Ent

Ear Nose Throat (ENT)
For 5th stage
http://goo.gl/rjRf4F I LOKA©http://www.muhadharaty.com/ENT I

Content
Topics: Page:
 ENT History 3
 Examination of the Ear 10
 Examination of the Nose 15
 Examination of the Throat & Mouth 17
 Examination of the neck 19
 ENT instruments 22
 Investigations and Notes 24
 ENT from Mosul medical college 27
Videos:
www.muhadharaty.com/lecture/1185
Photos:

Part1: ENT History
Personal data:
 Name.
 Age (congenital diseases, senile diseases).
 Sex (sex related diseases).
 Occupation.
 Address.
Date of admission.
Date of examination.
Chief compliant:
 In patient words.
 Don’t forget duration of chief compliant.
 Don’t use diagnostic or medical words.
 Return and correct unrelated compliant.
 If more than one, arrange them by chronological order and by importance.
 Common chief complaint  Neck pain, neck stiffness, neck mass, hoarseness, nasal
discharge or obstruction, headache or facial pain, head injury, otalgia, dysphagia, ear
discharge.
History of present illness:
 Describe each compliant in specific words.
 Analyze each compliant as regards:
o Location and radiation.
o Time: onset, frequency, course, duration.
o Quality and characteristics.
o Quantity and severity.
o Aggravating and reliving factors.
o Associated symptoms.
o Underlying concerns or perception.
o Previous medical advice and medications.
 Note: In general, unilateral symptoms should raise the level of suspicion since most
conditions that have serious consequences, such as tumors and malignancies, are
unilateral, at least initially.

Past medical history:
 Previous or concurrent medical conditions that are relevant to the current problem
 Problems that may affect the patient’s treatment or fitness for anesthesia.
 All of these problems must be determined and noted appropriately.
 Previous surgery or trauma.
 Previous use of medical devices.
Drug history:
 The doctor must enquire about drugs that may be directly relevant to the present ENT
complaint.
 Example  anticoagulants in a patient with a nosebleed or the use of aminoglycosides
in a patient with hearing loss.
 Also the doctor should determine whether the patient takes any other regular
medication, prescribed or otherwise.
 A history of adverse drug reactions and allergies should also be taken.
Social history:
 Details of the patient’s employment should be noted.
 Details of the patient’s home environment may also be relevant.
 Alcohol intake and smoking history should also be determined.
 History of noise exposure in the house or work.
Family history:
 Presence of the same symptom in other family member.
 Congenital diseases in the family.
 History of deafness.
Danger Signs in ENT History:
 Hoarse voice for more than 3 weeks (tumor).
 Foul-smelling otorrhoea (cholesteatoma).
 Unilateral foul nasal discharge in a child (foreign body).
 Unilateral nasal polyp/blood-stained rhinorrhea (tumor).
 Unilateral deafness (tumor).
 Persistent lump in the throat (tumor).

Most common symptoms:
The Ear:
 Pain and itching of the ear.
o Use SOCRATES questions.
 Hearing:
o Normal or abnormal?
o Onset – sudden or gradual?
o Unilateral or bilateral?
o Which is the better ear?
o What is the functional capacity of each ear? – can one hear and understand? Does
only hear loud noises? Is it worsened in crowds?
o Is the loss constant or fluctuating?
o Associated symptoms: vertigo, tinnitus, drainage, fullness of the ears?
o Past history: systemic diseases (vascular), previous surgery to the ear? History of
head trauma, ear infection as a child.
o Personal and social: noise exposure? Occupation? Drug intake (aminoglycosides,
diuritics, salicylates).
o Previous history of hearing aids?
o Family history: congenital or familial?
 Tinnitus:
o Associated symptoms – hearing loss, vertigo?
o High pitched or low pitched?
o Continuous, intermittent, pulsatile?
o Duration – recent or long-standing?
o Altered by head position or pressure on neck?
o Drug intake – aspirin and quinine?
 Ear discharge:
o Which ear? Unilateral or bilateral?
o Onset and duration?
o Continuous or intermittent?
o Predisposing factors? Sinusitis, colds, allergy.
o Character: mucoid, mucopurulent, purulent, serous.
o Associated otalgia.
o Odor – foul smelling or non-foul?
o Associated symptoms – headache hearing loss, dizziness, facial weakness.
o Past history of ear trauma or surgery.
 Otalgia:
o Onset and duration?
o Continuous or intermittent?
o Location – deep, superficial, circumaural.
o Nature – sharp, dull, boring.
o Pain on manipulation of ear? – points to otitis externa.

o Associated symptoms – ear discharge, hearing loss, tinnitus, headache, vertigo,
sore throat.
 Pinna deformity:
o Acquired, traumatic.
o Congenital- since birth?
o Family history of similar lesions?
o Birth and maternal history.
o Is there hearing loss?
 Vertigo:
o Duration of the episodes.
o Positional and other precipitating factors.
o Associated or fluctuating hearing loss or tinnitus.
o Whether the ear feels ‘full’ during the episode.
o A past history of significant head injury.
o Associated headaches.
 Unsteadiness:
o Onset and duration.
o Predisposing factors.
o Frequency.
 Nystagmus.
o Time and frequency.
o Special type of movement?
o Other ear symptoms?
The nose:
 Epistaxis:
o Unilateral, bilateral?
o Anterior, posterior, diffuse?
o Spontaneous or post-traumatic?
o Duration and onset?
o Amount of blood loss?
o Associated problems: colds, strong blowing of nose, medical problems such as
hypertension, use of anticoagulants, signs of blood dyscrasias, renal disease.
 Nose obstruction and rhinorrhea:
o Duration and onset?
o Constant or seasonal?
o Change in character with change in position.
o Facial pain.
o Spontaneous or post-traumatic.
o Associated symptoms: frequent sneezing, headache, post-nasal drip, nasal pruritus,
sore throat, earache, asthma.

