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Introduction to Otorhinolaryngology
and basic ENT examination
Prepared by Kibra Demtsu
(MD, otolaryngologist)

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Introduction to ENT
• Otolaryngology deals with the medical and surgical
condition of the ear, upper respiratory and alimentary
tract and related head and neck structures.
• Fields of subspecialty include
– Otology and neurotlogy deals with condition of the ear and
lateral skull base
– Head and neck oncology and micro vascular reconstruction

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– Rhinology deals with nose, sinus and endoscopic
anterior skull base approach.
– Laryngology deals with voice and airway
– Pediatric otolaryngology
– facial plastic surgery

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Ear examination
• External ear examination
– Look for position, size, color, shape of the auricle
– Palpate for swelling, tenderness on the auricle,
tenderness on the tragus, otitis externa and
mastoid tenderness, mastoiditis.

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• Otoscopic examination
– Look on the EAC for color, swelling, presence of
discharge and foreign body
– Look on the Tympanic membrane for its color
(normally pale), light reflex and handle of malleus,
presence of peroration or discharge.

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Clinical hearing tests
• The Rinne and Weber tests are simple clinical tests used to
differentiate between conductive and sensorineural hearing
loss, often used when more sophisticated audiometry isn't
available.
• The Rinne test compares air and bone conduction, while the
Weber test assesses sound lateralization.
• These tests are typically performed together.
• The Rinne and Weber tests help determine if hearing loss is
due to a problem with the outer or middle ear (conductive)
or with the inner ear or auditory nerve (sensorineural).
• They are often used as an initial screening tool to guide
further diagnostic testing.

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• Clinical hearing tests…
1 . Rinne test - Procedure: A vibrating tuning fork (typically 512
Hz) is placed on the mastoid bone (bone conduction) and then
next to the external ear canal (air conduction).
• It compares air conduction and bone conduction on the same
ear
• Positive Rinne: Air conduction is better than bone conduction
(normal hearing or sensorineural loss). IF AC > BC, normal or
sensory neural hearing loss.
• Negative Rinne: Bone conduction is equal to or better than air
conduction (conductive hearing loss). IF BC > AC, conductive
hearing loss

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2. Weber test - put vibrating 512 Hz tuning fork b/n incisors, on
the vertex or forehead
 It compares bone conduction and air conduction on the same ear.
 Assesses sound lateralization.
 Interpretation:
• Sound lateralizes to one ear:
 To the affected ear: Conductive hearing loss (sound is heard
louder in the ear with the conductive loss).
 To the unaffected ear: Sensorineural hearing loss (sound is heard
louder in the ear with normal hearing).
 Sound heard equally in both ears: Normal hearing or bilateral
hearing loss.

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3. Pure-tone audiometry, the best test. It is a
fundamental hearing test that measures an individual's hearing
sensitivity at different frequencies. This test uses pure tones,
which are sounds of a single frequency, presented at varying
intensities to find the softest sound a person can hear at each
frequency.

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Examination of the nose
• External examination
• Look for appearance, color,
swelling, paranasal sinus
tenderness
• Anterior rhinoscopy
• Look for nasal mucosa,
septum for deviation or
swelling, lateral nasal wall
for turbinate enlargement,
presence of mass including
polyp, nasal discharge

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• Nasal endoscopic examination - with 0 degree rigid
endoscope or flexible fiberoptic nasopharyngoscopy
 First pass
• Pass below the inferior turbinate
• Look for the nasal cavity and the nasopahrynx (presence
of discharge or mass on the Rosen Müller fossa,
Eustachian tube opening
 Second pass
– Pass between the middle turbinate and septum
– Look for the sphenoidal opening, superior meatus and
posterior ethmoidal opening
 Third pass - look for details of the middle meatus i.e.
osteomeatal complex (with 30 degree rigid endoscopy)

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Examination of the throat
• Examination of oropharynx
• Direct inspection of the oropharynx with light
• Look for the base of the tongue (posterior one third),
lateral pharyngeal wall (tonsils and tonsillar pillar),
posterior pharyngeal wall and soft palate
• Look for mucosa over the tongue, buccal mucosa, gum
and floor of the mouth
• Look for the tooth
• Look for opening of the salivary glands (swelling,
redness & discharge in case of sialodenitis )

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The Nasal Conchae
• Also known as turbinates, are curved, bony structures
inside the nasal cavity.
• They are located on the lateral (side) walls of the nasal
cavity and are crucial for warming, humidifying, and
filtering inhaled air.
• Their primary function is to increase the surface area
of the nasal cavity, allowing for efficient air processing.
• They are three pairs: superior, middle, and inferior.
• Beneath each concha is a space called a meatus, which
serves as a drainage pathway for the sinuses and
other structures.
• Can become enlarged or inflamed due to allergies or
infections, leading to nasal congestion and breathing
difficulties.

