Examination of

ear, nose and

throat
Dept of otolaryngology,
Renmin’s Hospital of Wuhan
University
Xuyu 许昱
 General points
 Good lighting: a basic necessity
The head mirror is positioned
in front of the examiner ’s eye to
the right or left ,the mirror is
adjusted so that the light is
focused on the patient
Instruments
 THE EAR
Instruments:
 Light source

 Aural speculum

 Cerumen loop or curette

 Suction apparatus

 Cotton tipped applicators

 The External Ear
 The pinna and periauricular area
• Size 、 shape 、 position
• Symmetry:bilaterally equal size
• no swelling , thickening
• Skin condition
• intact , no lump or lesion
• Tenderness
• move the pinna and push the tragus
• Palpate mastoid area for tenderness, swelling,
or nodules
 The External Ear
 The external auditory meatus
size / swelling / redness /
discharge note any odor. /lesion / foreign body
/cerumen.
 The External Ear
The tympanic membrane
Normal: Cone-shaped, light reflex shiny, translucent, pearl-
gray color
• landmarks visible:Umbo; Manubrium; short process
• Color
• contour
• perforations
Three essential steps for external
canal

 Straighten the canal by pulling the pinna upward

and backward to align the cartilaginous and bony
canals.
 The meatus should be inspected before a speculum
is instructed.
 Examine with a speculum.
Three essential steps for
external canal
 Otoscopic Exam
 Otoscope is used to inspect the external audiotry canal and middle
ear.
 Tilt the patient’s head toward the opposite shoulder
 as the speculum is inserted.
pull adult ear : pinna upper and back
pull infant and child ( <3 age ) : pinna down
 Slowly insert the speculum to a depth of 1.0 to 1.5 cm (1/2 inch).
 Note discharge, scaling, excessive redness, lesions, foreign bodies,
and cerumen.
 Inspect the tympanic membrane for landmarks, color, contour, and
perforations.
 Examination of the
eustachian tube
 Valsalva inflation
 tympanometry
 Auditory Assessment
 Hearing evaluation begins when the patients
responds to your questions and directions.
 Whisper test---Check the patient’s response to
your whispered voice, one ear at a time.
 The tuning fork is used to compare hearing by
bone conduction with that by air conduction.
Weber and Rinne Tests
 Any patient with unexpected findings should be
referred for a thorough auditory evaluation.
 Conductive Loss
 Results when sound transmission is
impaired through the external or
middle ear.
 Causes:
 obstruction
 otitis media

 perforated TM

 bony overgrowth of ossicles

 Sensorineural Loss
 Results from a defect in the inner ear that
leads to distortion of sound and
misinterpretation of speech.
 Causes:
 sustained exposure to loud noise
 Drugs
 Infections
 Trauma
 Tumors
 congenital disorders
 aging
 Assessment of hearing

Clincal tests: (1)Voice;

(2)Tuning fork;
Instrumental tests: (1)Pure tone audiometry;
(2)Impedance audiolohy;
(3)Evoked Resonse audiometry;
(4)Brain stem evoked response;
(5)others
 Voice Test
. test one ear at a time
. 30 ~ 60 cm
. whisper slowly
✖ unable to hear whisper ⇒ high tone loss
 First and most available
 The level: shout, conversational, and
whisper
 Tuning fork

• Distinguish between the various type of

hearing loss
• Frenquency range: 128,256,512,1024……
• Tests employed: Rinne test and Weber test
Rinne Test
 Strike the tuning fork
and hold it in line with
the external canal and
then against the post-
auricular skin.
 Ask in which position
the sound is louder?
 Rinne test: AC>BC (+)
BC>AC (--)
Weber Test:
 Strike the tuning fork
and place the base in
midline.
 Ask whether the
sound in the midline
or whether it is
lateralized.
 Sound is heard best
on the side with a
conductive deafness.
Hearing loss Webber test Rinne test

Conductive loss 聲音偏向較差一側 AC<BC

Sensorineural loss 聲音偏向較好一側 AC>BC

 Pure tone audiometry:

 Measure the threshold at different frequency;

