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ENT Clinical skill

dr. Reno Hardoyo kelan Sp



In order to
examine the ear,
nose and throat of
the patient one
needs a good
source of light and
Light Source:
Head light.


Ear specula,
Nasal Specula,
Tongue depressors,
Indirect laryngoscopy mirrors,
Posterior Rhinoscopy mirrors,
spirit lamp,
Jobson-Horne ear probes,
Nasal and aural forceps.
Barany's noise box,
Seigle's speculum,
Tuning forks, 512 Hz, 1024 Hz,

Seat of patient:
Revolving stools, both for the patient
and the examiner. The patient sits on
the stool at the same level as the doctor.
Patient's legs should be to one side of
the examiner.
The distance between the doctor and
patient should not be more than 8


Examination of the ear includes :

1. Pinna,
2. External auditory meatus,
3. Tympanic membrane,
4. Middle ear,
5. Tests for the function of Eustachian tube,
6. Tests of hearing,
7. Tests of balance,
8. Eyes.
9. Post aural area (Mastoid process), and
lymph nodes.

Examination of the Pinna:

Signs of

Note the condition of the canal skin,

and the presence of wax, foreign
tissue, or discharge. The mobility of
the eardrum can be evaluated using
a pneumatic speculum, which
attaches to the otoscope. The drum
should move on squeezing the

Pre aurikuler
Pre aurikuler tag

Atresia liang


Fistel Mastoid


Otits eksterna

Eksostosis liang telinga


Benda asing liang



Electric Otoscope: It consists
of a speculum, handle and a
magnifying attachment (1.5-2
The pinna is pulled
upwards, backwards and
The speculum of
appropriate size is
introduced along the axis of
the meatus with a rotating
motion using the left hand
for the right ear and the
right hand for the left ear.
The wall of the bony meatus
must not be irritated as it is
very sensitive.


One hand is left free for


In infants and young

children the pinna is
pulled downwards and
backwards to
straighten the meatus.

Wax and other debris

must be removed for
adequate examination.

A speculum that is too
narrow will penetrate
the bony EAM.
A speculum that is too
large will not enter
the cartilaginous
cleaning of the debris
will hinder view.

Tympanic membrane: (Using naked eye,

otoscope, and otomicroscope)

Colour: Hemorrhage,
dullness, blue, bullae
Perforations: Marginal
and Central, site, size.
Mobility: (Retractions)
by using a pneumatic
otoscope, or Siegle's

Middle ear:

Can be examined
through a
perforation. Look
at the colour of
mucosa, edema,
discharge, polyps,

Membran timpani normal

Otitis media serosa

Om serosa dg
ventilating tube

Timpano sklerosis


Glomus tumor
telinga tengah

Omsk benigna (tenang)

Omsk maligna

Tests for Eustachian tube


Qualitative Methods:
i] Valsalva Maneuver:

Principle: Demonstration
of tubal patency without
external aids.

Method: After taking a

deep breath, the patient
pinches his nose and
closes his mouth in an
attempt to blow air in his
ears. Otoscopy shows
movement of the drum.
Auscultation reveals

Tests for Eustachian tube


Qualitative Methods:
i] Valsalva Maneuver:

Note: Failure of this test

does not prove pathologic
occlusion of the tube.

This maneuver in the

presence of nasal and
nasopharyngeal infection
carries the danger of
transmission of infection
to the ear.

Tests for Eustachian tube


ii]Toynbee's test:
Principle: It is safer
and confirms normal
tubal function.
Method: The nose is
closed and the patient
swallows. There is in
drawing of the
tympanic membrane,
confirmed by otoscopy
and on auscultation
when a noise is heard.


