basic physical examination in ent[1]

8/11/2019 Basic Physical Examination in ENT[1]

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Basic Physical ExaminationBasic Physical Examination

in ENT Head and Neckin ENT Head and NeckDepartment of Otolaryngology Department of Otolaryngology

Head and Neck SurgeryHead and Neck SurgerySt. Lukes Medical CenterSt. Lukes Medical Center


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EQUIPMENTEQUIPMENT

1.1. C air !it HeadC air !it Headrestrest

".". Lig t SourceLig t Source#.#. $nstrument$nstrument

Ca%inetCa%inet


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EQUIPMENTEQUIPMENT

Head MirrorHead Mirror

& &lea'es %ot andslea'es %ot ands

free forfree fore(amination) e(amination)

& &positioned o'er t epositioned o'er t eleft eye and closeleft eye and closeto t e e(aminersto t e e(aminers

face)face)


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EQUIPMENTEQUIPMENTHow to focus the head mirrorHow to focus the head mirror

* e patient sits on t e stool at t e same le'el as t e doctor.* e patient sits on t e stool at t e same le'el as t e doctor.

+atient,s legs s ould %e to one side of t e e(aminer.+atient,s legs s ould %e to one side of t e e(aminer.

* e distance %et!een t e doctor and patient s ould not %e* e distance %et!een t e doctor and patient s ould not %emore t an - inc es Depending on t e ma(imum focal lengtmore t an - inc es Depending on t e ma(imum focal lengtof ead mirror/.of ead mirror/.

0i( t e mirror on t e left eye so t at part of t e mirror touc es0i( t e mirror on t e left eye so t at part of t e mirror touc est e nose.t e nose.

d2ust t e mirror so t at you are seeing t roug t e ole.d2ust t e mirror so t at you are seeing t roug t e ole.Close t e rig t eye and focus t e mirror %y rotating it.Close t e rig t eye and focus t e mirror %y rotating it.

Open %ot t e eyes.Open %ot t e eyes.


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EQUIPMENTEQUIPMENT

Basic InstrumentsBasic Instruments

#.#. 3ar specula3ar specula

4.4. Nasal SpeculaNasal Specula5.5. *ongue depressors*ongue depressors6.6. $ndirect laryngoscopy mirrors$ndirect laryngoscopy mirrors7.7. +osterior 8 inoscopy mirrors+osterior 8 inoscopy mirrors-.-. Nasal and aural forceps.Nasal and aural forceps.9.9. *uning forks: 51" H;: 1


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EAR EXAMEAR EXAM


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EAR EXAMEAR EXAM


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EAR EXAMEAR EXAM

& & %egin !it%egin !itinspection andinspection and

palpation of t epalpation of t epinna auricle/ andpinna auricle/ andstructuresstructuressurrounding t esurrounding t eear=) ear=)


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OTO !OP"OTO !OP"

Otoscopy is used toOtoscopy is used to'isuali;e t e ear'isuali;e t e earcanal>eardrum forcanal>eardrum for

t e purpose oft e purpose ofdetecting a%normaldetecting a%normalconditions t atconditions t atmig t re?uiremig t re?uirefurt er e'aluationfurt er e'aluationor treatment.or treatment.


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OTO !OP"OTO !OP"

& &grasp and retractgrasp and retractt e pinna %ack!ardt e pinna %ack!ard

and up!ard inand up!ard inadults andadults and

do!n!ards indo!n!ards ininfants=) infants=)


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OTO !OP"OTO !OP"@ n A annulus fi%rosusn A annulus fi%rosus

@ Lpi long process of incus/ ALpi long process of incus/ Asometimes 'isi%le t roug a ealt ysometimes 'isi%le t roug a ealt ytranslucent drumtranslucent drum

@ m um%o/ A t e end of t em um%o/ A t e end of t e

malleus andle and t e centre of t emalleus andle and t e centre of t edrumdrum

@ Lr lig t refle(/ A anteroAinferiorlyLr lig t refle(/ A anteroAinferiorly

@ Lp Lateral process of t e malleus/Lp Lateral process of t e malleus/

@ t ttic/ also kno!n as parst ttic/ also kno!n as parsflaccidaflaccida

@ Hm andle of t e malleus/Hm andle of t e malleus/


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PNEMATI! OTO !OP"PNEMATI! OTO !OP"

allo!s t e e(aminer toallo!s t e e(aminer too%ser'e mo'ement of t eo%ser'e mo'ement of t etympanic mem%ranetympanic mem%ranedirectly . $f t e tympanicdirectly . $f t e tympanic

mem%rane does not mo'emem%rane does not mo'epercepti%ly !itpercepti%ly !itapplications of slig tapplications of slig tpositi'e or negati'epositi'e or negati'epressure: a middle earpressure: a middle eareffusion is ig ly likely .effusion is ig ly likely .

