APPROACH TO EXAMINATION

OF ENT DISORDERS
Dr. Pua Kin Choo
ENT, Head & Neck Surgeon
Hospital Pulau Pinang
 History taking in ENT
• Nose & Paranasal sinuses
• Ear
• “Throat”
• Head & Neck
• General
 Nose & PNS

1. Nasal Obstruction (nose block)

:Bilateral- generalized swelling of
mucosal lining due to infection, allergy,
vasomotor changes, polypi & crusting.
 Unilateral- DNS-deviated nasal septum
- Tumour
- FB-foreign body
Alternating- vasomotor rhinitis due to an
alteration of the autonomic system
constriction of the mucosa
vasculature and the rate of
mucus secretion stimulated
by non-specific factors such as
ambient temperature change &
change of posture.
2. Nasal discharge
Rhinorrhoea- thin mucus runs
anteriorly (Allergy
rhinitis ; VMR : virus
infection)
Catarrh- Thicker secretion esp to
nasalpharynx (post
nasal drip)
Water- CSF rhinorrhoea
Blood Streaked- NPC
3. Sneezing
Due to irritation within the nose, by infection or
allergy or following inhalation of noxious gases
or polluted air (allergic rhinitis)
4.Itchiness
• Nose, eyes, throat, ear esp allergic
rhinitis. ( Atopic dermititis)
5.Epistaxis
• Adolescent male – angiofibroma
• Little’s area – allergic rhinitis, crusting
• Elderly – atrophic nasal mucosa (familial
telenggaectesia )
5.Pain in the face
Type of pain / distribution / duration /
stimulating factors / any features which make it
worse.
• Skin or mucosal lesions
• Periosteal disease
• Dental pain
• TMJ strain- temporomandibulr joint
• Vascular pain
• Migraine
• temporal arteritis
• Neuralgic pain (trigeminal neuralgia)
6.Disturbances of olfaction (smell)
Anosmia i.e. complete loss of smell
e.g. nasal polyp / atrophic
rhinitis / trauma / viral infection.
Parosmia i.e. perversion of smell
- cacosmia unpleasant odour
can be due to FB, rhinolith, tumour,
atrophic rhinitis.
Hyperosmia i.e. increased sense of smell
(hyterical neurosis)
7.Snoring
• Increased : allergic swelling of nasal
mucosal
• In children – hypertrophied adenoids with
or without hypertrophied tonsils
• Obstructive sleep apnoea
 Differential diagnosis of nasal
disease
• Allergic rhinitis: increased rhinorrhoea + frequent
sneezing + itchiness eye, nose + nasal blockage
• Vasomotor rhinitis: nasal blockage (alterating ;
temparature change ; postural)
• Sinusitis : facial pain, catarrh
• Nasal polyp: nasal block, loss of smell
(Sampter’s triad: nasal polyp + asthma + aspirin
hypersensitivity).
• Angiofibroma : adolescent male, with massive
epistaxis
• NPC/FB Nose: Bld stained nasal discharge
 Ear Disease
1. Deafness or Hearing Loss
• Gradual onset can be presbyacusis
• Sudden onset – occlusion of EAC
- trauma
- idiopathic
• Fractuating hearing loss – Meniere’s disease
• Hear better in noisy environment known as
paracusis willisii typically in otosclerosis
2. Discharge
• Can be from external meatus or middle ear
• Types: EAC discharge can be serus or
purulent
: middle ear discharge is usually
mucopurulent
• CSOM: central perforation is with profuse
mucopurulent discharge
: attic or marginal perforation discharge
is scanty, purulent foul smelling
• Blood stained: need TRO malignant ds
3. Pain
• Can arise from auricle, EAC or ME or
mastoid
• Types of pain / aggravating factor
• Referred pain from scalp, neck, nose,
nasopharynx, teeth, TMJ 7 larynx (from
sensory N from V, IX, X, c2, c3)
4. Itchiness
• Associated with OE, wax, FB, allergy
5. Tinnitus
• Subjective sensation of sound in the ear
• Can be due to irritation of cochlear
mechanism
• Continuous / intermittent or synchronous
