Basic Physical Examination in ENT – Head and Neck

1. Basic Physical Examination in ENT – Head and Neck Department of Otolaryngology – Head and Neck Surgery St. Luke’s Medical Center

2. EQUIPMENT • Chair with Head rest • Light Source • Instrument Cabinet

3. EQUIPMENT Head Mirror “leaves both hands free for examination” “positioned over the left eye and close to the examiner’s face”

4. EQUIPMENT How to focus the head mirror • The patient sits on the stool at the same level as the doctor. • Patient's legs should be to one side of the examiner. • The distance between the doctor and patient should not be more than 8 inches (Depending on the maximum focal length of head mirror). • 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. • Open both the eyes.

5. EQUIPMENT Basic Instruments • Ear specula • Nasal Specula • Tongue depressors • Indirect laryngoscopy mirrors • Posterior Rhinoscopy mirrors • Nasal and aural forceps. • Tuning forks, 512 Hz, 1024 Hz • Otoscope

6. EAR EXAM

7. EAR EXAM

8. EAR EXAM “ begin with inspection and palpation of the pinna (auricle) and structures surrounding the ear…”

9. OTOSCOPY Otoscopy is used to visualize the ear canal/eardrum for the purpose of detecting abnormal conditions that might require further evaluation or treatment.

10. OTOSCOPY “grasp and retract the pinna backward and upward in adults and downwards in infants…”

11. OTOSCOPY • An -  annulus fibrosus • Lpi  (long process of incus) - sometimes visible through a healthy translucent drum • Um  (umbo) - the end of the malleus handle and the centre of the drum • Lr  (light reflex) - antero-inferiorly • Lp  (Lateral process of the malleus) • At  (Attic) also known as pars flaccida • Hm  (handle of the malleus)

12. PNEMATIC OTOSCOPY "allows the examiner to observe movement of the tympanic membrane directly". "If the tympanic membrane does not move perceptibly with applications of slight positive or negative pressure, a middle ear effusion is highly likely". (Bluestone and Klein, 1990)

13. PNEUMATIC OTOSCOPY

14. TUNING FORK TEST Indication: Differentiate type of Hearing Loss • Sensorineural Hearing Loss • Conductive Hearing Loss

15. TUNING FORK TEST Preparation Tuning fork should be 512 Hz to 1024 Hz

16. 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

17. 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

18. RINNE TEST 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"

19. Test for Eustachian Tube Function 1. Valsalva Maneuver: Method: After taking a deep breath, the patient pinches his nose and closes his mouth in an attempt to blow air in his ears. Otoscopy shows movement of the drum. • Note: Failure of this test does not prove pathologic occlusion of the tube. • This maneuver in the presence of nasal and nasopharyngeal infection carries the danger of transmission of infection to the ear. 2. Toynbee's test: It is safer and confirms normal tubal function. • Method: The nose is closed and the patient swallows. There is in drawing of the tympanic membrane, confirmed by otoscopy.

20. NOSE

21. EXAMINATION OF THE NOSE The nose can be examined in three parts: • Examination of the external nose • Anterior Rhinoscopy • Posterior Rhinoscopy.

22. EXAMINATION OF THE EXTERNAL NOSE Inspection: • Congenital deformities (Clefts) • Acquired Deformities • Shape • Swelling ( Inflammatory, cysts, tumors) • Ulceration ( Trauma, neoplastic, infective) Palpation: • Tenderness • Crepitus • Deformities

23. Anterior Rhinoscopy • Examination of the Vestibule Look for: • Boil or Abcess • Ulcerations and abrasions • Excoriation because of discharge.

24. ANTERIOR RHINOSCOPY • Examination of the nasal cavity using a nasal speculum:

25. POSTERIOR RHINOSCOPY Post Nasal Mirror: It consists of a handle on which a small mirror is attached to shaft at an angle of 110.

26. POSTERIOR RHINOSCOPY Technique • Hold the mirror like a pen in the right hand. • Warm the mirror • Ask the patient to open the mouth. • Depress the anterior 2/3rds of the tongue • Feel the warmth of the mirror on the back of the wrist. It should not be hot. • 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.

27. POSTERIOR RHINOSCOPY

28. PARANASAL SINUSES

29. TRANSILLUMINATION TEST • Dim the room lights. • Place the lighted otoscope directly on the infraorbital rim (bone just below the eye). • Ask the patient to open their mouth and look for light glowing through the mucosa of the upper mouth. Principle: In the setting of inflammation, the maxillary sinus becomes fluid filled and will not allow this transillumination.

30. ORAL CAVITY

31. ORAL CAVITY Tongue Check for: • Common and taste sensations • Size: Macroglossia in acromegaly, Down's syndrome • Ulcers • Movements: Restricted in hypoglossal palsies, tumor infiltration • Fasciculation: Motor neuron disease • Depapillation: Vitamin deficiencies • Furrowing , as in geographic tongue • Coating: Thrush, black hairy tongue

32. ORAL CAVITY • Buccal Mucosa: Parotid duct opening Opposite upper 2nd molar), red or white patches, ulcers, moisture • Hard Palate: Swelling, ulcer, perforations, clefts etc. • Uvula: Position, deviations (Towards the normal side in palsies), ulcers • Floor of mouth: Wharton duct openings, ulcers, and bimanual palpation • Teeth and occlusion

33. OROPHARYNX • Soft Palate: Swelling, ulcer, movement, perforations, clefts etc. • Uvula: Position, deviations (Towards the normal side in palsies), ulcers • Tonsillar pillars: congestion, ulcers, patches. • Tonsils: Presence, size, crypts, ulcers • Posterior pharyngeal wall: Lymphoid follicles, ulcers.

34. LARYNGOSCOPY Definition Visual exam of the voice box (larynx) and the vocal cords. Laryngoscopy is also done to remove foreign objects stuck in the throat.

35. LARYNGOSCOPY There are two main kinds: 1.Indirect laryngoscopy - uses mirrors to examine the larynx and hypopharynx 2.Direct laryngoscopy - uses a special instrument (flexible or rigid scope)

36. INDIRECT LARYNGOSCOPY Technique • 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'.

37. INDIRECT LARYNGOSCOPY

38. HEAD AND NECK

39. NECK

40. LYMPH NODE LEVELS I--Submental and submandibular nodes II--Upper jugulodigastric group III--Middle jugular nodes draining the naso- and oropharynx, oral cavity, hypopharynx, larynx. IV--Inferior jugular nodes draining the hypopharynx, subglottic larynx, thyroid, and esophagus. V-- Posterior triangle group VI--Anterior compartment group

41. CERVICAL LYMPH NODES

42. THYROID AND PARATHYROID GLANDS

43. SALIVARY GLANDS

44. THANK YOU