• Hearing loss (progressive or sudden, uni- or bilateral).
• Tinnitus (type of noise, frequency, central or uni-/bilateral).
• Otalgia (severe or ache, deep or superficial, constant or intermittent).
• Otorrhoea (scanty debris or mucopurulent, clear or infected).
• Dizziness/vertigo (true rotatory vertigo: onset, duration, symptoms associated, repetition of episodes; imbalance/dizziness: first and further episodes, impact on daily life).
Examination of the ear
• Start by examining the better-hearing ear.
• Examine the pinna, in front and behind, looking for skin inflammation, discharge, scars, (Fig. 2.1) or skin lesions (pre-auricular sinus, skin tumours).
• Examine the external ear canal with a speculum and head light or an otoscope. Pull the ear backwards (and upwards for an adult). Notice inflammation, oedema, presence of wax and debris.
• Visualize the tympanic membrane entirely in quadrants starting from the attic at 12 o’clock (so as not to miss any pathology). Notice the status of the tympanic membrane (normal or dull, thin or tympanosclerotic), any possible perforation or retraction pockets, the state of the ossicles and the middle ear.
• Perform a pneumatic otoscopy with a Siegle's speculum or similar (Fig. 2.2), to assess middle-ear function, alternatively ask the patient to do a Valsalva manoeuvre while examining the tympanic membrane.
• If a mastoid cavity is seen, notice the shape, size, height of the facial ridge, remnant tympanic membrane, and ossicles, as well as size of meatoplasty.
• A fistula test can be carried out by applying intermittent pressure in the tragus with the finger, and observing for nystagmus (if there is reported dizziness/vertigo in the history).
• Tuning fork tests (Rinne and Weber at least, see p [link]).
• Free field hearing test (see p [link]).
• Check facial nerve function (see p [link]).
• Examine the post-nasal space with endoscope (especially if unilateral middle ear effusion to exclude malignancy).
• Examination of the cranial nerves (see p [link]).
Most patients will usually have a formal pure-tone audiogram (PTA) to assess their hearing; however, there are some situations in which it may be not possible to perform a PTA, such as at the bedside of the patient, or an outreach clinic with no audiological facilities.
• During this test the examiner's voice is used as a sound stimulus, while the patient's non-test ear is masked by rubbing the finger over the tragus.
• The patient's eyes are shielded with the examiner's hand to remove any visual clues (Fig. 2.3).
• Start by whispering a two-digit number or a bisyllable word (at the end of expiration) at approximately 60cm from the ear. If the patient repeats correctly in 50% of the occasions, the thresholds are 12dB or better.
• If there is no accurate response, then use conversation voice at that distance (= 48dB).
• If there is no response, use loud voice (= 76dB).
• Nasal obstruction (or congestion).
• Rhinorrhoea and post-nasal drip.
• Facial pain and headaches.
Examination of the nose
• Examine the nose externally from the front and side views, looking at the skin type and thickness, scars and lesions.
• Look and feel the nasal bones and nasal cartilages (septum, upper and lower lateral), looking for any asymmetry and deformity.
• Tilt the head of the patient backwards to examine the columella and the vestibule.
• Check the patency of the nasal airway on each side with a metallic tongue depressor or by occluding the nostril with the thumb and asking the patient to sniff through the nose.
• Perform Cottle's test to check for obstruction of the nasal flow at the anterior nasal valve area. This is done by asking the patient to sniff when applying upward and lateral traction to the skin lateral to the nose (and in turn the lower lateral nasal cartilage) opening the anterior nasal valve area (Fig. 2.4). This manoeuvre tests for collapse of the lower lateral cartilage as cause of nasal obstruction.
• Inspect nasal cavities using thudichum speculum and assess the nasal septum for deviation, perforation, vessels, mucosal lesions, inferior turbinates (hypertrophy, mucosal changes), nasal masses (polyps, lesions).
• Perform a rigid naso-endoscopy (see below) to inspect the rest of the nasal cavity and post-nasal space.
• In the absence of endoscopes, the post-nasal space can also be seen with a Sinclair–Thompson mirror (Fig. 2.5).
• Examine the neck for lymphadenopathy.
This is regarded as the standard technique for assessing the nose. It may be performed with the patient seated or laying supine on an examination couch.
• Before starting, warn the patient that the nasal spray tastes dreadful, that their throat will be numb, and that hot food or drink should not be consumed for an hour to avoid burns.
• Prepare the patient's nose with co-phenylcaine spray (lidocaine with ephedrine)—usually upto five sprays to each nostril. The anaesthetic and vasoconstrictive effect of the spray takes 6min to work, so it is essential to wait 6min before starting the procedure. A diluted solution of the co-phenylcaine can be given to children.
• Use a 4mm 0° and 30° endoscope. A 2.7mm scope can be helpful in a narrow nose.
• Use the standard three-pass technique; Fig. 2.6 shows the endoscopic views.
• Pain (in the mouth, throat and/or radiated to the ears).
• Dysphagia (and odynophagia).
• Dyspnoea and stridor.
• Weight loss, malaise.
• Haemoptysis, cough, aspiration.
• Gastro-esophageal reflux (GOR), post-nasal drip (PND).
• Neck lump/s (onset, change in size, pain).