Eluestone and Flein:Eluestone and Flein:

199


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PNEUMATI! OTO !OP"PNEUMATI! OTO !OP"


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TUNIN# $OR% TE TTUNIN# $OR% TE T

Indication: Differentiate type ofIndication: Differentiate type ofHearing LossHearing Loss

SensorineuralSensorineural Hearing LossHearing Loss Conducti'e Hearing LossConducti'e Hearing Loss
http://www.fpnotebook.com/ENT66.htmhttp://www.fpnotebook.com/ENT66.htmhttp://www.fpnotebook.com/ENT70.htmhttp://www.fpnotebook.com/ENT70.htmhttp://www.fpnotebook.com/ENT70.htmhttp://www.fpnotebook.com/ENT70.htmhttp://www.fpnotebook.com/ENT69.htmhttp://www.fpnotebook.com/ENT69.htmhttp://www.fpnotebook.com/ENT69.htmhttp://www.fpnotebook.com/ENT70.htmhttp://www.fpnotebook.com/ENT70.htmhttp://www.fpnotebook.com/ENT66.htm


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TUNIN# $OR% TE TTUNIN# $OR% TE T

PreparationPreparation

*uning fork s ould*uning fork s ould%e 51" H; to 1


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&EBER TE T&EBER TE T

*ec ni?ueG *uning 0ork*ec ni?ueG *uning 0orkplaced at midline fore eadplaced at midline fore ead

NormalG Sound radiates toNormalG Sound radiates to%ot ears e?ually%ot ears e?ually

%normalG Sound laterali;es%normalG Sound laterali;es

to one earto one ear@ $psilateral$psilateralConducti'e Hearing LossConducti'e Hearing Loss O8O8

@ ContralateralContralateral SensorineuralSensorineural Hearing LossHearing Loss
http://www.fpnotebook.com/ENT69.htmhttp://www.fpnotebook.com/ENT69.htmhttp://www.fpnotebook.com/ENT70.htmhttp://www.fpnotebook.com/ENT70.htmhttp://www.fpnotebook.com/ENT70.htmhttp://www.fpnotebook.com/ENT70.htmhttp://www.fpnotebook.com/ENT70.htmhttp://www.fpnotebook.com/ENT70.htmhttp://www.fpnotebook.com/ENT69.htm


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RINNE TE TRINNE TE T*ec ni?ue*ec ni?ue

@0irstG Eone Conduction0irstG Eone Conduction@ i%rating *uning 0ork eld oni%rating *uning 0ork eld onMastoidMastoid@+atient co'ers opposite ear !it+atient co'ers opposite ear !it

andand@+atient signals ! en sound ceases+atient signals ! en sound ceases@Mo'e t e 'i%rating tuning fork o'erMo'e t e 'i%rating tuning fork o'ert e ear canal t e ear canal Near: %ut notNear: %ut nottouc ing t e ear/touc ing t e ear/

@Ne(tG ir ConductionNe(tG ir Conduction+atient indicates ! en t e sound+atient indicates ! en t e soundceasesceases


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RINNE TE TRINNE TE T

NormalG ir Conduction is %etter t anNormalG ir Conduction is %etter t anEone ConductionEone Conductionir conduction usually persists t!ice as long asir conduction usually persists t!ice as long as

%one%one

8eferred to as positi'e test8eferred to as positi'e test

%normalG Eone conduction %etter%normalG Eone conduction %ettert an air conductiont an air conduction

SuggestsSuggests Conducti'e Hearing LossConducti'e Hearing Loss

8eferred to as negati'e test8eferred to as negati'e test
http://www.fpnotebook.com/ENT69.htmhttp://www.fpnotebook.com/ENT69.htmhttp://www.fpnotebook.com/ENT69.htm


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Test for Eustachian TubeTest for Eustachian Tube

FunctionFunction

1. Valsalva aneuver:1. Valsalva aneuver:

ethod:ethod:!fter ta"ing a deep #reath$ the patient pinches his nose and!fter ta"ing a deep #reath$ the patient pinches his nose and

closes hiscloses his mouth in an attempt to #low air in his ears. %toscopymouth in an attempt to #low air in his ears. %toscopyshowsshows movement of the drum.movement of the drum.

&ote: 'ailure of this test does not prove pathologic occlusion of&ote: 'ailure of this test does not prove pathologic occlusion ofthe tu#e.the tu#e.

(his maneuver in the presence of nasal and nasopharyngeal(his maneuver in the presence of nasal and nasopharyngealinfection carries the danger of transmission of infection to theinfection carries the danger of transmission of infection to theear.ear.

). (oyn#ee*s test:). (oyn#ee*s test:

It is safer and confirms normal tu#al function.It is safer and confirms normal tu#al function.

ethod: (he nose is closed and the patient swallows. (here is inethod: (he nose is closed and the patient swallows. (here is indrawing of the tympanic mem#rane$ confirmed #y otoscopy.drawing of the tympanic mem#rane$ confirmed #y otoscopy.


