HEARING – abnormal or normal?

Onset – sudden or gradual?

Unilateral or bilateral?
Which is the better ear?
What is the functional capacity of each ear?
– can one hear and understand? Does he
only hear loud noises? Is it worsened in
crowds?
Is the loss constant or fluctuating?
Associated symptoms: vertigo, tinnitus,
drainage or fullness of the ears?
HEARING
Past history:
Systemic disease? – vascular problems
Previous surgery to the ear?
Hx of head trauma
Ear infections as a child
HEARING
Personal and Social:
Noise exposure? – occupation?
Drug intake: aminoglycosides (injections, wound
irrigations) diuretics, salicylates
Previous use of hearing aids?
Family history: congenital or familial
TINNITUS
Unilateral or bilateral?
Associated symptoms – hearing loss, vertigo
High pitched or low pitched?
Continuous, intermittent, pulsatile?
Duration – recent or long-standing?
Altered by head position or pressure on
neck?
Drug intake – aspirine and quinine?
EAR DISCHARGE
Which ear? Unilateral or bilateral?
Onset and duration?
Continuous or intermittent?
Predisposing factors? Sinusitis, colds, allergy
Character: mucoid, mucopurulent, purulent, serous
Associated otalgia
Odor – foul-smelling or non-foul?
Associated symptoms – headache, hearing loss,
dizziness, facial weakness
Past history of ear trauma or surgery
OTALGIA
Onset and duration?
Continuous or intermittent?
Location – deep, superficial, circumaural
Nature – sharp, dull, boring
Pain on manipulation of ear? – points to
otitis externa
Associated symptoms – ear discharge,
hearing loss, tinnitus, headache, vertigo,
sore throat
PINNA DEFORMITY
Acquired, traumatic
Congenital – since birth?
Family history of similar lesions?
Birth and maternal history
Is there hearing loss?
EPISTAXIS
Unilateral or bilateral?
Anterior, posterior, or diffuse?
Spontaneous or post-traumatic?
Duration and onset
Amount of blood loss
Associated problems: colds, strong blowing
of nose, medical problems such as
hypertension, use of anticoagulants, signs of
blood dyscrasias, renal disease
OBSTRUCTION AND RHINORRHEA
Unilateral or bilateral?
Duration and onset
Constant or seasonal?
Change in character with change in position
Facial pain
Spontaneous or post-traumatic
Associated symptoms: frequent sneezing,
headache, postnasal drip, nasal pruritus, sore
throat, earache, asthma
Drug use – use of nasal drops; antihypertensives,
cocaine sniffing, tranquilizers, hormones
NASAL DEFORMITY
Congenital or acquired
Recent – acquired with trauma
Associated problems such as epistaxis, nasal
obstruction
Alcohol intake
History of acne rosacea
History of trauma
ORAL ULCERATIONS
Duration and onset
Persistent or intermittent
Location and pattern – are they in crops?
Painful or nonpainful?
Use of immunosuppressive drugs, sexual
habits and venereal disease
Associated problems – fever, malaise, other
mucosal ulcers (vaginal, anal, urethral)
INTRAORAL MASS LESIONS
Duration and onset
Location
Rapidity of growth
Painful or nonpainful
Odynophagia
Trismus
Presence of lymph nodes
Previous dental extractions or surgical
consult?
ALTERATIONS IN TASTE
Dysgeusia, hypogeusia, or ageusia
Onset and duration
Associated problems in smell,
medications, head injury, headache, ear
surgery (chorda tympani cut), facial pain
and visual disturbances
ODYNOPHAGIA
Onset and duration
Location – referred to ear?
Constant or intermittent?
Is it progressive?
Occurs with solids or liquids?
Associated symptoms of hoarseness, stridor,
odynophagia
History of foreign body ingestion
History of corrosive intake
DYSPHAGIA
Duration
Localization
With solids or liquids?
Associated symptoms
HOARSENESS
Duration (congenital or acquired)
Intermittent or progressive
Pattern or time of day worsened
History of vocal abuse, occupation
Environment – exposure to chemicals
Stridor
Pain
History of trauma, surgery under general
anesthesia, neck and chest surgery, thyroid status
Endotracheal intubation
AIRWAY OBSTRUCTION – STRIDOR
Duration
Exercise intolerance
Nature – stridor inspiratory or expiratory or both;
history of foreign body
Exacerbation – by exercise or sleep
Relieved by change in position, opening mouth,
protruding tongue
Associated with recent viral infection
History of trauma to neck; neck or chest surgery
medications
NECK MASSES
Location
Duration
Size: stable, growing, alternating
Single or multiple
Tender or nontender
Discrete, multiple, matted
Pulsatile
Erythematous
Associated problems such as weight loss,
hyperthyroidism, nasal obstruction, dysphagia,
hoarseness, intraoral lesions, pigmented skin
lesions, ear pain
DISCRETE SWELLING
Duration
Pain
Facial asymmetry
Constant or intermittent
DIFFUSE SWELLING
Uniglandular or multiglandular
Duration
Painful or nonpainful
Exacerbation with eating
Previous history of mumps or vaccination
Associated problems: e.g. Xerostomia,
alcohol intake, starvation, iodides, bromides,
antihypertensives, tranquilizers, joint pains,
fever, skin rashes
Basic Instruments in ORL in a Clinic Set up
ENT Chair
Treatment Unit/Suction Machine
Head Mirror
Light Source
Otoscope
Nasal Speculum
Laryngeal Mirrors
Tongue Depressors
HEAD MIRROR

