Examination of the ENT patient is done with the patient sitting down comfortably in a chair. The doctor sits on a chair in front of the patient.
The doctor should explain to the patient the procedures to be undertaken before beginning the examination. This is important in order to make the patient familiar with what the doctor is going to do, which in turn will help the patient to be totally relaxed before the examination is started. When examining the child, use of instruments should be avoided as far as possible. It is always a good practice to examine the normal ear or the normal side of the nose, neck, etc. before proceeding to the diseased side. This helps to gain confidence of the patient particularly children. This also helps to compare the pathology of the diseased side to the normal anatomy of the opposite side and also to prevent contamination of the normal side with infection, which may be present in the diseased side.
General Instruments and Equipment for ENT
The light necessary to examine the patient comes from an electric lamp source (usually the Bull's eye lamp) placed just behind, slightly above and lateral to the left ear of the patient for right-handed doctors. This light is reflected by the doctor's head mirror to the part to be examined.
The head mirror is concave, circular in shape and is approximately 10 cm in diameter. It has a focal length of about 20 cm and has a hole with a diameter of about 2 cm in the center. Advantages of using a head mirror or a headlight over a hand-held torch in ENT examination are listed in Table 1.1
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The advantage of the head mirror over a torch is that the light reflected from the head mirror can be directed into deep, dark and narrow areas commonly encountered in ENT examinations. Binocular vision is essential for appreciation of depth, which is again very important in ENT examination. Because both the hands of the examiner are free when using a head mirror or head light, he or she can perform various maneuvers like suction, mopping of the ear, removal of wax and foreign bodies and one can also do minor surgical procedures.
Suction machines are very useful to suck out discharge from the ear, nasal cavities, oral cavity and the pharynx in order to carry out proper examination. A spirit lamp or an electric warmer is used to heat laryngeal and posterior rhinoscopy mirrors in order to prevent fogging of the mirrors. A treatment unit with a built-in suction machine, lignocaine anesthetic sprays, mirror warmer and a light source for the head mirror is available in hospital in most of the Western countries and only in the bigger hospitals in this part of the world (Fig. 1.1).
Specific Instruments and Equipment for ENT Examination
The external auditory canal (EAC) and the tympanic membrane (TM) are examined through a metal ear speculum. Otoscope gives a magnified view of the TM and should be used after the ear has been examined through the metal speculum. A pneumatic ear speculum set, which has a small bulb along with the rubber tubing attached to a lens unit, can also be used for magnification as well as to check mobility of the TM by changing the air pressure within the EAC.4
This also helps in locating a pinpoint perforation in the TM, which may not be seen by otoscopic examination. A Jobson-Horne probe is a very useful double-ended instrument. It has a small ring at one end to remove wax, debris and foreign body while the other end is straight and serrated for making cotton swabs to mop discharge from the EAC. A wax hook is another instrument commonly used to remove wax. An angled ear dressing forceps is used to pack ribbon gauze dressings into the EAC. A 512 Hz frequency tuning fork is the most commonly used tuning fork to do tuning fork tests although 256 Hz and 1024 Hz tuning forks are also used. A 120 ml metal ear syringe (Simpson's ear syringe) is used to syringe out wax and foreign body. Microscope is routinely used in the outpatient clinic in developed countries for a more detailed examination of the TM and also to perform minor clinical procedures like removal of wax and foreign bodies, excision of granulations, suction of discharge, etc. Unfortunately most hospitals in this part of the world do not have microscopes in the outpatient clinics because they are expensive.
The nasal cavities are examined using a nasal speculum. Thudichum's nasal speculum is U-shaped with nasal plates at the ends and has a spring action. A straight Killian's nasal speculum or a modified curved Killian's nasal speculum is also commonly used. An angled nasal dressing forceps similar but slightly longer to the one used for ear is used to pack ribbon gauze dressings into the nose. Posterior rhinoscopy mirrors are used to examine the nasopharynx and the posterior choana (posterior opening of the nasal cavity). In infants and young children, proper examination of the deeper part of the nasal cavity is best done by an otoscope.
A right-angled tongue depressor is usually used to examine the oral cavity and the oropharynx. A laryngeal mirror is used to examine the base of the tongue, hypopharynx and the larynx. Rigid as well as flexible endoscopes to which light is provided by a cold light source with TV monitors are being more commonly used nowadays to examine the nasal cavity, the nasopharynx, hypopharynx and the larynx because they give good magnification and bright light.