DR MANPREET SINGH NANDA PROFESSOR ENT

2.  Mental state
 Consciousness
 Built and nutrition
 Attitude and Gait
 Facies
 Pallor – palmar creases, mm lips cheeks, conjuctiva,
nail beds
 Cyanosis – tongue (central), nail bed , tip of nose,
palmar skin
 Jaundice – sclera, nail bed , ear lobule, tip of nose
 Skin eruptions – macules ( change in skin colour),
papules , vesicles, pustules (solid projections)
 Neck nodes

3.  Pulse – pulse rate, rhythm (regular, irregular)
 Respiratory rate – fast, slow
 Temperature – continous ( fluctuates less
than 1 deg), remittent ( fluctuates more than
2 deg), intermittent
 Blood Pressure

4.  Examine the affected region
 Inspection
 Palpation
 Movements
 Measurements’
 LYMPH NODES
 General Examination- Cranial Nerves,
Respiratory
 CVS for surgery purpose

5.  External Ear
 - Auricle/Pinna
 - Pre auricular region
 - Post auricular/Mastoid region
 EAC
 TM
 Middle ear mucosa
 Eustachian tube
 Facial nerve and other CN
 Neck
 Nose and Throat

6.  INSPECTION
 Size – anotia (absence), microtia (small)
 Shape – cauliflower ear, bat ear (auricle
protrudes anteriorly)
 Colour- red (perichondritis)
 Position- displacement of auricle forwards,
laterally or inferiorly – mastoid abscess
 Swelling
 Scar
 Ulcer

8.  PALPATION
 Superficial palpation
 Using fingers (digital palpation) of cartilage and
soft tissue
 Soft tissue – mobility of skin (lost in malignancy),
thickening, swelling
 Raised temperature, tenderness
 Cartilage – defect or loss
 Deep palpation
 Tragal tenderness- inflammation
 Painful movement of pinna – acute otitis externa

9.  Sinus – pre auricular sinus
 Fistula
 Scar
 Swelling – cystic, lymphadenitis

10.  INSPECTION
 Scar, dermatitis, swelling, fistula
 Change in mastoid contour
 Normally – uneven bone, skin over it mobile
 PALPATION
 Superficial palpation
 Skin – mobile
 Raised temperature
 Swelling – margins, cystic (sebaceous cyst)
 Iron out mastoid – smooth surface –
coalescent mastoiditis

11.  Deep palpation
 Tenderness – mastoiditis
 1. Cymba concha – bony landmark for mastoid
antrum
 2. Midpoint of posterior border of mastoid
 3. Tip of mastoid
 NECK EXAMINATION
 Bezold’s abscess – pus track along SCM inferiorly
 Citelli’s abscess – pus track along digastric into
submandibular triangle
 Luc’s abscess – pus around zygoma
 IJV as hard cord on palpation along SCM – IJV
thrombosis

12.  Direct examination
 Without speculum
 Size of meatus – atresia/wide/narrow
 Wide – post op, syphilis, otosclerosis
 Narrow – congenital atresia, scar due to trauma,
burns tumour - osteoma
 Content of meatus – wax, discharge, FB, Polyp
 Digital examination –
 Adults – pinna pulled upwards, backwards and
laterally, tragus pulled forwards
 Children – pinna pulled downwards and laterally

14.  Look for furuncle, swelling
 Fungal infection (otomycosis) – black –
aspergillus niger, yellow – candida albicans
 Polyp – probe test – if probe all around – arise
from middle ear
 Impacted wax – whole EAC occluded
 Tumours
 With speculum examination – deep meatus to
straighten the canal
 Largest speculum which can enter
 Black coated
 Introduce in slow rotatory fashion upto cartilage
only

15.  Cough – vagal irritation
 Sagging of posterior superior EAC –
cholesteatoma, mastoid abscess, mastoiditis
 Absence of sensation in post sup EAC –
Hitselberger’s sign – mass lesion in CP angle

