Examination of the Ears, Nose, and Throat
THE CLINICAL CHALLENGE
Examination of the ears, nose, and throat reveals pertinent information regarding their form and function, as well as insight into the condition of the associated alimentary and respiratory tracts. Although many symptoms of the head and neck are manifestations of benign conditions, an attentive history and physical exam are critical to identifying the underlying etiology and potentially more serious underlying disease. A carefully performed physical exam may also allow the provider to avoid unnecessary testing, facilitate appropriate triage and management, and prevent delays in care.
Valuable information can be gathered by simply observing a patient’s appearance, behavior, and affect. A patient’s vital signs, alertness, orientation, and evidence of toxicity or distress should be noted. Retractions, increased work of breathing, diaphoresis, stridor, or wheezing should alert the physician to evaluate for possible underlying causes.
Head and Facies
The head and facial skeleton should be inspected and palpated for any lesions or asymmetries, as well as evidence of irregularities or step-offs, particularly in the setting of trauma. This includes inspection of the cranial bones, mandible, maxilla, zygomatic arch, orbital rims, and nasal dorsum. The condition of the skin, hair, and scalp should also be noted. The areas overlying the paranasal sinuses may be palpated for tenderness. Conditions involving the temporomandibular joint, which may result in clicking, dislocation, or locking of the jaw, may be assessed by having the patient open and close the jaw while simultaneously palpating both sides of the joint just anterior to the ear canal. Assessment of suboccipital, preauricular, and retroauricular lymph nodes is performed with bilateral palpation. The salivary glands, including bilateral parotid and submandibular glands, are assessed with external palpation and by using bimanual palpation with one hand placed intraorally. With the use of a headlight, the patency of Stensen and Wharton ducts can be inspected intraorally to look for salivary flow during bimanual palpation, when saliva may be “milked” out of the parotid or submandibular glands, respectively.
The ear exam involves evaluation of the external ear and auricle as well as otoscopic exam of the external auditory canal (EAC) and tympanic membrane (TM). It also entails hearing assessment with the use of tuning forks and evaluation of the vestibular system if clinically indicated.
The auricle and postauricular region should be inspected and palpated for any evidence of deformities, lesions, or asymmetries. The preauricular area may be evaluated for evidence of a sinus tract or drainage. Postauricular pain, swelling, fluid collection, ecchymosis, or lymphadenopathy may indicate an underlying infectious or traumatic process.
External Auditory Canal
The EAC should be inspected with an otoscope for discharge, lesions, foreign bodies, and cerumen. Foul odor may also indicate infection.
TM and Middle Ear
Otoscopy should be performed to evaluate the TM and middle ear using the largest speculum to afford the best view. The otoscope can be held like a pen while the little finger rests against the patient’s head to ensure stability and to prevent any injury that may occur with sudden patient movement. The speculum is carefully inserted roughly 1 cm into the canal with one hand while the other gently retracts the pinna posterosuperiorly to align the meatus and auditory canal. Landmarks such as the malleus, color, and contour of the TM should be observed. Fluid, air bubbles, and masses involving the middle ear can be appreciated behind the TM. Pneumatic otoscopy can be used to evaluate the mobility of the TM when there is concern for middle ear disorders by gently applying negative or positive pressure from the pneumatic bulb. An immobile TM may be secondary to middle ear fluid or perforation. An otoscope with a working channel can be used to remove any debris or cerumen that may inhibit visualization. In the absence of TM perforation, pressure equalizer (PE) tubes, or otitis externa, warm water irrigation may also be used. Size and location of any perforation and the presence of PE tubes should be noted.
Hearing can be grossly evaluated by monitoring the patient’s response to questions during the interview. The whispered voice test can also be used to crudely assess hearing by having the patient repeat back numbers, letters or words whispered into the patient’s test ear while the patient covers the nontest ear. The examiner stands an arm’s length behind the patient and whispers a combination of numbers and letters, asking the patient to repeat them. Each ear is tested separately. Concern for hearing impairment should be raised if the patient is unable to repeat 50% of the numbers or words correctly.
Tuning fork exams can be used to differentiate conductive and sensorineural hearing loss. The Weber and Rinne tuning fork exams are typically performed with a 512 Hz tuning fork. The tuning fork is made to vibrate by gently striking the prongs against a hard surface.
The Weber test is performed by placing the base of the vibrating tuning fork on the middle of the forehead and asking the patient where they hear the sound. With normal hearing, the sound is heard in both ears equally or centrally. This is referred to as a “negative” Weber. A bilateral symmetric loss will also be heard in the midline. A unilateral sensorineural loss will be heard louder in the unaffected ear, while a conductive loss will be heard in the affected ear.
The Rinne test is performed by first placing the vibrating tuning fork against the patient’s mastoid bone (bone conduction [BC]) and then positioning the still vibrating base of the tuning fork in the air, 1 to 2 cm away from the external auditory meatus on the same side (air conduction [AC]). The patient is then asked to identify the position in which the sound is louder: “behind” (BC) or “in front of” (AC) the ear. AC is perceived as louder than BC in those with normal hearing in that ear, as well as those with sensorineural hearing loss. BC is perceived to be louder in those with a conductive loss, such as that associated with an effusion or TM perforation. The test is considered “positive” if AC > BC and “negative” if BC > AC. Patients with findings suggestive of hearing loss should be referred to a specialist for a more complete evaluation, including audiometric testing.
Table 2.1 reviews how to interpret findings of the Weber and Rinne tuning fork exams.
TABLE 2.1 Tuning Fork Exam Interpretation
Figure 2.1: Inferior turbinate. Image of pale, boggy inferior turbinate as seen in allergic rhinitis. (Courtesy of Paul S. Matz, MD and from Kelly SF. Nasal swelling, discharge, and crusting. In: Chung EK, Atkinson-McEvoy LR, Lai NL, Terry M, eds. Visual Diagnosis and Treatment in Pediatrics. 3rd ed. Wolter Kluwer; 2015:182-188. Figure 23.2.)
Complaints of dizziness, vertigo, or disequilibrium often warrant a detailed and specialized exam. Vestibular testing is performed to determine whether the etiology is central (pathology originating from the cerebellum or brainstem) or peripheral (pathology arising from the inner ear or vestibular nerve). The physical examination evaluates for nystagmus, central oculomotor function, and the vestibulo-ocular reflex. Posture, coordination, and gait are also assessed. More detailed information regarding the workup of vertigo can be found in Chapter 7.
Examination of the nose begins with gross inspection. Note the shape of its dorsal aspect, the width of the tip, and any deviation from the midline. Examine the tip of the nose with gentle pressure for any tenderness. Examine each nasal vestibule. Anterior rhinoscopy allows for assessment of the nasal septum and inferior turbinates. The patient should be seated and their head tilted backward for better visualization. A nasal speculum is introduced carefully into the nare along the lateral wall, observing the color, vascularity, and any discharge. The nasal septum is evaluated for discoloration, deviation, hematoma, or perforation. The turbinates, attached to the lateral nasal wall, can be evaluated; pathologic findings may range from boggy, edematous, pale, or erythematous (Figure 2.1). Adjacent to the nose are the paranasal sinuses, which can be palpated to elicit any tenderness. Severe tenderness indicates an inflammatory process of the sinuses. Palpation may also reveal step-off deformities in the setting of trauma.