Tests of Hearing:

- This requires a quiet room of about 6 m

long since noise and poor acoustic properties

such as a narrow room with smooth walls
produce echoes which falsify the results.
- Each ear is tested separately.
- The better ear is tested first.
(for tunning fork test : The opposite ear is masked by a
moist plug of cotton pressed into the EAM moved in and
out. (Wagener's vibration method of masking). In cases of
severe unilateral deafness Barany's noise box has to be

[I] Whisper test:

Two syllable words are articulated at a

decreasing distance from the patient until these
words can be clearly repeated

[II] Tuning Fork tests:

(A C1 fork of 512 Hz is used).

i) Weber's test:
It is dependent on binaural
comparison of bone conduction.
- The tuning fork is placed in the
center of skull at the hairline.
- The patient with normal
hearing will hear equally in both
- The patient with a unilateral
conductive hearing loss localizes
the tone in the diseased ear.
- The patient with a unilateral
sensorineural loss will localize
to the healthy ear.

ii) Rinne's test:

This test rests on monaural
comparison to bone conduction.
The patient can tested in two ways;
i) Duration, ii) Intensity.
The patient is asked whether the
tuning fork placed in front of the
ear or behind the ear on the
mastoid is heard better.
- If air conduction is better than
bone conduction, Rinne's test is
positive. This is the finding in
normal ear and in sensorineural
- If bone conduction is better than
air conduction, Rinne's test is
negative. This is found in
conductive deafness.

iii) Schwabach's test:

Depends on comparison of the bone
conduction of the patient with that of the

iv) Bing test:

Increased loudness for

bone conducted sound less
than 2 kHz, occurs in the
normal or sensorineural
deafness when the EAM is
occluded without
increasing the pressure
( As the masking effect of
air conducting sound is
removed). There is no
change in conductive

Tests for non-organic hearing loss:

Stenger test:

If sounds of identical frequency but different intensity are
presented simultaneously to each ear, only louder sound will be
The test can be performed with tuning forks or a n audiometer.
- The examiner stands behind the patient.
- A tuning fork is struck and is held 20 cm from the good ear - the
patient hears the sound.
- The fork is then removed and placed 5 cm from the bad ear patient 'denies' hearing sound.
- Another fork is the held 15 cm from the good ear without the
patient noticing.
- If there is genuine hearing loss patient will the fork in the good ear.
- But if there is non-organic loss the patient will be unable to hear the
fork in the good ear as the fork is closer in his 'bad' ear.

Tests for non-organic hearing loss:

Chimani-Moos test:

- Modification of Weber. When the fork is placed

on the vertex, the patient indicates that he is

hearing the fork in the good ear and not in the
deaf ear.
- The meatus of the good ear is then blocked .
- A genuine deaf patient will still lateralize the
sound to the good ear, the malingerer will usually
deny hearing any sound at all.

Hearing tests

Hearing tests
Whispered speech test. Your GP will whisper a combination of
numbers and letters behind you and check if you can hear anything
by asking you to repeat the combination. Your GP will probably move
further away from you each time to test the range of your hearing.
Tuning fork test. Different tuning forks can be used to test your
hearing at a variety of frequencies. They can also help determine the
type of hearing loss.
Pure tone audiometry. An audiometer produces sounds of different
volumes and frequencies. During the test, you're asked to indicate
when you hear a sound in the headphones. The level at which you
can't hear a sound of a certain frequency is known as your threshold.
If your hearing loss has a sensorineural cause, a number of tests can
be performed to pinpoint where the problem lies.
Otoacoustic emissions. This is used to measure your cochlear
function by recording signals produced by the hair cells.
Auditory brainstem response. This measures the activity of the
cochlea, auditory nerve and brain when a sound is heard.

Tests of Balance

Romberg test

- Patient stands upright
with the feet parallel and
close together, eyes closed
,and the arms folded in
front of the chest or
- Unilateral peripheral
lesion or a unilateral
cerebellar lesion, the
patient tends to sway
towards the affected side.
- Central lesions give
irregular pattern of sway.

Unterberger's Stepping
Stepping on one spot with
the eyes closed.
Peripheral lesions- rotation
of the body axis to the side
of the labyrinthine lesion.
Central disorders- the
deviation is irregular.
Deviations of greater than
40 degree are significant

pointing test:

Method: The index finger

of the outstretched hand
is brought to the point o
the nose with the eyes
Result: Ataxia and
disorders of coordination
indicate an ipsilateral
cerebellar lesion or a
disorder of positional

Positional testing ( Dix Halpike method).

- Screening test for
Positional nystagmus.
- Nystagmus induced or
aggravated by this test is
attributable to cervical
proprioceptors and
vertebral artery

Positional testing ( Dix Halpike method).

(With the head in different
- The head is firmly grasped
with the patient sitting on a
- The patients head is rotated
45 to one side and then the
other while he is made to
assume the supine position
with the head hanging 30
below the edge of the table.
The head is kept in this
position for some time.
- The eyes should be
observed for nystagmus.

