Dr JALAL H

EAR EXAMI NATI ON

Introduction: -Good morning Sir / Madam
- My name is Dr.
-May I examine your ear
-Is there any pain in or around your ear?


I nspection:
[Inspect the pre-auricular, pinna and post-auricular region]
- On inspection of the ear, there is no abnormality noted, pinna appears to be normal, there is no
Scar, no sinus noted. (Tag, deformity, low set ears)
-
Palpation:
[Palpate the tragus, pinna, mastoid]
- There is no pain on manipulation of the tragus, pinna and no mastoid tenderness


I would like to proceed with otoscopic examination.
[Explain to patient that Im going to insert a speculum into the ear canal]

- On otoscopic examination, the external canal is patent, skin appears to be normal, no scar seen
(endaural), no discharge, no mass or granulation tissue seen.
(Wax, pus discharge, bleeding, swollen EAC, anterior hump, polyp, granulation tissue, keratin, widen
EAC, any meatoplasty)
If there is mastoid cavity: the mastoid cavity is present, facial ridge is high or low, the cavity is well
epithelized, no pus discharge, no keratin or granulation seen.

- The tympanic membrane appears intact, normal colour, not retracted, handle of malleus is in
normal position and cone of light is present.
(Attic retraction, scutum erosion, keratin)

(Tell examiner) I would like to proceed to examine the other ear
Then tell that I want to examine both ears under microscope.



Dr JALAL H
I would like to assess the hearing with Tuning fork and free field voice test.
- Explain to patient what Im going to do.
- Perform Rinnes test first: Strike the tuning fork {be gentle should not be so loud that examiner
also hears} and hear myself first then put in front (1.) of the ear then mastoid (2.). {Please support
patients head} Ask patient which one (1. or 2.) louder.
- Then Weber test: Place on forehead and support head at the back. Ask right/ left or loud at centre.
I would like to proceed with Free field test
- Explain to patient, tragal rub for masking and branys noise box (90-110) for shout,
- Use 9CH, 64D
- Whisper at 2 feet normal
- Whisper at 6 inch around 30dB loss
- Conversation speech at 2 feet 50dB loss
- Conversation speech at 6 inch 60dB loss
- Loud/shout at 2 feet 80-90 dB loss
- Loud/ shout at 6 inch > 90dB loss


And to complete my examination, I would like to do fistula test, examine for nystagmus and all the
cranial nerves especially facial nerve.
At last complete ENT examination nose, throat, and neck.
Thanks the patient before leaving the room
.

Siegelisation




Dr JALAL H
NOSE EXAMI NATI ON:
Introduction: -Good morning Sir / Madam
- My name is Dr.
-May I examine your nose
-Is there any pain in or around your nose?
I nspection:
From front, right and left side: no obvious swelling, scar, deformity or deviation seen.
From up: please lift hair and check for bicoronal flap
Look nose from up no scar, deformity (look for light reflection on nose)
Look for proptosis
Look for maxillary prominence

From down: look for deformity
Look for collumella scar

Please check for sinus tenderness (Frontal, ethmoidal, maxillary (on canine fossa is thinnest)

Cold spatula test: fogging is symmetrical from both side or unequal
(Explain to patient that u want to look for air vapor, pls breath normally)

On lifting the nasal tip: check for any collumella scar, comment on vestibule, any caudal dislocation,
any discharge

Anterior rhinoscopy: [inform examiner that u would like to proceed with antr rhinoscopy using killians
forceps then explain to patient that it wont hurt but let u know if there is any pain.]
Comment on
- mucosa (pale or pink)
- size of IT (ITH or boggy),
- MT, middle meatus any discharge, any polyp, mass or crusting, concha bullosa
- floor of the nose,
- septum (any deviation, perforation, littles area)
- Any ulceration, mass lesion,

Cottles sign ask the patient to sniff and look for alar collapse (+ve)
Cottles test pull the cheek gently laterally ask the patient to breath, if better or improved test is +ve
Posterior rhinoscopy examn (ET, FOR, nasopharynx). I would like to conform my finding using rigid
nasal endoscope
Proceed with oral cavity examn: Please ask patient to remove denture. Any oroantral fistula, palate
pushed down, sensation of palate.Check buccogingival sulcus palpate for any mass (nasal of
nasopharyngeal mass through ITF enter buccogingival sulcus. IDL, Ear and neck examn, cranial nerve
examn
Dr JALAL H
NECK EXAMI NATI ON
Introduction: -Good morning Sir / Madam
- My name is Dr.
-May I examine your neck
-Is there any pain anywhere?