o Drug-use – use of nasal drops (antihypertensive), cocaine sniffing, tranquilizers,
hormones.
 Nasal deformity:
o Congenital or acquired?
o Recent – acquire with trauma.
o Associated problems such as epistaxis, nasal obstruction.
o Alcohol intake.
o History of acne rosacea.
o History of trauma.
 Sneezing:
o Duration, frequency.
o Special time of odors.
o Reliving factors.
 Disturbance of smell:
o Head injury? – can lead to anosmia.
o History of viral upper respiratory tract infection – can lead to anosmia.
o Is there any mechanical obstruction or swelling of the nose – can lead to hyposmia
(reduced sense of smell).
o Presence of Cacosmia? - It is an unpleasant smell due to chronic sepsis in the nose
or sinuses.
o Presence of Parosmia? - It is a distorted sense of smell.
o Brief olfactory hallucinations (phantosmia) may occur in temporal lobe epilepsy.
 Nasal and facial pain:
o Use SOCRATES questions.
The Mouth:
 Sore mouth:
o It is mouth pain  SOCRATES.
 Oral ulceration:
o Duration and onset.
o Persistent or intermittent.
o Location and pattern – are they in crops?
o Painful or nonpainful?
o Use of immunosuppressive drugs, sexual habits and venereal disease.
o Associated problem: fever, malaise, other mucosal ulcers (vaginal, anal, urethral).
 Intraoral mass lesions:
o Duration and onset.
o Location.
o Rapidity of growth.
o Painful or nonpainful.
o Odynophagia.
o Trismus.
o Presence of lymph nodes.

o Previous dental extractions or surgical consult?
 Alternations in taste:
o Dysgeusia, hypogeusia, or ageusia.
o Associated problems in smell, medications, head injury, headache, ear surgery
(chorda tympani cut), facial pain and visual disturbances.
The Throat:
 Sore throat:
o It is throat pain  SOCRATES.
 Odynophagia:
o Location – referred to ear?
o Constant or intermittent?
o Is it progressive?
o Occurs with solids or liquids?
o Associated symptoms of hoarseness, strider, odynophagia.
o History of foreign body ingestion.
o History of corrosive intake.
 Dysphagia:
o Duration.
o Localization.
o With solids or liquids?
 Hoarseness:
o Duration.
o Congenital or acquired.
o Intermittent or progressive.
o Pattern or time of day worsened.
o History of vocal abuse, occupation.
o Environment – exposure to chemicals.
o Stridor.
o Pain.
o History of trauma, surgery under general anesthesia, neck and chest surgery,
thyroid status.
o Endotracheal intubation.
 Airway obstruction – stridor:
o Duration.
o Exercise intolerance.
o Nature – stridor inspiratory or expiratory or both, history of foreign body.
o Exacerbation – by exercise or sleep.
o Relieved by change in position, opening mouth, protruding tongue.
o Associated with recent viral infection.
o History of trauma to neck, neck or chest surgery, medications.

 Dysphonia:
o Onset, duration.
o Other vocal symptoms.
o Same thing in other family member.
o History of drugs taking.
 Sialadenopathy:
o Onset, duration.
o Site.
o Size.
o Fever, sweating.
The Neck:
 Neck masses:
o Location.
o Duration.
o Size: stable, growing, alternating.
o Single or multiple.
o Tender or nontender.
o Discrete, multiple, matted.
o Pulsatile.
o Erythematous.
o Associated problems such as weight loss, hyperthyroidism, nasal obstruction,
dysphagia hoarseness, intraoral lesions, pigmented skin lesions, ear pain.
 Discrete swelling:
o Duration.
o Pain.
o Facial asymmetry.
o Constant or intermittent.
 Diffuse swelling:
o Uniglandular or multiglandular.
o Duration.
o Painful or nonpainful.
o Exacerbation with eating.
o Previous history of mumps or vaccination.
o Associated problems: xerostomia, alcohol intake, starvation, iodides, bromides,
antihypertensive, tranquilizers, joint pains, fever, skin rashes.
See this history form  www.muhadharaty.com/lecture/3545

Part2: Examination of the Ear
Introduction:
 Wash hands.
 Introduce yourself.
 Confirm patient details.
 Explain examination.
 Gain consent.
Position the patient:
 At the same level.
 In chair.
 Can walk around patient.
Inspection:
 Inspect the pinna  Front and behind, Shape, Size, Skin
condition, Lesions, Scars, Pre-auricular area (common
place for sinus), Condition of cartilage, Any deformity.
 Inspect the external auditory meatus  Pull pinna
upwards, outwards and backwards, In infants
downwards and backwards, In children pull backwards,
Otorrhoea and otomycosis, Wax, Canal stenosis,
Exostoses and osteomas, Discharge, Foreign bodies.
 Findings:
o Congenital deformities are linked to sensorineural
deafness.
o Low-set ears imply a first branchial arch abnormality.

