The Ear, Nose, and Throat Exam: Jeffrey Texiera, MD and Joshua Jabaut, MD CPT, MC, Usa LT, MC, Usn

The Ear, Nose, and Throat
Exam
Jeffrey Texiera, MD and Joshua Jabaut, MD
CPT, MC, USA LT, MC, USN
Midatlantic Regional Occupational and Environmental Medicine Conference

Sept. 23, 2017
Disclosures
●We have no funding or financial interest in any product featured in this
presentation. The items included are for demonstration purposes only.
●We have no conflicts of interest to disclose.

Overview
● Overview of clinically oriented anatomy - presented in the format of the exam
● The approach
● The examination
● Variants of normal anatomy
● ENT emergencies
● Summary/highlights
● Questions
Anatomy
● The head and neck exam consists of some of the most comprehensive and
complicated anatomy in the human body.
● The ear, nose, and throat comprise a portion of that exam and a focused
clinical encounter for an acute ENT complaint may require only this portion of
the exam.
Ears
www.Medscape.com
www.taqplayer.info
Ear – Vestibular organ
www.humanantomylibrary.com
Nose/Sinus Anatomy
Inferior Middle
Turbinate Turbinate
Septum
Dorsum
Sidewalls
Ala Floor
Tip
www.ENT4Students.blogspot.com
Columella
Vestibule www.beautyepic.com
Oral cavity and oropharynx (throat)
www.apsubiology.org
Neck
www.rdhmag.com
The Ear, Nose, and Throat exam
Perform in a standardized systematic way that works for you
Do it the same way every time, this mitigates risk of missing a portion of the
exam
Practice the exam to increase comfort with performance and familiarize self with
variants of normal
Describe what you are doing to the patient, describe what you see in your
documentation
Use your PPE as appropriate

A question to keep in mind…
●T/F: The otoscope is the optimal tool for examining the tympanic membrane.
What you’ll need:
www.gloves4less.co.uk
www.welchallyn.com
www.mkmedicalsuk.com
www.welchallyn.com
www.selfcare-gloves.com
Ear exam
 Visually inspect auricle, make note
of color/deformity
 Pull auricle posterosuperiorly
 Use otoscope with speculum to

exam EAC and tympanic
membrane
 Note color of canal and TM, retractions, www.medical-dictionary.com

perforations, effusion, tympanostomy tube
 Conduct tuning fork exam www.taqplayer.info
www.healthline.com
Vestibular exam
 Dix-Hallpike Maneuver
 For posterior semicircular canal BPPV
 Supine Roll Test
 Horizontal SCC BPPV
 Fukuda Step Test
www.newhealthadvisor.com
Nasal exam
 Visually inspect the nose, make note
of gross deformity
 Palpate nasal bones for step-off
 Use otoscope with speculum to

visualize nasal mucosa
 Note color, swelling, deviation, mucus quality
www.epicbeauty.com
Oropharyngeal exam
 Using good light source, inspect oral
cavity and oropharynx
 With tongue relaxed, use 1-2 tongue

blades to press at base of tongue to
expose palatine tonsils
 With incomplete oral opening, use a

gloved hand to aid visualization of:
 Gingivobuccal sulcus, floor of mouth, retromolar

trigone, and roof of mouth
www.apsubiology.org
Neck exam
Most sensitive when performed
without gloves, however, must weight
PPE benefit.
Palpate with pads of the fingers,

rather than the tips
Glide over the pre-auricular, post-

auricular, parotid, anterior and
posterior triangles of the neck, include
supraclavicular fossa
www.rdhmag.com
www.rdhmag.com
Palpate the thyroid gland

Questions to keep in mind…
●T/F: Sudden sensorineural hearing loss is an otolaryngologic emergency.
●T/F: A hard mass on the roof of the mouth is always a cause for concern.
Normal Variants
Osteoma
Torus Palatine By Didier Descouens - Own work, CC BY-SA 4.0,
https://commons.wikimedia.org/w/index.php?curid=8469399
Scenario 1
51 y/o male presents with acute onset of “ear stuffiness” and decreased hearing
with tinnitus over past day. He has no imbalance. He had a URI about a week
ago.
PMHx = HTN, Hypercholesterolemia
Meds = Atenolol, simvastatin
Occupation = machinist
PE = normal, weber lateralized to opposite ear, rhinne negative