I would like to expose the neck from chin until upper chest for proper examination
I nspection
Look front, sides comment on scar, mass, etc then describe the mass
Swallow, protrude tongue: any mass moving
Palpation please explain to patient and ask if there is any pain
- Get behind the patient
- Start from 1a, 1b, 2, 3, 4, 5a, 5b, preauricular, post auricular and occipital.
If any mass obvious please examine the mass first then proceed with other neck level
Mass:
Inspection: site (right or left), location (level), size, surface, any pulsation, scar, sinus, margin, movement
on swallowing or deglutition if central. Please check whether superficial or deep to fascia and muscle.
Palpation: inspectory findings are confirmed. Any tenderness, consistency, movement vertically or
horizontally. Whether pulsatile. Mobile or fixed to underlying structures.
If thyroid also check for eye signs, pulse, tremor, and warmth of skin, IDL or FNPLS for vocal cord
movement.
Check for bruit for vascular tumours, Check for laryngeal crepitus
Inform that I would like to do complete ENT examination and cranial nerves examination.
Neck swelling usually will be thyroid, branchial cyst or lymph node, lipoma.





Dr JALAL H
LARYNX EXAMI NATI ON
Introduction: -Good morning Sir / Madam
- My name is Dr.
-May I examine you?
-Is there any pain anywhere?

Adequate neck exposure
Inspection of neck: from front, sides any scar, deformity.
- Ask patient to tell his name and address to assess the voice, good voice -vocal cord meeting, no
hoarseness
- Ask patient to take deep breath and lean nearer to hear stridor
- Request patient to count 1-10 in a single breath if can no air leak vocal cord meeting (good
approximation of glottis)
- Request patient to cough good cough able to produce good sub-glottic pressure
- Please check for laryngeal crepitus
IDL:
- Explain procedure to patient
- Need to open mouth, protrude tongue, breath using your mouth
- Request patient to open mouth and assess the oral cavity big cavity can use bigger mirror
- Try to use bigger mirror better view
- Please use proper IDL mirror - dip in cetrimide (if using heat check on your hand whether too
hot before placing inside the mouth.
- Request patient to protrude tongue
- Hold at centre of tongue not the tip of tongue
- Hold with thumb down, index finger at centre of tongue, middle finger lift the upper lip
- Introduce IDL mirror do not touch PPW pt will cough
- Comment on mucosa of larynx, vocal cord movement, epiglottis, pyriform sinus, aryepiglottic
fold, vallecula, base of tongue
- If gag or unable to visualize well, ask for flexible or 70 degree scope.

Dr JALAL H
CRANI AL NERVE EXAMI NATI ON:
Introduce yourself
I.Olfactory : if testing close one nose and test the other.
Coffee, vinegar, ammonia (trigeminal nerve)
II.Optic:
- visual acuity ask patient read your name in name tag, snellen chart, or ask to read poster in the
clinic room
- visual field ask patient to look straight, from the side bring a red pin and ask patient whether can
see the object
III, IV, VI:
- follow light left, right, up, down check eye movement H direction
- with light check for divergence and convergence
- papillary reflex- 2 and 3 nerve
V: Trigeminal nerve
Sensory component: Corneal reflex
Papillary reflex
Sensation of face (ophthalmic, maxillary, mandibular) ask to close the eye and
is sensation felt and equal
Hard palate sensation
Motor component: Clench teeth palpate masseter m
Ask to open against resistance, palpate the pterygoid m
VII: Facial nerve
Check all five branches
Lift the eyebrows, frown - test for temporal branch
Close the eyes tight and open against resistance - test for zygomatic branch
Blow the cheeks and dont let air leak - test fir buccal branch
Show the teeth - test marginal mandibular branch
Ask to contract the platysma muscle - test for cervical branch