LIGHT SOURCE

POSITION
There is NO adequate substitute for a proper
HEAD MIRROR and LIGHT source when
examining the cavities of the Head and
Neck.

Indeed, a good part of the examination

cannot be done in any other manner.
• size: 3 ½ inch diameter w/
a ½ inch hole in the center
and a focal length of 14
inches.
• Position: opposite to the
location of light source
• As close to the physician's
face as possible
1. Position the mirror over the
chosen eye and look through
the aperture.
2. Close the other eye to remove
the influence of binocular
vision temporarily while
focusing.
3. Focus your eye on a point in
space and adjust the mirror so
that the light falls on this point.
4. Then open the other eye and
proceed with the examination
• Should be a POINT
SOURCE if possible
• Unfrosted 100-watt or
stronger light bulb,
situated on a gooseneck
stand without a reflector
• Position: to the side of
the patient and slightly
behind.
Examiner: * may stand or
sit BUT should be
COMFORTABLE.
Px-slightly bending
forward at the waist, the
head slightly
hyperextended, w/ feet
on the floor & legs
uncrossed.
Children: mother’s lap
• 1. Inspection of the external ear (1/3) using Indirect light
. Mass? Impacted cerumen? Tenderness?
• 2. Straighten ear
adults: grasp the pinna, retracting it outward,
upward and slightly backward
pedia: pull downward and outward
3. Slowly place the otoscope speculum. Look at the
condition of the EOM.
4. Focus on the eardrum
a. Normal dimension: 8 mm x 9mm x 0.1 (thick)
b. Cone of light point forward because of the oblique
angle the membrane makes with the EAC
c. In case of perforation, describe the location (central,
marginal, attic), size, appearance of the middle ear
mucosa and the characteristic of the discharge.
- semi-transluscent, pearly white
oval presenting obliquely 55º w/
floor thus cone of light on
otoscopy
- Size- 1 cm2
- Umbo- center of TM
- 2 parts:
- Pars flaccida/ Shrapnells
membrane
- pars tensa- below malleolar fold
INSPECTION: Size, symmetry, skin color,
presence of deformities, lesions or nodules,

PALPATION: auricles and mastoid areas for

evidence of swelling, tenderness and nodules
1. Hold otoscope w/ the right hand if
examining the right ear and use the left
hand to examine the left ear. Use the
appropriate size of speculum.
Remember to examine the good ear
first.
2. Pull the ear gently then insert the
appropriate sized speculum into the ear
about 1 inch.
3. Examine tympanic membrane: light
reflex, color, shape, scarring &
perforations
4. Examine ear canal for erythema,
scaling, swelling, discharge and foreign
bodies and cerumen.
 • Riverbank 512 cycle fork*
- Conductive vs neural in origin by comparing
weber’s test the bone conduction of both ears.
Tuning fork - Vibrating tuning fork is placed @ any midline
structure (vertex, glabella, or incisors)

- SENSORINEURAL HEARING LOSS

- heard best on the left side (good ear)

