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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.
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:
Family history:
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 Unilateral or bilateral?
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.
o Associated symptoms.
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 Onset and duration.
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 Onset and duration.
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?
o Associated symptoms.
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.
o Associated symptoms.
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.
Introduction:
Wash hands.
Introduce yourself.
Confirm patient details.
Explain examination.
Gain consent.
Inspection:
Assessment of Hearing:
While assessing the auditory function it is important to find out:
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.
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
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).
Thank patient.
Wash hands.
Summarise findings.
Suggest further investigations – e.g. audiometry.
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.
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.
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.
Use small mirror introduced via the mouth or a fibre-optic endoscope via the nose.
With mirror (nasopharyngeal mirror).
Rigid endoscope.
Flexible endoscope.
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.
Introduction:
Important note: Do not try to examine the throat in a patient with stridor, as this may
induce laryngospasm and total airway obstruction.
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:
Indirect laryngoscopy:
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.
Introduction:
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:
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.
Do the following:
Thank patient.
Wash hands.
Summarize findings.
Head-mirror:
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:
Tuning fork:
Traditionally 512Hz.
Used for Rinne and Weber tests.
Help differentiate between conductive and sensorineual hearing loss.
Nasendoscopy:
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
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.
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
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.
Normal Congested tympanic membrane with loss of cone of light, redness and
tympanic pulging of the membrane
membrane
Dx: acute otitis media
Pain occur at night because there is no swallowing (eustachian tube is open)
Tympanosclerosis
Precipitation of ca carbonate
after healing of repeated
perforation or myringotomy
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 ()االهتزاز أطول لهذا التردد
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.
=================================================================
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.
Ulcer Rhinophyma
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
Polyp
=================================================================
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
Angular stomatitis:
Iron d. anemia
Vit. B. deficiency
Bacterial
Fungal
Contact dermatitis
The orifice of sublingual duct of Brtholine
DDx:
Diphtheria
Fungi
IMN
Vincent angina
WBC count
throat swab
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