Clinical Examination Guide

ENT

Components of the examination

• Introduction • Examination of ear and tests • Examination of nose • Examination of mouth and oropharynx • Cervical lymph node examination • Conclusion

Introduction

• Introduce yourself, confirm patient ID • Explain examination and gain consent, position patient sitting. • Ask if they are in any pain • Gather equipment and gel hands

Examination of Ear

Inspection Otoscopy Starting with the “good ear” • Hold otoscope with pen-like grip. Use your right • Inspect outer ear checking for: hand / eye for patient’s right ear and left hand/eye - Swelling, inflammation, skin conditions for patient’s left ear. - Scars, deformities • Retract patient’s pinna (back and up for an adult, - Hearing aids or back and down for a child) with other hand, - Evidence of discharge insert speculum and rest ulnar border of your hand against patient’s face. • Inspect external auditory meatus for skin changes, wax, foreign bodies • Palpate • Inspect tympanic membrane, noting colour, light - Mastoid Process reflex - Tragus • Systematically note anatomical structures - Temporomandibular joint • Remove otoscope and inspect speculum

Document Owner: Clinical Skills/LK Last Updated: Feb 2018 1. Umbro 2. Handle of the malleolus 3. Lateral process of malleolus 4. Pars flaccida 5. Pars tensa

Hearing Tests

Whispered voice test, screening for normal hearing • Explain you will whisper a number in their ear and you need them to repeat it • Rub the tragus of the opposite ear to mask sound to that ear • Whisper a number, 60cm from the ear you are testing and ask patient to repeat it • If they can hear the number, hearing is not significantly impaired Rinne’s test with 512Hz fork Weber’s test with 512 Hz fork • Strike fork and hold prongs a ~10cm from external • Strike fork and place the base in the middle of the forehead • Ask patient if they can hear it • Ask “Is the sound louder in one ear, or the same in • Place base of fork on mastoid bone and ask “Is it both?” louder, or quieter?” • Equal = normal W • Louder on the mastoid means is • Lateralise to good ear = sensorineural better than air conduction = Negative Rinne in the “bad ear” • Mask sound on good ear to confirm a negative • Lateralise to bad ear = in finding the “bad ear”

Rinne Weber Normal Positive both ears: AC>BC Central Conductive Loss Negative bad ear: BC>AC Lateralises to bad ear Sensorineural Loss Positive both ears: AC>BC Lateralises to good ear AC – air conduction BC – bone conduction

Vestibular function:

Unterberger/Turning test for unilateral lesion: • Ask patient to stand facing you, arms outstretched • Ask them to march on the spot and then close their eyes whilst continuing to march for ~50 steps • If lesion present, patient will gradually turn towards to the side of the lesion

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Dix-Hallpike manoeuvre - diagnostic for benign persistent paroxysmal (BPPV) Note the Dix-Hallpike and Epley maneuvers can cause great distress to patients suffering from true vertigo and should not be performed unsupervised or on patients who have neck or spinal pathology. • Explain to the patient the test may provoke • Ask the patient if they feel vertigo and observe for transient vertigo. Check for possible at least 30s for torsional (geotropic - contraindications and avoid the in neck and back towards the floor) pathology. • Return the patient to the upright position • With couch flat, position patient so that their head • Repeat with the head turned to the left to test the will overhang the edge of the couch when they lay left posterior canal. back. • Horizontal nystagmus after a 2-20s latent period • Begin with the patient sitting upright, eyes open, suggests a peripheral vestibular cause e.g. benign head turned 45° to the right (testing the right paroxysmal positional vertigo (BPPV). Vertical posterior canal). Holding the patients head with nystagmus without a latent period suggests a your hands, lay them down quickly until the head is central vestibular cause dependent 30° below the level of the couch. • If the test was positive, proceed directly to perform the Epley manoeuvre

See BMJ Learning Video: https://www.youtube.com/watch?v=8RYB2QlO1N4 for demonstration

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Epley Manoevre – for management of BPPV The Epley Manoeuvre should be performed immediately on diagnosing BPPV via the Dix-Hallpike, as the patient will already be in the correct position. Precautions as above

• Start with patient lying down, head turned to 45o extended over the end of the couch with affected • Wait 30-60 seconds ear facing the floor. • Ask the patient to swing their legs over the side of • Wait for any nystagmus to end before turning the the couch and sit up slowly whilst you support their patient’s head through 90o to face the other side so head to bring it to the midline but still facing down, that the affected ear is now facing up. chin resting on their chest. • Wait 60s then as you support their head, ask the • The patient should now be sitting with their chin on patient to roll the rest of their body fully on that their chest side. This will turn the head through a further • The patient can slowly bring their head up and 90o so they end lying on their side, affected ear still move when they feel comfortable facing up, head turned so they are looking the floor just to the side the couch.

BMJ Learning Video: https://www.youtube.com/watch?v=jBzID5nVQjk for demonstration

Post procedure advice: • The patient should try to minimise head movement for 24 hours after treatment • The Epley manoeuvre is highly effect, but sometimes two or three manoeuvres are required to treat BPPV • About 1 in 20 patients has BPPV resistant to repeated Epley manoeuvres

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Examination of nose

• From the front, look for deviation of the nasal bones, scars or skin abnormalities • Assess nasal patency by holding a cold metal tongue depressor underneath and observing misting pattern, or hold a tiny wisp of cotton wool under each nostril in turn and observe for movement • Lift the nasal tip gently to inspect the nasal septum to assess if it is deviated • Inspect the inferior turbinates and note any swelling, erythema or oedema

Examination of the mouth and oropharynx

• Inspect lips, noting abnormalities of the skin • Ask the patient to say “Ahh” to assess palatal • Ask the patient to open their mouth as wide as movement. Note the anterior palatoglossal folds, possible, noting any restriction tonsils and uvula and any asymmetry • Inspect tongue and sides of the mouth • Ask the patient to move tongue from side to side systematically and with help of the tongue when protruded depressor and pentorch, noting abnormalities of dorsum, lateral borders and under surface of tongue, insides of the cheeks, floor of the mouth and the hard palate

Cervical lymph node examination

Standing behind the patient, examining both sides together • Start on the mastoid process larynx is tethered (crepitus is normal when moving • Palpate down the anterior border of the trapezius a healthy larynx from side to side) and supraclavicular fossa • Continue up the midline to the submental area • Palpate the posterior triangle • Follow the inferior border of the horizontal ramus • Palpate up the posterior border of the SCM back of the mandible and palpate the submandibular up to the mastoid process nodes • Palpate down the anterior border of the SCM until • Move to the pre-auricular, post-auricular and your fingers meet at the sternal notch finally the occipital nodes • Palpate up the midline towards the chin, noting whether the thyroid is palpable and whether the

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For each area, note the following: • Presence of enlarged nodes – solitary or numerous • Shape – spherical or irregular • Size • Consistency – soft, firm, hard or rubbery • Tenderness • Temperature of overlying skin • Mobility / attachment

Conclusion

• Thank patient, ask them to get dressed, report/record findings • Consider referral for further audiology testing

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