ENT Examination Procedure
By MBBS Gang
• Ear Examination
o Palpation + Notes
o Inspection + Notes
o Rinne's Test + Notes
o Weber's Test
o ABC Test
• Oral Cavity
• Oropharynx + Notes
• Indirect Laryngoscopy
• Cold Spatula Test
• Cottle’s Test
• Anterior Rhinoscopy
• Posterior Rhinoscopy
Ear examination
Palpation: [Tragal tenderness & fistula test are done under palpation]
Introduce yourself + Briefly describe procedure that will be performed + assure no harm
→ take consent
→ ask patient to come bit close but patient’s legs should be in your side way and turn
head laterally (so the ear comes to your front)
→ now check temperature [1] by back of the hand of pre- & post-auricular region and
mastoid by comparing (check the normal site 1st then compare it with the ear to be
examined) → then palpate lymph nodes [2] placing 4 fingers over pre- & post- auricular
region (palpate in circular motion against bone + compare both sides)
→ now check tenderness [3] by - a) pulling pinna, b) pressing on tragus, c) 3 finger test
(ask patient which one caused pain while performing those and see facial expression)
→ check fluctuation [4] if swelling present by 2 finger test (swell <2cm) and 4 finger
test (swell >2cm)
→ (Not necessary, only if time permits) ask patient to face his/her face towards you, go
for fistula test [5] (sequentially open and close the meatus by pressing on tragus and
notice direction and duration of eye movement and ask patient if they feel vertigo)
Notes:
1) Temperature raised - abscess, peri-chondritis,
2) >1cm size of lymph node is clinically significant lymph node in head & neck region
3) 3 finger test - place index finger on root of zygoma / some book say posterior border
of mastoid, middle finger for cymba concha and thumb for mastoid tip → give
intermediate pressure and ask if they feel pain
a) Pinna tenderness - Acute otitis externa, peri-chondritis,
b) Tragus tenderness - Furuncle
c) 3 finger test +ve – Mastoiditis
3 finger test -ve – It is normal
4) Fluctuation Test – +ve in seroma/abscess
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5) Fistula test -ve – Normal ear or dead inner ear
Fistula test +ve – Cholesteatoma, oval/round window fistula, post fenestration surgery
of ear
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Ear examination cont. …
Inspection
Adjust level [Doc should be sitting lower than patient level + patient erect leaning
forward towards doc]
→ introduce yourself +briefly describe procedure that will be performed + assure no
harm
→take consent
→ set bull's eye lamp on left side at shoulder level
→ wear head mirror
→ask patient to come bit close but patient’s legs should be in your side way and turn
head laterally (so the ear comes to your front)
→ put an act of examining the ear to be examined with bare eyes without touching
patient
→ do the same for the other ear by asking patient to turn head to show u have
compared both sides
→ check pinna [1], post-auricular sulcus [2], pre- & post-auricular region [3,4], mastoid
[5] and facial asymmetry [6]
→ then pull the ear by asking patient [adult= up-out-backwards, child = down-
backwards]
→ now set head mirror over right eye
→ focus light over external auditory meatus (distance between your view and ear
should be 25cm aka paper reading distance)
→ now see with both eyes open through the hole of mirror
→ see meatus [7], external auditory canal, tympanic membrane (if possible, if discharge
is present within EAC then dry mop it with Jobson Horne probe) *
→ now take aural speculum in left hand, put it inside ear canal using crock-screw
movement till osseo-cartilaginous junction (marked by end of hair follicles) while pulling
ear with right hand best if u can do both with only left hand
→ see ear canal [8] and tympanic membrane [9]
→ remove speculum, examination complete
Notes:
1) Pinna - size, shape (anatomy), position level (upper - eyebrow, lower - base of alae
nasi), infections (redness, swelling, vesicles), trauma, scars, [by comparing both sides]
2) Post-auricular sulcus - if absent → D/D = furuncle, sub-periosteal abscess, mastoiditis
3) Pre-auricular region - sinus, accessory tragus
4) Post-auricular region - Scar, oedema, fistula, redness, swelling
5) Mastoid - fistula, sinus, redness, swelling
6) Facial asymmetry - by comparing expression both sides of face
7) meatus - size (by comparing on both sides)
8) ear canal - contents (wax, debris, discharge, polyp)
If discharge → colour, quantity guess, smell, blood (+/-)
Wall swelling - furuncle, osteoma, granulation tissue etc
9) Tympanic membrane
Colour, Congestion, Cone of light, bulge/retraction, Handle of malleus, perforation [
mobility by asking patient to do Valsalva .... Not that much necessary]
If perforation → number, size, site (which quadrants), shape, margin, what you see
through perforation (usually, mucosa lining of mid ear, but if you say Post superior
quadrant of perforation, you must see incudo-stapedial joint)
Ear Examination cont. …
Rinne's test
Introduce yourself + Briefly describe procedure that will be performed + assure no harm
→take consent
→ ask patient to come bit close and turn head laterally
→ take tuning fork and hold it at neck above footplate at stem
→now go for duration method
→ tell patient to raise hand when he stops hearing