22. The Nasal Conchae…
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Summary Based on the Image
Drainage Site Structures Draining Into It
1. Superior meatus ➤ Posterior ethmoid sinuses
2. Sphenoethmoidal recess ➤ Sphenoid sinus
3. Middle meatus ➤ Frontal sinus
➤ Maxillary sinus
➤ Anterior and middle ethmoid sinuses
4. Inferior meatus ➤ Nasolacrimal duct (drains tears from
the eyes)

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• Indirect Laryngoscopic evaluation
– Can be done with either 70 or 90 degree rigid endoscopy, flexible fiberoptic
laryngoscopy, laryngeal mirror
– Direct laryngoscopy under General aesthesia
– Look for the
• Valleculae (space b/n the tongue base and epiglottis)
• Hypopharynx (pyriform sinus, posterior pharyngeal wall and post cricoid)
• Supraglotic structures (epiglottis, aryepiglottic structure and false VCs)
• Glottis structure (look for mobility of the vocal cords, anterior and posterior
commissure)
• Subglottis - the cricoid cartilage, which forms the only complete cartilaginous
ring of the airway, and the conus elasticus, which contributes to the subglottic
wall.

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Facial nerve disorders
 Anatomy of CN 7 ,,,,
 Supranuclear vs. infranuclear disorder
 Infranuclear disorders
1. Bellys palsy
2. Herpes zooster otics
3. Melkersson rosenthal syndrome
4. CPA angle tumors
5. Temporal bone ,,, infection, trauma, tumors
6. Parotid tumors esp. malignant penetrating trauma to the parotid area
7. Iatrogenic ,,,, temporal bone and parotid surgeries

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Facial Nerve Disorders
• Supranuclear and infranuclear facial nerve disorders differ in
the location of the lesion and the resulting symptoms.
• Supranuclear lesions affect the brain pathways controlling
facial movement.
• Infranuclear lesions affect the facial nerve itself or its nucleus
in the brainstem.
• This leads to distinct patterns of facial weakness.

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Supranuclear Facial Nerve Lesions:
• Location:
 Lesions occur in the brain, specifically in the pathways above the facial
nerve nucleus in the brainstem. This is often due to strokes or other
central nervous system disorders.
• Symptoms:
 Lower facial weakness: The lower two-thirds of the face on the opposite
side of the lesion are primarily affected.
 Forehead and eye muscles spared: The muscles of the forehead and
around the eye (innervated by bilateral cortical pathways) are often
spared because they receive input from both sides of the brain.
 Possible other neurological signs: Symptoms may include other signs of
brain dysfunction, such as hemiparesis (weakness on one side of the
body).
• Example:
 A stroke affecting the motor cortex or internal capsule can lead to a
supranuclear facial palsy.

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Infranuclear Facial Nerve Lesions:
• Location:
 Lesions occur within or distal to the facial nerve nucleus in the brainstem,
including the nerve itself and its branches.
• Symptoms:
 Complete facial paralysis: The entire side of the face (upper and lower) is
affected by the lesion.
 Other symptoms: Depending on the location of the lesion, symptoms may
include hyperacusis (increased sensitivity to sound), taste disturbances,
impaired lacrimation (tear production), and decreased salivation.
 No sparing of forehead or eye muscles: Unlike supranuclear lesions,
infranuclear lesions cause paralysis of all muscles innervated by the facial
nerve on the affected side.
• Examples:
 Bell's palsy (an idiopathic form of facial paralysis), tumors, infections, or
trauma to the facial nerve can cause infranuclear lesions.