Examination of the nose

The nose can be

examined in three
1. Examination of
the external nose,
2. Anterior
3. Posterior

Examination of the External


deformities: Clefts,
Acquired Deformities,
( Inflammatory, cysts,
Ulceration ( Trauma,
neoplastic, infective).

It is carried for;
crepitus, and
Tenderness over the
tip is due to a boil.
Over the dorsum is
due to trauma.

Loss of smell (anosmia) is a relatively common

problem, though often undiagnosed. In patients
who make mention of this problem, olfaction can
be crudely assessed using an alcohol pad sniff
test as follows:
Ask the patient to close their eyes so that they
don't get any visual cues.
Occlude each nostril seqeuentially, making
sure that they can move air adequately thru
Occlude one nostril and then present an
alcohol pad to the other side, asking the
patient to inform you when they are able to
detect its smell.

to detect the odor of the alcohol pad at a

distance of 10 cm. Alcohol is used for
convenience, as most exam rooms have
these pads. More sophisticated testing
can be done using vials containing very
distinctive odors (e.g. coffee grounds 0

The Nose

First check to see if the patient is able to

breathe through either nostril effectively.
Push on one nostril until it is occluded and
have them inhale. Then repeat on the other
side. Air should move equally well through
each nares.
To look in the nose, have the patient tilt their
head back. Push up slightly on the tip of the
nose with the thumb of your left hand. Place
the end of the speculum into the nares under
direct vision. Now look through the viewing

Anterior Rhinoscopy:

It consists of the following steps:

1. Examination of the vestibule (Skin lined
part of the nares),
2. Examination of the nasal cavity using
the Thudichum's speculum,
3. Patency tests,
4. Probe test,
5. Examination after vasoconstriction.

Examination of the vestibule:

This is carried out by tilting the tip of
The lining which is skin and has all the
dermal appendages (Hair, sebaceous
glands etc.). All the diseases affecting
these adnexa can occur in the vestibule.
Ulceration may be neoplastic, infective.
Excoriation because of discharge.

Examination of the nasal cavity using

a speculum:
Nasal speculum:
It is an inverted 'U' shaped instrument. It
has two blades at the lower end.

Method of holding the instrument:

Hold it in the left hand keeping the right hand
free for other instruments.
Pick the instrument with the thumb and the
index finger of the L hand with the blades
directed towards the elbow.
The loop is directed downwards.
Pronate the forearm and flex the wrist there by
aligning the blades with the nares.
The legs of the speculum are controlled by the
middle and the ring fingers.

Use of the speculum:

The axis of the anterior nares is upwards
and backwards, whereas that of the
posterior nares is horizontally backwards.
Lift the tip of the nose with the blades so
that the two axes are in straight line
Introduce the speculum with the blades
Introduce the speculum in an upwards and
backwards direction.

Once inside the nose, gradually open the

blades avoiding discomfort to the patient.
Look at roof, floor, lateral and medial
walls of the nose.
Septum: Position, spurs, deviation, colour
of mucosa, ulcers, crusting, vessels, and
Lateral wall: Inferior and middle
turbinates, size ,colour, shape.

The color of the mucosa. It
can become quite reddened
in the setting of infection.
The presence of any
discharge as well as its color
(clear with allergic reactions;
yellowish with infection).
The middle and inferior
turbinates, which are shelflike projections along the
lateral wall. Any polypoid
growths, which may be
associated with allergies and
obstructive symptoms?
The other nostril is examined
in a similar manner.

Meatii for pus and discharge, and polyps.

Middle meatus is situated higher up so tilt
the head backwards at an angle of 45. If
any growth or polyp is suspected confirm
by the probe test.

Probe test:
It is carried out by spraying the nose with
4% Lignocaine with 1:100000 adrenaline
or 10% cocaine.
The lesion or area is palpated to
determine its character and mobility.

Patency test:
By placing a cold tongue depressor or a
wick of cotton below the nostril, nasal
patency can be assessed.
Compare the two sides always.

