Learning_objectives To understand the anatomy and physiology of the ear, nose and throat (ENT). To be able to inspect the oral and nasal cavity and the external ear To understand the basic use of an otoscope and be able to identify the structures in your partner’s ear Theory_and_background A full ENT examination should include examination of the lymph nodes of the head and neck. Indications for an ENT examination The following list of reasons for an ear, nose or throat examination and is by no means exhaustive, A patient could present with; Consider asking about alcohol & tobacco habits. OTOSCOPY Anatomy of the ear The ear is divided anatomically and clinically into the external, middle and inner ear Patient safety Inspection_of_external_structures Examination of pinna and adjacent tissues Inspect the Pinna, check for; Examine the lymph nodes Examine the mastoid process for Observe and note evidence of hearing aid Inspect the external meatus for; Inspect the canal (viewing through a speculum) for; Otoscopy_-_position The pinna of the ear to be examined is held firmly and gently pulled upwards and backwards to straighten the canal using the hand not holding the otoscope. The patient should be positioned with the head flexed laterally away from the examiner. Be aware that the external auditory canal has a bend which normally restricts the examiners view. Holding the instrument Otoscope is held in the same hand as the ear being examined The speculum should be as wide as possible to comfortably fit into the ear canal Holding the otoscope (like a pen) horizontally provides a secure cradle for the instrument The curled fingers can rest against the cheek and the handle will not catch the shoulder (as it may if held vertically) In addition, this position will help protect against accidentally pushing too deeply into the outer ear Inspection of the Tympanic Membrane Nasal_Examination External Inspection Nose Shape – Look from the sides & above, is there any; Internal Inspection Picture attributed to Dr A. Tomlinson, California Sinus Centers, https://www.youtube.com/watch?v=aP2oYudd4Qk Inspect the front of the nose first by tipping the nose up and inspecting without a speculum. You can insert a big otoscope speculum as far as the nasal hairs go or use a Thudichum or Kilian speculum and a light. Don’t touch the septum; it’s very sensitive. You should be able to identify the septum medially and the inferior turbinates laterally. Internal Inspection contd. Thudichum Speculum Killian Nasal Speculum Permission kindly granted by Surgical Holdings UK to use above images 2018 Polyps Internal inspection should also cover; Palpation Gently palpate as appropriate; As stated above turbinates are sensitive to touch. Nasal Airway Assessment Cover one nostril and ask the patient to sniff. This gives a reasonable idea of nasal airway and sounds wet if there is discharge. Airway patency is very subjective; even flow meter readings often don’t match patient scoring. Throat_Examination Take a clear history; Throat Symptoms What symptoms does the patient have?; Inspection Inspect the lips. Note pallor, angular stomatitis and asymmetry Retract the lips with the teeth partly closed. Examine the gums (with and without any dentures) note gingivitis (inflammation of the gums), ulcers (eroded patches of tissue), missing teeth, dental carries. Note the buccal mucosa of the cheeks. The Parotid duct opens behind the 2nd molar. Ask the patient to lift their tongue. If the tip can touch the roof of the mouth and the vermillion border (outer edge of lips) there is no tongue tie. (Ankyloglosia.) Inspect the floor of the mouth to beyond the last molar; use a speculum against the cheek & one to hold the tongue across. Consider neurological examination: Palpation Palpate associated lymph nodes. Document Document all findings clearly and ensure all abnormalities reported to your supervisor. Glossary