Dr JALAL H

Please comment on 4 aspects:
i) patient has got left or right facial nerve palsy
ii) UMN or LMN
iii) Partial or complete
iv) HB grading
If the patient has got VII nerve palsy please tell examiner or straight away examine 4 areas:
1) Mastoid look for scar, post op developed facial nerve palsy
2) Ear EAC, retraction pocket, cholesteatoma, tumour
3) Oral cavity parapharyngeal tumour causing the VII nerve palsy and medialising lateral
pharyngeal wall.
4) Examine parotid tumour causing facial nerve palsy

VIII: Vestibulocochlear nerve - Tuning fork, Free field
IX Glossopharyngeal- - Gag reflex, Soft palate sensation
X: Vagus - - VC movement (need to do IDL), cough, count 1-10, gag reflex
XI: Accessory nerve - - Shoulder movement, SCM and trapezius
XII:Hypoglossal nerve - Tongue movement










Dr JALAL H
LONG CASE PRESENTATION

Mr. /Mrs. --------------- -------- years old M/C/I gentlemen / lady

HISTORY:
Presented with C/C -










PERSONAL HISTORY: smoker, alcoholic,


PAST MEDICAL HISTORY: DM, HTN, Asthma, Cardiac disease
Drug history, allergy
FAMIL HISTORY: cancer,




Dr JALAL H
O/E:
Patient is sitting comfortable, no pallor, no jaundice,
1. Voice 4. Facial asymmetry
2. Cough 5. No drooling of saliva, able to close the eye completely
3. Count 1-10

EARS:
Rt Lt
Inspection 1. Abnormality, same
2. Scar, no sinus

Palpation pain 1.tragus,
2. Pinna same
3. Mastoid tenderness
Otoscopy examination
EAC: 1.patency
2. Skin same
3. Scar seen (endaural),
4. Discharge, mass or granulation tissue
5. Mastoid cavity

TM: appears intact, normal colour, not retracted, same
TM movement is normal,
Handle of malleus is in normal position and
Cone of light is present.







[Mastoid cavity is present, facial ridge is high or low, the cavity is well epithelized, no pus discharge, no keratin or granulation]
Tuning fork - Rt Lt
Rinnes + +
Webers ------------------

Free field voice test: Patient able to hear whisper at 2 feet indication normal hearing
Fistula test- Negative / Positive
Dr JALAL H
NOSE:
Inspection:
1> Front: breathing with mouth closed, No obvious swelling, scar, deformity or deviation seen
2> Top: No bicoronal scar, no deformity [light reflection on nose]
No proptosis
Maxillary prominence appears normal

3> Below: No deformity, No collumella scar

Palpation:
1. Sinus: No sinus tenderness
2. Cold spatula test: Equal and adequate airflow on both side
3. On lifting the nasal tip: No collumella scar,
Vestibule is normal,
No caudal dislocation,
No discharge
4. Cottles test
5. Numbness:
Anterior Rhinoscopy:
1. Mucosa: pale or pink
2. IT: ITH or boggy
3. MT, middle meatus: No discharge, polyp, mass or crusting, concha bullosa
4. Floor of the nose:
5. Septum: No deviation, perforation, littles area







Posterior rhinoscopy: (ET, FOR, nasopharynx)
Dr JALAL H
ORAL CAVITY:
1. Mouth opening
2. Denture:
3. Lips:
4. Buccogingival sulcus:
5. Oral hygiene/ Teeth:
6. Retromolar region:
7. Floor of oral cavity:
8. Tongue: - ulcer - movement
9. Palate:
10. Parotid duct opening:
Palpation: tongue, mass

OROPHARYNX:
1. Tonsil:
2. Posterior pharyngeal wall:
3. Gag reflex:
IDL:
1. Base of tongue
2. Vallecula
3. Epiglottis
4. Piriform fossa
5. Arytenoids
6. Vocal cord
7. Post cricoid area

Dr JALAL H
NECK:
Inspection:
1. Scar , swelling, engorged veins
2. Swallowing / protrusion of tongue

Palpation:
1. Trachea
2. Laryngeal crepitus
3. Lymph node level






CRANIAL NERVE:








Dr JALAL H
SWELLING
Inspection
1. Site
2. Size cm * cm
3. Skin overlying, - redness -scar -sinus
4. Relation to surrounding area
5. Pulsation

Palpation
1. Confirm size, site
2. Multiple/single
3. Tenderness
4. Consistency
5. Mobile/ fixed
6. Edges
7. Skin overlying -Attached - warm
8. Relation to muscle -superficial -deep
9. Auscultation