→ now hit the upper end of prongs on your elbow
→ asap put the foot plate over the mastoid region of patient and wait
→ patient raises hand
→ asap take the tuning fork 2cm near the external acoustic meatus (place the junction
of upper 1/3rd & lower 2/3rd of the prongs near meatus)
→ ask patient if he still hears
→ if yes Rinne's +ve (normal) if no Rinne's -ve (conductive deafness)
→ now go for intensity method
→ hit the upper end of prongs on your elbow
→ put the prongs 2 cm near meatus (place the junction of upper 1/3rd & lower 2/3rd of
the prongs near meatus)
→ ask patient if he/she hears
→ if yes or no in both case, switch the tuning fork over mastoid
→ ask again if he/she hears the sound
→ if yes, ask in which he heard the best 1st or 2nd
→ if 1st one Rinne's +ve (normal) if 2nd Rinne's -ve (conductive hearing loss)
→ now write your result:
Rinne's test (+ve or -ve) on R/L Ear using Intensity and Duration method. The patient
heard the maximum intensity of sound for maximum duration by air/bone conduction
[If there are ≥2 tuning forks, check the number over stem region and choose the 512 Hz
one. If not available, request them to provide the same. Try to perform Rinne's Test with
256Hz, 512Hz & 1024Hz forks if given in in front of you.]
Rinne’s Test Result Degree of
Deafness
256 Hz 512 Hz 1024 Hz
-ve +ve +ve 20- 30 dB
-ve -ve +ve 30-45 dB
-ve -ve -ve 45-60 dB
Ear Examination cont. …
Weber's test
Introduce yourself + Briefly describe procedure that will be performed + assure no harm
→take consent
→ ask patient to come bit close, look forward stay steady
→ take tuning fork (512Hz) and hold it at stem above footplate
→ now hit the upper end of prongs on your elbow
→ place the foot plate in the middle of the forehead
→ wait for some seconds and ask in which ear he/she hearing more /best also if he/she
hearing equally in both ear
→ if sound is heard equally in both ear (normal hearing), if heard more in a particular ear
(abnormal)
→ now write down the result
→ after doing weber's test, it is found that patient is hearing more or better in right/left
ear so the sound is lateralized to R/L ear
→ Probable diagnosis is .......
Tuning Fork Tests Conductive Deafness Sensorineural Deafness
Rinne 's Negative Positive
Weber's Lateralised to diseased ear Lateralised to better ear
ABC (Absolute Bone Not Reduced Reduced
Conduction)
Ear Examination cont. …
Absolute Bone Conduction (ABC) Test
Introduce yourself + Briefly describe procedure that will be performed + assure no harm
→take consent
→ ask patient to come bit close, look forward stay steady
→ now ask patient to close E.A.C by pressing tragus on tragus (u can do it yourself by
left hand)
→ tell him/her to raise hand when he/she stops hearing
→ now take tuning fork (512Hz, if not available ask for it) and hold it at stem above
footplate
→ now hit the upper end of prongs on your elbow
→ place the foot plate over the mastoid
→ patient raises hand
→ Asap close your same ear as of patient's examined ear by pressing over tragus
→ put the footplate over your mastoid as of the same sided ear
→ try to hear sound
→ if you don't hear sound ⇨patient's ABC normal to that of examiner
if you hear sound ⇨ patient's ABC is less than examiner)
→ write down finding....... Via ABC test it is found patient's ABC is reduced in right/left
ear = SNHL or Via ABC test it is found patient's ABC is not reduced in right/ left ear = CHL
or normal ear
Oral cavity examination
Introduce yourself + Briefly describe procedure that will be performed + assure no harm
→take consent
→ ask patient to come bit close
→ check outer surface of both lips and philtrum
→ ask patient to pull his/her lower lip down and upper lip up (check inner mucosa
condition of the lips [1], gum condition [2] of front teeth and buccal frenulum’s
position)
→ now ask patient to show teeth by saying "e" (check outer surface of teeth [3])
→ now wear the head mirror and check position of bull's eye lamp (must be on patient's
left side near shoulder)
→ ask patient to open the mouth widely by saying "a" and focus light into oral cavity
→ now check tongue's [4] upper surface, hard [5] and soft palate [6], upper surface of
all teeth
→ now ask patient to protrude the tongue out totally
→ examine the whole tongue surface and tip
→ then ask to move tongue left and right (check tongue movement and lateral surface
of tongue)
→ after that ask to the patient to take tongue inside and lift it up
→ lower surface of tongue, check floor of mouth [7], frenulum position and inner
surface of lower teeth
→ now take a Lack's tongue depressor and hold the blade end with smaller size and
grooved end ending with a little hook like curve
→ Now tell patient you are introducing it inside. �
→ 1) Then use tongue depressor lower surface to retract cheek gently
→see buccal mucosa [8], retro molar triangle [9], pterygomandibular raphe, buccal
mucosa lateral to upper 2nd molar tooth, gingivio-buccal sulcus [10] all around up &
down (place between gum and buccinator), gums outer surface at molar pre molar
region
→2) Ask patient to lift tongue then use tongue depressor to lateralize tongue by Lower
surface of blade
→ see lateral gutters on both side (space between tongue and gums), inner surface of
gums of molar, premolar teeth.