with pulse
• Pulsatile tinnitus can be due to glomus
tumour.
6. Vertigo
Duration: seconds is BPPV
Minutes to Hours: meneire’s disease
Days to Weeks: vestibuloneunonitis
7. Blocking sensation
• Wax
• MEE (unilateral commonly occur in NPC)
 Throat History
1. Dysphagia – difficulty in swallowing food
(tumour)
2. FB sensation – lump in the throat (LPR)
3. Odynophagia – painful swallowing (oral
or hypopharyngeal disease)
4. Regurgitation – soft palatal disease
5. Hoarseness
6. Stridor
 Head & Neck
• Neck lump –midline :Thyroid/ thyroglossal
duct cyst
• Lateral : L.N./ branchial cyst
• Cranial nerves symptoms e.g. blurring of
vision /diplopia/ numbness/ facial
asymmetry/ hoarseness/ dysarthria
 Check list for history taking
• Nasal: discharge/ sneezing/ itchiness/
epistasis/ smell/ facial pain/ swelling/
snoring
• Ear: Deafness/ tinnitus/ vertigo/ discharge/
pain/ itchiness/ facial asymmetry
• Throat history: odynophagia/ dysphagia/ fb
sensation / regurgitation/ ulcer/ growth/
trismus /dysarthria/ hoarseness /stridor
• Head & Neck history : Neck lump/ cranial
nerves symptoms 1-12
ENT Examination
 Examination of the ear
• Introduce yourself to the patient.
• Position the patient.
• Ascertain which is the better ear and start with
non disease ear first.
• Inspect the pinna, mastoid and EAC.
• Otoscopy examination.
• Voice test.
• Tuning fork test.
• Check for Facial nerve palsy/ nystamus.
 The Pinna
• Examine the pinna from front and behind.
• Scar, inflammation, deformity, sinus.
• Mastoid process-scar, inflammation,
swelling.
 Otoscopy
• Status of EAC.
• Status of TM-handle of malleus,cone of
light, perforation.
• Perforation-site, size, type of perforation.
• Perforation-attic, central, marginal.
 Examination of the nose
• Introduce yourself.
• Position the patient.
• Inspect the face / external nose.
• Cold spatula test.
• Sinus tenderness
• Anterior rhinoscopy with a thudiculum speculum.
• Oral examination
• Post nasal space examination.
• Neck
 External nose
• From front and laterally, superiorly.
• Deformity, scar, inflammation, swelling.
 Anterior rhinoscopy
• Status of turbinate( colour, swelling)
• Status of septum (deviation, perforation)
• Status of nasal mucosa (colour, discharge)
• Status of nasal cavity (mass lesion,
polyps,discharge)
 Examination of the throat
• Introduce yourself
• Position the patient and expose the neck
down to the clavicles
• Assess speech
• Oral examination
• Nasopharynx
• Indirect laryngoscopy
• Neck
ANATOMY OF THROAT
 Oral cavity
• Anterior two third of tongue
• Hard palate
• Upper & lower alveolus
• Buccal mucosa
• Floor of mouth
 Oral pharynx
• Posterior one third of tongue
• Soft palate
• Tonsils
• Pharyngeal wall
 Nasopharynx
• Mirror
• Nasal endoscope
 LARYNX
Larynx level :
At birth C4
6 years old C5
Puberty C6
Glottic area
at birth +/- 24 mm2
adult 44mm2
 Assess speech

• Ask patient to count 1-10 in single breath

• Ask patient to cough
 Indirect laryngoscopy
• Explain to patient what you are to do
• Warm the laryngeal mirror
• Ask patient to protrude the tongue and
gently grasp it with a swab held in the
other hand.
• Status of posterior pharyngeal wall,
epiglottis, valeculae, base of tongue,
pyriform fossae, arythenoid, vocal cords.
 NECK
• Lymphatics (level I ,ll, lll, lV, V, Vl)
• Lumps ( goitre, parotid, submandibular
gland, branchial cyst, carotid body
tumour, thyro glossal duct cyst …..)
 Cranial Nerves Exam

• Name
• Functions
• test
 Tools
• Otoscope
• Tuning fork (512 Hz)
• Measuring tape
Thank You