ENT EXAMINATION

ENT DEPARTMENT
SYIAH KUALA MEDICAL FACULTY/
ZAINOEL ABIDIN HOSPITAL
 Learning Objectives

Students should be able to perform

a basic head and neck exam with
equipment available to a primary
care practitioner (flashlight, tongue
blade, otoscope)
Light Source:
- Mobile: Head light

Instruments :
- Ear specula,
- Nasal Specula,
- Tongue depressors,
- Indirect laryngoscopy mirrors,
- Posterior Rhinoscopy mirrors,
- spirit lamp,
- Nasal and aural forceps.
- Tuning forks, 512 Hz, 1024 Hz,
- Otoscope
Instrument
 EXAMINATION OF
THE EAR
Examination of the ear includes :
1. Pinna,
2. External auditory meatus,
3. Tympanic membrane,
4. Middle ear,
5. Tests for the function of Eustachian tube,
6. Tests of hearing,
7. Tests of balance,
8. Eyes.
9. Cranial nerves
10. Post aural area (Mastoid process), and lymph nodes.
Ear Inspection
Inspect for:
• Size • Shape • Symmetry
• Landmarks • Color • Position
• Deformity or Lesion
Inner Ear
 OTOSCOPY:
Technique:
– The pinna is pulled upwards, backwards and
outwards.
– The speculum of appropriate size is introduced
along the axis of the meatus with a rotating
motion using the left hand for the right ear and
the right hand for the left ear.
– One hand is left free for instrumentation.
– In infants and young children the pinna is pulled
downwards and backwards to straighten the
meatus.
– Wax and other debris must be removed for
adequate examination
Inserting Otoscope
MEMBRAN SHRAPNEL

FOR.ROTUNDUM

ANNULUS
Examination of the External Auditory
Meatus:
– Patency: Atresia, stenosis
– Swelling: Inflammatory, neoplastic.
– Discharge: Wax, mucoid, purulent,
haemorrhagic, watery.
– Tragal tenderness.
– Sagging of the postero-superior meatal
wall.
Ear Wax
Foreign bodies
Exostosis
Furunculosis
Tympanic membrane: (Using naked eye,otoscope, and
otomicroscope)
• Position,
• Colour: Hemorrhage, dullness, blue, bullae
• Ossicles
• Perforations: Marginal and Central, site, size.
• Mobility: (Retractions) by using a pneumatic otoscope, or
Siegle's speculum.

Middle ear:
• Can be examined through a perforation.
• Look at the colour of mucosa, edema, discharge, polyps,
promontory
Assessment of tympanic membrane
Color and Appearance
Yellow (amber) serous fluid behind TM
• Suggests Serous Otitis Media
• Air bubbles may also be seen in serous otitis
Marked erythema may suggest Acute Otitis Media
• Fever and crying can also bring this on
Landmarks obscured
• Suggests Acute Otitis Media
• Position
– Bulging TM suggests Acute Otitis Media
– Retracted TM suggests eustachian tube dysfunction
• Mobility
– Immobile TM suggests effusion
 Otitis Media

Oklusi tuba Hiperemis

Supurasi Perforasi
Tipe jinak Tipe bahaya
Myringitis
Otomycosis
Polyp
Glomus Jugulare Tumor
Neoplasma
Secretory Otitis Media (Otitis
Media with Effusion)
Myringotomy and Insertion
of aVentilation Tube
Atelectasis
Tympanic membrane Perforation
posterosuperior marginal perforation
Quadrant Posterior Perforation
Anterior Perforations
Subtotal Perforations
Total Perforation
Posttraumatic Perforations
Tympanosclerosis Associated
with Perrforation
Tympanosclerosis with Intact
Tympanic Membrane
Epitympanic Retraction Pocket
Epitympanic Cholesteatoma
Mesotympanic Cholesteatoma
 Examination of the nose

