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ent examination.power point presentation
- 2. • Two typesof 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 theear • 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 • Primaryotalgia – 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 andrelieving 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 ofauditory 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 • Nasalcomplaints 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 • Treatmentfor 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 EXTERNALNOSE • 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 EXTERNALNOSE • 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 ANDCOLLUMELA • 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/KilliansNasal 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 • Sizeof 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 • Bluntprobe • 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 ofnose • 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 INCHILDREN • 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 oralcavity 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 INORAL 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 invoice – 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 PRESENTINGILLNESS • 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
Editor's Notes
- #3 1. The patient sitting on the stool must be at the same level as the doctor. 2. The patient's legs must be placed to one side of the examiner. 3. The distance between the doctor and the patient must not be more than 8 inches (i.e. the focal length of the head mirror). 4. The mirror is fixed over the right eye in such a way part of the mirror touches the nose. 5. The mirror is adjusted in such a way that the right eye sees through the hole in the mirror. The mirror is adjusted while keeping the left eye closed and the right eye is kept open. Then both eyes are opened.