Mesiarc ENT Hospital

Examination of the Ear

ORAL ACTIVITY

Includes: Lips-buccal mucosa-Gums and teeth-Hard palate-Ant 2/3 tongue-Floor of mouth-retro molar trigone.

SYMPTOMATOLOGY:

Pain /referred pain
Salivation: Dryness/ excessive salivation
Disturbance of taste sensation
Difficulty in opening mouth
Bleeding from gums
Red painful gums
Sore tongue
Recurrent painful lip and oral ulcers
Small clusters of vesicles
Fissures over lips and angle of mouth
Ill-fitting dentures
Foul breath

EXAMINATION OF ORAL CAVITY::

LIPS:

PMoisture /color /lumps /ulcers /cracking / scaliness
Swelling/ulcers/vesicles/crusts/scaly/redness/nodular lesion/Chancre
Hemorrhagic red multiple spots over lips and oral mucosa
Bluish pigmented spots over lips and oral mucosa.
Unilateral / bilateral cleft lips
Angioedema lips: Diffuse-nonpitting-tense swelling-non-itching

ORAL mucosa:

Alveolar mucosa /labial mucosa / buccal mucosa /mucosa over hard and soft palate

Change in color
Vesicles /bullae
White striae
Submucosal fibrosis (Blanched appearance with sub mucosal scars)
Leukoplakia –Persistent painless thickened white patches
Erythroplakia
Bluish pigmentation
Atrophic changes in mucosa
Reddish swollen Stensen’s ductal papilla
Aphthous ulcers
White patches and nodules
Koplik’s spots: small white speks with red back ground
Fordyce spots-small yellowish spots/granules
Petechiae-small red spots

Gums and teeth:

Teeth/gingiva/Gingival margins/ alveolar mucosa/intedental papillae/gingival sulcus

Toothache
Loose tooth
Impaction
Dental caries
Artificial dentures
Missing tooth
Redness of gingiva
Swollen interdental papillae
Gum bleeding
Gingival (Gum) hyperplasia-swollen heaped up masses (dilantin, pheno, pregnancy, leukemia)
Bluish black lining of gums (lead line)
Swelling and ulceration of gingival (gum) margins and interdental papillae

Roof of the mouth: Hard palate

Cleft palate
High arch
Oronasal / oroantral fistula
Bulging
Bony growth
Torus palatinus: a mid line mass
Ulcers
Oral thrush (thick white plaques) –candidiasis
Deep purple color lesions –Kaposi’s Sarcoma

Tongue Anterior 2/3:tip / dorsum / lateral borders / under surface

Ulcers: Chronic non healing / pain full: yes /No
Persistent ulcers or nodule: white / red
Indurations: yes / no
Fissures / nodules
Hairy tongue
Geographic tongue: Scattered smooth red areas denuded of papillae.
Smooth tongue (Atrophic glossitis - Bald tongue) -absent papillae- Vitamin deficiency/anti cancer drugs
Hairy Leukoplakia: feathery, corrugated pattern-in HIV/AIDS
Macroglossia
Haemangioma / Lymphangioma
Edema / Abscess
Deviation on protrusion; Yes / No

Floor of the mouth:

Short frenulum –Ankyloglossia
Aphthous ulcers: Painful, small oval or round ulcers-white or yellowish grey withreddened halo.
Ranula / Sublingual dermoid / Ludwig’s angina
Wharton’s duct:
Bimanual palpation

Retro molar trigone:

Impacted last molar
Tumour lesion

OROPHARYNX

IIncludes: Tonsils and pillars-Soft palate-Base of tongue-posterior pharyngeal wall.

SYMPTOMATOLOGY:

Sore throat
Painful swallowing
Fever
Difficulty in swallowing
Neck stiffness
Change in voice: Hypernasality
Muffled or hot potato voice
Referred ear pain.
Snoring
Halitosis
Hard of hearing

EXAMINATION OF ORAL CAVITY::

Tonsils and pillars:

Hypertrophied -Obstructive
Small and embedded
Large normal tonsils
Crypts: White and yellow spots (follicular tonsillitis
Membranes
Ulceration over tonsils
Mass over tonsils
Pus on squeezing
Exudates over tonsils
Palpation: Hard /pulsation, tenderness in tonsillar area /elongated styloid process.
Pillars: Congestion
Congestion: Pillars / posterior pharyngeal wall /tonsils

Movement of soft palate:

Soft palate movement on- ah /yawn
Asymmetrical: Deviation – Right /Left
Gag reflex: yes / No
Soft palate: Bulging / Redness / tenderness
Bifid uvula
Nasal regurgitation

Posterior pharyngeal wall:

Reddened throat with exudates
Gray exudates (pseudomembrane) over Uvula / Phx / tongue
Granular pharyngitis
Purulent discharge

Base of tongue and Valleculae

On IL mirror

Normal /congested mucosa.
Mass- solid / cystic

Palpation of tongue base:

LARYNX

SYMPTOMATOLOGY:

Hoarseness:

Duration
Sudden/gradually worsening
Association with Dysphagia / Dyspnoea /Strider
Diurnal variation
Vocal abuse
Fatigability
Chronic rhino nasal allergy: Yes / No
History of Asthma: yes / No
On topical steroids: Yes / No
Smoking Duration:
History Hypothyroidism: yes / No
Loudness
Pitch
Tone
Preceding /associated RTI

Quality of voice:

Hoarseness
Breathy
Husky voice
Week cry
Bitonal
Dysphonic /spasmodic
Whispered or feeble
Aphonia
Puberphonia
Strider
Aspiration: Episodes of cough on oral feeds
Easy fatigability of voice
Breathing difficulty: sudden /gradual
Stridor (Noisy breathing): acute /gradual
Cough and expectorant: Clear/blood stained/purulent/foul smelling fever/Dry cough
Irritant paroxysmal cough: yes /no
Dysphagia: sudden / Gradual
FB history: Fish bone / chicken or mutton bone / Coin /seeds
Throat pain: Duration –
Acute or chronic
Radiation of pain: yes / no
Difficulty in swallowing: For solids or liquids/Duration: acute or chronic
Fever: high /mild /decreased appetite
Weight loss
FB sensation in throat (hawking)
Snoring
Mass in the neck: yes /No

PERSONAL HISTORY:

Smoking
Alcohol
Spicy food
Tobacco chewing /Pan
Radiation exposure

Profession:

Teacher
Singer

EXAMINATION OF LARYNX

External examination
Indirect laryngoscopy
Flexible or rigid fibre optic endosscopy
Assessment of voice
Assessment of cervical lymph nodes.
Asses of neck mass

INDIRECT LARYNGOSCOPY:

Oropharynx:
- External examination
- Indirect laryngoscopy
- Flexible or rigid fibre optic endosscopy
- Assessment of voice
- Assessment of cervical lymph nodes.
- Asses of neck mass
Oropharynx:
- External examination
- Indirect laryngoscopy
- Flexible or rigid fibre optic endosscopy
- Assessment of voice
- Assessment of cervical lymph nodes.
- Asses of neck mass
Larynx-Epiglottis:
- Ary epiglottic folds
- Arytenoids-corniculate-
- Ventricular bands-ventricles
- True vocal folds: Oedema
- Position of vocal cord: Median /Para median /Moderated abduction/full
- Vocal cord movement: Normal
- Nodules: single / multiple
- Laryngeal: Polyp / ulceration / submucosal hemorrhage
- Anterior and posterior commissure
- Sub glottis: stenosis/web
- Tracheal rings
Laryngopharynx-
- Pyriform fossae: mass lesion/pooling saliva /FB
- Post cricoid region
- Posterior wall of laryngopharynx
Assesment of voice:
Neurological assessment:
External examination of larynx:
Skin:
- Redness
- Swelling / tenderness
- Widening of laryngeal frame work
- Surgical emphysema /Soft tissue swelling
- Movement of larynx: With deglutition / side to side
- Laryngeal crepitus: Present/absent
- Carotid pulsation

EXAMINATION OF NECK

Lymph nodes / Neck mass:

Memorial Sloan Kettering LN levels:

Upper Horizontal Chain Of Lymph Nodes:
- Sub mental and submandibular-Level I
- Submandibular
- Parotid
- Post auricular
- Occipital
- Facial
Upper Horizontal Chain Of Lymph Nodes:
- Internal jugular group (Levels II, III &IV)
  - Upper
  - Middle
  - Lower
- Spinal accessory chain (Level V)
- Prelaryngeal (Level VI (juxtavisceral chain))
- Pretracheal(Level VI (juxtavisceral chain))
- Para tracheal(Level VI (juxtavisceral chain))
- Mediastinal nodes
Lymph nodes:
- Lymph node enlargement: Acute /Chronic
- Tender: Yes/No
- Hard / firm / rubbery /soft / Discrete / Matted /tenderness
- Size
- Shape
- Mobility in both (side to side and up and down) direction: yes / No
- Fixity to skin
- Fixity to muscle / Bone
Trachea and thyroid gland
- Tracheal deviation: Mass effect-mediastinal mass, atelectasis or large pneumothorax
- Thyroid gland: Moving with deglutition
- Size
- Shape
- Consistency: Firm /hard /soft
- Fixity: skin /muscle/bone
- Nodules / tenderness /Bruit over the gland
- Carotid artery pulsation: present / absent.

INVESTIGATIONS

Flexible fibre optic endoscopy (rhinolaryngoscopy):
Direct laryngoscopy:
- For glottic cancers:
  - Size
  - Site
  - Extent
  - Exophytic
  - Deep infiltration
  - VC mobility
  - Involvement of anterior commisure
  - Spread to vocal process
  - Supraglottic / subglottic spread
  - Ventricle checked
  - Paraglottic space
  - Hypopharynx
  - Neck mass /lymph node
- Laryngoscopy for supraglottic cancers:
  - Size
  - Site
  - Extent
  - Extension to vallecula /pre glottic space: Involved /No
  - Tongue base involvement: Involved /No
  - Extension to lateral pharyngeal wall: Involved /No
  - Medial wall of pyriform sinus: Involved /No
  - Vocal cord mobility: Yes /No
  - Paraglottic space: Involved /No
  - Hypopharynx: Involved /No
  - Neck mass: yes /No
- Laryngoscopy for subglottic tumours:
  - Size
  - Site
  - Extent
  - Vocal cord mobility: Yes / No
  - Paraglottic space; Involved / No
  - Oesophagus / posterior tracheal wall: involved /No
  - Neck mass: present / No
Videostroboscopy
- Fundamental frequency
- Bilateral symmetry
- Periodicity of successive vibrations
- Glottic closure
- Amplitude of vibration
- Mucosal wave
- Non-vibration portion