o Trauma may produce a hematoma of the pinna or mastoid bruising.
o Basal cell and squamous cell cancers affect the fine skin of the rim of the pinna.
o Tenderness on palpation of the tragus suggests inflammation of the canal or
adjacent temporomandibular joint.
o A very wide meatus suggests previous mastoid surgery.
Assessment of Hearing:
While assessing the auditory function it is important to find out:
 Type of hearing loss (CHL, SNHL or mixed).
 Degree of hearing loss.
 Site of lesion.
 Cause of hearing loss.
Clinical tests of hearing:
 Finger friction test  rubbing the thumb and finger close to the ear.
 Watch test  by clicking watch.
 Speech (voice) test  conversation voice, distance of 6 meters.
 Tuning fork tests.
Gross hearing assessment:
 Ask the patient if they have noticed any change in their hearing recently.
 Explain that you’re going to say a word or number and you’d like them to repeat it back
to you.
 With your mouth approx. 15cm from the ear, whisper a number or word.
 Mask the ear not being tested by rubbing the tragus.
 Ask the patient to repeat the number or word back to you.
 If the patient repeats the correct word or number, repeat the test at an arms length
from the ear (normal hearing allows whispers to be perceived at 60 cm).
 Assess the other ear in the same way.
Weber’s test:
 Tap a 512 HZ tuning fork & place in the midline of the forehead.
 Ask the patient “Where do you hear the sound?”
o Normal = sound is heard equally in both ears.
o Unilateral or asymmetrical hearing loss:
 Neural deafness = sound is heard louder on the side of the intact ear.
 Conductive deafness = sound is heard louder on the side of the affected ear.
o Bilateral or symmetrical loss of either type: the sound is heard equally in both ears.

Rinne’s test:
 Tap a 512 HZ tuning fork & place at the external auditory meatus & ask the patient if
they are able to hear it (air conduction).
 Now move the tuning fork (whilst still vibrating), placing its base onto the mastoid
process (bone conduction).
 Ask the patient if the sound is louder in front of the ear (EAM) or behind it (mastoid
process).
o Normal = Air conduction > Bone conduction (Rinne’s positive)
o Neural deafness = Air conduction > Bone conduction (both air & bone conduction
↓ equally)
o Conductive deafness = Bone conduction > Air conduction (Rinne’s negative)
Otoscopy:
 Ask the patient if they have any ear discomfort (if so, examine the non-painful side
first)
Pinnae
 Inspect the pinnae – note shape / size / deformity – e.g. haematoma / BCC
Ear canal / tympanic membrane
 Ensure the light is working on the otoscope & apply a sterile speculum (the largest that
will comfortably fit in the external auditory meatus)
 Pull the pinna upwards & backwards – straightens the external auditory meatus
 Position otoscope at the external auditory meatus:
o Otoscope should be held in your right hand for the patient’s right ear and vice versa
o Hold the otoscope like a pencil and rest your hand against the patient’s cheek for
stability
 Advance the otoscope under direct supervision
 Look for any wax, swelling, erythema, discharge or foreign bodies
 Examine the tympanic membrane:
o Colour  pearly grey & translucent (normal) / erythematous (inflammation)
o Erythema or bulging of the membrane?  inspect for a fluid level e.g. otitis media
o Perforation of the membrane?  note the size of the perforation
o Light reflex present?  absence / distortion may indicate ↑ inner ear pressure e.g.
otitis media
o Scarring of the membrane?  tympanosclerosis – can result in significant hearing
loss
 Withdraw the otoscope carefully
 Discard the otoscope speculum in a clinical waste bin
 Normal Tympanic membrane  Color: Pearly grey / Mobile / See the anatomical land
marks.

 Findings:
o If the drum is not perforated, discharge is due to otitis externa.
o White scars on the tympanic membrane are tympanosclerosis.
o The drum may look normal, or dull, or golden, or bluish.
o Fluid or effusion behind the drum is called otitis media with effusion and a fluid
level may be seen.
o In acute suppurative otitis media the drum becomes gradually more inflamed and
may eventually perforate.
o Types of Tympanic membrane perforations  Safe (Central) / Unsafe (Marginal
and Attic perforations).
Assessment of Balance (Labyrinthine function):
 1- Testing for nystagmus:
o With the patient seated, hold your finger an arm’s length away, level with the
patient’s eyes.
o Ask the patient to look at, and follow, the tip of your finger. Slowly move your
finger up and down and then side to side.
o Be careful not to get the eyes too far deviated to the side as this generates a
physiological nystagmus.
o Look at the patient’s eyes for any oscillations and note:
 whether they are horizontal, vertical or rotatory.
 which direction of gaze causes the most marked nystagmus.
 in which direction the fast phase of jerk nystagmus occurs.
 whether jerk nystagmus changes direction when the direction of gaze changes.
 if nystagmus is more obvious in one eye than the other (ataxic or dysconjugate
nystagmus).
 2- Dix–Hallpike positional test:
o Ask the patient to sit upright, close to the edge of the couch.
o Warn the patient about what you are going to do.
o Turn the patient’s head 45° to one side.
o Rapidly lower him, so that the head is now 30° below the horizontal.
o Say: ‘Keep your eyes open even if you feel dizzy.’
o Watch the eyes carefully for nystagmus.
o Repeat the test, turning the head to the other side.
 3- Unterberger’s test:
o Ask the patient to march on the spot with his eyes closed.
o The patient will rotate to the side of a damaged labyrinth.
 4- Fistula test
o Repeatedly compress the tragus against the external auditory meatus to occlude
the meatus.
o If this produces a sense of imbalance or vertigo with nystagmus, it suggests an
abnormal communication between the middle ear and the vestibular apparatus,
e.g. erosion due to cholesteatoma.

