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Dept of otolaryngology, Renmin’s Hospital of Wuhan University Xuyu 许昱
Good lighting: a basic necessity The head mirror is positioned in front of the examiner ’s eye to the right or left ,the mirror is adjusted so that the light is focused on the patient
Instruments: Light source Aural speculum Cerumen loop or curette Suction apparatus Cotton tipped applicators
The External Ear
The pinna and periauricular area
• • • •
Size 、 shape 、 position Symmetry:bilaterally equal size no swelling , thickening Skin condition
intact , no lump or lesion move the pinna and push the tragus Palpate mastoid area for tenderness, swelling, or nodules
The External Ear
The external auditory meatus size / swelling discharge note any odor. /lesion
/ redness /
/ foreign body
The External Ear
The tympanic membrane Normal: Cone-shaped, light reflex shiny, translucent, pearlgray color
• • • •
landmarks visible:Umbo; Manubrium; short process Color contour perforations
Three essential steps for external canal
Straighten the canal by pulling the pinna upward and backward to align the cartilaginous and bony canals. The meatus should be inspected before a speculum is instructed. Examine with a speculum.
Three essential steps for external canal
Otoscope is used to inspect the external audiotry canal and middle ear. Tilt the patient’s head toward the opposite shoulder as the speculum is inserted. pull adult ear : pinna upper and back pull infant and child ( <3 age ) : pinna down Slowly insert the speculum to a depth of 1.0 to 1.5 cm (1/2 inch). Note discharge, scaling, excessive redness, lesions, foreign bodies, and cerumen. Inspect the tympanic membrane for landmarks, color, contour, and perforations.
Examination of the eustachian tube
Valsalva inflation tympanometry
Hearing evaluation begins when the patients responds to your questions and directions. Whisper test---Check the patient’s response to your whispered voice, one ear at a time. The tuning fork is used to compare hearing by bone conduction with that by air conduction. Weber and Rinne Tests Any patient with unexpected findings should be referred for a thorough auditory evaluation.
Results when sound transmission is impaired through the external or middle ear. Causes:
obstruction otitis media perforated TM bony overgrowth of ossicles
Results from a defect in the inner ear that leads to distortion of sound and misinterpretation of speech. Causes:
sustained exposure to loud noise Drugs Infections Trauma Tumors congenital disorders aging
Assessment of hearing
Clincal tests: (1)Voice; (2)Tuning fork; Instrumental tests: (1)Pure tone audiometry; (2)Impedance audiolohy; (3)Evoked Resonse audiometry; (4)Brain stem evoked response; (5)others
Voice Test . test one ear at a time . 30 ~ 60 cm . whisper slowly " unable to hear whisper ⇒ high tone loss First and most available The level: shout, conversational, and whisper
Distinguish between the various type of hearing loss Frenquency range: 128,256,512,1024…… Tests employed: Rinne test and Weber test
Strike the tuning fork and hold it in line with the external canal and then against the postauricular skin. Ask in which position the sound is louder? Rinne test: AC>BC (+) BC>AC (--)
Strike the tuning fork and place the base in midline. Ask whether the sound in the midline or whether it is lateralized. Sound is heard best on the side with a conductive deafness.
Hearing loss Conductive loss
Webber test 聲音偏向較差一側
Rinne test AC<BC AC>BC
Sensorineural loss 聲音偏向較好一側
Pure tone audiometry:
Measure the threshold at different frequency; Assess the categories of hearing loss according the audiogram: sensorineural deafness, conductive deafness and mixed deafness.
Audiogram: Frequency is placed along abscissa with low frequency to the left; Intensity is along ordinate. The right side is marked in red with circles; The left side is marked in blue with X’s; Bone conduction is designated by open arrow.
Measure intra-tympanic pressure. The changes can be plotted graphically on a tympanogram. Clinical studies suggest that tympanometric curves fall into three patterns as follows: Type A=Normal Type As=stiff ossicular chain Type Ad=ossicular discontinuity
Type B=fluid in the middle ear
Type C=negative pressure in the middle ear
Loud noise in one ear excites contraction of the stapedius muscle of the opposite ear, which can be recorded by tympanomety. If the normal pathways malfunction , the response will not occur , thich can distinguish between sensoring and neural hearing loss.
Evoked response audiometry:
A group of tests that response the electric activity along the auditory pathway, which is related to the auditory stimulation .
Brain stem evoked response:
The electric activity also can be noted with the BSER. The average response show 7 peaks.
It is usual to measure the time taken from peak 1 to 5, and hearing threshold of high frequency. The changes can indicate the acoustic nerve lesion, brainstem tumor or multiple scerosis.
Assessment of vestibular function
The vestibular system of the inner ear is an essential part of the balancing mechanism of the body. A thorough neurologic examination is performed with special attention to gait, coordination , the presence or absence of spontaneous nystagmus, the Romberg test, and past point.
Nystagmus: a rhythmic movement of the eyes with each cycle characteristically consisting of fast and slow component. Past point: on pointing to an object, particularly with eyes closed, the patient will point past the objects.
Positional tests: To test for labyrinthine dyfunction that occurs when the patient’s head is in different positions.
Caloric tests: To stimulate convection movements in the endolymph of a semicircular canal; This is achieved by changing the temperature in the external auditory canal.