→ Now, ask patient to close mouth after taking out the blade.
Notes:
1) Lips
Clefts
Colour (blue in case of severe cyanosis)
Swelling, vesicles
2) Gums
Colour - extensive red and locally swollen (gingivitis
Ulceration - trauma (brush), viral ulcer/ Vincent infections)
Appearance - whole gums swollen (hyperplasia gum - scurvy, AML, drug, oral hygiene)
Tumour - benign/malignant
3) Teeth -
Colour
Shape - (Hutchison teeth in congenital syphilis)
Cavities - black area eroded.
Ridging on outer surface - Vitamin D & C deficiency
4) Tongue -
Volume (if larger than normal: macroglossia - Lymph-angioma, neuro-fibromatosis &
cretinism),
Colour - pale (Anemia), whitish (leucoplakia), blue (venous haemangioma), black hairy
(Aspergillus niger)
Crack - if longitudinal - syphilis, if transverse – congenital cause
Papillae - geographical tongue (harmless patches of desquamation), Bald tongue (no
papillae seen →may be pernicious Anemia)
Tip and frenulum - notched tip and small thick frenulum restricting speech & protrusion
(ankyloglossia/tongue tie)
Tongue surfaces - swelling (if present describe its character ...may be lingual thyroid
tissue)
Ulcer - (if seen ask if painful/painless)
depending on site
Tip, side, dorsum - TB ulcer
Sides of tongue – Dental ulcer
Syphilitic ulcer – dorsum (painless)
Carcinomatous - margins
Mobility - restricted in advanced carcinoma & tongue-tie
5) Hard Palate
Arch & bulge – high arch (mouth breather) low arch & bulge (tumour in nasal cavity)
Perforation - past surgery/cleft palate/Wegner's granuloma
Ulcer - trauma, Cancer & other infections
Oro-antral fistula - tooth extraction
6) Soft palate
Movement during phonation - no movement & hangs loosely (paralysis)
Ulcer - trauma, Cancer & other infections
7) Mouth floor
Frenulum
Opening of submandibular gland opening - either side of frenulum (same as parotid
ducts findings)
Ulcer- Scar, trauma, corrosive burn
Mass-
Ranula (bluish cyst due accumulation of saliva within injured salivary gland)
Dermoid cyst (opaque mass in midline)
Frenulum swelling - stone in submandibular gland ducts
8) Buccal mucosa
Ulcer - traumatic (bleeding seen), aphthous (white yellow center red surrounding),
leucoplakia(white), erythroplakia (red),
Vesicles and swelling (mucus cyst, pemphigus)
Cheek nibbling (habitual) - white mucosa
Blanched mucosa -sub mucosal fibrosis
Opening of parotid ducts near upper 2nd molar - congested and red (acute parotiditis
due to viral or suppurative parotiditis)
9) Retromolar triangle – most common site for carcinoma & submucosal fibrosis
10) Gingivio-buccal sulcus - mass (benign/malignant tumour or inflammation reaction)
Oropharynx examination
Introduce yourself + Briefly describe procedure that will be performed + assure no harm
→take consent
→ ask patient to come bit close
→now wear the head mirror and check position of bull's eye lamp (must be on patient's
left side near shoulder)
→ ask patient to open the mouth widely by saying "a" and focus light into oral cavity
→ then take Luck's tongue depressor and by putting it over whole ant 2/3rd of tongue,
depress the tongue (depressor shouldn’t press post 1/3rd gag reflex will get
triggered)
→ see anterior pillars [1]
→ then tonsil, tonsillar fossa [2] and uvula [3]
→ now see posterior pillars [1] and posterior wall of pharynx [4]
→ if u see enlarged tonsil out of tonsillar fossa
→ ask patient to perform deglutition
→ check if both tonsil is touching each other or not
→ if touches it is Grade 4 tonsillitis not Grade 3
→ remove depressor and ask patient to close mouth
Notes:
1) Anterior and Posterior Pillars
Size and symmetry
Congestion of mucosa (+/-) (chronic tonsillitis)
Ulceration & extra growths (may be due to malignancy spread)
2) Tonsil and surroundings
Size and symmetry (unilateral enlargement highly suggesting malignant origin whereas
bilateral is due to infection)
Ulcers (TB, Cancer, tonsilloliths)
Bulging (para-pharyngeal abscess, peri-tonsilitis, para-pharyngeal tumour)
Crypts (yellow spots in crypts follicular tonsillitis)
Membrane (membranous tonsillitis, diphtheria)