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NO ENO E


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EXAMINATION O$ THE NO EEXAMINATION O$ THE NO E

* e nose can %e e(amined in t ree* e nose can %e e(amined in t reepartsGpartsG

#.#. 3(amination of t e e(ternal nose3(amination of t e e(ternal nose4.4. nterior 8 inoscopynterior 8 inoscopy

5.5. +osterior 8 inoscopy.+osterior 8 inoscopy.


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EXAMINATION O$ THEEXAMINATION O$ THEEXTERNA' NO EEXTERNA' NO E

$nspectionG$nspectionG@ Congenital deformities Clefts/Congenital deformities Clefts/@ c?uired Deformitiesc?uired Deformities@ S apeS ape@ S!elling $nflammatory: cysts: tumors/S!elling $nflammatory: cysts: tumors/@ lceration *rauma: neoplastic: infecti'e/lceration *rauma: neoplastic: infecti'e/

+alpationG+alpationG@ *enderness*enderness@ CrepitusCrepitus@ DeformitiesDeformities


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Ante(io( Rhinosco)y Ante(io( Rhinosco)y

1.1. 3(amination of t e esti%ule3(amination of t e esti%ule

Look forGLook forGEoil or %cessEoil or %cess

lcerations and a%rasionslcerations and a%rasions

3(coriation %ecause of disc arge.3(coriation %ecause of disc arge.


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ANTERIOR RHINO !OP" ANTERIOR RHINO !OP"

).). +,amination of+,amination ofthe nasal cavitythe nasal cavity

using a nasalusing a nasalspeculum:speculum:


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PO TERIOR RHINO !OP"PO TERIOR RHINO !OP"

+ost Nasal MirrorG+ost Nasal MirrorG

$t consists of a$t consists of aandle on ! ic aandle on ! ic a

small mirror issmall mirror is

attac ed to s aftattac ed to s aftat an angle of 11


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PO TERIOR RHINO !OP"PO TERIOR RHINO !OP"*ec ni?ue*ec ni?ue

".". Hold t e mirror like a pen in t e rig t and.Hold t e mirror like a pen in t e rig t and.

4.4. Iarm t e mirrorIarm t e mirror

6.6. sk t e patient to open t e mout .sk t e patient to open t e mout .

-.-. Depress t e anterior ">#rds of t e tongueDepress t e anterior ">#rds of t e tongue1


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PO TERIOR RHINO !OP"PO TERIOR RHINO !OP"


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PARANA A' INU EPARANA A' INU E


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TRAN I''UMINATION TE TTRAN I''UMINATION TE T@ Dim t e room lig ts.Dim t e room lig ts.

@ +lace t e lig ted otoscope+lace t e lig ted otoscopedirectly on t e infraor%ital rimdirectly on t e infraor%ital rim

%one 2ust %elo! t e eye/.%one 2ust %elo! t e eye/. @ sk t e patient to open t eirsk t e patient to open t eir

mout and look for lig tmout and look for lig tglo!ing t roug t e mucosaglo!ing t roug t e mucosaof t e upper mout .of t e upper mout .

+rincipleG $n t e setting of+rincipleG $n t e setting ofinflammation: t e ma(illaryinflammation: t e ma(illarysinus %ecomes fluid filled andsinus %ecomes fluid filled and!ill not allo! t is!ill not allo! t istransillumination.transillumination.


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ORA' !A*IT"ORA' !A*IT"

ORA' !A*IT"ORA' !A*IT"


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ORA' !A*IT"ORA' !A*IT"*ongue*ongue

C eck forGC eck forGCommon and taste sensationsCommon and taste sensationsSi;eG Macroglossia in acromegaly:Si;eG Macroglossia in acromegaly:Do!n,s syndromeDo!n,s syndrome

lcerslcersMo'ementsG 8estricted inMo'ementsG 8estricted inypoglossal palsies: tumorypoglossal palsies: tumor

infiltrationinfiltration0asciculationG Motor neuron disease0asciculationG Motor neuron disease

DepapillationG itamin deficienciesDepapillationG itamin deficiencies0urro!ing : as in geograp ic tongue0urro!ing : as in geograp ic tongueCoatingG * rus : %lack airy tongueCoatingG * rus : %lack airy tongue


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ORA' !A*IT"ORA' !A*IT"@Euccal MucosaG +arotid duct opening OppositeEuccal MucosaG +arotid duct opening Opposite

upper "nd molar/: red or ! ite patc es: ulcers:upper "nd molar/: red or ! ite patc es: ulcers:moisturemoisture

@Hard +alateG S!elling: ulcer: perforations:Hard +alateG S!elling: ulcer: perforations:clefts etc.clefts etc.

