S TEST
• Screening test
• Hit the prongs of your tuning fork with the thenar prominence of
your palm
• Hold it at the base of the tuning fork and put it at the center of
the head (can be at the vertex, center of the forehead, or in
between the two central incisors) then ask the patient where
Figure 29. Air Bubbles
he/she feels it
• Normal: Midline/No
MYRINGOTOMY TUBE lateralization
• Used to drain the fluid in patients with
• Conductive Hearing Loss:
otitis media with effusion not relieved
Lateralizes to the poor ear
by medication for more than 3 months.
• Sensorineural Hearing Loss:
• If not done, the patient will have blue
Lateralizes to the good ear
ear which is severe form of hearing
• Always perform in a quiet
loss
environment
Figure 33. Weber’s test

Figure 30. Myringotomy Tube

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RINNE TEST D. ANTERIOR RHINOSCOPY
• Screening test
• To check if the air conduction is greater
than bone conduction
• Hold the tuning fork at the stem
• Place at the mastoid area and instruct
the patient to tell you if she can no longer
hears or feels it
• Once the patient says that, transfer the
tuning fork approximately 1-2 cm in front
of the external auditory canal. (If she can
still hear it, AC>BC)
• “Positive test” Normal: AC > BC
• “Negative test” Abnormal: BC < AC;
suggests conductive hearing loss but you Figure 35. Anterior rhinoscopy Figure 36. Nasal speculum

have to correlate it also with your

Weber’s test Figure 34. Rinne test • Allows visualization of the inferior and middle turbinates as
well as the nasal septum.
SCHWABACH TEST • Examination of the nasal septum using a nasal speculum
• Bone conduction of the examiner is compared with that of the • Open the speculum upwards to avoid damage to vascularized
patient nasal septum
• Heel of the fork is held against the patient’s mastoid bone until • The middle and inferior turbinate will be visualized upon
the patient no longer can hear the tone insinuation of nasal speculum. If you cannot visualize the
• It is then placed against the mastoid bone of the examiner, who middle turbinate, then probably there is a mass or nasal
attempts to hear it congestion.
• Try to first administer a nasal decongestant, if the presumed
• Of course, the examiner must have no hearing loss to properly
mass shrinks, then it was only nasal congestion, if not, rule out
judge this test
mass in the nasal cavity.
• In the absence of a nasal speculum, one may opt to use an
otoscope. Make sure that to disinfect prior to usage, as one
IV. NOSE EXAMINATION may have previously used it to examine the patient’s ear canal.
• Note for nasal septum deviation, most common among
A. THREE PARTS OF NOSE EXAMINATION patients with epistaxis
• The most common area of epistaxis among pediatric patients is
• Examination of The External Nose Kiesselbach’s Plexus
• Anterior Rhinoscopy
• Posterior Rhinoscopy NICE TO KNOW!
“The limitation of anterior rhinoscopy is only at the level of
B. EXAMINATION OF THE EXTERNAL NOSE the middle meatus; behind that, you cannot see any
structures already."
INSPECTION
• Check for:
E. POSTERIOR RHINOSCOPY
o Congenital deformities (Clefts)
• Requires the use of postnasal mirror
o Acquired deformities (Fractures)
• May use nasal speculum or Otoscope if speculum is not
o Shape
o Swelling (Inflammatory, Cysts, Tumors) available; use the largest speculum that can comfortably fit the
nose of the patient
o Ulceration (Trauma, Neoplastic, Infective)
• Tilt the patient’s head backwards, then gently press the tip of
the nose backwards and insert the nasal speculum
PALPATION • Structures that can be visualized in the posterior part of the
• Check for: nasal cavity
o Tenderness (e.g, in infection) o Nasopharynx
o Crepitus (e.g. in nasal fracture) o Middle Turbinate
o Deformities o Inferior Turbinate
o Eustachian Tube
C. INTRANASAL EXAMINATION o Posterior Cona
• Intranasal examination begins with nasal vestibule. Folliculitis
F. NASAL MIRROR
of the vibrissae may occur in this area
• Topical vasoconstrictors (e.g., 0.5% phenylephrine), applied in
• Consists of a handle on which
a spray or cotton placed intranasally, will decongest the a small mirror (S0: size zero)
mucosa to improve the view in patients with obstructive is attached to shaft at an angle
mucosal swelling of 110
• The floor of the nose should be seen all the way back to the
• Rarely used, endoscopy is
palate preferred/
• The patient is asked to say “k,k,k” and if no obstruction present,
Figure 37. Nasal mirror
the soft palate is seen to rise with each vocalization
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G. POSTERIOR RHINOSCOPY TECHNIQUES o Secondary to trauma or septal abscess
o Seen in neglected nasal bone fracture
o Also seen in patients with history of tumors involving the
external nose (e.g. nasal glioma, meningocele)
• Mass/ Congenital Anomaly
• Nasal Folliculitis/ Vestibulitis
• Nasal Polyps
• Nasal Septum Deviation
• Purulent Discharge (Rhinitis)
• Central Septal Deviation: can be inborn or with a history of
trauma. Patients with this kind of deviation will have septal spur
epistaxis or recurrent epistaxis
• Nasal Septum Hematoma: with a history of trauma or
epistaxis. This must be immediately identified. If not, it can
result to saddle nose deformity.
• Inspection of the columella may show evidence of a deviated
septum
• Crepitation may result from nasal fracture, or tenderness may
Figure 38. Posterior rhinoscopic technique
be found in infection
• Edema or “bags” under the eye sin children may indicate
1. Hold the mirror like a pen in the right hand
allergy
2. Warm the mirror
3. Ask the patient to open the mouth
4. Depress the anterior 2/3 of the tongue
5. Feel the warmth of the mirror on the back of the wrist. It should
not be hot
6. 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 to as it may trigger gagging.
7. Instruct the patient to breathe through the nose.
8. Tilt the mirror in different direction to see various structures of
nasopharynx.