 Findings:
o Normal patients have no nystagmus or sensation of vertigo.
o In BPPV there is a delay of up to 20 seconds before the patient experiences vertigo
and rotatory jerk nystagmus towards the lower ear occurs (geotropic).
o The response fatigues, so there is less, or no, response if you repeat the test
immediately (adaptation).
o Central pathology produces immediate nystagmus, not necessarily with vertigo,
and no adaptation.
o Lack of dizziness plus relatively coarse nystagmus is central till proved otherwise.
Cranial nerves examination.
To complete the examination:
 Thank patient.
 Wash hands.
 Summarise findings.
 Suggest further investigations – e.g. audiometry.
See this video  www.muhadharaty.com/lecture/3546

Part3: Examination of the Nose
Introduction:
 Wash hands.
 Introduce yourself  Any hyponasal speech (rhinolalia clausa )?
 Confirm patient details, Explain examination, Gain consent.
 Head-mirror or headlight.
Inspection:
 Look at the external surface and appearance of the nose. Note any skin disease or
deformity.
 Stand behind the patient; look down the nose from above for any external deviation.
 At rest, the nostrils face down towards the floor but the nasal cavity passes posteriorly
along the upper surface of the hard palate. To look into the nose, ask your patient to
hold her head in the normal position (discourage her from throwing her head back).
Gently elevate the tip of her nose with the pad of your thumb to align the nostrils with
the rest of the cavity.
 Look in and assess the alignment and mucosal covering of the septum.
 In an adult use a large-size speculum on your otoscope to see the inferior turbinates.
Do not try to pass instruments into a child’s nose.
 Place a metal spatula under the nostrils and look for the condensation marks. Inspect
the external nose:
o Compare nose to rest of face, Size and shape.
o Skin, Swelling, bruising, ulcers.
Assess the nasal airways:
 Airway on each side of the nose should be tested.
 This can be done by occluding each nostril in turn and asking the patient to sniff in.
 Occlusion of the nostril should be done by placing the thumb over the nasal aperture
rather than pressing on the side of the nose.
 At this point, also look for collapse of the soft tissues of the nose during inspiration, so-
called alar collapse.

Mist test:
 Hold a cold shiny surface, such as a metal tongue depressor, under the nose.
 Look for the pattern of misting that occurs as the patient breathes.
Palpation and Percussion:
 Feel the nasal bones gently to distinguish bony from cartilaginous deformity.
 In trauma, check the integrity of the infraorbital ridges and of the range of eye
movements to exclude ‘orbital blowout’.
Next:
 The nasal tip should be elevated  this gives an opportunity to examine the nasal
vestibule for any small lesions that may otherwise be covered up by the blades of a
nasal speculum.
 Examination of the nasal cavity demands a good light source, for example a head-
mirror.
 A thudicum speculum is used to hold open the nasal aperture and then systematic
examination of the nasal cavity can follow.
 If a head-light and thudicum speculum are not available, an auroscope and ear
speculum can be used instead.
 Each area of the nasal cavity should be examined in turn.
 Looking at the septum, floor of the nose and then the lateral wall where the inferior
and middle turbinates will often be seen (and are frequently confused with nasal
polyps).
 Note the appearance of the nasal mucosa, including its color, surface and hydration.
Post nasal space examination:
 Use small mirror introduced via the mouth or a fibre-optic endoscope via the nose.
 With mirror (nasopharyngeal mirror).
 Rigid endoscope.
 Flexible endoscope.
Tests of olfaction: Are usually confined to specialist clinics.
Note: It must be remembered that the ear and nose are connected by the eustachian
tube, and therefore nasal pathology may produce ear problems. Therefore, examination of
the nose is incomplete without also examining the ears.

Part4: Examination of the Throat & Mouth
Introduction:
 Wash hands, introduce yourself, confirm patient details, explain examination.
 Gain consent, a good light is essential.
 Remember to ask the patient to remove all dentures.
Important note: Do not try to examine the throat in a patient with stridor, as this may
induce laryngospasm and total airway obstruction.
 Headlamp, mirror or other light source.
 Seated in chair with space to examine from all sides.
Oral examination:
 Look at his lips, then ask him to half-open his mouth. Inspect the mucosa of the
vestibule, buccal surfaces and buccogingival sulci for discoloration, inflammation,
ulceration or nodules, then at the bite closure.
 Ask him to open his mouth fully and touch behind the upper incisors with the tip of his
tongue. Check the mucosa of the floor of mouth and the orifices of the submandibular
glands.
 Test the movements of the tongue.
 Ask him to stick out his tongue. Look for deviation (XIIth nerve dysfunction), mucosal
change or fasciculation.
 Now ask him to deviate his tongue to one side. Retract the opposite buccal mucosa
with a tongue depressor to view the lateral tongue border clearly. Repeat on the other
side.
 Pay particular attention to the side of the tongue right at the back; this is known as
‘coffin corner’ since carcinomas of the tongue may easily be missed in this region.
 Look at the hard palate. Note any cleft, abnormal arched palate or telangiectasia.
 Look at the oropharynx. Ask him to say ‘Aaah’. Use a tongue depressor if needed.

