Examination of Ear Nose and Throat needs specialised
illumination and instruments.Since
these are cavities proper illumination, focussing of illumination
special instruments are necessary.
Two types of illumination is used in otolaryngologcial
examination:
1. Semi mobile illumination like the Bull's
lamp
2. Mobile illumination like the Clair's head light, or
cold light based head bands.
Bull's lamp: is a semi mobile source of
illumination.It has a
100 watts milk white bulb which provide the source of
illumination.This
light is focussed with theplano convex
lens placed in front of the bulb.Ideally the Bulls lamp is
placed 6 inches above and behind the left shoulder of the patient,
at the level of left ear of the patient.
Pic
showing the method of clinical examination using Bull's eye
lamp
The examiner and the patient must be
conveniently be seated on adjustable stools.While using a Bull's lamp
the examiner must focus the light using a head mirror to illuminate
the patient.
The head mirror is a concave mirror.It has a hole in the
centre.The approximate
focal length of the mirror is about 10 inches.It has a plastic head band
with a lever with 2 ball and socket joints.The joints are at right
angles to each other.
Focusing the light with head mirror:The art of focusing the
light to the desired spot comes only with practice.But there are certainbasic steps which must be
followed.
1. The patient sitting on the stool must be
atthe same level as
the doctor.
2. The patient's legs must be placed to one
side of the examiner.
3. The distance between the doctor and the
patient must not be more than 8 inches (i.e. the focal length of the
head mirror).
4. The mirror is fixed over the right eye in
such a way part of the mirror touches the
nose.
5. The mirror is adjusted in such a way that
the right eye sees through the hole in the mirror.The mirror is adjusted while
keeping the left eye closed and the right eye iskept open.Then both eyes are
opened.
Clair's head light provides mobile
illumination.The
source of light is from a small 9 volt bulb.It is placed in front of a
adjustable concave mirror.The mirror and the bulb are held via a plastic adjustable
head band.The power
supply to the bulb is from a 9 volt transformer.The major advantage of this
illumination is that it is freely mobile and the patient may be
examined in various positions.This illumination is highly useful while performing operative
procedures inside the theatre.
Examination of
throat:
Throat consists of oral cavity and oro
pharynx.
The term oral cavity
include
1. Lips
2. Teeth
3. Gums
4. Tongue
5. Palate - both hard and
soft
6. Floor of the
mouth
7. Cheeks
The oropharynx
include
1. Uvula
2. Soft palate
3. Anterior and posterior tonsillar
pillars
4. Tonsils
5. Posterior pharyngeal
wall
Lips are common site
for
1. Malignancy
2. Herpes
3. Primary
syphilis
Teeth and gums must be carefully examined for
evidence of focal sepsis.Bleeding gums are commonly seen in vitamin c
deficiencies.
Tongue should be carefully examined.The patient's ability to
protrude the tongue is also ascertained.If the patient has tongue
tie then full protrusion of tongue is not possible.Size of the tongue must also
be seen.Macroglossia
is seen in acromegaly / Down's syndrome.
In hypoglossal nerve palsy the tongue deviates
to the side of the lesion.The tongue on the paralised side may show wasting of lingual
musculature.Fasciculation of tongue is seen in motor neuron disease.
Loss of papilla is seen in patient's with
vitamin deficiency, in those patients who have under gone
irradiation of that area.
Malignancy of tongue is common over its
lateral surface.Any
suspicious swelling of tongue must be palpated for signs of
induration, which is a characteristic feature of malignant lesions
of tongue.
Tongue coating is seen in cases of oral thrush
and in patients with febrile illness.
Opening of the wharton's duct can be seen
under the tongue.If
there is swelling in this area then it must be palpated to rule out
submandibular gland calculus.
Pic
showing malignancy of tongue
The opening of the parotid duct can be
examined after gently retracting the cheek.It lies opposite to the
upper second molar.
Palate is examined for ulcers, clefts,
perforations or presence of masses.
The position of the uvula must be seen.Normally uvula is in the
midline.In cases of
palatal paralysis uvula deviates to the opposite
side.
Tonsillar pillars must be clearly seen.It is commonly congested in
chronic tonsillar infections.Tonsils must be examined.Its size must be
noticed.Tonsillar
enlargement can be classified under the following
heads:
Grade 0 - Tonsils are found confined to the
space between the anterior and posterior
pillars
Grade 1 - Tonsils are enlarged and is just
seen coming out of the anterior
pillar.
Grade 2 - The enlarged tonsil reaches to about
half the distance of uvula.
Grade 3 - The enlarged tonsil comes into
contact with the uvula.
Grade 4 - The enlargement of tonsil is so much
that both tonsils lie virtually in contact with each other i.e.
kissing tonsils.
Pic showing Grade
III tonsillar enlargement
Hypopharynx
include:
1. Posterior pharyngeal
wall
2. Pyriform
fossa
3. Post cricoid
region
Examination of this area is done
by
1. Indirect
laryngoscopy
2. Flexible and rigid
endoscopy
3. Imaging
Indirect
laryngoscopy:
1. The mirror used is plane mirror with a long
handle.
2. It is held like a pen in the dominant hand
with the mirror pointing downwards.
3. The mirror is warmed with a spirit lamp,
the temperature is tested on the back of the
hand
4. The patient is asked to protrude the tongue
and it is held with a gauze.
5. The mirror is introduced into the mouth and
gently slide under the uvula.
6. The mirror is tilted to get good view of
the larynx.
7. The patient is asked to say
eee.
8. The mobility of the vocal cord can be
tested.
Movie showing indirect laryngoscopy being done
Examination of the neck is one of the important aspects of laryngeal examination. Neck should be palpated from behind the patient and enlarged nodes if any must be sought for.
