BasicBasic PhysicalPhysical ExaminationExamination inin ENTENT –– HeadHead andand NeckNeck
DepartmentDepartment ofof OtolaryngologyOtolaryngology –– HeadHead andand NeckNeck SurgerySurgery St.St. Luke’sLuke’s MedicalMedical CenterCenter
EQUIPMENTEQUIPMENT
1. ChairChair withwith HeadHead restrest
2. LightLight SourceSource
3. InstrumentInstrument CabinetCabinet
EQUIPMENTEQUIPMENT
HeadHead MirrorMirror
““leavesleaves bothboth handshands freefree forfor examination”examination”
““positionedpositioned overover thethe leftleft eyeeye andand closeclose toto thethe examiner’sexaminer’s face”face”
EQUIPMENTEQUIPMENT
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.
EQUIPMENTEQUIPMENT
BasicBasic InstrumentsInstruments
3. EarEar speculaspecula 4. NasalNasal SpeculaSpecula 5. TongueTongue depressorsdepressors 6. IndirectIndirect laryngoscopylaryngoscopy mirrorsmirrors 7. PosteriorPosterior RhinoscopyRhinoscopy mirrorsmirrors 8. NasalNasal andand auralaural forceps.forceps. 9. TuningTuning forks,forks, 512512 Hz,Hz, 10241024 HzHz 10. OtoscopeOtoscope
EAREAR EXAMEXAM
EAREAR EXAMEXAM
EAREAR EXAMEXAM
““ beginbegin withwith inspectioninspection andand palpationpalpation ofof thethe pinnapinna (auricle)(auricle) andand structuresstructures surroundingsurrounding thethe ear…”ear…”
OTOSCOPYOTOSCOPY
OtoscopyOtoscopy isis usedused toto visualizevisualize thethe earear canal/eardrumcanal/eardrum forfor thethe purposepurpose ofof detectingdetecting abnormalabnormal conditionsconditions thatthat mightmight requirerequire furtherfurther evaluationevaluation oror treatment.treatment.
OTOSCOPYOTOSCOPY
““graspgrasp andand retractretract thethe pinnapinna backwardbackward andand upwardupward inin adultsadults andand downwardsdownwards inin infants…”infants…”
OTOSCOPYOTOSCOPY • 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)
PNEMATICPNEMATIC OTOSCOPYOTOSCOPY
"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)
PNEUMATICPNEUMATIC OTOSCOPYOTOSCOPY
TUNINGTUNING FORKFORK TESTTEST
Indication:Indication: DifferentiateDifferentiate typetype ofof HearingHearing LossLoss
SensorineuralSensorineural HearingHearing LossLoss ConductiveConductive HearingHearing LossLoss
TUNINGTUNING FORKFORK TESTTEST
PreparationPreparation
TuningTuning forkfork shouldshould bebe 512512 HzHz toto 10241024 HzHz
WEBERWEBER TESTTEST
Technique:Technique: TuningTuning ForkFork placedplaced atat midlinemidline foreheadforehead
Normal:Normal: SoundSound radiatesradiates toto bothboth earsears equallyequally
Abnormal:Abnormal: SoundSound lateralizeslateralizes toto oneone earear • Ipsilateral Conductive Hearing Loss OR • Contralateral Sensorineural Hearing Loss
RINNERINNE TESTTEST TechniqueTechnique •First:First: BoneBone ConductionConduction •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:Next: AirAir ConductionConduction Patient indicates when the sound ceases
RINNERINNE TESTTEST Normal:Normal: AirAir ConductionConduction isis betterbetter thanthan BoneBone ConductionConduction AirAir conductionconduction usuallyusually persistspersists twicetwice asas longlong asas bonebone ReferredReferred toto asas "positive"positive test"test"
Abnormal:Abnormal: BoneBone conductionconduction betterbetter thanthan airair conductionconduction SuggestsSuggests ConductiveConductive HearingHearing LossLoss ReferredReferred toto asas "negative"negative test"test"
TestTest forfor EustachianEustachian TubeTube FunctionFunction 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. NOSENOSE
EXAMINATIONEXAMINATION OFOF THETHE NOSENOSE
TheThe nosenose cancan bebe examinedexamined inin threethree parts:parts:
3. ExaminationExamination ofof thethe externalexternal nosenose
4. AnteriorAnterior RhinoscopyRhinoscopy
5. PosteriorPosterior Rhinoscopy.Rhinoscopy.
EXAMINATIONEXAMINATION OFOF THETHE EXTERNALEXTERNAL NOSENOSE
Inspection:Inspection: • CongenitalCongenital deformitiesdeformities (Clefts)(Clefts) • AcquiredAcquired DeformitiesDeformities • ShapeShape • SwellingSwelling (( Inflammatory,Inflammatory, cysts,cysts, tumors)tumors) • UlcerationUlceration (( Trauma,Trauma, neoplastic,neoplastic, infective)infective)
Palpation:Palpation: • TendernessTenderness • CrepitusCrepitus • DeformitiesDeformities AnteriorAnterior RhinoscopyRhinoscopy
1. ExaminationExamination ofof thethe VestibuleVestibule
LookLook for:for: BoilBoil oror AbcessAbcess UlcerationsUlcerations andand abrasionsabrasions ExcoriationExcoriation becausebecause ofof discharge.discharge.