- CONDUCTIVE HEARING LOSS,

- - (the right-sided nerve is normal and has
been straining to hear air-conducted sounds
so when equally conducted bone impulses are
received equally by both ears, the right ear
(Bad ear) hears best)
 - duration of Bone conduction vs air
RINNE test conduction
- Place the struck tuning fork over the
mastoid first then later hold the fork
next to the ear (ask w/c is louder)
- Normal ear: fork is heard 2x as long
by air conduction as by bone
- Bone conduction of the examiner is compared
with that of the patient.
- -heel of the tuning fork is held against the
patient’s mastoid bone until the patient no
longer can hear the tone. It is then placed
against the mastoid bone of the examiner ,
who attempts to hear it.
The appearance of the
external nose and face
often gives a clue to the
patient’s symptoms.
Deviated septum
Crepitation- nasal
fracture
Tenderness- infection
Edema- allergy
1. Hold it with the thumb on the
joint, the index finger free to
steady it on the patient’s nose and
the rest of the fingers on the stem
proper to hold the speculum.
2. Always try to open the stem or
tines in an upward action and not
down into the floor of the nose.
3. For children, simply lifting the tip
of the nose may suffice, though
pediatric speculums are also
available
1. Decongest the nose with Ephedrine
sulfate to visualize all the structures.
2. Can be seen: Middle & inferior
turbinates, middle meatus.
3. Septum- deviations:
4. Discharge: from where? (sinusitis from
frontal, maxillary, & anterior ethmoid
sinusitis- m
5. Polyps- usually arise from the ethmoid
air cells and from the middle meatus.
6. Allergy- pale mucosa of the nose
middle meatus)
Structures evaluated in ANTERIOR
RHINOSCOPY:
Vestibule
Mucosa
Nasal septum
Lateral wall of the nose
- Nasopharynx: - look at the area Steps:
behind the nose from below and
behind. 1. Warm the mirror
Done in px w/: 2. Depress the tongue &
1. hx of epistaxis ask the px to breath
2. neck masses through the nose.
3. enexplained serous otitis media 3. Hold mirror like a pen
(esp. unilateral) and place it into the
4. sinusitis oropharynx w/o
5. possible antrochoanal polyps making the px gag
4. Move it around to get a
full picture
Choana
Posterior end of the
vomer
turbinates
Meatus
Eustachian tubes
Adenoids
Ask the patient to open Using a wooden tongue
their mouth blade and a good light
source

Depress the tongue

gently, not against the
teeth
Patient gags if you touch
the posterior 3rd of the
tongue
Inspect the inside of
the patient’s mouth
Buccal folds
Floor of the mouth
Teeth
Salivary ducts
Gingiva
Upper surfaces
Palpation for any
abnormalities found
Temporomandibular
joint
Placing the fingertips
directly over the joint
and asking the patient
to open and close the
mouth
Nasopharynx
From the base of the skull to the top of the soft
palate
Constriction and expansion of these tubes regulate
pressure in the middle ear

Oropharynx
Begins at the circumvallate pappilae, junction
between the soft and hard palate
Hypopharynx/ Laryngopharynx
Superior border of hyoid and lower border of
cricoid cartilage
Subsites:
Pyriform sinuses
Hypopharyngeal walls
Postcrisoid area
Posterior
Rhinoscopy
Rhinoscope is advanced
through the mouth to
examine the back of
the nasal cavity above
the soft palate
History of epistaxis
Neck masses
Unexplained otitis media
(unilateral)
Sinusitis
Possible antrochoanal
polyps
Prepare the mirror
Depress the tongue gently and ask patient to
breath through the nose
Hold the mirror into the oropharynx without
making the patient gag
Move it around to get a full picture
 Involved in breathing, sound
Also called Voice Box production and protects the
trachea against aspiration
Controls movemnt of
laryngeal inlet:
Oblique arytenoid
Controls movement of
vocal folds
Cricothyroid
Thyroarytenoid
Lat Cricoarytenoid
Transverse arytenoid
Post arytenoid
Elevators of the
Larynx:
Digastric
Stylohyoid
Mylohyoid
Geniohyoid
Depressors:
Sternohyoid
Sternothyroid
Omohyoid
Clinical examination of
the laryngeal inlet
By placing a laryngeal
mirror against the soft
palate gently raised
upward
Allows visualization of
the hypopharynx and
larynx
Pull out tongue gently
without resting it on the Note that you see a mirror
lower tooth image
Warm mirror Look for masses,
congestion, pooling of
Place mirror behind the saliva and variations in
soft palate elevating the vocal cord mobility
uvula
Observe the larynx as the
patient breathes deeply
and on phonation
Ask patient to say
“eeeee” and then to
take a deep breath
Allow evaluation of the
motion of the vocal cords
and arytenoid cartilages
Pharyngeal walls
move symmetrically
with gagging
Vocal cord
symmetrical with
phonation
Inspect the neck for
asymmetry, scars, or
other lesions.
Palpate the neck to
detect areas of
tenderness, deformity, or
masses.
Auscultation of the neck
will help evaluate the the
carotid arteries
Inspect the neck looking
for the thyroid gland.
Note for symmetry
Move to a position
behind the patient.
Identify the cricoid
cartilage with the fingers
of both hands
Move downward two
or three tracheal rings
while palpating for the
isthmus.
Move laterally from
the midline while
palpating for the lobes
of the thyroid.
Note the size, symmetry,
and position of the lobes,
as well as the presence of
any nodules
The deep cervical chain of lymph nodes lies below the
sternomastoid :
Inform that this will cause discomfort.
Hook your fingers under the anterior edge of the
sternocleidomastoid muscle.
Ask the patient to bend their neck toward the side
you are examining.
Move the muscle backward and palpate for the
deep nodes underneath.
Palpate with the pads of
your index and middle
fingers for the various
lymph node groups.
Preauricular
Postauricular
Occipital
Tonsillar
Submandibular
Submental
Superficial (Anterior)
Cervical
Supraclavicular
Thank you!!