 Look at the soft palate for any cleft or structural abnormality. Note any telangiectasia.
 Look at the tonsils. Note their symmetry, size, color, any discharge or membrane.
 Use the tongue depressor to scrape off any white plaques gently.
 Touch the posterior pharyngeal wall gently with the tongue depressor to stimulate the
gag reflex. Check for symmetrical movement of the soft palate.
Palpation:
 If there is any lesion in the mouth or salivary glands, put on a pair of gloves and palpate
it with one hand outside on the patient’s cheek or jaw and the gloved finger of your
other hand inside his mouth.
 Feel the lesion and identify its characteristics (SPACESPIT).
 If the parotid gland is abnormal or enlarged, examine the facial nerve and check if the
deep lobe (tonsil area) is displaced medially.
 Palpate the length of the duct, and include the submandibular gland.
 Palpate the cervical lymph nodes systematically.
The larynx:
 Much information can be gained simply by listening to the patient’s voice.
 Note any  Stridor, Hoarseness, Any other dysphonia.
 They may have a hoarse voice suggestive of a lesion on the vocal fold, or they may have
a weak breathy voice with a poor ‘bovine’ cough, suggestive of a vocal fold palsy.
 To confirm the diagnosis, the larynx must be viewed.
 The traditional method is to use the head-mirror and an angled laryngeal mirror held at
the back of the mouth, against the soft palate.
 Nowadays fibre-optic endoscopes are generally preferred since
they give a superior view and are tolerated by most patients.
Indirect laryngoscopy:
 With mirror or nasendoscope.
 Can assess the base of the tongue, vallecula, Epiglottis, false and
true vocal cords.
 Look for abnormality in the mucosa (congestion, mass, vocal cord nodule).
 Check vocal cord mobility by asking the patient to say (EEE).
Examination of neck:
 Head and neck cancers metastasise to neck nodes and to the lungs.
 Tonsillar infections are the commonest cause of enlarged lymph nodes.
See this video  www.muhadharaty.com/lecture/3550 www.muhadharaty.com/lecture/3553

Part5: Examination of the neck
Rapid systemic examination of the neck:
 It is important to ensure that the examination is
systematic and methodical to avoid missing a small or
second mass.
 Exactly which system is used does not matter as long as
all regions are palpated.
 The following is a suggested method: Start at the
mastoid tip, and work forward to feel the post- and pre-
auricular lymph nodes; from here, move forward to feel
the parotid followed by the submandibular region.
 The hands meet under the chin in the midline; now
move down the midline, feeling in turn each lobe of the thyroid gland and the isthmus.
 From the suprasternal notch, follow up the anterior border of the sternomastoid
muscle back to the mastoid tip once more.
 Now follow the posterior border of the sternomastoid muscle down to the clavicle;
move laterally along the clavicle and to the anterior border of the trapezius muscle,
palpating the posterior triangle as you go; follow right round to the midline posteriorly.
 Feel the cervical spine up to the skull base and note any occipital lymph nodes.
 Finally move forwards along the skull base to finish once more at the mastoid tip.
Introduction:
 Wash hands, introduce yourself.
 Confirm patient details – name / DOB.
 Explain examination, Gain consent.
 Appropriately position & expose the neck for optimal examination.
General inspection:
 Skin  skin lesions, Ulceration, Scars, wounds, Stoma, Obvious large masses.
 Body habitus – does the patient appear cachectic?
 Voice – does it appear weak / hoarse?
 Identify any scars on the neck – may suggest previous surgery (thyroidectomy).
 Observe for any obvious masses in the neck.
 If a mid-line lump is present:
o Ask the patient to swallow some water – thyroid masses will rise / thyroglossal cyst
will not.
o Ask to protrude the tongue – thyroglossal cyst will rise with tongue movement /
thyroid masses will not.

 Look for obvious systemic signs that may relate to neck pathology:
o Cachexia – malignancy.
o Exopthalmos / Proptosis – Graves disease.
 Note: If there is a mid-line lump / scar or systemic signs suggestive of thyroid disease,
ask examiner if a full thyroid status exam should be performed.
Palpation:
1- Lymph nodes:
 Can be enlarged for a number of different reasons – e.g. infection / malignancy
 Lymph nodes are usually smooth, rubbery, with some mobility.
 An enlarged, hard, irregular lymph node would be suggestive of malignancy.
 Palpate the lymph nodes:
o Supra-clavicular – left sided enlarged lymph node – Virchows node
o Anterior cervical chain
o Posterior cervical chain
o Sub-mental
o Sub-mandibular
o Occipital
o Pre-auricular
o Post-auricular
2- Thyroid gland:
 Palpation of the thyroid gland may not be expected in an OSCE with a neck lump that is
not related to the thyroid. However to perform a thorough examination of the neck,
this should ideally be included as part of the assessment.
 Place the 3 middle fingers of each hand along the midline of the neck below the chin.
 Locate the upper edge of the thyroid cartilage (“Adam’s apple”).
 Move inferiorly until you reach the cricoid cartilage / ring.
 The first 2 rings of the trachea are located below the cricoid cartilage and the thyroid
isthmus overlies this area.
 Palpate the thyroid isthmus using the pads of your fingers (not the tips).
 Palpate each lobe of the thyroid in turn by moving your fingers out laterally from the
isthmus.
 Ask the patient to swallow some water, whilst you feel for symmetrical elevation of the
thyroid lobes (asymmetrical elevation may suggest a unilateral thyroid mass).
 Ask the patient to protrude their tongue once more (if a mass is a thyroglossal cyst, it
will rise during tongue protrusion).
3- Submandibular gland:
 The submandibular glands can be bilaterally palpated inferior and posterior to the body
of the mandible.