 Assess the categories of hearing loss according the

audiogram: sensorineural deafness, conductive
deafness and mixed deafness.
 Audiogram: Frequency is placed along abscissa with low frequency to the left;
Intensity is along ordinate. The right side is marked in red with circles; The left
side is marked in blue with X’s; Bone conduction is designated by open arrow.
Impedance audiology:
 Measure intra-tympanic pressure. The
changes can be plotted graphically on
a tympanogram.
 Clinical studies suggest that
tympanometric curves fall into three
patterns as follows:
Type A=Normal
Type As=stiff ossicular chain
Type Ad=ossicular discontinuity
 Type B=fluid in the middle ear

 Type C=negative pressure in the

middle ear
 Stapedial reflex:
 Loud noise in one ear excites
contraction of the stapedius muscle
of the opposite ear, which can be
recorded by tympanomety.
 If the normal pathways malfunction ,
the response will not occur , thich
can distinguish between sensoring
and neural hearing loss.
Evoked response
audiometry:
 A group of tests that response the electric activity
along the auditory pathway, which is related to the
auditory stimulation .

Brain stem evoked

response:
 The electric activity also can be
noted with the BSER. The
average response show 7 peaks.
 It is usual to measure the time
taken from peak 1 to 5, and hearing
threshold of high frequency.
 The changes can indicate the
acoustic nerve lesion, brainstem
tumor or multiple scerosis.
Assessment of vestibular
function
 The vestibular system of the inner ear
is an essential part of the balancing
mechanism of the body.
 A thorough neurologic examination is
performed with special attention to
gait, coordination , the presence or
absence of spontaneous nystagmus,
the Romberg test, and past point.
 Nystagmus: a rhythmic
movement of the eyes with
each cycle
characteristically consisting
of fast and slow
component.

 Past point: on pointing to

an object, particularly with
eyes closed, the patient will
point past the objects.
 Positional tests: To test for
labyrinthine dyfunction that
occurs when the patient’s head
is in different positions.
 Caloric tests: To stimulate convection
movements in the endolymph of a
semicircular canal; This is achieved
by changing the temperature in the
external auditory canal.
Inspection of the
nose
 Instruments
 Light source
 Nasal speculum
 Tongue depressor
 Small angled miror
 Mirror warmer
 Suction apparatus
 Vasoconstrictor spray(ephedrine )
 External examination
 Anterior rhinoscopy
 Posterior rhinoscopy
 Testing of olfaction
 External examination
First look at the
external nose. Ask
patient to remove
glasses. Observe
first and carefully
for asymmetry ,
signs of
inflammation,
trauma , tumor, or
anomalies.Look at
 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 shape of the noce should be
noted. There is the nose with age,
resulting in drooping of the nasal
tip, and there amy be deformities of
the nasal bony and cartilaginous
dorsm following a nasal fracture.
Saddle deformity of the nose may
follow destruction of the bony
septum or cartilaginous septum from
a variety of causes.
 Facial swelling is unusual in
maxillary sinusitis but occurs
with dental root infections and in
carcinoma of the maxillary
Palpation
-nasal bones : helps to
distinguish cartilaginous from
bony distortion.
-the orbital margins. Note any
entderness, swelling, expansion
or depression of bone, for
example after injury or when
malignancy is suspected
-the facial skeleton
 A preliminary examination of the
nasal vestibule and interanasal
contents can usually be made by
exerting gentle upward pressure
on the tip of the nose with the
finger
 Anterior rhinoscopy
 Examination of the nasal cavity
required a spreading speculum to
displace the ala. So we usually use a
nasal speculum.
The light is first directed at the nose,
and the blades of the speculum are
gently introduced under direct vision to
spread the nares upward and
downward.
 The tips of the blades should not touch the
sensitive nasal mucosa. Move the patient and
the examiner ‘s head slightly in different
directions, then we can see most of the available
structure. Look carefully for all the structures.
Note the size of turbinates and condition of
mucose, nasal septum
 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.
 The nasal septum
 The nasal septum should lie in
the midline, but may be deviated
or thickened. When deviated,
hypertrophy of the contralateral
inferior turbinate may also
develop causing bilateral nasal
blockage.
 The inferior turbinate
Situated on the lower portion of the lateral
nasal wall. The submucosal vascular bed
shows considerable alteration in size with
changes in ambient humidity and
temperature. In allergic rhinitis the inferior
turbinate may be hypertrophied
and its mucosa pallid. In vasomotor
rhinitis the mucosa is also swollen
but is classically reddened.
 Nasal endoscopy
 A nasal endoscope is necessary for a
thorough examination of the nasal
cavities, the mucosa having been
sprayed with surface anesthetic.
 Posterior rhinoscopy
 Posterior rhinoscopy is really an
examination of the nasopharynx.It is
achieved by the use of a small angled mirror
that is placed just posterior to the uvula.
Tell the patient to lean forward, with the
mouth open and the tongue firmly
depressed with a tongue depressor. A
mirror is warmed with the flame of a spirit
lamp and passed into the mouth over the
upper surface of the tongue until it lies in
the space between the uvula and posterior
pharyngeal wall.
Posterior rhinoscopy:
 .
 During this inspection,many patients may feel
discomfort. So this method has now been
superseded in most centers by the use of rigid
telescope. But these can be passed with ease in
the majority of patients, under local
anaesthesia.
 Position the angle of the mirror so that the
choana, the posterior ends of the turbinates
and septum can be seen.Carefully examine the
orifices of the eustachian tubes, the posterior
ends of the turbinates and septum.
 Hypertrophy of the posterior end
of the inferior turbinate may also
be seen in the posterior choanae
and, in children and young
adults, an adenoid mass may be
visualized
 EXAMINATION OF THE
THROAT
-Oropharynx,Hypopharynx
and Larynx
 Instrument
 Light source
 Tongue depressors
 Angled mirrors
 Gauze sponges
 Mirror warmer
 Finger cots
 Topical anesthetic
 Oropharynx
Tonsils :
color , small plugs , size
Tonsils grade
1+ : visible
2+ : halfway between tonsillar pillars and
uvula
3+ : touching the uvula
4+ : touching each other

