ENT examination from VIKAS SINHA
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ENT Examination - Based on Practical ENT (Vikas Sinha) Framework
Note: Vikas Sinha's Practical ENT is not in the digital library, but the following covers all examination topics from that book's syllabus (History Taking, Ear, Nose, Throat, Larynx, Neck) using authoritative sources: Cummings Otolaryngology and K.J. Lee's Essential Otolaryngology, cross-referenced with Scott-Brown's and Shambaugh's Surgery of the Ear.
1. History Taking in ENT
A structured ENT history follows this framework (Cummings Otolaryngology, p. 83):
Step 1 - Review
- Prior medical records, radiographic images, lab values, pathology specimens
Step 2 - Chief Complaint
- Location, duration, temporal characteristics, aggravating/relieving factors, related complaints
Step 3 - Patient History
- Medical history, surgical history, allergies, medications
- Social history (living situation), family history
Step 4 - Risk Factors
- Tobacco and alcohol use, drug use, sexual practices
Step 5 - Systems Review
- Respiratory, cardiac, neurologic, endocrine, GI, urogenital, musculoskeletal, skin, psychiatric
2. Examination of the Ear
Instruments
- Hand-held otoscope (with pneumatic bulb attachment, various specula sizes)
- Binocular microscope (for complete otologic exam)
- 512-Hz tuning fork (primary), also 256 Hz and 1024 Hz
External Ear
- Inspect auricle (pinna) for deformity, skin lesions, preauricular pits/sinuses/skin tags
- Note any drainage (preauricular areas)
- Palpate mastoid for tenderness (mastoiditis)
External Auditory Canal (EAC)
- Grasp the pinna and elevate superiorly and posteriorly to straighten the canal (in adults); in children, pull the pinna downward and backward
- Insert the otoscope speculum (appropriately sized)
- Assess overall patency - stenosis may be congenital or acquired
- Note: cerumen, discharge color/consistency, foreign bodies
- Outer 1/3 = cartilaginous (hair follicles, sebaceous and apocrine glands - produce cerumen)
- Inner 2/3 = osseous (thin skin over bone)
- Look for: erythema/edema (otitis externa), granulation tissue at bony-cartilaginous junction (malignant otitis externa - especially in diabetics/immunocompromised)
Tympanic Membrane (TM)
The TM is oval, cone-shaped, surrounded by the fibrous white annulus. Landmarks to identify:
- Umbo - central attachment of malleus handle
- Handle (manubrium) of malleus - runs superiorly from umbo
- Lateral process of malleus - prominent superiorly (very prominent in retraction)
- Pars flaccida - superior part, no fibrous layer, most common site of retraction pockets and cholesteatoma
- Pars tensa - the rest of the drum, has radial and circular fibrous layers
- Light reflex - cone of light in anteroinferior quadrant (5 o'clock on right, 7 o'clock on left)
Normal TM: pearly gray, translucent, can see through to promontory and round window
Pathological findings to note:
| Finding | Significance |
|---|---|
| Retraction | Negative middle-ear pressure / eustachian tube dysfunction |
| Perforation | Chronic otitis media |
| Amber fluid / air-fluid levels | Serous effusion (glue ear) |
| Dull gray/white, retracted | Mucoid effusion |
| White chalky patches | Myringosclerosis (tympanosclerosis) |
| White mass with granulation tissue | Acquired cholesteatoma |
| White pearl (ant-sup quadrant, intact TM) | Congenital cholesteatoma |
| Thickened, erythematous, bullae | Myringitis bullosa |
| Vascular mass behind TM | Glomus tumor, aberrant carotid, dehiscent jugular bulb |
| Thin, draped membrane | Adhesive otitis media |
Pneumatic otoscopy: Apply gentle pressure with pneumatic bulb after sealing canal. Normal TM moves briskly. Immobile TM indicates middle-ear effusion or perforation.