 Move inwards from the inferior border of the mandible near its angle with the patient’s
head tilted forwards.
 Submandibular gland swellings are usually singular (whereas lymph node swelling often
involves multiple nodes).
 Salivary duct calculi are relatively common and may be felt as a firm mass within the
gland.
4- Assessing a neck lump:
 Size – width / height / depth.
 Location – can help narrow the differential – anterior / posterior triangle / mid-line.
 Shape – well defined?
 Consistency – smooth / rubbery / hard / nodular / irregular.
 Fluctuance – if fluctuant, this suggests it is a fluid filled lesion – cyst.
 Trans-illumination – suggests mass is fluid filled – e.g. cystic hygroma.
 Pulsatility – suggests vascular origin – e.g. carotid body tumour / aneurysm.
 Temperature – increased warmth may suggest inflammatory / infective cause.
 Overlying skin changes – erythema / ulceration / punctum.
 Relation to underlying / overlying tissue – tethering / mobility (ask to turn head).
 Auscultation – to assess for bruits – e.g. carotid aneurysm.
Do the following:
 Swallow Larynx should rise, a goitre may rise, too.
 Examination of Laryngeal skeleton.
 Position of trachea.
To complete the examination:
 Thank patient.
 Wash hands.
 Summarize findings.
Suggest further investigations:
 Thyroid status examination – if a thyroid mass is suspected.
 Examination of the lymphoreticular system – if lymphoma is suspected.
 Examination of oral cavity, oropharynx & nasal cavity to exclude mucosal lesion.
 Ultrasound scan of lesion.
 Fine needle aspiration – to allow histological diagnosis.
 Routine bloods – FBC/U+E/CRP – may be useful if considering infection / malignancy.
 Early referral to ENT – if there is suspicion of malignancy / presence of red flags

Part6: ENT instruments
The head-light:
 Good illumination is essential when examining all areas in
ENT.
 Most ENT surgeons now use a battery-powered or fibre-
optic head-light.
 This has the advantage that it allows hands-free
illumination.
Head-mirror:
 Use of the head-mirror is a valuable skill that is easy and
quick to learn.
 The basic principle of the head-mirror is that light is
reflected from the mirror on to the patient.
 The mirror is concave and thus the light is focused to a
point. Also, it has a hole through which the examiner can
look, thus allowing binocular vision.
 Correct positioning of the patient, the examiner and the
light source is important.
 How to use a head-mirror  Place the mirror over the right eye, close the left eye, and
adjust the mirror so that you can look through the hole directly at the patient’s nose.
Now adjust the light and mirror until the maximum amount of light is reflected on to
the patient. When the left eye is opened, you should have binocular vision and the
reflected light should be shining to the patient’s nose. The focal length of the mirror is
approximately 60 cm; this means that the reflected light will be brightest and sharpest
when the examiner and the patient are this distance apart.
Aural speculum:
Examination of the external ear by use of aural speculum and head
light or mirror (the pinna is pulled upward and backward)
Otoscope (Auroscope):
 The auroscope should be held in the left hand when examining the
left ear and in the right hand when examining the right ear.
 The external auditory meatus (EAM; ear canal) should be
straightened by gently lifting the pinna upwards and backwards.
 Choose the largest speculum that will comfortably fit into the ear
canal, since this will give the best view and admit the most light.

 Then the auroscope is gently inserted along the line of the ear canal.
 As with all examinations, try to be methodical.
 Some auroscopes have a pneumatic bulb that can be attached. This allows air to be
puffed in and out of the ear canal, and with experience the examiner can learn to
assess the mobility of the drum.
Microscope:
 Sometimes we use microscope to examine the ear.
 Its magnification is 6-20 times.
Tuning fork:
 Traditionally 512Hz.
 Used for Rinne and Weber tests.
 Help differentiate between conductive and sensorineual hearing loss.
Nasendoscopy:
 Nasendoscopy is a skill that even the most junior of ENT
doctors must master.
 The patient sits facing the examiner and the procedure is
explained.
 The nose is frequently prepared with either topical
decongestant or anaesthetic spray.
 The tip of the endoscope is passed into the nose and through
the nasal cavity, either just below or just above the inferior turbinate.
 Towards the back of the nose, the eustachian tube will be seen opening into the
nasopharynx.
 The endoscope is then angled downwards and over the superior surface of the soft
palate to sit behind the uvula.
 At this point the tongue base and entire laryngopharynx can easily be seen.
Other instruments:
 Tongue depressor.
 Wax hook.
 Nose and ear forceps.
 Thudichum’s nasal speculum.
 Nasopharyngeal mirror.
 Rigid endoscope.
 Flexible endoscope.
 Laryngeal mirror.
 Laryngoscope.

