LEARNING OBJECTIVES
After reviewing this module, the student will have the ability to:
- Develop a systematic approach to interviewing and examining the
ENT patient
- Gain understanding of all components of the comprehensive head
and neck physical exam
- Learn about what special tools are used in Otolaryngology to
examine the patient
HISTORY
Chief complaint: Ear? Nose? Throat? Neck?
HPI:
Onset, frequency, duration
Associated symptoms
What has the patient already tried?
Pertinent positives & negatives
Always think: “Could this be related to underlying malignancy or
something more serious?”
Previous work-up, testing, imaging, or interventions
What has already been done or tried for this?
HISTORY
Past Medical History: Allergies? Asthma?
Neurologic or rheumatologic disorders?
Past Surgical History: Head and neck
procedures?
Allergies- Aspirin Sensitivity?
Meds- Is this problem medication-related?
Social History - Smoker? Alcohol use?
Family History- Does this run in the
patient’s family?
S
Sampter Triad:
Allergies + Asthma
+ Aspirin sensitivity
Remember: The patient
may not know their full
medical history. Often, you
will have to ask specific
and directed questions to
get the information you are
looking for
Familial/genetic syndromes,
such as MEN (which may
have concurrent thryoid or
parathyroid carcinoma,
pheochromocytoma, or typical
physical features
ENT REVIEW OF SYSTEMS
Gen: fever/chills/weight changes
Ear: tinnitus/ vertigo/ hearing loss/ otalgia/ otorrhea
Nose: congestion/ rhinorrhea/ epistaxis/ decreased smell
Throat: pain/ dysphagia/ odynophagia
Larynx: hoarseness/ voice changes/ noisy breathing/ difficulty
breathing / pain with speaking (odynophonia)
Trachea: noisy or difficulty breathing
Neck: lymphadenopathy/ new lumps or bumps/ pain/ swelling
Face: sinus pain/ pressure/ swelling/ numbness
PHYSICAL EXAM
Tips:
Remember that you will be approaching the patient very
closely and are examining the head and face so be careful
not to invade the patient’s personal space. (Also, check your
breath and monitor the volume of your voice accordingly!)
Try to go in the same order each time you examine the
patient
Tools:
Pen light, tongue blades, nasal speculum (or otoscope for
nasal exam if speculum not available), otoscope
Your eyes and hands
INITIAL EXAM
First, start by looking at the skin of the face
Look for scars, any concerning lesions
Check for symmetry, is there muscle weakness?
Does the patient have tell-tale signs?
Nasal crease in allergies
Noisy nasal breathing?
Listen to the patient’s voice as they give the history/answer
questions
Is it breathy? Nasal? Does the patient have stridor?
Be observant. Most of this can be done within the first few
minutes in the exam room
You can also usually get a sense within a few moments if the
patient is acutely ill or whether their problem is more
chronic in nature
FACE/CRANIAL NERVES
CN VII
Bilateral muscles of facial expression
Asymmetry or weakness
CN V
Bilateral sensation in all distributions (V1-V3)
Extraocular Muscles (CN III, IV, VI)
CN VIII – hearing (see ear exam)
CN X - palate rise, voice
CN XI - shoulder shrug, head turn
CN XII- tongue protrusion
Facial muscle function is graded
from 1-6 using the House-
Brackmann classification.
A score of 1 denotes full motion
while 6 indicates no mobility.
Each side is graded individually
when there is asymmetry
between sides.
EARS
External exam
Deformities? Preauricular pits? Ulcers or lesions?
Otoscopy
External Auditory Canal
erythema, stenosis, debris or discharge
Tympanic Membrane
Normal: Shiny, translucent, visible light reflex
Tympanosclerosis (white)
Erythema, bulging, dull, retractions
Perforations
Pneumatic otoscopy
Mobility of TM
EARS
Microscopy: 3D image
Tuning fork exam
Rinne: Air vs. bone conduction
Just outside to EAC vs. over mastoid
Normal: AC > BC
Weber: Tuning fork on top/center of head
Normal: equal on both sides
Does the sound lateralize?
NOSE
Eternal exam
Deformities, symmetry, size/patency of
nares
Nasal speculum (anterior rhinoscopy)
Septum, inferior turbinates
Septal deviation, boggy or pale turbinates/
mucosa, hypertrophy of inferior turbinates,
rhinorrhea, masses, prominent vessels
Rigid or flexible nasal endoscopy
Vasoconstriction + decongest with Afrin
(oxymetazolone)
Exam of sinus openings, mucosa, middle
turbinates
MOUTH
*Use your tongue blades!
Teeth, gums, alveolar ridge
Edentulous, dentures (remove), caries, bite
Mucosa
Buccal mucosa, palatal mucosa, lingual mucosa,
vestibule (between teeth and lips)
Retromolar trigone
Tongue surfaces, including sides; examine
bulk/atrophy, fasciculations, strength
Floor of mouth: look under the tongue!
Palpation: feel for masses on tongue/floor of mouth
Retromolar
trigone
SALIVARY GLANDS
Palpate for masses, stones
Check for salivary duct patency
Stenson’s duct (parotid gland
opening on buccal mucosa)
Wharton’s duct (submandibular
and sublingual gland, located on
floor of mouth)
ORAL CAVITY & OROPHARYNX
*Use your tongue blade here too!
Palate and uvula
Tonsils
Enlarged, symmetry, exudates, masses
Grading tonsils
1+ fills <25% of oropharynx between
tonsillar pillars
2+ 25-50%
3+ 50-75%
4+ >75%
Posterior pharyngeal wall
Erythema, drainage, purulence, exudates
NECK
External Exam
Lymphadenopathy
Thyroid
Range of motion
Masses
Exact location, size, mobility, depth,
tenderness, texture, firmness,
fluctuance
Larynx and trachea
FIBEROPTIC NASOPHARYNGOSCOPY
What is it?
Exam of nasal passages, nasopharynx,
oropharynx, hypopharynx, larynx
Use afrin/lidocaine before exam to
decongest, vasoconstrict, and provide
local anesthesia
Indications?
Voice changes, neck masses, shortness
of breath/noisy breathing, concern for
mass anywhere along the aerodigestive
tract (from nose down to larynx)
TAKE-HOME POINTS
All new patients should have full Head & Neck exam
Always be on the lookout for signs/symptoms of
malignancy
Good lighting and the right tools are essential
Thorough exam is essential, especially when considering
consultation/referral to a specialist
ACKNOWLEDGEMENTS/RESOURCES
Photo credits – Thank you to Megan M. Gaffey, MD and Lauren Thomas for
participating in physical exam.
Primary Care Otolaryngology, 3
rd
edition. Edited by Mark K. Wax. (Available
through the American Academy of Otolaryngology- Head and Neck Surgery
Website- http://www.entnet.org)
American Academy of Otolarynoglogy Website (www.entnet.org); ENT EXAM
videos: http://www.entnet.org/EducationAndResearch/The-ENT-EXAM.cfm
Thank you to Christian Stallworth, MD for overseeing this project and providing
advisory support.
Editing and input: Jeanne Hatcher MD, John Morehead MD