Sudden Sensorineural Hearing Loss
▪20 cases /100,000 (1-2% bilateral)
▪Predisposing factors = URI, cholesterol
▪Etiology = viral infection vs. ischemic event
vs. autoimmune?
▪Management
○Steroids (high-dose, short-term, d/c if no
response)
○Antivirals (controversial)
www.medical-
dictionary.com
Scenario 2
27 year old female presents with 3 days history
of progressive “droopy lip”. Her right eye has
been bothering her and her right ear seems
sensitive to loud noises. Avid hiker, lives in
Maryland.
PMHx = None
Meds = None
PE = facial droop on the right side

Facial Nerve Paresis/Paralysis
▪Management
▪Multiple etiologies:
○Determine cause (imaging, etc)
○Infection (Lyme Disease)
○Steroids (high-dose, short-term, d/c
○Tumor (Vestibular schwannoma, if no response)
brainstem tumor)
○Antivirals (controversial)
○Idiopathic (Bell’s Palsy – HSV
infection?) ○Antibiotics (Lyme Disease)
▪Protection of the cornea which is at ▪Prognosis
risk due to inadequate eye closure is
the first priority!! ○Poor - complete paralysis, rapid
onset
○Good – paresis, gradual onset
Scenario 3
10 y/o male s/p blow to nose by baseball during a game three days ago. Severe
but brief nosebleed. Significant swelling over last three days now resolved
revealing a “crooked nose”. No nasal obstruction.
PMHx = none
Meds = none
PE = vision normal
Nasal Fractures
▪AGAIN, Remember ABCDs!!! (Other injuries)
▪Remember to assess vision!
▪Must rule out Septal Hematoma
▪Imaging studies NOT needed
▪Management is purely cosmetic
○Closed reduction- must be done within the first 10 days
○Open reduction (at least 6 months later) for failed

closed reduction or electively
By Afrodriguezg - Own work, CC BY-SA 4.0,

Scenario 4
88 y/o male presents with severe nosebleed. By report, started spontaneously.
Has not responded to pressure. Has bled through “several tissues”
PMHx = HTN, CAD, no bleeding history, s/p coronary stenting
Meds = Atenolol, Norvasc, Flonase, Plavix, Aspirin
PE = tachycardia, pale, lethargic, nosebleed from right nostril

Epistaxis
▪Consider contributing factors:
▪Remember ABCs!!! (“C” in this case)
○Meds (Plavix, coumadin, aspirin)
▪Resuscitate the patient first!
○Clotting factors (DIC, platelets)
▪Anterior versus posterior
Hereditary Coagulopathy (Von
○Anterior = far more common (Digital Willebrand, Vitamin K deficiency)
trauma)
▪ Management
○Posterior = rare, significant blood
loss ○Pressure
○Afrin (vasoconstrictor)
○Packing (Anterior versus Posterior)

Juvenile Nasal Angiofibroma
● Epistaxis will usually not require
ENT intervention unless posterior
bleed
●One exception is teenage age

males
●Rare tumor with first presenting

symptoms unilateral Epistaxis
●All teenage males require flexible

nasal endoscopy if presenting with
epistaxis
Scenario 5
52 y/o male who was cleaning his ear
with a Q-tip when he felt sudden
pain. Blood came form the ear and
he felt some difficulty hearing but
denies vertigo
PMHx = None
Meds = None
PE = see image
By Michael Hawke MD - Own work, CC BY 4.0,

