very useful

2. • Two types of illumination is used in otolaryngologcial
examination:
• 1. Semi mobile illumination like the Bull's lamp
• 2. Mobile illumination like the Clair's head light, or
cold light based head bands.

4. ART OF EXAMINATION
• Listen – Heart of good history taking
 Patience with open mind
 Observe/vigilant
 Relatives
 Opening greetings – Patient at ease
 Good eye contact
 Patient’s own language
 Remember – patient too assesses you

6. SYMPTOMATOLOGY
Otorrhoea (Ear discharge)
Otalgia (Ear ache)
Hearing Loss/impairment
Vertigo
Tinnitus
Ear fullness/blockage
Aural polyp
Itching in ear
Swelling and Deformity
Foreign body/ injury

7. Discharge from the ear
• Infection – EAC - otitis externa,Otomycosis,
furunculosis, acute dermatitis, neoplasm
• Middle ear – ASOM, CSOM, Mastoiditis,
cholesteatoma,CSF leak
• Side – B/L, Right , left
• Onset – sudden – ASOM
• gradual/insidious –CSOM, malignancy
• Amount
• scanty –CSOM -AAD, Otitis externa,
• profuse – CSOM –TTD

8. • Duration –long – CSOM-AAD, Otitis externa
• intermediate – CSOM-TTD short – ASOM, Furuncle
• Progress – intermittent – CSOM-TTD
• continous – CSOM-AAD, granulations, malignancy
• Nature – purulent – furuncle, mastoiditis, malignant
otitis externa, CSOM-AAD
• Mucoid/mucopurulent – granular myringitis, CSOM-
TTD, ASOM (late stage)
• Watery – CSF leak, eczematous/viral otitis externa
• Bloody – ASOM (initial stage), trauma, granulations,
malignancy
• Pulsatile – ASOM with pin point perforation,glomus
tumour, ICA aneurysm

9. • Colour – green – pseudomonas infection, yellow
• black – otomycosis, yellow
• Smell – odourless – allergic otitis externa, CSOMTTD
foul smell – CSOM-AAD, cholesteatoma
• Aggravating factors – cold, head bath, pharyngitis,
tonsillitis – CSOM-TTD
• Preceding history – trauma – CSF leak, ear surgery,
skin disease
• Associated complaints
• Ear ache – Acute otitis externa, pruritus –chronic
otitis externa, otomycosis, eczema of skin – recurrent
otitis externa, retro orbital pain ,abscess, hearing
loss, vertigo

10. • otalgia
• Primary otalgia – local causes – inflammation,
trauma, neoplasm affecting external and middle
ear, inner ear – no pain
• Auricle – perichondritis, trauma
• EAC – furuncle, impacted wax, acute otitis
externa, FB, otomycosis, neoplasm, myringitis
• Middle ear – ASOM, cholesteatoma, mastoiditis,
ET obstruction, malignancy, CSOM- no pain
unless otitis externa, intra cranial complications
of CSOM
• Barotrauma- due to flying or scuba diving
• referred otalgia

11. • RT, LT, B/L
• Onset – sudden – furuncle, ASOM, trauma,
• gradual- otitis externa due to CSOM,
malignant
• otitis externa, malignancy
• Duration – short – ASOM, perichondritis long –
malignancy
• Nature – dull – impacted wax, secretory otitis
media, eczematous otitis externa,
• sharp –furuncle
• throbbing – ASOM
• Location – front of ear – furuncle, deep in ear –
middle ear pathology, behind ear – mastoiditis,
lymphadenitis, below ear – ET pathology

12. • Aggravating and relieving factors
• Relieved on discharge from ear – ASOM,
increase
• on swallowing – ASOM, increase on yawning,
• chewing – furuncle, increase on pulling pinna
• and pressing tragus – acute otitis externa

13. HARD OF HEARING
• Hard of hearing – if hearing loss can improve on
treatment
• Deaf – very severe or profound with little or no residual
hearing
• Rt/Lt/bilateral
• Unilateral – CSOM, Acoustic neuroma, mumps
• Bilateral – presbycusis, meniere’s disease, otosclerosis,
noise induced
• Onset – sudden – wax, viral deafness, ASOM, traumatic
perforation, head injury, blast injury,vascular causes,
acoustic trauma, labyrinthitis
• Gradual/insidious – CSOM, OME, otosclerosis,NIHL,
presbycusis, acoustic neuroma