Figure 39. Nasopharynx illustration

H. ABNORMALITIES OF THE NOSE

Figure 40. Abnormalities of the nose
(Please refer to the illustrations on Figure 40)
• Rhinophyma (Photo from Left to Right – Top to bottom)
o Skin condition affecting the nose, wherein the skin is
thickened, and the sebaceous glands are enlarged V. PARANASAL SINUSES
o Male, 30-60 years old
o Commonly seen in Caucasians, and fair-skinned individuals
but there are also cases among Filipinos
o Tends to recur
o Treatment: Dermabrasion Figure 41.
Paranasal
• Nose rings sinuses
• Nasal crease
o Seen in patients with allergic rhinitis
• Foreign Object
• Saddle Nose Deformity
o Secondary to lysis of septal cartilage, seen in patients with
septal hematoma
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• Clinically, we can only examine and evaluate the anterior not be related to eating, dryness of the mouth, and discharge
sinuses into the mouth.

A. PHYSICAL EXAMINATION B. PHYSICAL EXAMINATION

• Sphenoid Sinuses cannot be assessed clinically because it is • Buccal mucosa: Parotid duct (red or white patches, ulcers)
posteriorly located (unless you do CT scans) o Parotid duct: seen opposite to the secondary maxillary
• Dim the room lights molar
• Place the lighted otoscope directly on the infraorbital rim o Bacterial parotitis: patients presenting with lateral swelling
(bone just below the eye) and purulent discharge coming out from the duct
• Ask the patient to open their mouth o Sialolithiasis: if patient comes out with stones. Manage it
and look for the light glowing with antibiotics as well as surgery
through the mucosa of the upper • Hard palate: Swelling, ulcer, perforations, clefts, etc.
mouth • Uvula: Position, deviations (towards the normal side in
• Principle: in the setting of palsies), ulcers
inflammation, the maxillary sinus o If pushed laterally, then there is peritonsillar cellulitis,
becomes fluid filler and will not allow abscess, or mass
transillumination • Floor of mouth: Wharton Duct openings, ulcers, teeth
• If acute, you may start the patient (absence) and occlusion
with systemic or oral antibiotics Tongue
• Failure to respond to systemic
antibiotics, you may start radiologic
imaging
Figure 42. Physical
examination of the paranasal
sinus