3) Posterior pharyngeal wall
Large Lymph nodules and surrounding hypertrophy (pharyngitis)
Purulent discharge streaks (chronic sinusitis and polyps on posterior nasal septum)
Glazed mucosa of Wall/crust over it (atrophic Pharyngitis)
4) Uvula (deviation to any side → paralysis of pharyngeal muscle to opposite site)
Indirect laryngoscopy
Introduce yourself + Briefly describe procedure that will be performed + assure no harm
→take consent
→ ask patient to come bit close (Patient is seated opposite the examiner)
→ ask Patient to sit erect with the head and chest leaning slightly towards you
→ Now ask patient to protrude his/her tongue ( )
→ now use left hand to hold the tongue by wrapping it in gauze between the thumb and
middle finger (to get a firm grip of the tongue and to protect it against injury by the
lower incisors)
→ put the index finger of left hand to push away the upper lip or moustache out of the
way (so they don’t block the view)
→ take Laryngeal mirror (size 4 to 6)
→ take a cotton piece dip it in defogging Savlon solution
→ now wipe out the mirror part of IL probe with defogging solution (to prevent fog
formation in mirror inside oral cavity)
→ After that, introduce IL probe into the mouth (you can entering along hard palate
straight but it might block view so start entering keeping the mirror-handle junction
along the angel of mouth) upto anterior pillars (don't touch posterior wall of pharynx)
→ place the back of the mirror gently (firmly if needed but patient may gag) against the
uvula and soft palate
→ ask patient to breathe quietly
→ now Focus the light on the laryngeal mirror
→ then see laryngeal inlet with Rima glottis (ant structures seen towards the top of
mirror & post structure seen towards lower part of mirror)
→ after confirming laryngeal inlet see the movements of the cords and compare
movement between both cords ask patient to take deep inspiration (See abduction of
cords), Ask to say "Aa" (see adduction of cords) lastly ask to say "Eee" (for adduction
and tension)
Cold spatula test
Introduce yourself + Briefly describe procedure that will be performed + assure no harm
→take consent
→ ask patient to come bit close (Patient is seated opposite the examiner)
→ take a tongue depressor
→ dip long Blade of tongue depressor in cold water, keep it for a minute, take out and
wipe the excess water with cotton (if it is AC room, no need or winters)
→ now place the cold Blade side 1cm beneath the nostrils
→ compare the amount fogging on both side
→ blocked nasal airway will show reduced fogging
→ report if good fogging/misting on either side (no blocks good airway patency),
reduced fogging/misting on the ipsilateral side (that side nasal airway block)
This test doesn't reveal the level of nasal airway instructions (5 levels - vestibular,
valvular, turbinal, attic, choanal obstruction)
Cottle's test
Introduce yourself + Briefly describe procedure that will be performed + assure no harm
→ Take consent
→ ask patient to come bit close (Patient is seated opposite the examiner)
→ ask patient if he has nasal obstruction (even if she/he says no, perform test because it
is exam)
→ fix the head of the patient with left hand (by informing patient) use your right hand
and put two fingers over the cheek of the patient
→ now pull the cheek laterally and ask patient if the blockage has been relieved
→ if yes, the anatomical obstruction is at the level of nasal valve (limen nasi)
→ if no, the obstruction is at higher level (turbinal, attic, choanal) or it is physiological
obstruction (allergic rhinitis)
Examination of Para-Nasal Sinuses
Introduce yourself + briefly describe procedure that will be performed + assure no harm
→ take consent → ask patient to come bit close (Patient is seated opposite the
examiner)→ now start with inspection of the areas of the face overlying sinuses → look
for redness, swelling, fistula over those areas and proptosis or displacement of eye →
now go for palpation → ask patient to keep his/her head steady → then support