@ 'ulaG +osition: de'iations *o!ards t e'ulaG +osition: de'iations *o!ards t enormal side in palsies/: ulcersnormal side in palsies/: ulcers

@0loor of mout G I arton duct openings: ulcers:0loor of mout G I arton duct openings: ulcers:and %imanual palpationand %imanual palpation @*eet and occlusion*eet and occlusion


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OROPHAR"NXOROPHAR"NX@ Soft +alateG S!elling: ulcer:Soft +alateG S!elling: ulcer:

mo'ement: perforations:mo'ement: perforations:clefts etc.clefts etc.

@ 'ulaG +osition: de'iations'ulaG +osition: de'iations*o!ards t e normal side in*o!ards t e normal side in

palsies/: ulcerspalsies/: ulcers @ *onsillar pillarsG congestion:*onsillar pillarsG congestion:

ulcers: patc es.ulcers: patc es.

@ *onsilsG +resence: si;e:*onsilsG +resence: si;e:crypts: ulcerscrypts: ulcers

@ +osterior p aryngeal !allG+osterior p aryngeal !allGLymp oid follicles: ulcers.Lymp oid follicles: ulcers.


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'AR"N#O !OP"'AR"N#O !OP"

DefinitionDefinitionisual e(am of t e 'oice %o( laryn(/isual e(am of t e 'oice %o( laryn(/and t e 'ocal cords.and t e 'ocal cords.

Laryngoscopy is also done to remo'eLaryngoscopy is also done to remo'e

foreign o%2ects stuck in t e t roat.foreign o%2ects stuck in t e t roat.


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'AR"N#O !OP"'AR"N#O !OP"

* ere are t!o main kindsG* ere are t!o main kindsG

1.$ndirect laryngoscopy A uses mirrors1.$ndirect laryngoscopy A uses mirrorsto e(amine t e laryn( andto e(amine t e laryn( andypop aryn(ypop aryn(

".Direct laryngoscopy A uses a special".Direct laryngoscopy A uses a specialinstrument fle(i%le or rigid scope/instrument fle(i%le or rigid scope/


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IN+IRE!T 'AR"N#O !OP"IN+IRE!T 'AR"N#O !OP"*ec ni?ue*ec ni?ue

#.#. Mirror is eld like a pen in t e rig t and !it t e glassMirror is eld like a pen in t e rig t and !it t e glasspointing do!n!ards.pointing do!n!ards.

5.5. Iarm t e mirror and test t e temperature on t e %ack ofIarm t e mirror and test t e temperature on t e %ack oft e and.t e and.

7.7. * e patient is asked to stick out t e tongue ! ic is eld* e patient is asked to stick out t e tongue ! ic is eld!it a piece of gau;e.!it a piece of gau;e.

9.9. * e patient is asked to %reat t roug t e mout .* e patient is asked to %reat t roug t e mout .

11.11. * e mirror is introduced into t e mout to t e u'ula ! ic* e mirror is introduced into t e mout to t e u'ula ! icis gently pus ed %ack to get a 'ie! of t e laryn( and t eis gently pus ed %ack to get a 'ie! of t e laryn( and t epyriform fossae.pyriform fossae.

1".1".

* e patient is asked to say , aa, and ,3ee,.* e patient is asked to say , aa, and ,3ee,.


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IN+IRE!T 'AR"N#O !OP"IN+IRE!T 'AR"N#O !OP"


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HEA+ AN+ NE!%HEA+ AN+ NE!%


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NE!%NE!%


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'"MPH NO+E 'E*E''"MPH NO+E 'E*E'I-- u#mental andI-- u#mental and

su#mandi#ular nodessu#mandi#ular nodes

II--/pper 0ugulodigastricII--/pper 0ugulodigastric

groupgroup

III-- iddle 0ugular nodesIII-- iddle 0ugular nodesdraining t e nasoA anddraining t e nasoA andorop aryn(: oral ca'ity:orop aryn(: oral ca'ity:

ypop aryn(: laryn(.ypop aryn(: laryn(.

IV--Inferior 0ugular nodesIV--Inferior 0ugular nodesdraining t e ypop aryn(:draining t e ypop aryn(:

su%glottic laryn(: t yroid: andsu%glottic laryn(: t yroid: andesop agus.esop agus.

V-- Posterior triangle groupV-- Posterior triangle group

VI--!nterior compartmentVI--!nterior compartmentgroupgroup


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!ER*I!A' '"MPH NO+E!ER*I!A' '"MPH NO+E


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TH"ROI+ AN+ PARATH"ROI+TH"ROI+ AN+ PARATH"ROI+#'AN+#'AN+


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A'I*AR" #'AN+A'I*AR" #'AN+


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THAN% "OUTHAN% "OU

basic physical examination in ent[1]

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