Color Atlas of ENT Diagnosis (eBook)

1 ENT Examination

Instruments

Examination of the Ear

Hearing Loss

Tests of Balance

Tinnitus

Examination of the Nose

Examination of the Pharynx and Larynx

Instruments

Fig. 1.1 The instruments needed for an ENT examination: The laryngeal and postnasal mirrors require warming to avoid misting, and hot water or a spirit lamp is necessary. An angled tongue depressor or wooden spatula is needed for examining the oropharynx and postnasal space. Angled forceps are used for dressing the nose or ear. A tuning fork is essential for the diagnosis of conductive or sensorineural (perceptive) hearing loss. A C1 or C2 (256 or 512 cps) is needed. The very large tuning forks used to test vibration sense are unsatisfactory, and may give a false Rinne test. A Jobson-Horne probe is widely used in ENT departments. A loop on one end is for removing wax (and foreign bodies) from the ear or nose. Cotton wool attached to the other end is used for cleaning the ear.

An auriscope, nasal and aural specula complete the basic instruments. A sterile swab and media are necessary for throat, nasal, or ear specimens to be taken for culture and sensitivity. A “narrow” swab holder as shown here is extremely useful for aural specimens, as the more common swab is too wide and can be traumatic for the deep meatus and middle ear.

The doctor's clean white coat remains appropriate dress for noninterventional examination when using these instruments. Surveys have shown that patients prefer their doctor not to wear casual dress. “Scrubs” are frequently used now for patient examination and are necessary for interventional procedures. The concern of cross infection has led to the use of disposable instruments, but this is not at present established practice.

Fig. 1.2a,b Lighting. The head mirror (a) gives effective lighting for examining the upper respiratory tract and ear, and leaves both hands free for using the instruments. Initially, the technique of using a head mirror is not easy, and some may prefer a fiberoptic or electric headlight (b).

Fig. 1.3 Rigid and flexible fiberoptic endoscopes. These are important additional examination instruments. The flexible endoscope is of value to see the laryngeal region (see Fig. 1.61) in those with a marked gag reflex in whom indirect laryngoscopy (see Fig. 1.60) with a mirror is difficult. The rigid endoscope is important in examination of the nasal cavities.

A sterile plastic sheath to use over the endoscope is also shown.

Examination of the Ear

Fig. 1.4 Retracting the pinna. The meatus is S-shaped. To see the drum more clearly, therefore, the pinna is retracted backwards and outwards. The index finger may be used to hold the tragus forward. If this step of straightening the meatus accentuates the pain in someone presenting with an earache, one can be virtually certain that the diagnosis is either a furuncle or furunculosis (see Fig. 2.47).

Fig. 1.5 Head mirror and speculum. These are used for the initial examination of the meatus and drum.

Fig. 1.6 The auriscope. This is best held like a pen. In this way, the examiner's little finger can rest on the patient's cheek; if the patient's head moves, the position of the ear speculum is maintained in the meatus.

Fig. 1.7a Preferred way to hold the auriscope. When the left ear is examined, the auriscope is held in the left hand and vice versa.

b Incorrect way to hold the auriscope.

Fig. 1.8 Pneumatic otoscope. A handheld air-filled bulb attached to the auriscope enables air to be gently inflated against the drum to demonstrate drum mobility.

Reduced mobility is conspicuous and is evidence of middle ear fluid. Reduced mobility is also seen, however, with tympanosclerosis, which increases the rigidity of the drum. Malleus fixation is a rare cause of reduced mobility of a drum of normal appearance.

The fistula test may be done with the pneumatic otoscope. Pressure change by pressing on the bulb will cause dizziness in those with erosion of the labyrinth by cholesteatoma (see Fig. 2.68) or with a perilymph fistula.

Fig. 1.9 A normal drum. The main landmarks seen on the pars tensa of a normal drum are the lateral process (top arrow) and handle (middle arrow) of the malleus, and the light reflex (lower arrow). The drum superior to the short process is the pars flaccida or attic part of the drum. A normal drum is grey and varies in vascularity and translucency.

Fig. 1.10 A tympanic membrane showing the panoramic view obtained with a fiberoptic endoscope. Fiberoptic auriscopes are not in common use and the conventional auriscope is widely used. For this reason most drums are shown as they are seen with an auriscope. It is interesting to compare the appearance of a normal drum with the auriscope and the appearance with a fiberoptic. A thin posterior scar indrawn onto the stapes is clearly seen (arrow) and would not be so apparent with most conventional auriscopes.

For the most clear view of the eardrum, and for fine use of instruments, the microscope (Fig. 1.15) is used.

Fig. 1.11 A more vascular drum. This has vessels extending down the handle of the malleus to the umbo (arrow).

These vessels may also be more conspicuous following mild barotrauma to the ear, e.g., rapid descent in an airplane in which delayed eustachian tube opening causes pain. More severe trauma leads to hemorrhage into the drum or perforation.

Fig. 1.12 The incus (lower arrow) may show as a shadow through a thin drum, as may the round window and opening of the eustachian tube, although this is less common. The chorda tympani nerve may also be seen through the drum (top arrow).

Fig. 1.13 The chorda tympani nerve is the nerve of taste to the anterior two thirds of the tongue (excluding the circumvallate papillae), and is also the secretomotor nerve to the submandibular and sublingual salivary glands. The chorda tympani nerve usually lies behind the pars flaccida. It is not normally visible, but if the nerve is more inferior, it shows through the drum (arrow).

Referred Ear Pain

If examination of the drum and meatus is normal in a patient complaining of earache, the pain is referred. Referred ear pain may be from nearby structures such as the temporo-mandibular joint, neck muscles, or cervical spine. It may also be from the teeth, tongue, tonsils, or larynx. Cranial nerves V, IX, and X which supply these sites have their respective tympanic and auricular branches supplying the ear. Earache also frequently precedes a Bell's palsy.

Fig. 1.14 Examination of the ear with an otoendoscope or microscope when projected to a TV monitor is a useful teaching aid and a reassurance to some patients.

Fig. 1.15a,b Microscope examination of the drum. a Although most drums can be well seen and conditions diagnosed with the auriscope, the increased magnification that is obtainable with the operating microscope and easier instrumentation, make this apparatus standard in any well-equipped outpatient department. A video camera or tutor arm may be attached to the microscope for demonstration. The auricular branch of the vagus nerve supplies part of the deep meatus and eardrum, as well as some skin in the post auricular fold. Therefore, instrumentation of the ear may produce a sensation of faintness from a vasovagal episode; also a cough may be triggered. Many therefore prefer to have the ear examination with the patient lying down, particularly for procedures such as difficult suction clearance of wax and debris from the deep meatus. Routine examination of the drum with the microscope may be carried out with the patient sitting up (b).

Fig. 1.16 Siegle's speculum. The pneumatic otoscope has replaced the use of Siegle's speculum (see Fig. 1.8). With plain (not magnifying) glass it is useful to test drum mobility with the microscope.

Hearing Loss

Most hearing loss is easy to diagnose as either a well-defined conductive or sensorineural type. (“Mixed” hearing loss may occur, but this diagnosis is usually non-contributory, and the term is better avoided.)

Lesions to the left of the red line (Fig. 1.17) cause conductive hearing loss, and are frequently curable. Hearing loss to the right of the red line is due to a sensorineural lesion, and is usually not so amenable to treatment. The black line separates the cochlear from the retrocochlear hearing losses.

The etiology and management of “sudden” sensorineural hearing loss remains controversial. Etiological factors include viral infections, vascular occlusion, an autoimmune process or membrane breaks. Discussion of the treatment,...