Facial Nerve Assessment
The House-Brackmann grading system (AAO-HNS):
| Grade | Function | Features |
|---|---|---|
| I | Normal | Normal at all times |
| II | Mild dysfunction | Forehead: moderate-good; Eye: complete closure; Mouth: slight asymmetry |
| III | Moderate | Forehead: slight movement; Eye: closure with effort; Mouth: slightly weak |
| IV | Moderately severe | Forehead: none; Eye: incomplete closure; Mouth: asymmetric with effort |
| V | Severe | Forehead: none; Eye: incomplete closure; Mouth: slight movement |
| VI | Total paralysis | No movement |
3. Tuning Fork Tests
Always performed in a quiet room with ears cleared of cerumen. Standard fork: 512 Hz (also use 256 Hz and 1024 Hz for complete assessment).
Weber Test
- Strike the tuning fork, place on nasofrontal suture or center of forehead (or on central incisors with teeth clenched)
- Ask: "Where do you hear the sound - left, right, or midline?"
| Result | Interpretation |
|---|---|
| Midline ("Weber negative") | Normal, or equal bilateral loss |
| Lateralizes to affected side | Conductive hearing loss on that side (background noise blocked, bone conduction enhanced) |
| Lateralizes to opposite side | Sensorineural hearing loss on the affected side |
Rinne Test
- Place vibrating 512-Hz fork firmly on the mastoid process (bone conduction - BC)
- When sound is no longer heard, immediately move fork in front of the ear canal (air conduction - AC)
- Ask: "Can you still hear it?"
| Result | Interpretation |
|---|---|
| AC > BC (still hears it) - Rinne positive | Normal, or sensorineural HL |
| BC > AC (no longer heard) - Rinne negative | Conductive hearing loss |
| False Rinne negative | Profound SNHL in test ear - cross-hears via contralateral cochlea |
Degree of Hearing Loss by Tuning Fork (Rinne Test)
| Hearing Loss (dB) | 256 Hz | 512 Hz | 1024 Hz |
|---|---|---|---|
| < 15 dB | Positive | Positive | Positive |
| 15-30 dB | Negative | Positive | Positive |
| 30-45 dB | Negative | Negative | Positive |
| 45-60 dB | Negative | Negative | Negative |
Combined Weber + Rinne Interpretation
| Scenario | Weber | Rinne |
|---|---|---|
| Right conductive HL | Lateralizes RIGHT | Right: BC > AC (negative); Left: AC > BC (positive) |
| Right sensorineural HL | Lateralizes LEFT | Bilateral positive (AC > BC) |
| Normal | Midline | Bilateral positive |
Other Tuning Fork Tests
- Schwabach test - compare patient's BC with examiner's BC; prolonged = conductive HL, shortened = SNHL
- Absolute Bone Conduction (ABC) test - occlude ear canal; increased lateralization in Weber = indicates conductive component
- Bing test - occlusion effect; positive Bing (sound increases with occlusion) = SNHL or normal; absent Bing = conductive HL
4. Examination of the Nose and Paranasal Sinuses
External Inspection
- Frontal, profile, and base views
- Note: deformity, asymmetry, tip projection, dorsal width, alar base width
- Skin quality, lesions, discoloration
Anterior Rhinoscopy (Thudichum Speculum + Headlight)
- Insert speculum directed laterally (avoid touching sensitive septum)
- Assess:
- Nasal septum - deviation, spurs, perforations, Kiesselbach's plexus vessels (epistaxis site)
- Inferior turbinate - size, mucosal character
- Boggy, edematous, pale = allergic rhinitis
- Erythematous, edematous = infective rhinitis / sinusitis
- Nasal vestibule - lesions, discharge, clots, foreign bodies
- Nasal airway patency - bilaterally