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Anatomy of the facial nerve
• Functions of the facial nerve
1. General somatic efferent (motor supply to facial
muscles),,,,,,,facial motor area of the precentral
gyrus.
2. General visceral efferent (parasympathetic
secretory motor supply to submandibular and
sublingual salivary glands and the lacrimal
gland),,,,,,,superior salivatory and lacrimal nuclei (in
the lower pons).

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3. Special visceral afferent (taste sensation from
the anterior two-thirds of the tongue),,,,sensory
nucleus located in the pons
4. General somatic afferent (cutaneous
sensations from the pinna and the external
auditory meatus),,,,also located in the lower pons
• The sensory and parasympathetic fibers of the
facial nerve are collectively bound in a facial
sheath; these structures together have the
name nervus intermedius.

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Portions of the facial nerve
1. Intracranial also called cisternal
– From pons to internal auditory canal meatus
– The motor root and the nervus intemedius leave the pons at the
cerbropontine angel (CPA)
2. Intratemporal,
2.1 Meatal,,,, longest
2.2 Labyrinthine,,, shortest and predisposed to traction and trauma
– Gives off three branches
– 1. greater superficial petrosal,,,, parasympathetic to the lacrimal
gland and general sensory from the palate
– 2. external superficial l petrosal,,,,,,,, to the otic ganglion
– 3. Lesser superficial petrosal
2.3 Tympanic (horizontal)
- Courses along medial aspect of the tympanic cavity

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2.4 Mastoid (vertical segment)
• Gives off three branches
1. nerve to stapedius muscle
2. chorda tympani ,,, parasympathetic to the
submandibular, sublingual and taste sensation from
the anterior two third of the tongue.
3. sensory branch which joins auricular branch of
Vagus nerve ,,, carries general sensation from the
pinna and external auditory meatus

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3. Extra temporal
from stylomastoid foramen to parotid gland ,,,
terminal branches
After leaving the stylomastoid foramen it gives off
three branches before it enters the parotid gland
1. posterior auricular nerve ,, motor to the
auricular muscle and occipital belly of
occiptofrontal muscle
2. nerve to the posterior belly of digastric
muscle
3. nerve to the stylohyoid muscle

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CN 7
 After it enters parotid gland ,,,, it courses between the
deep and superficial lobes of the parotid gland.
 It gives two branches at the pes ancerinus ,,,,
temporofacial and cervicofacial nerve
 Terminal branches
- Frontal, zygomatic, buccal, marginal mandibualar &
cervical.

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Supranuclear vs. infranuclear facial nerve
paralysis

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Bell’s palsy
• The term bell’s palsy is reserved to cases of facial nerve
disorder in which its signs and symptoms are consistent with
the disease but diligent search fail to identify the cause
• Signs and symptoms
1. paralysis of all muscle in one same side of the face
2. sudden onset
3. absence of CNS disorder
4. absence of signs of temporal bone and cerebropontine angle disease
(CPA)

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• Etiology,,,,,
– unknown
– Possible hypothesis
• Immunologic reaction to viral infection (mumps, measles & HSV)
• Ischemic neuropathy
• Autoimmune
• Management
– Prednisolone and antiviral
• Outcome
– 80 to 90% of patients have excellent prognosis

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Herpes zoster oticus
• Also called ramsay hunt syndrome
• Etiology
– Primary infection by varicella zoster infection of facial
nerve in non immuned or partially immuned host.
– 8th
cranial nerve can also be involved
– antibody titer raise

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• Presentation
– Vesicles on the auricle, post auricular vesicles
– Facial nerve paralysis
– tinnitus, hearing loss, vertigo
– compared to bells palsy, ramsay hunt syndrome causes more
sever symptoms and patients develop complete nerve
degeneration.

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• Ophthalmic branch of the trigeminal could be
involved,,, keratoconjuctivites, uveitis
• Management
– Initiation of early corticosteroid ,,, improves post
herpetic pain improvement
– Initiation of early acyclovir ,,,
– ophthalmic consultation
• Prognosis
– only 10% of them have complete recovery
– 66% have incomplete loss

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Melkersson rosenthal syndrome
• Consists triads of recurrent orofacial edema, recurrent
bilateral (alternating) facial nerve paralysis, fissured
tongue.
• Recurrent or facial edema is most consistent of the
three symptoms.
• Only one third of patients with this syndrome have
complete triad.
• Orofacial odema at first is temporary and has complete
resolution but with recurrence, patients will develop
deformity around the mouth esp. permanent edema .