The nose can be examined in three

parts:
1. Examination of the external nose,
2. Anterior Rhinoscopy,
3. Posterior Rhinoscopy
4. Naso endoscopy
1.Examination of the External Nose:
Inspection:
• Congenital deformities: Clefts, sinuses.
• Acquired Deformities,
• Shape,
• Swelling, ( Inflammatory, cysts, tumors)
• Ulceration ( Trauma, neoplastic,
infective).
Deformitas of the nose
 Palpation:
It is carried for;
• tenderness,
• crepitus, and
• Deformities
Tenderness over the tip is due to a boil.
Over the dorsum is due to trauma.
 2. Anterior Rhinoscopy:
It consists of the following steps:
1. Examination of the vestibule (Skin
lined part of the nares),
2. Examination of the nasal cavity
using the Thudichum's speculum,
3. Patency tests,
4. Probe test,
5. Examination after vasoconstrictio
 Use of the speculum:
• Introduce the speculum with the blades closed..
• Introduce the speculum in an upwards and backwards
direction.
• Once inside the nose, gradually open the blades avoiding
discomfort to the patient.
• Look at roof, floor, lateral and medial walls of the nose.
• Septum: Position, spurs, deviation, colour of mucosa,
ulcers, crusting, vessels, and perforations.
• Lateral wall: Inferior and middle turbinates, size
,colour, shape.
• Meatii for pus and discharge, and polyps.
 3. Posterior Rhinoscopy:
Different methods of examining the area
are;
• Post nasal mirror.
• Nasopharyngoscope.
• Examination under anaesthesia after
palatal retraction.
• Digital palpation.
• Radiological examination.
Posterior Rhinoscopy
 Method of Posterior Rhinoscopy:
Technique:
• Hold the mirror like a pen in the right hand.
• Warm the mirror slightly on the flame of the spirit lamp
• Ask the patient to open the mouth.
• Take the tongue depressor in the left hand and depress
the anterior 2/3rds of the tongue.
• Feel the warmth of the mirror on the back of the wrist.
• 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.
• Instruct the patient to breath through the nose.
• Tilt the mirror in different direction tot see various
structures of the nasopharynx
Evaluation of Frontal and
Maxillary Sinuses
Transillumination of the right
maxillary sinus
Nasal Endoscopic Examination
Meatus medius Exam
Post nasal drip
EXAMINATION OF THE THROAT
The throat consists of the ; oral cavity
,and the oropharynx

ORAL CAVITY
It includes the following structures:
- Lips
- Teeth
- Gums
- Tongue
- Hard and soft palates,
- Floor,
- Cheeks
OROPHARYNX
It includes the following structures:
• Uvula,
• Soft palate,
• Anterior and posterior tonsillar pillars,
• Tonsils,
• Posterior pharyngeal wall.
Tonsilar hipertrophy : grading scale
Tongue:
• common and taste sensations,
• size: Macroglossia in acromegaly, Down's syndrome.
• ulcers: Traumatic, dental, apthous, malignant,
tuberculous, syphilitic.
• movements: Restricted in hypoglossal palsies, tumor
infiltration.
• fasciculation: Motor neuron disease,
• depapillation: Vitamin deficiencies,
• furrowing , as in geographic tongue
• coating: Thrush, black hairy tongue.
• Hypoglossal palsy: Tongue deviates towards the
lesion.
• Cheeks: Parotid duct opening Opposite upper 2nd
molar), red or white patches, ulcers, moisture.
• Palate: Swelling, ulcer, movement, perforations, clefts
• Uvula: Position, deviations (Towards the normal side in
palsies), ulcers.
• Tonsillar pillars: Linear congestion, ulcers, patches.
• Tonsils: Presence, size, crypts, ulcers, express the
contents of the crypts by pressing on the pillars to
see whether purulent.
• Posterior pharyngeal wall: Lymphoid follicles, ulcers.
• Floor of mouth: Wharton duct openings, ulcers, and
bimanual palpation.
• Teeth and occlusion
• The upper and lower vestibule of the cheek
Penilaian Adenoid
• Triad of hyponasality,
snoring, and mouth
breathing
• Rhinorrhea, nocturnal
cough, post nasal drip
• “Adenoid facies”
• “Milkman” & “Micky Mouse”
• Overbite, long face,
crowded incisors
 EXAMINATION OF THE LARYNX &
HYPOPHARYNX
Hypopharynx consists of the:
– Posterior pharyngeal wall,
– Pyriform fossae, and
– Post cricoid area.
Examination can be carried out by:
1. Indirect laryngoscopy,
2. Flexible or rigid endoscopes,
3. Direct laryngoscopy.
4. X-rays.
 INDIRECT LARYNGOSCOPY:
• The mirror is plane, on a straight handle.
• Mirror is held like a pen in the right hand with the
glass pointing downwards.
• Warm the mirror and test the temperature on the
back of the hand.
• The patient is asked to stick out the tongue which is
held with a piece of gauze.
• The patient is asked to breath through the mouth.
• 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.
• The patient is asked to say 'Aaa' and 'Eee'
 Examination of the Neck
• Inspection: Position, shape, thyroid
angle, movement with swallowing,
retraction of the suprasternal notch on
inspiration.

• Palpation: Cartilages for irregularity,

scars, tenderness, subcutaneous
emphysema, laryngeal crepitus.
Location of the Thyroid
Thyroid Examination
Palpating Anterior Cervical Lymph
Nodes
Cervical Adenopathy
 Tuning Fork Tests
Indication: Differentiate Hearing Loss cause
• Sensorineural Hearing Loss
• Conductive Hearing Loss

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
Weber Test
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
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"
Tes Cukit ( Skin Prick Test)
Indikasi
• Rinitis alergi
• Asthma
• Kecurigaan alergi terhadap makanan
• Kecurigaan reaksi alergi terhadap
sengatan serangga
 Persiapan Tes Cukit

• Persiapan bahan/material ekstrak

alergen.
• Pesiapan Penderita
• Persiapan pemeriksa