Nasal Endoscopy (Rigid Endoscope - 0°)
After applying local anesthetic + topical decongestant:
- Pass along nasal floor - view septum, inferior turbinate, eustachian tube orifice
- Withdraw and reintroduce above inferior turbinate - view middle turbinate
- Pass posteriorly to nasopharynx
- Withdraw to head of middle turbinate, direct laterally - view lateral nasal wall, middle meatus, uncinate process, ethmoidal bulla
Sinus Tenderness
- Palpate/percuss over:
- Frontal sinuses - above medial end of eyebrow
- Maxillary sinuses - over cheeks (below eye)
- Ethmoid sinuses - medial to eye
- Tenderness suggests acute sinusitis
Imaging (Paranasal Sinuses)
- CT scan (coronal/axial/sagittal) - gold standard; shows bony anatomy, drainage pathways, cribiform plate, lamina papyracea, anterior ethmoid artery
- MRI - assess soft tissue, intracranial/orbital extension
- Plain X-rays - limited value; Water's view (PA occipito-mental) for maxillary sinus
5. Examination of the Oral Cavity and Oropharynx
Oral Cavity (Lips to Anterior Tonsillar Pillars)
- Lips and commissures - carcinoma, mucocele, angular stomatitis
- Teeth and gingiva - condition, occlusion
- Retromolar trigone - inspect (carcinoma site)
- Tongue - dorsal, ventral, and lateral surfaces; use gauze to move it
- Floor of mouth - bimanual palpation; Wharton's ducts
- Buccal mucosa - Stenson's duct (opens near 2nd upper molar), Fordyce spots, leukoplakia, erythroplakia
- Hard palate - torus palatinus (benign midline bony outgrowth)
Oropharynx
- Tonsil grading (Brodsky scale):
- 0 = entirely within fossa
- 1+ = just outside fossa, < 25% oropharyngeal width
- 2+ = 26-50%
- 3+ = 51-75%
- 4+ = > 75% ("kissing tonsils" if meeting midline)
- Tonsil surfaces - exudates, erythema, tonsilliths, asymmetry (lymphoma if atypical)
- Soft palate and uvula - symmetry, movement ("Aaa" - assesses CN X)
- Posterior pharyngeal wall - lesions, bulge (peritonsillar abscess)
- Vallecula - inspect for masses
6. Examination of the Larynx
Indirect Laryngoscopy (Mirror Laryngoscopy)
Patient positioning:
- Feet uncrossed, back straight, hips against chair
- Lean slightly forward from waist, chin slightly upward ("sniffing position")
- Tongue pulled forward with gauze sponge
Technique:
- Warm the dental mirror (prevent fogging)
- Place just posterior to soft palate, elevate uvula
- Ask patient to say "eeeee" (high pitch) to assess cord adduction
- Ask patient to breathe quietly - assess cord abduction
Structures to inspect:
- Epiglottis - shape, mucosa (omega-shaped normally)
- Aryepiglottic folds - symmetry, edema
- False vocal cords (vestibular folds) - pink, do not meet in midline
- True vocal cords - white, translucent, crisp borders; meet at midline on phonation
- Arytenoids - symmetry, mobility, mucosa
- Posterior commissure/interarytenoid area - edema = GERD laryngitis
- Subglottis - partially visible on cord abduction
- Piriform sinuses - ask patient to puff cheeks to distend
Vocal fold findings:
- Translucent white with crisp borders = normal
- Edema entire cord length = Reinke's edema (smoker's polyposis)
- Ulcerative/exophytic lesion = malignancy (requires operative laryngoscopy)
- Vocal fold paralysis = gap between cords on adduction, asymmetric movement
Flexible Nasopharyngoscopy - preferred in strong gag reflex, pediatric patients, or when functional assessment during swallowing/phonation needed.