Part7: Investigations and Notes

Part8: ENT from Mosul medical college
ENT = Ear Nose Throat
ORL = otorhinolaryngology
1- The Ear:
Symptoms of the ear:
 Pain:
o Primary or secondary.
o Otogenic (caused be otitis media for example).
o Non-otogenic (cause be problems in the tooth, glossopharyngeal nerve, C2 and C3,
maxillary division of trigeminal nerve, temporomandibular joint, cervical spine).
 Discharge:
o Mucus: due to perforated tympanic membrane.
o Serious: due to otitis externa or perforated tympanic membrane.
 Hearing loss.
 Tinnitus.
 Vertigo.
Note: anything cause hearing loss could lead to tinnitus.
Examination of the ear:
 Introduce yourself to the patient:
o Check hearing function, Any deafness?
o Communication
 Position the patient:
o At the same level
o In chair
o Can walk around patient
 Inspect the pinna
o Front and behind
o Skin condition
o Lesions
o Scars
o Pre-auricular area (common place for sinus)
o Condition of cartilage

Findings in inspection of the pinna Photos
Post auricular scar
Indications:
1-Tympanoplasty
2-mastoid surgery (mastoidectomy)
3-resection of benign parotid gland tumor
Benefit: cosmetic.
Discharging ear
Causes:
1-wax
2-otitis media
3-otits externa
4-mastoiditis
5-F.B. in the ear
Preauricular sinus
Cause: congenital.
Treatment: no treatment unless infected 
antibiotics or surgery.
Could convert to fistula (discharge) or
abscess (closed).
Auricular hematoma
Causes:
1-trauma
2-bleeding tendency
3-infection.
4-allergic skin diseases
Treatment: complete surgical evacuation of
the subperichondrial blood and prevent its
recurrence.
It need drainage  if not  deformity of
the ear.
Main complication: cauliflower ear.
Cauliflower ear
Due to repeated trauma and hematoma
Common in boxers.
Treatment: cosmetic surgery.

Auricular ulcer
Occur in squamous cell carcinoma
Acute mastoiditis
Causes: untreated acute otitis
media(commonest) + trauma
Medical treatment: long term antibiotics.
Surgical treatment:
1-tympanostomy tube.
2-mastoidectomy.
Complications:
1-subperiosteal abscess 2-skin fistula
3-hearing loss 4-facial palsy
5-meningitis 6-brain abscess
Right acute mastoiditis
The right pinna pushed forward and
downward.
Postauricular Hearing aid
or
behind the ear (BTE)
BAHA: Bone Anchored Hearing Aid

 Palpation:
o Tragal tenderness: due to otitis externa.
o Tenderness on mastoid bone: due to acute
mastoiditis.
 Inspect the external auditory meatus:
o Pull pinna upwards, outwards and backwards
o In infants downwards and backwards
o In children pull backwards
o See: Otorrhoea, otomycosis, Wax, Canal stenosis, Exostoses, osteomas.
 There are three methods of inspection of external auditory meatus:
1- Aural (ear) speculum:
o It is unaided eye method:
o Use head light or mirror.
o The pinna is pulled upward and backward.
Findings:
o Wax.
o Otitis externa: red, pain, pus.
o Otomycosis: due to candida albicans (white) or aspergillus niger (dots)  both
called wet newspaper.
o Foreign body: very severe irritation / put light or esperto or oil.
Wax,
Conductive hearing
loss
Otomycosis Otitis Externa
Foreign body in the ear

2- Otoscope:
o It is aided eye method.
o Examine right ear with right hand.
o Pull the pinna upward, outward and backward.
o The auroscope magnification is 1.5-2.0 times.
3- Microscope:
o It is aided eye method.
o Its magnification is 6-20 times.
o Uses:
o 1-detailed examination of the ear (magnified up
to 6-20 times)
o 2-certain surgical operations
o 3-biopsy
o 4-cleaning
 Examination of the tympanic membrane:
o Oval – pearly gray color.
o There is handle of malleus.
o There is cone of light  shatter ‫اختفاء‬ the cone
of light when the tympanic membrane is pulled
or pushed.
o Divided by two lines into 4 quadrants.
 Tympanic membrane perforations:
o Causes :
1-trauma
2-infection
3-iatrogenic (medical mistakes)
Normal
tympanic
membrane
Congested tympanic membrane with loss of cone of light, redness and
pulging of the membrane
Dx: acute otitis media
Pain occur at night because there is no swallowing (eustachian tube is open)

o Types of perforation:
1- Safe (Central)  the perforation is surrounded by part of the tympanic
membrane.
2- Unsafe (Marginal and Attic perforations).
cholesteatoma
Otitis media with effusion 
Eustachian tube dysfunction is
the commonest cause
Myringotomy with insertion of Grommet
ventilation tube
-indication
1-CHRONIC O.M. with effusion (commonest in
child)
2-recuurent O.M.
3-Eustachian tube dysfunction with recurrent s and
s (commonest in adult)
4-recuurent episodes of barotrauma
Complication: blockage , otorrhea , chloesteatoma ,
tympanosclerosis
Tympanosclerosis
Precipitation of ca carbonate
after healing of repeated
perforation or myringotomy
Perforation of the tympanic membrane

 Assessment of tympanic membrane mobility
o Valsava manover (close mouth and nose and swallow)
o Seigle pneumatic speculum (also used for magnification)
o Politzerization (balloon in the nose and drink water)
o Causes of fixed tympanic membrane  fluid behind the membrane (otitis media),
fibrosis, calcifications (tymeno-sclerosis), perforation.
 Assessment of Hearing
o While assessing the auditory function it is important to find out:
 Type of hearing loss ( CHL, SNHL or mixed )
 Degree of hearing loss.
 Site of lesion.
 Cause of hearing loss.
o Causes of conductive hearing loss:
 Sclerosis of bone.
 Calcification of oval window.
 Fluid behind the membrane.
o Clinical tests of hearing:
 Finger friction test: rubbing the thumb and finger close to the ear.
 Watch test: by clicking watch.
 Speech (voice) test: conversation voice, distance of 6 meters.
 Tuning fork tests.
o Tuning fork tests:
 Traditionally 512Hz (‫التردد‬ ‫لهذا‬ ‫أطول‬ ‫)االهتزاز‬
 Rinne and Weber (they were both German)
 Help differentiate between conductive and sensorineual
hearing loss
o Rinne`s test:
 Compare Air and Bone conduction in the same ear
 Normal subject = AC > BC (Rinne +ve)
 CHL = BC > AC (Rinne -ve)
 SNHL = AC > BC (Rinne +ve) and often the BC is not heard.
 False negative Rinne  in very severe SNHL.
o Weber test:
 In normal subjects the sound is heard in the midline or in both ears equally.