patient’s head with left hand and start palpation with right hand → in palpation 1st
check skin mobility over areas → then start checking tenderness sequentially using
thumb →
1) Place thumb directing upward below roof of orbital cavity just lateral to glabella and
above medial canthus → give mild pressure → ask if it hurts→ Do the same over other
side → tenderness present → might be Frontal Sinusitis (this area often gives false
tenderness due pressure on Supra Orbital Nerve)
2) Place thumb over the lateral side of the nose bridge close to medial canthus →give
mild pressure → ask if it hurts→ Do the same over other side→ tenderness present →
might be Ethmoidal Sinusitis
3) Place the thumb over canine fossa just lateral of ala of nose →give mild pressure →
ask if it hurts→ Do the same on opp/ side→ tenderness +ve → might be Maxillary
Sinusitis
4) Frontal sinus lies deep so not easy to examine. In OPD, Anterior rhinoscopy may
reveal anterior wall of sphenoid (in atrophic rhinitis or DNS) or discharge, crust in the
olfactory fissure while posterior rhinoscopy revealing pus and secretion above middle
turbinate’s posterior end may suggest sphenoid sinusitis.
Areas of inspection
1) Maxillary Sinus - area over cheek, lip, lower eye lids.
2) Frontal Sinus - Forehead, Root of nose, Upper lids,
3) Ethamoidal sinusitis - Orbit, Peri-orbital region, Upper & Lower lids
[Extra regions if cross question asked
a) vestibule of mouth by everting the lip
b) upper alveolus, teeth & palate
c) vision]
Maxillary Sinus Ethmoidal Sinus Frontal Sinus
Anterior rhinoscopy
Introduce yourself + Briefly describe procedure that will be performed + assure no harm
→take consent
→ ask patient to come bit close (Patient is seated opposite the examiner)
→ wear head mirror Focus light into nose
→ then 1st raise the tip of nose by left hand's thumb check vestibule of nose under light
(for Anterior Nasal Septum lesions e.g., furuncle)
→ now take appropriate size Thudicum nasal speculum in left hand
→ hold it properly
→ close /approximate the prongs of speculum totally and slowly introduce it inside nose
upto osseo-cartilaginous junction
→ now release the prongs
→ this will open the cavity widely
→ Focus light into cavity and see the structures - nasal passage, septum, floor of nose,
anterior end of inferior turbinate and inferior meatus, discharge, mass or foreign body
→ not partially close the prongs and take it out (don't close fully because it may catch
hairs)
The structures visualized and examined on Anterior Rhinoscopy:
1. Nasal septum 7. Crusts
2. Nasal cavity 8. Polyp
3. Turbinates 9. Mass
4. Middle meatus 10. Bleeding
5. Colour of mucosa 11. Pus
6. Discharge 12. Maggots (if any)
Posterior Rhinoscopy
Introduce yourself + Briefly describe procedure that will be performed + assure no harm
→take consent
→ ask patient to come bit close (Patient is seated opposite the examiner)
→ advice patient to relax and breath quietly through nose while doing procedure
→ now take posterior rhinoscopy mirror wipe the mirror side with Savlon solution
dipped cotton
→ then hold PR mirror in right hand like pen and hold a tongue depressor at its small
curve ended blade in left hand
→ now ask patient to open mouth widely and Focus light inside mouth
→ introduce the tongue depressor 1st upto anterior 2/3rd and depress the tongue gently
(tell patient to relax tongue if it is hard to depress)
→ then slowly introduce the PR mirror from Angel of mouth towards the end of uvula
along upper surface of tongue depressor (be very cautious not to touch posterior
pharyngeal wall or tonsillar pillars)
→ now try to focus light over mirror surface of PR mirror (না পারেলও যায় আেস না,
েদখেত পারেলই হল ; আসল হল মুেখর মেধ� Focus করা )
→ try to see the structures of nasopharynx - choanal openings, posterior ends of
turbinates, ET tube opening - Torus tubaris - fossa of Rosenmüller – adenoid (lateral to
medial) [By the way, adenoids are hard to recognise if not enlarged)
→ now slowly take out the mirror and remove tongue depressor
→ ask to close mouth