7. Neck Examination
Inspection
- Asymmetry, swellings, scars, skin changes, stridor (auscultate at different levels)
- Tracheal position (midline vs. deviated)
- Subcutaneous crepitus (laryngeal fracture, pneumomediastinum)
Palpation Sequence
Palpate while visualizing underlying structures:
- Midline - trachea (position), larynx, thyroid cartilage, cricoid cartilage ("signet ring"), hyoid bone
- Lateral click - move larynx side to side (normal clicking sensation should be present)
- Thyroid gland - from behind (stand behind patient), assess size, consistency, nodules
- Salivary glands - parotid, submandibular
- Lymph nodes - systematic palpation by levels
Lymph Node Levels (American Academy of Otolaryngology - HNS Classification)
| Level | Location | Key Nodes |
|---|---|---|
| IA | Submental triangle | Submental nodes |
| IB | Submandibular triangle | Submandibular nodes |
| IIA | Upper jugular (above spinal accessory nerve) | Jugulodigastric (skull base to hyoid) |
| IIB | Upper jugular (below spinal accessory nerve) | |
| III | Middle jugular | Hyoid to inferior cricoid border |
| IV | Lower jugular | Inferior cricoid to clavicle |
| V | Posterior triangle | Spinal accessory chain + supraclavicular |
| VI | Central compartment | Pretracheal, paratracheal, thyroid |
Triangles of the Neck
The sternocleidomastoid (SCM) muscle divides the neck:
- Anterior triangle - bounded by SCM, sternohyoid, digastric; subdivided into submandibular, carotid, muscular triangles
- Posterior triangle - bounded by SCM, trapezius, clavicle; subdivided into occipital and supraclavicular triangles
8. Cranial Nerve Examination in ENT
| Cranial Nerve | Test |
|---|---|
| CN V (Trigeminal) | Facial sensation, jaw deviation |
| CN VII (Facial) | Forehead wrinkling, eye closure, smile, nasolabial fold - graded by House-Brackmann |
| CN IX (Glossopharyngeal) | Gag reflex, posterior pharyngeal sensation |
| CN X (Vagus) | "Aaa" - soft palate rise (deviation away from lesion) |
| CN XI (Accessory) | Shoulder shrug, SCM power |
| CN XII (Hypoglossal) | Tongue protrusion (deviates toward lesion) |
9. Audiological Tests
After clinical examination, the following objective tests are used:
- Pure Tone Audiometry (PTA) - air and bone conduction thresholds in soundproof booth (gold standard for hearing)
- Tympanometry - measures TM compliance and middle ear pressure
- Type A = normal
- Type B = flat (effusion or perforation)
- Type C = negative pressure (ETD)
- Stapedial reflexes - acoustic reflex via CN VII and VIII
- Speech audiometry - speech reception threshold, word discrimination
- Otoacoustic emissions (OAE) - cochlear hair cell function (neonatal screening)
- Electric Response Audiometry (ERA/ABR) - brainstem responses; retrocochlear pathology
- Caloric testing / Electronystagmography - semicircular canal function (vestibular)
10. Vestibular Examination
| Test | Method | Assesses |
|---|---|---|
| Romberg test | Stand feet together, eyes closed | Postural control, proprioception |
| Unterberger/Fukuda stepping test | March 50 steps on spot, eyes closed | Unilateral vestibular loss (rotates toward lesion) |
| Dix-Hallpike maneuver | Rapid positional change with head turned 45° | BPPV - posterior semicircular canal |
| Head Impulse Test (HIT) | Rapid head thrust; observe catch-up saccade | Semicircular canal hypofunction |
| Head Shaking Nystagmus | Shake head 30 cycles, observe nystagmus | Asymmetric vestibular loss |
Frenzel lenses are applied during positional testing to inhibit fixation suppression of nystagmus.
BPPV (Dix-Hallpike): Nystagmus onset latency 2-5 sec, geotropic (toward ground), fatigable, rotatory upbeat; resolves in 60-90 sec. Persistent nystagmus (>90 sec) = central cause.
Sources: Cummings Otolaryngology Head and Neck Surgery, pp. 83-87; Shambaugh Surgery of the Ear, pp. 203-206; Bailey and Love's Short Practice of Surgery 28th Ed., pp. 774-786; K.J. Lee's Essential Otolaryngology.
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