Clinical Methods in ENT PT Wakode
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1Basics of History Taking
  • Introduction
  • History Taking
  • Examination of Swelling, Ulcer and Fistula
2

Introduction1

Dear students, by the time you are posted in ENT you have already completed your clinical posting in General Surgery and General Medicine. So, you are well acquainted with patient's history taking. Let me tell you that though basic principles remain the same, the clinical examination in ENT is a bit different from what you have learnt so far. And this is so because Ear, Nose and Throat are small darker cavities in the human body. They are partially hidden and to examine them you need good illumination. Not only that but these are very sensitive parts of the body and while examining them one has to have a “feathery touch” and some patience also. Because many a times even with utmost care, patient does not co-operate in the examination. One more difference is that the teacher can teach you how to examine a tumor on hand, foot or even abdomen and more than one student can see it simultaneously. But this is not the case in ENT. It is very difficult to examine the patient by two people simultaneously because of small and relatively inaccessible anatomical areas. And hence, one has to put more efforts to be proficient in the ENT examinations. Let me say that it is a scientific art.
So, before we actually embark on the clinical examination it is better, if we get acquainted with various instruments commonly needed to examine a patient.
 
Bull's Eye Lamp (Figure 1-1)
This is the most important instrument for proper illumination of the relatively darker cavities like ear, nose and throat. It consists of a heavy base, stand and a cylindrical box. This box contains an electrical bulb and a powerful convex lens. Electrical bulb should be milky white so that you get a good circular focus.4
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Figure 1-1: Bull's eye lamp
 
Head Mirror (Figure 1-2)
This is another important equipment needed. It has a circular concave mirror and a headband attached to it. It has a central hole of diametre of approximately 2 cm through which examiner can see. The concave mirror has focal length of approximately 23.6 cm. The headband is fixed to the head and then the concave mirror is held close to the right eye completely covering it. Examiner closes his left eye and focuses the light on the patient's body. Then he sees with his right eye through the central hole.
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Figure 1-2: Head mirror
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Once he gets a good focus he opens his left eye and examines the patient by keeping both eyes open. With little practice this becomes a routine. Light coming from the Bull's eye lamp is reflected from the head mirror on the patient's body. As the rays focussed on the patient are parallel to visual axis of examiner you get very good illumination. Your both hands are free for various manipulations like syringing or removal of foreign body, etc. This illumination system is best in the present circumstances. Torch, or otoscopes are in the use but these instruments keep your hand engaged and manipulations like removal of wax, FB, etc. are not possible. Hence, this lighting system is popular all over the world.
 
Aural Speculum (Figure 1-3)
This instrument is used to examine the ear canal and tympanic membrane. They are polished from outside but having dull finish inside so that they do not reflect much light to cause glare. Black finish ear speculums are used in operation theatre for the same reason. Aural speculum of appropriate size should be chosen and negotiated in the ear canal. It should pass easily the junction of bone and cartilage. It should be snugly fitting, not too large or too small for the ear under examination.
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Figure 1-3: Aural speculum
 
Nasal Speculum (Figure 1-4)
Thudicum's nasal speculum is in the common use. It has blades and a U-shaped metallic strip to hold the instrument. Nasal speculum of appropriate size should be chosen. It is usualy held in the left hand with the blades of the instrument facing the patient. Index finger and thumb hold the instrument and middle and ring finger control the movements of blades. Slowly it is negotiated in the patient's nostril without hurting the patient.
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Figure 1-4: Nasal speculum
You can examine nasal septum, turbinates and any abnormality in the nose with the help of this instrument. Long bladed instrument may be painful and should not be used without anaesthesia.
 
Laryngeal Mirrors (Figure 1-5)
These are small plane mirrors fixed in a circular metallic bracket. They are used to examine the larynx and pharynx, which is otherwise inaccessible for examination. They have a small handle to hold the instrument. The mirror surface is gently heated before doing the examination. This is to prevent condensation of patient's breath on the mirror. As you do not see the actual larynx but a mirror image. The procedure is known as Indirect Laryngoscopy.
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Figure 1-5: Laryngeal mirror
 
Post-nasal Mirrors (Figure 1-6)
These mirrors are similar to laryngeal mirrors but smaller in size and the handle is not straight. It is having two bends in it. This is to suit the instrument in the post-nasal space and to keep the hand of clinician away from the visual field while examining. This examination is called as Posterior Rhinoscopy, popularly known as PR examination.7
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Figure 1-6: Post-nasal mirror
 
Siegle's Pneumatic Speculum (Figure 1-7)
This instrument is having a rubber bulb, rubber tubing and an adapter that can be attached to an ear speculum. The adapter has fitted in it a convex lens having a magnification of 2X.
 
USES
  1. To see a magnified view of the tympanic membrane
  2. To elicit the mobility of tympanic membrane
  3. To elicit fistula test.
 
Tuning Forks (Figure 1-8)
Tuning forks of 256, 512 and 1024 Hertz are used in ENT practice. They are different from the tuning forks used by physicist. Medical tuning forks have a strong metallic base, stem and prongs. They are used to perform hearing tests like Rinnie test, Weber test, etc.
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Figure 1-7: Siegle's speculum
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Figure 1-8: Tuning forks
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Wire Vectis with Cerumen Spud (Figure 1-9)
This instrument is used for removal of FB/wax in clinical practice.
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Figure 1-9: Wire vectis
 
Tongue Depressor (Figure 1-10)
This is used to depress the tongue during oral cavity and oropharynx examination. It is also used during posterior rhinoscopy. Cold spatula test is also possible with it.
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Figure 1-10: Tongue depressor
 
Cotton Wool Carrier (Figure 1-11)
This instrument is used to clean the cavity if it is full of discharge, wax or pus. It has serration at one end. Surgical cotton is wrapped to that end and the instrument is negotiated in the nose or ear to wipe out the secretions. This is superior over various buds available in the market. Ring end can be used to remove foreign bodies also.
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Figure 1-11: Cotton wool carrier
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Nasal Packing Forceps (Figure 1-12)
It is used for the nasal/aural packing, removal of FB or crusts.
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Figure 1-12: Nasal packing forceps
 
Suction Cannula
To clear the secretions from the ear nose or throat.
 
Spirit Lamp
It is used to warm the mirror in indirect laryngoscopy and posterior rhinoscopy. Few people also use hot air blasts instead of spirit lamps.
 
Sitting Arrangement (Figure 1-13)
It is better to have a small cubicle arrangement rather than a big hall for examination. Patient is sitting on a revolving stool or a chair at a distance of approximately 1.5 feet away from the clinician. Patient's head and neck and clinician's eyes should preferably come in same horizontal plane. Bull's eye lamp is kept on the left side of the patient approximately one foot away and behind, at a little higher level so that the heat generated does not cause discomfort to patient. Clinician should sit on a chair with an instrument trolley available on his right hand side. Parallel rays coming from the Bull's eye lamp are reflected from the concave mirror, on the patient's body and we get a good circular focus. With the help of this illumination, examination of relatively darker cavities of nose, ear and throat becomes easier.10
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Figure 1-13: Sitting arrangement
 
Otoscope (Figure 1-14)
This is one more useful instrument in ENT. It is used to examine the ear. It has disposable black coloured ear speculum, magnifying lens having magnification power X 2. It is battery or electrically operated. It gives bright-magnified view of the tympanic membrane. Some of the otoscopes have facility for changing ear canal pressure. This helps to test mobility of tympanic membrane and fistula test. However, removal of wax, FB is very difficult when the instrument is in ear canal and clinician's one hand gets engaged in holding the instrument.
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Figure 1-14: Otoscope