Anterior Rhinoscopy with


Posterior Rhinoscopy:

It is carried out to examine the post nasal space

(nasopharynx). It is a difficult space to examine
so the disease may be hidden for quite a long
time. Different methods of examining the area
i. Post nasal mirror.
ii. Nasopharyngoscope.
iii. Examination under anaesthesia after palatal
iv. Digital palpation.
v. Radiological examination.

Symptomatology of lesions of the


Nasal obstruction
Post nasal drip
Bleeding. Should be taken seriously as it
may be due to a tumor.
Aural symptoms of deafness, discharge,
and blockage.

Method of Posterior

Post Nasal Mirror:

it consists of a handle on which a
small mirror is attached to shaft at
an angle of 110. There is another
angulation in the shaft.

Hold the mirror like a pen in the right hand.
Warm the mirror slightly on the flame of the
spirit lamp to avoid condensation from the
expired air.
Ask the patient to open the mouth.
Take the tongue depressor in the left hand
and depress the anterior 2/3rds of the tongue.
Feel the warmth of the mirror on the back of
the wrist. It should not be hot.

Introduce the mirror

from the angle of the
mouth over the tongue
depressor and slide it
behind the uvula. Avoid
touching the posterior
wall of the pharynx as it
may trigger gagging.
Instruct the patient to
breath through the
Tilt the mirror in
different direction tot
see various structures
of the nasopharynx.

Digital palpation

Posterior Rhinoscopy with



The throat consists of the ; oral

cavity ,and the oropharynx

It includes the
following structures:
Hard and soft palates,

It includes the
following structures:
Soft palate,
Anterior and posterior
tonsillar pillars,

Posterior pharyngeal


Lips: Common site for

carcinoma, herpes and
primary syphilis.
Teeth and gums: Bleeding
from gums, state of
dentition, foul discharge
from a tooth, sensations.
Tongue: It includes the
anterior 2/3rds,
posterior 1/3rd,
dorsum and
the margins.

Check for:
common and taste
size: Macroglossia in
acromegaly, Down's
ulcers: Traumatic,
dental, apthous,
tuberculous, syphilitic.

movements: Restricted in hypoglossal

palsies, tumor infiltration.
fasciculation: Motor neuron disease,
depapillation: Vitamin deficiencies,
furrowing , as in geographic tongue
coating: Thrush, black hairy tongue.
Hypoglossal palsy: Tongue deviates
towards the lesion.

Cheeks: Parotid duct

opening Opposite
upper 2nd molar), red
or white patches,
ulcers, moisture.
Palate: Swelling, ulcer,
perforations, clefts etc.
Uvula: Position,
deviations (Towards
the normal side in
palsies), ulcers.

Tonsillar pillars: Linear congestion, ulcers,

Tonsils: Presence, size, crypts, ulcers, express
the contents of the crypts by pressing on the
pillars to see whether purulent.
Posterior pharyngeal wall: Lymphoid follicles,
Floor of mouth: Wharton duct openings, ulcers,
and bimanual palpation.
Teeth and occlusion
The upper and lower vestibule of the cheek.

Tonsillar grading

T0 = sdh dilakukan tonsilektomi

T1 = tonsil sdh melewati pillar
T2 = tonsil sdh melewati pillar
anterior dan posterior
T3 = tonsil sdh
mendekati/mencapai garis tengah
T0 = tonsil masih dalam fossa
T1 = tonsil <dr 25% jarak uvulapillar anterior
T2 = tonsil 25%-50% jarak uvulapillar anterior
T3 = tonsil 50%-75% jarak uvulapillar anterior
T4 = tonsil >75% jarak uvulapillar anterior

The mirror is plane, on a
straight handle.
Mirror is held like a pen in
the right hand with the
glass pointing downwards.
Warm the mirror and test
the temperature on the back
of the hand.
The patient is asked to stick
out the tongue which is held
with a piece of gauze.

The patient is asked

to breath through the
The mirror is
introduced into the
mouth to the uvula
which is gently
pushed back to get a
view of the larynx and
the pyriform fossae.
The patient is asked
to say 'Aaa' and 'Eee'.

Direct laryngoscopy

Examination of the Neck forms an

integral part of examination of the

Inspection: Position, shape, thyroid

angle, movement with swallowing,
retraction of the suprasternal notch
on inspiration.
Palpation: Cartilages for
irregularity, scars, tenderness,
subcutaneous emphysema, laryngeal

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