Examination of the oral cavity, pharynx, and larynx
• Ask the patient to remove any dentures, and open the mouth wide to assess for trismus.
• Inspect in order the tongue (dorsum, lateral edges, and ventral aspect), floor of the mouth, teeth, gums (including retromolar trigones), and parotid duct opening opposite the upper second molar teeth.
• Then inspect the hard and soft palate, palatine tonsils, and posterior pharyngeal wall. Ask the patient to say ‘aahh’ to assess palatal elevation.
• Feel with a gloved finger any pathological areas and perform bi-manual examination of the submandibular gland with a finger of one hand in the floor of the mouth and the other hand on the neck.
• Examine next the hypopharynx and larynx with a flexible naso-endoscope (or a laryngeal mirror).
• Use topical anaesthetic and decongestant as per rigid naso-endoscopy (see p [link]).
• The endoscope is passed through the nose either between middle and inferior turbinates or under the inferior turbinate, along the floor of the nasal cavity into the post-nasal space, where the Eustachian tube and adenoids can be seen. The soft palate can also be assessed for elevation and velopharyngeal competence.
• By advancing over the superior aspect of the soft palate, the tongue base, vallecula, laryngeal inlet and piriform fossa can be seen. Visualization of these areas can be improved by asking the patient to stick out their tongue, and performing a Valsalva manoeuvre.
• Asking the patient to say ‘eeee’ and to speak helps to assess vocal cord movement.
• Fine movements of the vocal cords (‘mucosal wave’) require stroboscopic examination. Most often performed in a specialist voice clinic.
• The endoscope used is usually a rigid endoscope through the patient's mouth, but some flexible naso-endoscopes can also been used.
• A microphone is placed on the patient's neck and the frequency of cord vibration (‘fundamental frequency’) is matched to the frequency of a strobe light flashing.
• The resulting images shown in effect a slow motion recording of the vocal cords and allows detailed assessment during phonation.
• Place the patient sitting up and leaning forward with the head slightly extended.
• An appropriate size laryngeal mirror is selected.
• The mirror surface is gently warmed.
• Ask the patient to open their mouth and put out their tongue as far as they can.
• Gently wrap the tongue in gauze and hold it between finger and thumb.
• Introduce the warmed mirror into the mouth, gently pushing the soft palate and uvula upwards. If there is a strong gag reflex, local anaesthetic spray (i.e. xylocaine) may be helpful.
• Ask the patient to concentrate on their breathing; sometimes asking them to pant improves the view.
• Once a view of the larynx is obtained ask the patient to say ‘eeee’ and note the movement of the vocal cords.
Examination of the neck
• Start by inspecting the neck from the front, looking for scars or masses, deformity or asymmetry.
• Ask the patient to swallow and look for any possible thyroid mass rising on swallowing.
• After enquiring if there are any areas of pain or tenderness in the neck, move behind the patient and feel, in a systematic and comprehensive way, all levels of the neck (Fig. 2.7).
• If a neck lump or other abnormality is found, describe it adequately and its relation to the anatomical structures in the neck: site, size, shape, consistency, fixity, pulsation, overlying skin. The position of the neck lump will give clues as to the likely diagnosis (Fig. 2.8).
Examination of the thyroid
Full neck examination is required, plus some additional important points:
• Start by examining the patient's hands and looking at their face; note cold or hot and sweaty hand, which may indicate hypo- or hyperthyroidism. Look at the skin of the face and hair quality, in particular for loss of the hair in the lateral part of the eyebrow, which may occur in hypothyroidism.
• Look at the neck at the front and ask the patient to swallow.
• Ask the patient also to speak and to cough, listening for a breathy voice or a weak cough, which may represent a vocal cord palsy due to infiltration of the recurrent laryngeal nerve.
• Move behind the patient and feel the midline from the chin to the sternal notch. Feel for any midline lumps, in particular thyroglossal cysts, which will elevate on protrusion of the tongue, so distinguishing them from thyroid lumps in the isthmus.
• The normal thyroid gland is impalpable, if there is a palpable lump, try to ascertain if this is solitary or if there are multiple nodules. Localize it in either lobe or isthmus. Remember to ask the patient to swallow again to check the lump rises during swallowing.
• If a thyroid mass is present, feel above and below it. Assess retrosternal extension by percussion on the sternum and assess vascularity by auscultation.
Examination of the cranial nerves
This is carried out at any part of the examination of the ear, nose, throat, and neck when there is clinical suspicion of cranial nerve affectation by the pathology (i.e. otorrhoea with facial palsy, nasopharyngeal mass and dysphonia, parotid lump and facial palsy, etc.).
• Test for smell sensation (I).
• Test visual acuity (II), pupilary reaction (II, III), and extra-ocular muscle movements: superior oblique muscle—downward and outward gaze (IV); lateral rectus—lateral gaze (VI); and the rest of the extra-ocular muscles (III).
• Test corneal reflex and facial sensation (V).
• Test facial motor function (VII): raise the eyebrows (frontal branch), close the eyes (zygomatic), blow up the cheeks (buccal), smile or show teeth (marginal mandibular).
• Test hearing (VIII) with tuning fork, free field test and/or audiometry.
• Test palatal sensation (IX) and elevation (X), vocal cord movement (X, on laryngoscopy).
• Finally test sternomastoid contraction and shoulder elevation (XI).