Clinical Examination in ENT

Clinical Examination in ENT - Tools & Tricks

• Head Mirror & Light: (Bull's lamp/LED) Non-dominant eye; focal length ~20-25 cm.
• Aural Speculum: Largest comfortable; pull pinna up & back (adults), down & back (children).
• Tuning Forks: (512 Hz for Rinne/Weber). 📌 Strike gently, place firmly.
• Nasal Speculum: (Thudichum's) Blades open vertically.
• Tongue Depressor: Depress anterior 2/3rds.
• Laryngeal Mirrors: Warm to prevent fogging.
• Jobson Horne Probe: Wax/foreign body.
• Siegle's Speculum: TM mobility.

⭐ Standard tuning fork frequency for clinical hearing tests (Rinne, Weber) is 512 Hz as it provides the best balance between decay time and bone conduction perception.

Clinical Examination in ENT - Sound Sleuthing

• Otoscopy: Inspect External Auditory Canal (EAC) & Tympanic Membrane (TM).
• Tuning Fork Tests (TFTs): Standard 512 Hz fork.
  • Rinne Test: Compares Air Conduction (AC) & Bone Conduction (BC).
    • Normal/SNHL: AC > BC (Positive).
    • CHL: BC > AC (Negative).
  • Weber Test: Lateralization.
    • CHL: Towards diseased ear.
    • SNHL: Towards better ear.
  • Schwabach Test: Compares patient's BC to examiner's.
• Audiometry:
  • Pure Tone Audiometry (PTA): Hearing thresholds.
  • Impedance Audiometry: Middle ear function (Tympanometry, Stapedial reflex).

⭐ A 512 Hz tuning fork is preferred for clinical hearing tests as it balances audibility and minimizes vibratory sensation.

Clinical Examination in ENT - Sniffing Out Signs

• External Nose & Vestibule:
  • Inspect: Deformities, skin (rhinophyma); vestibule (furuncles, crusting).
• Anterior Rhinoscopy (Thudichum's speculum):
  • Septum: DNS, spurs, perforations; Kiesselbach's plexus (bleeding).
  • Lateral Wall: Turbinates (size, color, hypertrophy); meatus (discharge, polyps).
• Posterior Rhinoscopy (Mirror):
  • Visualize: Choanae, Eustachian tube (ET) openings, adenoids, Fossa of Rosenmüller.
• Sinus Examination:
  • Palpate: Frontal, maxillary sinus tenderness.
  • Transilluminate: Maxillary/frontal sinuses (↓ glow if sinusitis).

⭐ The Fossa of Rosenmüller, a common site for nasopharyngeal carcinoma, is best visualized during posterior rhinoscopy.

Clinical Examination in ENT - Oral Odyssey

• Inspection: Systematic approach.
  • Lips: Symmetry, color, lesions.
  • Buccal mucosa, gingiva, teeth (note caries, missing teeth).
  • Tongue: Dorsum, ventral surface, lateral borders. Assess mobility (CN XII), papillae.
  • Palate: Hard & soft; uvula (midline, movement on phonation).
  • Tonsils: Size (Brodsky 0-4), crypts, exudate, symmetry.
  • Oropharynx: Posterior wall, pillars.
• Palpation: Bimanual for floor of mouth, tongue base, and any lesions. Note tenderness, induration, fixity.
• Duct Openings: Stensen's (parotid - opposite upper 2nd molar), Wharton's (submandibular - floor of mouth).
• Tools: Bright light source, tongue depressor(s).

⭐ Ludwig's angina: a rapidly progressive, potentially life-threatening cellulitis of the submandibular, sublingual, and submental spaces. Often odontogenic; airway compromise is a critical concern.

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Clinical Examination in ENT - Voice & Vital Nodes

• Voice Assessment (GRBAS Scale):
  • Grade, Roughness, Breathiness, Asthenia, Strain.
  • Hoarseness: key symptom (e.g., laryngitis, palsy, nodules, malignancy).
  • Stridor: Inspiratory (laryngeal), Expiratory (tracheal), Biphasic (subglottic).
• Neck Examination (Lymph Nodes):
  • Inspect: scars, sinuses, swellings, visible pulsations.
  • Palpate systematically: submental, submandibular, jugulodigastric, cervical (anterior/posterior chains), supraclavicular.
  • Note: 📌 Site, Size (cm), Shape, Surface, Skin changes, Consistency (e.g. matted), Tenderness, Mobility (fixed?).

⭐ Jugulodigastric node (Level II) is often called the "tonsillar node" as it's the primary drainage for the palatine tonsil.

High‑Yield Points - ⚡ Biggest Takeaways

• Tuning fork tests (Rinne, Weber) are crucial to differentiate CHL vs. SNHL.
• Otoscopy: Identify landmarks like malleus handle, umbo, and cone of light.
• Anterior rhinoscopy for nasal cavity; posterior mirror exam for nasopharynx.
• Indirect Laryngoscopy (IDL) for vocal cords; tonsil grading (Brodsky scale).
• Systematic neck palpation of lymph node levels is vital for staging.
• Assess key ENT cranial nerves (V, VII, VIII, IX, X, XI, XII) for deficits.
• Cold caloric test (COWS) evaluates vestibular function (horizontal SCC).