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EXAMINATION OF THE
PATIENT
In order to
examine the ear,
nose and throat of
the patient one
needs a good
source of light and
specialized
instruments.
Light Source:
Head light.
Instruments:
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,
Otoscope.
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
inches.
EXAMINATION OF THE
EAR
Shape,
Size,
Symmetry,
Signs of
inflammation,
Ulcers.
Pre aurikuler
pit/sinus
Pre aurikuler tag
Mikrotia
Atresia liang
telinga
Mastoiditis
Fistel Mastoid
Serumen
Otits eksterna
Otomikosis
OTOSCOPY:
Methods:
Electric Otoscope: It consists
of a speculum, handle and a
magnifying attachment (1.5-2
x).
Technique:
The pinna is pulled
upwards, backwards and
outwards.
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.
OTOSCOPY:
Mistakes:
A speculum that is too
narrow will penetrate
the bony EAM.
A speculum that is too
large will not enter
the cartilaginous
meatus.
Unsatisfactory
cleaning of the debris
will hinder view.
Position,
Colour: Hemorrhage,
dullness, blue, bullae
Ossicles
Perforations: Marginal
and Central, site, size.
Mobility: (Retractions)
by using a pneumatic
otoscope, or Siegle's
speculum.
Middle ear:
Can be examined
through a
perforation. Look
at the colour of
mucosa, edema,
discharge, polyps,
promontory.
Om serosa dg
ventilating tube
Timpano sklerosis
kolesteatoma
Glomus tumor
telinga tengah
Omsk maligna
Qualitative Methods:
i] Valsalva Maneuver:
Principle: Demonstration
of tubal patency without
external aids.
Qualitative Methods:
i] Valsalva Maneuver:
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.
Quantitative
Methods:
Acoustic
impedance
Tympanometry.
Tests of Hearing:
Principle:
This test rests on monaural
comparison to bone conduction.
Method:
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.
Results:
- If air conduction is better than
bone conduction, Rinne's test is
positive. This is the finding in
normal ear and in sensorineural
deafness.
- If bone conduction is better than
air conduction, Rinne's test is
negative. This is found in
conductive deafness.
Stenger test:
Principle:
If sounds of identical frequency but different intensity are
presented simultaneously to each ear, only louder sound will be
perceived.
The test can be performed with tuning forks or a n audiometer.
Method:
- 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.
Chimani-Moos test:
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
Method:
- Patient stands upright
with the feet parallel and
close together, eyes closed
,and the arms folded in
front of the chest or
outstretched.
Results:
- 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
test
Method:
Stepping on one spot with
the eyes closed.
Result:
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
Finger-nose
pointing test:
Inspection:
Congenital
deformities: Clefts,
sinuses.
Acquired Deformities,
Shape,
Swelling,
( Inflammatory, cysts,
tumors)
Ulceration ( Trauma,
neoplastic, infective).
Palpation:
It is carried for;
tenderness,
crepitus, and
deformities.
Tenderness over the
tip is due to a boil.
Over the dorsum is
due to trauma.
The Nose
Anterior Rhinoscopy:
noting:
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.
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.
Posterior Rhinoscopy:
Nasal obstruction
Post nasal drip
Bleeding. Should be taken seriously as it
may be due to a tumor.
Pain
Aural symptoms of deafness, discharge,
and blockage.
Method of Posterior
Rhinoscopy
Technique:
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.
Digital palpation
EXAMINATION OF THE
THROAT
ORAL CAVITY
It includes the
following structures:
Lips
Teeth
Gums
Tongue
Hard and soft palates,
Floor,
Cheeks.
OROPHARYNX
It includes the
following structures:
Uvula,
Soft palate,
Anterior and posterior
tonsillar pillars,
Tonsils,
Posterior pharyngeal
wall.
Check for:
Tongue:
common and taste
sensations,
size: Macroglossia in
acromegaly, Down's
syndrome.
ulcers: Traumatic,
dental, apthous,
malignant,
tuberculous, syphilitic.
Tonsillar grading
INDIRECT
LARYNGOSCOPY:
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.
Direct laryngoscopy
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