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Essentials on EENT-HNS History Taking and Physical Examination Walfrido C. Adan, Jr., MD, DPBOHNS History Chief complaint: Eye? Ear? Nose? Throat? Neck? HPI: Onset, frequency, duration Associated symptoms What has the patient already tried? Pertinent positives & negatives Always think: “Could this be related to something more serious or an underlying malignancy?” Previous work-up, testing, imaging, or interventions What has already been done or tried for this? History Past Medical History: Allergies? Asthma? Neurologic or rheumatologic disorders? Past Surgical History: Head and neck procedures? Sampter Triad: Allergies + Asthma + Allergies- Aspirin Sensitivity? Aspirin sensitivity Meds- Is this problem medicationrelated? Social History - Smoker? Alcohol use? Family History- Does this run in the patient’s family? S EENT Review of Systems Gen: fever/chills/weight changes Head and Scalp: itchiness, masses, change in hair color Eye: blurring of vision, diplopia, headache, spots Ear: tinnitus/ vertigo/ hearing loss/ otalgia/ otorrhea Nose: congestion/ rhinorrhea/ epistaxis/ decreased smell Throat: pain/ dysphagia/ odynophagia Larynx: hoarseness/ voice changes/ noisy breathing/ difficulty breathing / pain with speaking (odynophonia) Trachea: noisy or difficulty breathing Neck: lymphadenopathy/ new lumps or bumps/ pain/ swelling Face: sinus pain/ pressure/ swelling/ numbness Equipment ENT chair Light source simple unfrosted 100W or stronger light bulb, situated on a gooseneck stand w/o a reflector. positioned slightly behind and just to the right of the patient’s head. Equipment Head Mirror Size: 3 ½ inch diameter w/ a ½ inch hole in the center Focal length: 14 inches Positioned over the left eye so that it is possible to see the patient and the focused spot of light through the hole in the center of the mirror as well as with the other eye. The head mirror & light leaves both of the examiner’s hands free for the examination. Basic instruments Ophthalmoscope Snellen’s, Jaeger’s charts, pin hole Tongue blade/depressor Nasal speculum Bayonet forceps Otoscope / Aural Speculum Cotton applicator Pneumatoscope Tuning forks (Riverbank 512 Hz, 1024 Hz) Laryngeal mirror No. 4 Nasopharyngeal mirror No. 0 The Head and Scalp Shape Bumps and masses Discoloration Hair loss Discharge Lice and other parasites The Eye Anatomy The Eye Observe for masses Color in the lens Color of the sclera Symmetry Foreign objects The Eye – Visual Acuity The Eye – Visual Acuity The Eye - Ophthalmoscopy The Eye – Ophthalmoscopy Fundoscopy The Eye - Movement The Ear Patient’s History Minimal history should include an inquiry about hearing impairment, tinnitus, dizziness(vertigo) or imbalance, discharge from the ear, earache and headache. If any of the complaints are found, they should be characterized in detail. Ear Examination Inspection and palpation of the pinna and surrounding structures Otoscopy Retract the pinna to straighten the ear canal Adults: backward and upward Pedia: downward Otoscopy An - annulus fibrosus Lpi (long process of incus) sometimes visible through a healthy translucent drum Um (umbo) - the end of the malleus handle and the centre of the drum Lr (light reflex) - anteroinferiorly Lp (Lateral process of the malleus) At (Attic) also known as pars flaccida Hm (handle of the malleus) Pneumatic Otoscopy "allows the examiner to observe movement of the tympanic membrane directly". "If the tympanic membrane does not move perceptibly with applications of slight positive or negative pressure, a middle ear effusion is highly likely". (Bluestone and Klein, 1990) Tuning Fork Test Indication: Differentiate type of Hearing Loss Sensorineural HL Conductive HL Weber Test Technique: Tuning Fork placed at midline forehead Normal: Sound radiates to both ears Abnormal: Sound lateralizes to one ear • Ipsilateral (affected ear) Conductive HL • Contralateral (good ear)Sensorineural HL Rinne Test First: Bone Conduction Vibrating tuning fork is placed over the mastoid Patient signals when sound ceases Move the vibrating tuning fork over the ear canal (but not touching the ear) Next: Air Conduction Patient indicates when the sound ceases Rinne Test Normal (Positive): AC>BC AC usually persists twice as long as BC Abnormal (Negative): BC>AC Suggest Conductive HL How is it reported? AD WEBER’S RINNE’S AS The Nose The nose can be examined in three parts: Examination of the external nose Anterior rhinoscopy Posterior rhinoscopy Examination of the external nose Inspection: Congenital deformities (clefts) Acquired deformities Shape Swelling (inflammatory, cysts, tumors) Ulceration (trauma, neoplastic, infectious) Palpation: Tenderness Crepitus Deformities Anterior Rhinoscopy Good light Look at skin and scars Assess shape Examine the vestibule Look for boil or abscess, ulcerations, abrasions or excoriations Discharge, scabs or blood clots Inspect the mucosa, septum, roof, lateral wall and floor Note for the color of the mucosa, edema, mass, discharge, septal deviation Posterior Rhinoscopy TECHNIQUE: Hold the mirror like a pen in the right hand. Warm the mirror Ask the patient to open the mouth Depress the anterior 2/3rds of the tongue Instruct the patient to breath through the nose Introduce the mirror from the angle of the mouth over the tongue depressor and slide it behind the uvula. Avoid touching the posterior wall of the pharynx as it may trigger gagging Tilt the mirror in different direction to see various structures of the nasopharynx Posterior Rhinoscopy Nasal endoscopy Rigid or flexible nasal endoscopy Vasoconstriction + decongest with oxymetazoline Exam of sinus openings, mucosa, middle turbinates Paranasal Sinuses Oral Cavity Lips Teeth and alveolar ridge Buccal Mucosa Retromolar trigone Tongue Floor of mouth Hard Palate Oropharynx Soft Palate Uvula Tonsillar pillars Tonsils Posterior pharyngeal wall Laryngoscopy Visual examination of the larynx May also be done to remove foreign objects stuck in the throat Indirect laryngoscopy Direct laryngoscopy Indirect Laryngoscopy TECHNIQUE: Mirror is held like a pen in the right hand with the glass pointing downwards. Warm the mirror and test the temperature on the back of the hand. The patient is asked to stick out the tongue which is held with a piece of gauze. The patient is asked to breath through the mouth. The mirror is introduced into the mouth to the uvula which is gently pushed back to get a view of the larynx and the pyriform fossae. The patient is asked to say 'Aaa 'and 'Eee'. Indirect Laryngoscopy View of the larynx Tongue base Vallecula Epiglottis False cord Vocal cord Piriform fossa Arytenoid cartilage Neck Inspect, palpate, auscultate External Exam Lymphadenopathy Thyroid gland Range of motion Masses Exact location, size, mobility, depth, tenderness, texture, firmness, fluctuance Larynx and trachea Neck Lymph Node Levels I--Submental and submandibular nodes II--Upper jugulodigastric group III--Middle jugular nodes draining the naso- and oropharynx, oral cavity, hypopharynx, larynx. IV--Inferior jugular nodes draining the hypopharynx, subglottic larynx, thyroid, and esophagus. V-- Posterior triangle group VI--Anterior compartment group Thyroid and Parathyroid Glands Salivary Glands Palpate stones for masses, Check for salivary duct patency Stensen’s duct (parotid gland opening on buccal mucosa) Wharton’s duct (submandibular and sublingual gland, located on floor of mouth) THANK YOU!