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• Causes,,,,, unknown
• Possible cause ,,,, variant of sarcoidosis
,,,, vasomotor disorder
,,,, allergic cause
• Management ,,,, only symptomatic (eye care)

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HIV infection
• Acute infection with the virus ,,,,, sudden onset
of facial nerve paralysis mimics bell’s palsy
• Chronic infection ,,,,, risk of infection with VZV

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Other causes
• Temporal bone pathology
– Trauma
– Infection,,, otitis media, cholesteatma
– Tumors
• CPA tumors
– Vestibular schwannoma ,,,,, unilateral hearing loss, tinnitus,
vertigo, facial nerve palsy
– Facial nerve schwannoma
– Lipoma
– Meningioma
• Malignant parotid tumors

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Traumatic conditions of the CN 7
• Occurs in temporal bone trauma and penetrating facial
trauma (around the parotid area)
• Temporal bone trauma
• More common in fractures that involve the otic
capsule ,,,, because the most vulnerable portion is the
labyrinthine segment and geniculate ganglion area.
• causes
– Nerve transection
– Nerve compression by fractured bone segment, or edema
– Neural hematoma

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• Dx ,,,,high resolution temporal bone CT to see facial canal in
side the temporal bone
• Management
– Early onset,,,,,, occurswithin 24 hrs of trauma or not identified at first
• is due to transection or compression by bony segment,,,,,
surgical exploration and decompression
– Late onset,,,, occurs after 24 hrs of trauma
is due to odema
give steroid and see for 7 days
surgical exploration if no improvement after 7
days

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Types of Nerve Injuries:
• Neuropraxia:
 A mild injury causing temporary nerve conduction block, often
due to compression or contusion.
 Symptoms may include pain, numbness, and muscle weakness.
• Axonotmesis:
 Involves damage to the nerve's axons (the nerve fibers) but the
surrounding connective tissue remains intact.
 This can lead to loss of sensation and motor function, but
recovery is possible with proper treatment.
• Neurotmesis:
 The most severe type, where the nerve is completely severed.
 This results in a complete loss of nerve function in the affected
area, and surgical repair is often necessary.

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Causes of facial nerve palsy in pediatrics
1. Facial nerve paralysis at birth
– Mostly are caused by birth related trauma (78%)
• Usually not associated with other CN abnormalities.
• Associated signs include facial hematoma, ecchymosis
and swelling.
• Cause of trauma include forceps delivery, intrauterine
facial nerve injury by sacral prominence (palsy in
normal and CS delivery), supranuclear palsy secondary
to intracranial hemorrhage.

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– Other cause are congenital
• Congenital lower lip palsy
• Mobius syndrome
– clinical features range from unilateral cn7 palsy to bilateral cn 6
and 7 palsy. CN 9, 10, 12 can be involved.
– Cause ,,, ??? Disorder of rhombencephalon including both motor
nuclei and traversing long tracts. MRI evidence suggests evidence
of absence of the seventh cranial nerve in the internal auditory
canal,
• CHARGE syndrome ,,,, multiple CN palsy (7, 9, 10), a
complex genetic disorder characterized by a wide range of
birth defects. The acronym "CHARGE" represents,
Coloboma, Heart defects, Atresia choanae, Retardation of
growth and development, Genitourinary abnormalities,
and Ear abnormalities and deafness. It's a rare condition,
with an estimated incidence of about 1 in 10,000 births.
2. Bell’s palsy in children is uncommon.

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Bilateral facial nerve paralysis
• Clinical features
 difficulty of facial expression, drooling and
oral incompetence, bilateral difficulty of
closing the eyes
• Cause
– bell’s palsy (rare), gullian barre syndrome, multiple
idiopathic CN neuropathy, benign intracranial
hypertension, syphilis, leukemia, sarcoidosis,
bacterial meningitis.

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Progressive palsy
• Are usually due to tumor
• Cause
 most common is primary facial nerve
neuroma
 metastasis from temporal bone tumors and
distance metastasis or parotid tumors

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