VI. OTHER METHODS OF NASAL AND SINUS

EXAMINATION
• Palpation and percussion over the frontal and maxillary sinuses
or teeth may produce pain in some cases of sinusitis
Figure 43. Parts of the oral cavity
• Transillumination is useful but is not a substitute for
radiographs in the evaluation of sinus disease
C. OROPHARYNX
• Culture and Sensitivity test are needed when infection is
present
• Endoscopic techniques are useful in evaluating pathology in
portions of the nasal cavity and nasopharynx that are difficult to
visualize with traditional methods
• Paranasal sinus radiographs are required to fully evaluate
absence or presence and extent of sinus disease
o The four most useful views are: laterals, Walters, Caldwell
and base of the skull

VII. ORAL CAVITY

• It involves the anterior border of the lip to the junction of
• anterior 2/3 and posterior 1/3 of the tongue and the junction of Figure 44. Oropharynx
the soft and hard palate
• Soft palate: swelling, ulcer, movement, perforations, clefts, etc.
A. PATIENT HISTORY • Uvula: position, deviations (towards the normal side in palsies),
ulcers
• Patients with disorders of the mouth usually will have one or o Bifid uvula: presents with hyponasality
more of the following symptoms: pain, bleeding, the presence • Tonsillar pillar: congestion, ulcers, patches
of mass or lump, difficulty in eating or speaking, discharge, and • Tonsils: presence, size, crypts, ulcers, symmetry
disturbance in taste • Posterior pharyngeal wall: lymphoid follicles, ulcers
• The most frequent pharyngeal complaints are: sore throat, a
discharge in the throat, a sense of a lump, fullness or swelling, ACUTE EXUDATIVE
difficulty in swallowing TONSILLOPHARYNGITIS
• Nasopharyngeal symptoms include: drainage or obstruction of
nasal breathing
• Any adult with persistent unilateral middle ear fluid should
have the nasopharynx examined for neoplasm
• Patients with salivary gland disease will usually complain of
one or more of the following symptoms: swelling of the cheek
Figure 45. Acute Exudative Tonsillopharyngitis
or beneath the jaw, or pain in these areas which may or may
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TONSILITIS WITH PRESENCE OF WHITISH FOOD E. INDIRECT LARYNGOSCOPY
DEBRIS

• Another form of tonsillitis with

presence of whitish food debris that
can cause halitosis

Figure 46. Tonsilitis with presence of whitish food debris

UNILATERAL SWELLING OF THE TONSILS

• Unilateral swelling of the tonsil as a

result of chronic and recurrent
tonsillitis suggestive of peritonsillar
abscess (potato voice) Figure 50. Indirect laryngoscopy
o Treatment includes antibiotic
therapy and I&D (incision and 1. Mirror is held like a pen in the right hand with the glass pointing
drainage) downwards
2. Warm the mirror and test the temperature on the back of the
Figure 47. Unilateral swelling of the tonsil hand
3. The patient is asked to stick out the tongue which is held with a
TORUS PALATINUS piece of gauze
• Torus Palatinus: a bony 4. The patient is asked to breathe through the mouth
overgrowth, congenital abnormality 5. The mirror is introduced into the mouth to the uvula which is
usually not noted by patient until gently pushed back to get a view of the larynx and the pyriform
adulthood or when patient applies fossae
dentures, associated with 6. The patient is asked to say “Eee”. You can also ask the patient
Osteoma in the external auditory to say “Eee” at a high pitch to visualize better the movement of
canal, usually painless unless vocal cords
traumatized