（ 2+ , 3+ , 4+ ➾ Acute Infection ）
 Tell the patient to stay his tongue in
the mouth and not to protrude. Gently
depress the tongue with a wooden or
metal depressor. The palatine arch
palatine tonsils, and posterior
pharyngeal
If walls are usually easily
not, ask the
visible. to say
patient
“ah”,this makes
the palate move
upward, the
tongue move
downward, and
exposes more of
 The tonsillar pillars, the palatine
tonsils, soft palate and uvula can
then be inspected. The tonsils
sould be symmetrical and any gross
asymmetry should be viewed with
suspicion.
Likewise the
soft palate
should be
symmetrical
and the gag
reflex
present
Hypopharynx and larynx
 Examine the hypopharynx and larynx
together by indirect laryngoscopy
using a large angled mirror.
 The patient should sit upright with
neck straight and the head thrust
forward, encourage the patient to
relax and breathe deeply and
rhythmically.
Have him stike out his tongue and
gently but firmly grasp it with gauze
sponges. Introduce the warm mirror,
make it reach the soft palatine, rotate
it ,focus the light on the mirror, ask
him to say “ee”.
 The following structures should
come into view insequence.
 The patient is asked to protrude the
tongue,any dentures having been
removed, and it is grasped with a
gauze swab. The thumb may be
above or below the tongre according
to the preference of the examiner, but
one finger should be able to raise the
upper lip if necessary.
 A large size of laryngeal mirror is
warmed and placed firmly but gently
on the soft palate just above the
base of the uvula. The light then
directed to the varousp arts of the
larynx and hypopharynx by tilting the
mirror.The patient is asked to
breathe easily and steadily
throughout.
 The first structure to come into view
is the epiglotis which usually
overhangs the superior of the larynx.
The epiglottis sometimes overhangs
to such a degree that it is impossible
to view the larynx with a mirror, and
flexible nasolaryngoscopy is used
 Fibreoptic examination
 Fibreoptic examination is now commonly used in the
assessment of laryngeal and pharyngeal disease. A
good mirror examination provide a better view than
fibreoptic examination but the latter is especially
useful in those with an overhanging Epiglottis and a
prominent gag reflex. It can be used in young infants
and has the added advange of providing a
comprehennsive view of at least one nasal cavity and
the postnasal spacee as well as the larynx and
pharynx.
硬管喉镜检查法

直接喉镜
支撑喉镜
 Question
 How to examine the nasal cavity?
 Which methods can be used to do
the laryngeal examination?
 What is the essential steps for
external canal exam?
 How to distinguish between the
various type of hearing loss?