Inspection of the nose
Light source Nasal speculum Tongue depressor Small angled miror Mirror warmer Suction apparatus Vasoconstrictor spray(ephedrine )
External examination Anterior rhinoscopy Posterior rhinoscopy Testing of olfaction
First look at the external nose. Ask patient to remove glasses. Observe first and carefully for asymmetry , signs of inflammation, trauma , tumor, or anomalies.Look at
Size and shape Obvious bend or deformity: a deviated nose is often best looked at from above Swelling Scars or abnormal creases Redness (evidence of skin disease) Discharge or crusting Offensive smell
The shape of the noce should be noted. There is the nose with age, resulting in drooping of the nasal tip, and there amy be deformities of the nasal bony and cartilaginous dorsm following a nasal fracture. Saddle deformity of the nose may follow destruction of the bony septum or cartilaginous septum from a variety of causes.
Facial swelling is unusual in maxillary sinusitis but occurs with dental root infections and in carcinoma of the maxillary
Palpation -nasal bones : helps to distinguish cartilaginous from bony distortion. -the orbital margins. Note any entderness, swelling, expansion or depression of bone, for example after injury or when malignancy is suspected -the facial skeleton
A preliminary examination of the nasal vestibule and interanasal contents can usually be made by exerting gentle upward pressure on the tip of the nose with the finger
Examination of the nasal cavity required a spreading speculum to displace the ala. So we usually use a nasal speculum.
The light is first directed at the nose, and the blades of the speculum are gently introduced under direct vision to spread the nares upward and downward.
The tips of the blades should not touch the sensitive nasal mucosa. Move the patient and the examiner ‘s head slightly in different directions, then we can see most of the available structure. Look carefully for all the structures. Note the size of turbinates and condition of mucose, nasal septum
Identify nasal septum medially; turbines laterally; inferior turbinate (nearly always possible to see); the middle turbinate is often difficult to see as it is small.
The nasal septum
The nasal septum should lie in the midline, but may be deviated or thickened. When deviated, hypertrophy of the contralateral inferior turbinate may also develop causing bilateral nasal blockage.
The inferior turbinate
Situated on the lower portion of the lateral nasal wall. The submucosal vascular bed shows considerable alteration in size with changes in ambient humidity and temperature. In allergic rhinitis the inferior turbinate may be hypertrophied and its mucosa pallid. In vasomotor rhinitis the mucosa is also swollen but is classically reddened.
A nasal endoscope is necessary for a thorough examination of the nasal cavities, the mucosa having been sprayed with surface anesthetic.
Posterior rhinoscopy is really an examination of the nasopharynx.It is achieved by the use of a small angled mirror that is placed just posterior to the uvula. Tell the patient to lean forward, with the mouth open and the tongue firmly depressed with a tongue depressor. A mirror is warmed with the flame of a spirit lamp and passed into the mouth over the upper surface of the tongue until it lies in the space between the uvula and posterior pharyngeal wall.
During this inspection,many patients may feel discomfort. So this method has now been superseded in most centers by the use of rigid telescope. But these can be passed with ease in the majority of patients, under local anaesthesia. Position the angle of the mirror so that the choana, the posterior ends of the turbinates and septum can be seen.Carefully examine the orifices of the eustachian tubes, the posterior ends of the turbinates and septum.
Hypertrophy of the posterior end of the inferior turbinate may also be seen in the posterior choanae and, in children and young adults, an adenoid mass may be visualized
EXAMINATION OF THE THROAT -Oropharynx,Hypopharynx and Larynx
Light source Tongue depressors Angled mirrors Gauze sponges Mirror warmer Finger cots Topical anesthetic
color , small plugs , size
1+ : visible 2+ : halfway between tonsillar pillars and uvula 3+ : touching the uvula 4+ : touching each other （ 2+ , 3+ , 4+ ¿ Acute Infection ）
Tell the patient to stay his tongue in the mouth and not to protrude. Gently depress the tongue with a wooden or metal depressor. The palatine arch palatine tonsils, and posterior pharyngeal walls are usually easily If not, ask the visible. patient to say “ah”,this makes the palate move upward, the tongue move downward, and exposes more of
Likewise the soft palate should be symmetrical and the gag reflex present
The tonsillar pillars, the palatine tonsils, soft palate and uvula can then be inspected. The tonsils sould be symmetrical and any gross asymmetry should be viewed with suspicion.
Hypopharynx and larynx
Examine the hypopharynx and larynx together by indirect laryngoscopy using a large angled mirror. The patient should sit upright with neck straight and the head thrust forward, encourage the patient to relax and breathe deeply and rhythmically.
Have him stike out his tongue and gently but firmly grasp it with gauze sponges. Introduce the warm mirror, make it reach the soft palatine, rotate it ,focus the light on the mirror, ask him to say “ee”.
The following structures should come into view insequence.
The patient is asked to protrude the tongue,any dentures having been removed, and it is grasped with a gauze swab. The thumb may be above or below the tongre according to the preference of the examiner, but one finger should be able to raise the upper lip if necessary.
A large size of laryngeal mirror is warmed and placed firmly but gently on the soft palate just above the base of the uvula. The light then directed to the varousp arts of the larynx and hypopharynx by tilting the mirror.The patient is asked to breathe easily and steadily throughout.
The first structure to come into view is the epiglotis which usually overhangs the superior of the larynx. The epiglottis sometimes overhangs to such a degree that it is impossible to view the larynx with a mirror, and flexible nasolaryngoscopy is used
Fibreoptic examination is now commonly used in the assessment of laryngeal and pharyngeal disease. A good mirror examination provide a better view than fibreoptic examination but the latter is especially useful in those with an overhanging Epiglottis and a prominent gag reflex. It can be used in young infants and has the added advange of providing a comprehennsive view of at least one nasal cavity and the postnasal spacee as well as the larynx and pharynx.
How to examine the nasal cavity? Which methods can be used to do the laryngeal examination? What is the essential steps for external canal exam? How to distinguish between the various type of hearing loss?