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;

  • otalgia (pain in ear)
  • vertigo (spinning or swaying sensation)
  • foreign body
  • tinnitus (hearing of sound when no external sound is present)
  • swelling
  • deafness
  • trauma
  • otorrhoea (discharge in ear)
  • airway obstruction
  • rhinorrhoea (runny nose)
  • post nasal discharge (catarrh)
  • sneezing
  • loss of smell (anosmia)
  • facial pain due to sinusitis
  • snoring associated with nasal obstruction
  • sore throat / spots on tonsils (i.e. pus in crypts (deep dips within the tonsillar tissue). crypts serve to increase the surface area of the tonsils & are part of the immune system.)
  • food sticking or regurgitation.
  • masses or ulcers and if painful
  • voice changes

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

  • Note the external ear consists of a cartilaginous and a bony part
  • The bony part is painful if touched with a speculum inserted too far (if too small a speculum used)
  • Use the diagram to identify and label malleus, incus, stapes, cochlea, semi-circular canals, cochlear nerve, auditory nerve

Patient safety

Inspection_of_external_structures

    

Examination of pinna and adjacent tissues

Inspect the Pinna, check for;

  • size, shape, symmetry
  • position of any ulcers, lumps
  • position of any tenderness, scars

Examine the lymph nodes

  • particularly pre and post auricular

Examine the mastoid process for

  • any tenderness

Observe and note evidence of hearing aid

Inspect the external meatus for;

  • discharge – blood / pus
  • swelling / masses

Inspect the canal (viewing through a speculum) for;

  • skin
  • discharge/debris
  • swelling
  • masses
  • wax
  • Foreign bodies!

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;

  • Abnormal Nasal Creases
  • Deviation
  • Scars
  • Discharge or crusting
  • Redness or skin disease
  • Offensive odour (from the patient)

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;

  • Mucosa: is there any swelling, redness or oedema (rhinitis)
  • Septum: straight or deviated.
  • Masses (or foreign bodies in a child.)
  • Mouth: polyps (abnormal growth of tissue projecting from a mucous membrane) or tumours may hang into the pharynx or grow through the palate.
  • Polyps are grey / yellow whereas turbinates are normally pink
  • Oedematous turbinates can look like polyps (e.g. in hay fever when inflamed) but polyps are not sensitive to touch whereas turbinates are exquisitely so.

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;

  • Enquire on general history
  • Sore throat, food sticking, visible lesions +/- causing pain.
  • Ask about alcohol & tobacco habits.
  • Ask about their dental history.

Throat Symptoms

What symptoms does the patient have?;

  • Sore throat / spots on tonsils (i.e. pus in crypts. Crypts serve to increase the surface area of the tonsils & are part of the immune system.)
  • Food sticking or regurgitation.
  • Masses or ulcers and are these painful?
  • Voice changes
  • Ask about alcohol & tobacco habits.
  • B. Dental history eg; facial swelling or glands in the neck.

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.

  • Note oral hydration, halitosis,
  • Note ulcers or masses
  • Use a bright light. With the tongue out: inspect the tonsils, uvula and soft palate. Ask for head up to inspect the palate.
  • Only use a tongue depressor if the view isn’t adequate. Children often show their epiglottis!

  • Any further examination of the larynx requires specialised equipment.

Consider neurological examination:

  • Lips; VII – stroke, ear disease, parotid
  • Tongue XI – motor neurone disease, malignant otitis externa
  • Sensation – V, IX, Cauda Equina

Palpation

Palpate associated lymph nodes.

Document

Document all findings clearly and ensure all abnormalities reported to your supervisor.

Glossary

  • Angular stomatitis- inflammation at the angles of mouth, with possible cracking or scaling, causes are multi-factorial.
  • Ankyloglosia – Tongue tie
  • Anosmia – loss of smell
  • Leucoplakia – white patches on tongue
  • Ossicles – Incus, Stapes and malleolus
  • Otalgia – pain in ear
  • Otorrhoea – discharge in ear
  • Polyp – small growth, often benign, originating in mucous membrane
  • Post nasal discharge – catarrh
  • Rhinitis – Inflammation of the mucous membrane inside the nose, also known as coryza.
  • Rhinorrhoea – runny nose
  • Septum – a partition separating 2 chambers, such as between the nostrils.
  • Speculum – latin word for “mirror” a medical device inserted into a body passage to facilitate visualisation or inspection.
  • Sternutation – sneezing
  • Tinnitus – ringing or buzzing in the ears
  • Turbinate – shell shaped network of bones, vessels and tissue in the nasal passageway.