Tympanic Membrane Perforation
▪Direct trauma or barotrauma (Diving, weightlifting)
▪2 Main Features:
○TM trauma – usually resolves if edges aligned
○Middle Ear trauma – variable
▪Management
○Topical drops and water precautions – observe TM for spontaneous healing
○Otherwise, perform tympanoplasty
○If hearing loss/vertigo/nystagmus – explore ear surgically versus observation
bedrest (Barotrauma)
Normal Ear Drum Acute Otitis Media
By Michael Hawke MD - Own work, CC BY-SA 4.0, By Michael Hawke MD - Own work, CC BY 4.0,
https://commons.wikimedia.org/w/index.php?curid=40796102 https://commons.wikimedia.org/w/index.php?curid=40801810
Large Perforation with Cholesteatoma Hemotympanum
By Michael Hawke MD - Own work, CC BY 4.0, By Peter0531 - Own work, CC BY-SA 3.0,
https://commons.wikimedia.org/w/index.php?curid=40797038 https://commons.wikimedia.org/w/index.php?curid=33842438
Scenario 6
21 y/o male presents with 5 days
history of progressive right greater
than left odynophagia. Given PCN
by primary care three days ago.
Drooling, cannot take PO
PMHx = none
Meds = none
PE = fever, tachycardia, trismus

Peritonsillar Abscess
▪ABC Resuscitation
▪Crucial Clinical components
○Fever/pain/inflammation
▪Management
○Trismus
○Incision and drainage- Gold
○Palatal edema/asymmetry (Tonsil Standard
usually looks OK)
○Consider admission for IV
▪Imaging only in pediatric patients hydration/antibiotics
○Sometimes multiple I/D required
○Consider Tonsillectomy after 6
weeks
Summary
● Conduct your ENT exam in a routine way each time and when you are
uncertain of what you find, just describe what you see
● Airway, Breathing and Circulation are Paramount to all ENT emergencies and
resuscitation
● Clinician recognition and understanding abnormal anatomy stems from

extensive exposures to what normal looks like
References
Flint, P. W., & Cummings, C. W. (2014). Cummings otolaryngology head & neck
surgery 6e
Pasha, R., & Golub, J. S. (2014). Otolaryngology: Head & neck surgery : clinical
reference guide.
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The Ear, Nose, and Throat

Midatlantic Regional Occupational and Environmental Medicine Conference

●We have no conflicts of interest to disclose.

● Variants of normal anatomy

Use your PPE as appropriate

 Pull auricle posterosuperiorly

 Use otoscope with speculum to

 Note color of canal and TM, retractions, www.medical-dictionary.com

 Conduct tuning fork exam www.taqplayer.info

 For posterior semicircular canal BPPV

 Supine Roll Test

 Horizontal SCC BPPV

 Fukuda Step Test

 Palpate nasal bones for step-off

 Use otoscope with speculum to

 Note color, swelling, deviation, mucus quality

 With tongue relaxed, use 1-2 tongue

 With incomplete oral opening, use a

 Gingivobuccal sulcus, floor of mouth, retromolar

Palpate with pads of the fingers,

Glide over the pre-auricular, post-

Palpate the thyroid gland

PMHx = HTN, Hypercholesterolemia

Meds = Atenolol, simvastatin

PE = normal, weber lateralized to opposite ear, rhinne negative

PE = facial droop on the right side

▪Remember to assess vision!

▪Must rule out Septal Hematoma

▪Imaging studies NOT needed

▪Management is purely cosmetic

○Closed reduction- must be done within the first 10 days

○Open reduction (at least 6 months later) for failed

By Afrodriguezg - Own work, CC BY-SA 4.0,

PMHx = HTN, CAD, no bleeding history, s/p coronary stenting

Meds = Atenolol, Norvasc, Flonase, Plavix, Aspirin

PE = tachycardia, pale, lethargic, nosebleed from right nostril

○Packing (Anterior versus Posterior)

●One exception is teenage age

●Rare tumor with first presenting

●All teenage males require flexible

By Michael Hawke MD - Own work, CC BY 4.0,

PE = fever, tachycardia, trismus

● Clinician recognition and understanding abnormal anatomy stems from

Wikimedia Common Access

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