14. hard of hearing
• Type – conductive – defect in external and middle ear,
SNHL – defect in inner ear or VIII CN, mixed
• Progress – stable – CSOM TTD (non discharging),
perforated TM
• Progressive – CSOM AAD,CSOM TTD
discharging,otosclerosis, meniere’s disease, acoustic
neuroma, presbycusis
• Fluctuating – meniere’s disease, secretory otitis media
• Degree – mild – diseases of EAC like wax, FB, mild to
moderate – diseases of middle ear, mild to profound – inner
ear diseases

15. hard of hearing
• Duration – since birth – genetic, prenatal drugs, maternal
infections, prolonged labour, infancy infections like
mumps, measles, meningitis
• Recent – trauma, inflammation, neoplasm, vascular
• Childhood – ASOM, OME, young adults – otosclerosis,
old age – presbycusis
• Family history – otosclerosis, meniere’s disease
• Drug history – ototoxic drugs like aminoglycoside,
quinine, salicylates, cytotoxic drugs
• Occupational history – noisy enviroment
• Trauma, viral fever, psychogenic

16. TINNITUS
• Perception of auditory sensation/sound ringing
• or noise with no external stimuli
• 33% population
• Classification
• Subjective tinnitus – only perceived by patient,
• Mainly psychogenic/functional, more common
• Objective tinnitus – perceived by patient as well as
examiner. Seen in chronic contractions of palatal or
tympanic muscles, live insects in ear, intracranial
vascular tumours, patulous ET, AV malformations,
clicking TM joint

17. RELATED COMPLAINTS
• Nasal complaints like nasal obstruction,
• discharge, post nasal discharge
• Throat complaints like irritation, dysphagia,
• change in voice
• Allergy and bronchial asthma – ET dysfunction, serous
otitis media
• DM – Malignant otitis externa, sudden SNHL
• HTN – Sudden SNHL
• Radiation – SNHL
• Mumps, measles, chicken pox – SNHL
• Anti thyroid drugs - giddiness

18. COMPLICATIONS OF CSOM
• Fever – high grade
• Headache – severe and deep seated
• Nausea and vomiting – labyrinthitis,
• complications of CSOM, Meniere’s disease
• Convulsions
• Diplopia
• Cervico facial pain
• Facial nerve palsy – idiopathic (bell’s palsy),
• complications of ASOM/CSOM
• Post aural swelling - mastoiditis

19. BIRTH HISTORY
• Children – immunisation schedule
• OBSTETRIC HISTORY – early deafness
• Ototoxic drugs to mother during 1st trimester
• Infections to mother – rubella, mumps
• Birth trauma
• Post natal jaundice

20. past history
• Treatment for the same illness in the past or any
other illness
• Diabetes, HTN, TB, Asthma and allergies, HIV,
• HBV, syphilis, radiation exposure
• Surgeries - ear, hospital admissions, Trauma
• Deliveries and pregnancies
• Drug history- at present or past- steroids, insulin,
ocp, anti hypertensives, nasal decongestants,
ototoxic drugs
• Allergy history – drugs or diet or allergen
• FOR DRUG ALLERGY – WRITE IN RED

28. symptoms
• Nasal obstruction
• Nasal discharge
• Post-nasal drip
• Sneezing
• Epistaxis
• Headache or facial pain
• Disturbances of smell
• Nasal twang of voice
• Onset,duration,progression,severity

29. • External Nose
• Nares and Columella
• Vestibule
• Anterior Rhinoscopy
• Posterior Rhinoscopy
• PNS

30. EXAMINATION OF EXTERNAL NOSE
• INSPECTION
• External deformity – deviation, crooked /saddle
/hump
• Scar/sinus
• Skin colour change – rash
• Widening of nasal bridge – polyps
• Swellings – cysts, rhinophyma, tumours

31. EXAMINATION OF EXTERNAL NOSE
• PALPATION
• Superficial and deep (pressure applied) With
thumb and index finger
• Temperature
• Fixity of skin/mobility
• Tenderness
• Bony framework/shape change
• Crepitus - #

32. ANTERIOR NARES AND COLLUMELA
• Symmetry
• Caudal dislocation
• FACE
• Dark circles around eyes – allergy
• Vestibule – lifting tip of nose (Not on rhinoscopy)
• Erythema
• Ulcer
• Perforation
• Crusting
• Furuncle

33. ANTERIOR RHINOSCOPY
• Vienna/Thudicum/Killians Nasal Speculum
• Topical decogestants/ Xylocaine
• Left hand
• Widen the vestibule/ Never touch septum
• Otoscope (children)
• Speculum close introducing/partial open removal
• Inferior turbinate- ant end/middle turbinate -hyp
• Inf/middle meatus – discharge/polyp
• Nasal septum – spur/deviation
• Floor of nasal cavity