 In CHL the sound is heard in the affected ear (absence of environmental noise),
i.e.; lateralized toward the affected ear
 In SNHL the sound is heard in the non-affected ears.
 Assessment of Balance ( Labyrinthine function)
 Cranial nerves examination
=================================================================
2- The Nose:
Symptoms of the nose:
 Discharge (rhinorrhea).
 Epistaxis.
 Obstruction or block  causes of nasal obstruction:
o Vestibule: big boil.
o Nasal cavity: turbinate hypertrophy, septal deviation, sinusitis, polyp.
o Post-nasal space: tumor, adenoid hypertrophy (it is the most common cause of
nasal obstruction in children)
 Nasal fetor:
o Unilateral offensive nasal discharge in children  foreign body.
o Unilateral offensive nasal discharge in adult  rhinolith, tumor, chronic infection.
Examination of the nose:
 Introduce yourself
o Any hyponasal speech (rhinolalia clausa )?
 Position the patient
o Head-mirror or headlight?
 Inspect the external nose
o Compare nose to rest of face
o Size
o Skin
o Swelling, bruising, ulcers
o Rhinophyma:
 Due to untreated rosacea (heavy alcohol aggravate it)
 Treatment: carbon dioxide laser or complete excision with skin graft)

o Shape 
 Banana nose=deviated nose  trauma, septal deviation.
 High arched nose=roman nose=prominent nose  Congenital, Trauma.
 Saddle nose  HOT SALT (septal haematoma
_operation_trauma_syphilis_septal abscess_leprosy_TB)
 Examine the nasal tip, vestibule, and assess the nasal airways
o Nasal tip  elevation of nasal tip to see the vestibule.
o Nostrils and air flow
o Mist test  For airway patency
 Palpation and Percussion
Deviated nose Saddle nose Prominent nose
Ulcer Rhinophyma
Elevation of nasal tipSeptal hematoma Mist Test

 Anterior rhinoscopy:
o Thudichum’s speculum, Killian speculum, otoscope?
 Obvious lesions
 Mucosa
 Septum
 Turbinates (and osteomeatal complex)
o Thudichum’s nasal speculum
 Used to examine the nasal cavity.
 See  septum, floor of nose, middle and inferior turbinate, middle meatus.
Polyp
 Post nasal space examination:
o With mirror ( nasopharyngeal mirror) (also use tongue depressor)
o Rigid endoscope
o Flexible endoscope
=================================================================
3- The Throat:
Symptoms of the throat:
 Horsiness (don’t horsiness of the voice, but only horsiness).
 Sore throat.
 Dysphagia and odynophagia.
 Cough – stridor.

Examination of the throat:
 Introduce yourself
 Position the patient:
o Headlamp, mirror or other light source
o Seated in chair with space to examine from all sides
 Assess speech:
o Stridor
o Hoarseness
o Any other dysphonia
 Oral examination
o Lips, perioral lesions
o 1 or 2 tongue depressors
o Inspect tongue, buccal mucosa and oropharynx
o Salivary duct orifaces
o Say ‘Ahhh’ (movement of soft palate) // Say 'Eeee' (movement of vocal cords)
o Finger examination of floor of mouth, cheeks
Tongue depressor
Used for examination of oral cavity and oropharynx
Can use with nasopharyngeal mirror r to examine posterior
nasal space.
Herpes labialis Peri-oral eczema
Angular stomatitis:
 Iron d. anemia
 Vit. B. deficiency
 Bacterial
 Fungal
 Contact dermatitis
The orifice of sublingual duct of Brtholine
Parotid gland orifice
Using gauze to dry
the area and
watching the flow
by pressing above
Stenson’s duct is a
good indicator of
salivary flow.
Antrochoanal polyp Acute follicular tonsilitis

 Indirect laryngoscopy
o With mirror or nasendoscope
o Can assess the base of the tongue, vallecula,
Epiglottis, false and true vocal cords.
o Look for abnormality in the mucosa ( e.g.
congestion , mass, vocal cord nodule>>>)
o Check vocal cord mobility by asking the patient
to say (EEE)
o The mirror is warmed before examination to
avoid fogging
 Examination of neck
o Head and neck cancers metastasise to neck nodes and to the lungs
o Tonsillar infections are the commonest cause of enlarged lymph nodes
o Skin  Skin lesions, Ulceration, Scars and wounds, Stoma, Obvious large masses.
o Swallow  Larynx should rise, a goitre may rise, too.
o Examine from behind  Let patient know what you are doing, Tender areas,
Gentle, One side at a time.
o Lymph nodes in the anterior and posterior triangle
o Thyroid gland
o Laryngeal skeleton
o Position of trachea
Membranous tonsilitis
DDx:
 Diphtheria
 Fungi
 IMN
 Vincent angina
Mention 2 Ix:
 WBC count
 throat swab
Post-tonsillectomy Peritonsillar abscess

Ent

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