16.  Normal – pearly white colour, obliquely set,
anterior and posterior malleolar fold (longer)
 Handle of malleus – whitish bony landmark
 Umbo
 Cone of light/light relex – triangular in shape
anterio inferiorly – unreliable landmark
 Short or lateral process of malleus – small
yellowish prominence – at 12 o clock position -
always present – last landmark to be destroyed
in disease
 Quadrants – 4 – imaginary line through tip of
umbo, 2 nd vertically along handle of malleus –
ant sup/inf, post sup/inf

18.  Colour of TM – normal pearly white/greyish
white, red in ASOM, acute myringitis
 Congestion with yellowish tint – ASOM
 Diffuse congestion/ localised at handle of
malleus – ASOM
 Dark grey colour/dull appearance – tubal
occlusion
 Dull white/thickened cotton like drum – senile
sclerosis, scarring
 Chalky white appearance – tympanosclerosis
after otitis media
 Dull lusterless/bulging – secretory otitis media
 Blue drum – transudative otitis media
 Dark blue drum - haemotympanum

19.  TM normally inclined downwards and medially
 Protrude outwards – bulging drum – acute otitis
media (pus),Haemotympanum (blood),OME with
good ET function (air) – increase length of handle
of malleus, less prominent short process and
malleolar folds, absence of cone of light
 Pulled inwards – retracted TM- OME with poor ET
function, ET obstruction, atelectasis – shortening
of handle of malleus, more prominent short
process, anterior and post malleolar folds,
distorted cone of light
 Retraction – attic region (retraction pocket) if
deepens – cholesteatoma sac

21.  Siegle’s pneumatic speculum/ Valsalva
maneuvre
 Normal – change in shape of triangular light
reflex/ handle of malleus movement
 Decreased/absent – ET dysfunction, adhesive
otitis media (fixed), ankylosis of ossicular
chain, SOM
 Hypermobility – Patulous ET, atrophy of TM

23.  Perforation – ovoid/ kidney shaped/ round,
small, medium, large, sub total, total,
central/marginal, pars tensa/attic, dry/wet,
single/multiple (TB, measles, wegner’s
granulomatosis), margins – regular/irregular,
edge of perforation – thick (CSOM)/ thin
(ASOM)
 Scars
 Bulla – grey/red/bluish pearls like structures
attached to surface of TM
 Chalky white patch - tympanosclerosis

25.  Only through perforation/ if TM thinned out/
semitransparent
 Middle ear mucosa – oedema/ polyp
 Granulation tissue
 Ossicles, ET, round window, oval window
 FB
 Fistula

26.  Posterior rhinoscopy/ Nasopharyngoscopy/
DNE/ Through perforation
 Valsalva Maneuvre
 ET catheterisation – check patency of ET
 Few drops in ear if perforation and bitter
taste in mouth
 TUNING FORK TESTS
 Rinne’s
 Weber
 ABC

27.  FISTULA TEST
 Apply intermittent pressure on tragus/
siegle’s pneumatic speculum – ask patient to
look straight – check for vertigo/ nystagmus
towards opposite side
 FACIAL NERVE EXAMINATION
 Paralysis in ASOM, CSOM, Malignant otitis
externa, herpes zoster, tumours and trauma
 Wrinking of forehead/ closure of eyes/ loss
of naso labial folds/ deviation of angle of
mouth/ cant whistle or blow

28.  NOSE AND THROAT EXAMINATION
 Rhinitis/sinusitis
 Pharyngitis/tonsillitis/adenoids
 EYE EXAMINATION
 Nystagmus
 Corneal relex – absent in acoustic neuroma
 Blue sclera – osteogenesis imperfecta
 Papilloedema – CP angle tumours/ otitic
hydrocephalus/ temporal abscess
 Interstitial keratitis – congenital syphilis

29.  RS/CVS/CNS
 CN paralysis
 VI – petrous apex lesions
 IX, X, XI, XII – advanced malignant otitis
externa/ advanced glomus jugulare tumours
 AUSCULTATION
 Stethoscope over ear canal/ mastoid – bruits
heard in vascular lesions
 Stethoscope into EAM – transmitted sounds
heard in patulous ET