ANTERIORANTERIOR RHINOSCOPYRHINOSCOPY
2. ExaminationExamination ofof thethe nasalnasal cavitycavity usingusing aa nasalnasal speculum:speculum:
POSTERIORPOSTERIOR RHINOSCOPYRHINOSCOPY
PostPost NasalNasal Mirror:Mirror:
ItIt consistsconsists ofof aa handlehandle onon whichwhich aa smallsmall mirrormirror isis attachedattached toto shaftshaft atat anan angleangle ofof 110.110.
POSTERIORPOSTERIOR RHINOSCOPYRHINOSCOPY Technique 2. Hold the mirror like a pen in the right hand.
4. Warm the mirror
6. Ask the patient to open the mouth.
8. Depress the anterior 2/3rds of the tongue
10. Feel the warmth of the mirror on the back of the wrist. It should not be hot.
12. 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.
14. Instruct the patient to breath through the nose.
16. Tilt the mirror in different direction tot see various structures of the nasopharynx. POSTERIORPOSTERIOR RHINOSCOPYRHINOSCOPY
PARANASALPARANASAL SINUSESSINUSES
TRANSILLUMINATIONTRANSILLUMINATION TESTTEST
• 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.
ORALORAL CAVITYCAVITY
ORALORAL CAVITYCAVITY TongueTongue
CheckCheck for:for: CommonCommon andand tastetaste sensationssensations Size:Size: MacroglossiaMacroglossia inin acromegaly,acromegaly, Down'sDown's syndromesyndrome UlcersUlcers Movements:Movements: RestrictedRestricted inin hypoglossalhypoglossal palsies,palsies, tumortumor infiltrationinfiltration Fasciculation:Fasciculation: MotorMotor neuronneuron diseasedisease Depapillation:Depapillation: VitaminVitamin deficienciesdeficiencies FurrowingFurrowing ,, asas inin geographicgeographic tonguetongue Coating:Coating: Thrush,Thrush, blackblack hairyhairy tonguetongue
ORALORAL CAVITYCAVITY
• BuccalBuccal Mucosa:Mucosa: ParotidParotid ductduct openingopening OppositeOpposite upperupper 2nd2nd molar),molar), redred oror whitewhite patches,patches, ulcers,ulcers, moisturemoisture
• HardHard Palate:Palate: Swelling,Swelling, ulcer,ulcer, perforations,perforations, cleftsclefts etc.etc.
• Uvula:Uvula: Position,Position, deviationsdeviations (Towards(Towards thethe normalnormal sideside inin palsies),palsies), ulcersulcers
• FloorFloor ofof mouth:mouth: WhartonWharton ductduct openings,openings, ulcers,ulcers, andand bimanualbimanual palpationpalpation
• TeethTeeth andand occlusionocclusion
OROPHARYNXOROPHARYNX • 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.
LARYNGOSCOPYLARYNGOSCOPY
DefinitionDefinition VisualVisual examexam ofof thethe voicevoice boxbox (larynx)(larynx) andand thethe vocalvocal cords.cords.
LaryngoscopyLaryngoscopy isis alsoalso donedone toto removeremove foreignforeign objectsobjects stuckstuck inin thethe throat.throat.
LARYNGOSCOPYLARYNGOSCOPY
ThereThere areare twotwo mainmain kinds:kinds:
1.Indirect1.Indirect laryngoscopylaryngoscopy -- usesuses mirrorsmirrors toto examineexamine thethe larynxlarynx andand hypopharynxhypopharynx
2.Direct2.Direct laryngoscopylaryngoscopy -- usesuses aa specialspecial instrumentinstrument (flexible(flexible oror rigidrigid scope)scope)
INDIRECTINDIRECT LARYNGOSCOPYLARYNGOSCOPY
Technique
3. Mirror is held like a pen in the right hand with the glass pointing downwards.
5. Warm the mirror and test the temperature on the back of the hand.
7. The patient is asked to stick out the tongue which is held with a piece of gauze.
9. The patient is asked to breath through the mouth.
11. 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. 12. The patient is asked to say 'Aaa' and 'Eee'.
INDIRECTINDIRECT LARYNGOSCOPYLARYNGOSCOPY
HEADHEAD ANDAND NECKNECK
NECKNECK
LYMPHLYMPH NODENODE LEVELSLEVELS
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 CERVICALCERVICAL LYMPHLYMPH NODESNODES
THYROIDTHYROID ANDAND PARATHYROIDPARATHYROID GLANDSGLANDS
SALIVARYSALIVARY GLANDSGLANDS
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