Ear, Nose and Throat Examination

This includes an assessment of hearing as well as the appearance of the ear.

History¹

The following issues should be included:

• Classic symptoms of ear disease: deafness, tinnitus, discharge (otorrhoea), pain (otalgia), and vertigo
• Previous ear surgery, or head injury
• Family history of deafness
• Systemic disease (e.g. stroke, multiple sclerosis, cardiovascular disease)
• Ototoxic drugs (antibiotics (e.g. gentamicin), diuretics, cytotoxics)
• Exposure to noise (e.g. pneumatic drill or shooting)
• History of atopy and allergy in children

Inspecting the external ear^1,2

Inspect the external ear before examination with an otoscope/auriscope. Swab any discharge, and remove any wax. Look for obvious signs of abnormality:

• Size and shape of pinna
• Extra cartilage tags/pre-auricular sinuses or pits
• Signs of trauma to pinna
• Suspicious skin lesions on the pinna including neoplasia
• Skin conditions of the pinna and external canal
• Infection/inflammation of external ear canal with discharge
• Signs/scars of previous surgery

Inspecting the ear canal and ear drum²

A modern electric otoscope/auriscope with its own light source is primarily used to examine the ear. An otoscope also has its own magnification, which gives a good view of the tympanic membrane (TM). Batteries need to be fully operational to allow optimal light during examination.

The examination technique involves grasping the pinna and pulling it up and backwards (posteriorly and superiorly), which helps to straighten the ear canal and for inspection of the TM (In infants, only pull the pinna posteriorly not superiorly for examination).

Hold the otoscope near to the eyepiece rather than at the end, this helps to reduce the patient’s discomfort due to hand movements, which are exaggerated in the ear. Modern otoscopes are designed to use a disposable speculum. It is necessary to fit the correct size of speculum to achieve the best view; it is tempting to use a small piece for ease of insertion, but this simply restricts the image available.

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 balloon.

Inspecting the tympanic membrane (TM)^1,2

Move the otoscope in order to see several different views of the drum; it is not always possible to see the whole drum in one single view using an otoscope. The drum is roughly circular (~1cm in diameter). In a normal drum the following structures can be identified:

• Handle/lateral process of the malleus
• Light reflex/cone of light
• Pars tensa and pars flaccida (attic)

Occasionally, in a healthy, thin drum, it is possible to see the following:

• Long process of incus
• Choridatympani
• Eustachian opening
• Promontory of the cochlea

Common pathological conditions related to the ear include:

• Perforations (note size, site and position)
• Tympanosclerosis
• Glue ear/ middle ear effusion
• Retractions of the drum
• Haemotympanum (blood in the middle ear)
• Check facial nerve function if ear pathology is serious

Basic hearing tests¹

Detailed hearing tests are usually performed in audiology clinics.
A patient with normal hearing should hear equally as well in both ears.

• Tuning fork tests: Weber test and Rinne test³
• Free field voice testing (whisper from 40cm)

Full nose examinations assess the function, airway resistance and occasionally sense of smell. It includes looking into the mouth and pharynx. Common symptoms of nasal disease include:

• Airway obstruction
• Rhinorrhoea (runny nose)
• Sneezing
• Loss of smell (anosmia)
• Facial pain caused by sinusitis
• Snoring (associated with nasal obstruction)

History

The following issues should be covered:

• Allergies/atopic disease
• Smoking
• Pets at home
• Occupation
• History of previous surgery
• Previous trauma
• General medical history
• Seasonal or daily variation in symptoms

Inspection of the nose

First look at the external nose. Ask patient to remove glasses. Look at nose from front and side for any signs of the following:

• Size and shape
• Obvious bend or deformity: a deviated nose is often best looked at from above
• Swelling
• Scars or abnormal creases
• Redness (evidence of skin disease)
• Discharge or crusting
• Offensive smell

The nose can be inspected from the front to examine the anterior nares by lifting the tip of the nose up and looking inside without a speculum. Check patency of each side and ask the patient to sniff. To assess the nasal airway hold a cold metal tongue compressor under the nose while the patient exhales and note the condensation under both nostrils, or occlude one nostril whilst the patient sniffs to give a reasonable idea of airway patency.

Most otolaryngologists use either a head mirror or illuminated spectacles with a thudicum speculum to open up the nose, which allows examination of the nasal cavity. Holding the instrument comfortably can take practice at first. Insert the thudicum gently, identify nasal septum medially; turbines laterally; inferior turbinate (nearly always possible to see); the middle turbinate is often difficult to see as it is small.

Check for inflammation (rhinitis), position of septum, presence of polyps (touch to check sensitivity; it should be insensitive to touch). A foreign body, usually accompanied by an offensive unilateral discharge, may be seen inside the nose of a child.

A mirror and headlight or an endoscope instrument is used to view the nasopharynx (postnasal space, which contains the eustachian tube orifices and pharyngeal recess (of Rosenmuller), and may contain adenoids or nasopharyngeal cancer), but this is not always possible during a routine examination. Finally examine the palate. Look for large nasal polyps and tumours arising from the soft palate.

This includes a through examination of the oral cavity.

History

General history plus, ask the patient about tobacco or alcohol use, and dental history.

Inspection

Ask patient to remove dentures and examine mouth systemically (use a bright torch): tongue, hard and soft palate, tonsillar fossa, gingivolabial/gingivobuccal sulci, floor of mouth/undersurface of tongue as follows:

• Examine mouth and note condition of tongue
• Examine back of tongue and tonsils (press down on tongue with a tongue depressor)
• Palate the base of tongue (look for tumours that may not be easily visible)
• Inspect uvula and soft palate
• Inspect hard palate (ask patient to tip their head backwards, until the whole hard palate is visible)
• Examine buccal area and the gingivolabial (gingivobuccal) sulcus, (space between cheek and gums)
• Examine the floor of mouth, check for submandibular duct stones or masses (ask patient to stick their tongue out)
• Examine the nasopharynx and larynx with a mirror or flexible fibre-optic nasendoscope