34. anterior rhinoscopy
• Size of nasal speculum – age/ nose size
• Colour of nasal mucosa – normal pink, common
cold, rhinitis medicamentosa – generalised
congested, acute sinusitis – localised congestion,
allergic – pale, atrophic– dry with crust
Secretions
• Sup turbinate – extension
• Cant – post end of turbinates and septum, roof

36. PROBE TEST
• Blunt probe
• To examine nasal mass
• Consistency
• Mobility or fixed
• Sensation to touch
• Bleed on touch
• Origin/attachment – pass probe all around

37. Post rhinoscopy mirror
• Warm on mirror side
• Breathe through nose – relax soft palate
• Tongue depressor
• Don’t touch oropharynx – gag reflex
• Choana/ post end of septum and turbinates
• E.T orifices/ fossa of rosenmuller/ adenoids
• Look for polyp/ mass/ epistaxis/ pus

39. EXAMINATION OF PARANASAL
SINUS
• INSPECTION
Look for swelling over PNS
Skin changes
Orbit – lid oedema, conjuctival congestion,
proptosis
• PALPATION
Palpate both sides simultaneous for compare
Use index finger and thumb
Look at facial expression while palpating

40. • Maxillary – canine fossa/ ant wall of cheek
lateral to nose
• Frontal – floor of frontal above medial canthus /
ant wall
• Ethmoidal – medial wall of orbit just behind root
of nose
• Tenderness in acute sinusitis

41. • TRANSILLUMINATION TEST
• Rarely done
• Dark room
• Maxillary – bright light applied on hard palate
with lips closed – crescentric glow observed B/L
in region of eye lids and over maxillary sinus
• Frontal – light applied at floor of frontal sinus –
light glow observed on ant wall – result
compared with other side
• Absent/poor glow – pus/mass/thickening of
mucosa

42. functional tests of nose
• COLD SPATULA TEST
• Tongue depressor cold – in front of ant nares –
fogging – compared for nasal obstruction
• COTTON WOOL TEST
• Fluff of cotton held against each nostril and
movement seen
• COTTLE TEST
• Elevation of naso labial fold relieves nasal
obstruction in case nasal valve involved
• EXAMINATION OF LYMPH NODES – level II/RP

43. NOSE EXAMINATION IN CHILDREN
• Nasal discharge – minimal – normal in first few
days of life
• B/L choanal atresia – life threatening
• Diagnosis – by passing blunted small rubber or
plastic catheter through nose and taken out from
oral cavity
• Contrast X Ray under GA
• Otoscope

49. examination of oral cavity and larynx

50. • Chief Complaints
• In patient’s own words
• Chronological order as they occur
• according to severity
• Duration Short with pain - acute inflammatory
• Long without pain – neoplastic
• Long with slight pain – chronic inflamm
• Long with severe pain – malignant
• Throat - Oral cavity, Oropharynx,
Laryngopharynx and Larynx, Neck

51. CHIEF COMPLAINTS IN ORAL CAVITY
Ulcers
Dry mouth (Xerostomia)- mouth breathing
Bad smell (Halitosis) –poor hygiene,ulcers,post
nasal drip
Pain
Loss of taste (Dysgeusia) Excess salivation -
poor hygiene, ulcers
Tongue tie (Ankyloglossia) Difficulty in opening
mouth (Trismus) – SMF
Swellings
Cleft palate
Circumvellate papillae of tongue
Bleeding gums - scurvy

52. oropharynx
• Sore throat
• F.B Sensation – allergy, post nasal drip,
functional, malignancy
• Difficulty in swallowing (Dysphagia)
• Pain during swallowing (Odynophagia)
• Regurgitation
• Snoring
• Foreign body

53. Larynx
• Change in voice – hoarse, cracked voice in
males(puberphonia),
• vocal fatigue- elders, functional
• Repeated clearing of throat- GERD, Chronic
laryngitis
• Difficulty in breathing - infections, tumours
• Cough and expectoration
• Neck swellings

54. HISTORY OF PRESENTING ILLNESS
• Mode of onset – sudden, gradual
• Side
• Any cause of onset
• Duration
• Progress – slow , rapid, intermittent, continous,
increasing, declining
• Factors aggravating or relieving
• Treatment for the same, since when and where
• How it has impacted life style
• LOOK FOR NEGATIVE ANSWERS