Figure 48. Torus Palatinus

D. LARYNGOSCOPY

• Visual exam of the hypopharynx

• Also done to remove foreign objects stuck in the hypopharynx
• 2 types:
1. Indirect laryngoscopy: uses mirrors to examine the
larynx and hypopharynx
2. Direct laryngoscopy: uses a special instrument (flexible
or rigid scope)
o Flexible scope is passed through the nose
o Rigid scope is passed through the mouth

Figure 51. Parts of the vocal cords

• In indirect laryngoscopy, what is anterior is seen posterior, what

is posterior is seen anterior, the right remains at the right side,
and the left remains at the left side.
• In direct laryngoscopy, what is anterior is anterior and what is
posterior is posterior
• Patients with breathy voice maybe associated with elderly
individuals or thyroid mass.

Figure 49. Different extents of isolated cleft palate: A) uvula, B) soft palate, C) incomplete hard
palate, D) complete hard palate

Figure 52. Vocal Cords

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VIII. NECK

Figure 56. Sublingual, Submaxillary, and Parotid glands

• Superiorly, it is bounded by the mandible, and inferiorly with the

clavicle.
• The neck is divided into 2 triangles: anterior and posterior
triangle
• For the posterior triangle, the posterior boundary would be the
trapezius muscle
• For the anterior triangle, the posterior boundary would be the
sternocleidomastoid muscle, and the anterior boundary would
be the midline

Figure 53. Triangles of the neck: (a) the two large triangular divisions; (b) the six lesser A. SYSTEMATIC EXAMINATION OF THE NECK
triangular subdivisions; (c) the detailed muscular anatomy of the neck
• There are approximately 300 nodes in the neck
• Thyroid gland: situated anteriorly in the center
o It is usually not palpable
o If it is palpable, there is a mass in the thyroid gland or an
enlarged thyroid gland and it is noted if it moves with
deglutition.
• Thyroglossal duct cyst: does not move with deglutition but
moves with tongue protrusions
• Pain, weakness of muscles or muscle group, dysesthesia,
swelling or masses, deformities, and changes in the
appearance of the skin are the more common complaints

Figure 57. Mastoid process, sternomastoid, and clavicle

• You may start at the tip of the mastoid going to the center of
the mandible area, down to the clavicle, then up to the anterior
border of the sternocleidomastoid muscle, then behind going to
the posterior margin of the sternocleidomastoid muscle, going
below to the level of the clavicle to the trapezius muscle, then
back to the tip of the mastoid
• Cervical and Metastatic Nodes are often located in the
anterior triangle of the neck (this area must be carefully
Figure 54. Locations of the lymph nodes of the head and neck inspected, particularly deep to the sternocleidomastoid muscle
along the course of the carotid sheath)
• Thyroid is the most common structure in the anterior triangle
→ Normally, it is not palpable.
• Crepitation of the thyroid cartilage against the cervical
vertebrae is normally present
• The examiner can either be in front or behind the patient,
following a systematic approach
Figure 55. Thyroid and Parathyroid
• Examination of the neck while standing allows the examiner to
Glands
compare both sides of the anterior triangles of the neck. This is
the preferred method for examining the thyroid gland and for
anterior cervical adenopathy (Boies)

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• A posterior triangle mass is usually associated with
Lymphadenitis especially among pediatric patients

• A mass on the anterior triangle

above the hyoid bone maybe
suggestive of thyroglossal cyst

Figure 60.
Posterior triangle
mass maybe of
the parotid gland

B. PRINCIPLES OF ENT EXAMINATION

• A mass on the anterolateral
triangle maybe caused by
submandibular mass
1. Good illumination
2. Practice your technique
3. Correct equipment
4. Be methodical

Figure 58. Goiter

Figure 61. Structures to be felt by massaging with fingers

IV. REFERENCES
• Viva Transes
• Dr. Nufable’s Lecture recording
• ADAMS, GL., et al, Boies Fundamentals of Otolaryngology 6th
ed. Ch. 1 p3-23
Figure 59. Bilateral mass

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