Ears, Nose and Throat Examination

Inspection

Ears: deformity, masses, skin lesions, pull back behind auricles
Nose: asymmetry, lesions, or deformity
Lips: color, moisture, lesions, cracking, scaliness
[ use tongue blade and light to inspect]
Oral mucosa: color, areas of pigmentation, ulcers, white patches, nodules,
Gums: color, swelling, ulceration, bleeding, retraction,
Hard palate: color, lesions, masses,
Tongue: color, lesions, texture,
Pharynx: color, swelling, lesions, symmetry
Soft palate: uvula
Tonsils: color, ulcers, swelling, symmetry, exudate

Palpate ears

1. Auricles/tragi/mastoids: tenderness, nodules, edema,
   - pull auricle up and down, press the tragus, palpate over mastoid

2. Gross auditory acuity test
   - test cranial nerve VIII by ONE of two methods: Finger rub one ear at at a time with opposite ear occluded OR stand 1-2’ in front or behind patietn and ask patietn to occlude one ear with finger then whisper two-syllable words and ask patient to repeat the word.

Otoscopic Exam

1. Hold scope in a way that protects patient from injury by using fingers or side of hand held against face. Pull auricle upward and back to straighten the canal.

2. Examin ear canals for discharge, foreign bodies, erythema, edema, cerumen, masses

3. examin tympanic membranes for color, contour, malleus, cone of light, perforations

Special tests for the ear

Weber test or rinne test

Weber Test

Place tuning fork at middle of head or bridge of nose and ask patient in which ear the sound is best heard or if it is equal.

Normal (Equal hearing): The sound is heard equally in the center of the head.

Conductive Hearing Loss: The sound "lateralizes" (is heard louder) in the affected or "bad" ear.

Sensorineural Hearing Loss: The sound "lateralizes" (is heard louder) in the unaffected or "good" ear.

Rinne test

hold tunign fork over mastoid until patient cannot hear sound, then immediately hold tuning fork facing forward next to ear and ask patient if sound is heard again

A "positive" test (AC > BC) is normal, while a "negative" test (BC > AC) indicates conductive hearing loss

Palpation of the nose

Nose for tenderness, masses, palpate bone and cartilage midline and lateral

nares for patency

frontal sinuses and maxillary singuses for tenderness

examine internal nose using otoscope with nasal illuminatorI

Internal Examination of the nose

use otoscope with nasal illuminator

Insert nasal speculum without touching the septum, enough to get visualization of the inferior turbinate and septum, using a light source.

Assess mucosa for color, swelling, bleeding, exudate, ulcers, polyps

Assess septum for deviation, inflammation, perforation

Transillumination of the sinuses

This is a special test. Place light source upward under each brow to illuminate frontal sinus. Place light source just below eye and point downward; look at roof of mouth for illumination.)

Palpation of the mouth

1. Tongue and floor of mouth: induration (With gloves on, use a piece of gauze to hold the tip of the tongue and distract the tongue outward and lateral to visualize the sides and underneath of the tongue for abnormalities; palpate base of mouth and sides of tongue for induration.)

2. Gums/teeth: tenderness, loose teeth (Use gloves and palpate over upper and lower gums and teeth.)

signs and symptoms of Acute otitis media on assessment

Otoscopic Findings (Objective)

• Tympanic Membrane (TM) Bulging: The most critical diagnostic marker; the eardrum appears pushed outward (often described as a "doughnut" or "wheel" shape). [1, 2, 3]

• Loss of Landmarks: The normal anatomical features of the eardrum (e.g., the handle of the malleus, the cone of light) are obscured due to the bulging. [1, 2]

• Erythema and Opacification: The eardrum appears intensely red and cloudy or opaque due to pus. [1, 2, 3, 4, 5]

• Reduced TM Mobility: When assessed with pneumatic otoscopy, the eardrum moves poorly or not at all. [1, 2]

• Perforation & Otorhea: If the pressure causes the eardrum to rupture, spontaneous, purulent, or blood-tinged drainage may be visible in the ear canal. [1, 2]

Systemic and Behavioral Signs (Subjective)

• Otalgia: Ear pain or earache, which is often the primary complaint.

• Behavioral Changes: Infants and younger children frequently display non-specific symptoms such as unusual irritability, restlessness, and disturbed sleep.

• Ear Tugging/Pulling: Children will reflexively pull, rub, or hold their affected ear.

• Fever: Often low to moderate grade, especially in infants.

• Gastrointestinal Symptoms: Young children may experience a temporary loss of appetite (anorexia), vomiting, or diarrhea.

• Hearing Loss: A feeling of fullness or muffled hearing in the blocked ear is a common complaint in older children and adults.

signs and symptoms of Acute otitis externa on assessment

Classic Signs (Physical Examination)

• Tragal/Pinna Tenderness: Exquisite pain when applying pressure to the tragus (the small cartilage in front of the ear canal) or by pulling the pinna (earlobe/auricle) upward and backward. This is considered the hallmark sign. [1, 2]

• Canal Edema and Erythema: The external auditory canal is red (erythematous) and swollen (edematous), which can sometimes make visualization of the tympanic membrane difficult. [1, 2]

• Otorrhea: Moist, purulent, or watery discharge or desquamated epithelium lining the canal. [1]

• Debris: Accumulation of moist, white, yellow, or gray debris in the canal. [1, 2]

• Lymphadenopathy: Swollen, tender lymph nodes around the ear or in the upper neck region. [1, 2]

• Cellulitis: Potential spread of redness and swelling to the outer auricle or surrounding skin. [1, 2, 3]

Reported Symptoms

• Otalgia: Severe ear pain that is disproportionate to physical findings and often exacerbated by jaw movement (like chewing).

• Pruritus: Severe, unrelenting itching inside the ear (often an early symptom).

• Aural Fullness: A plugged or muffled feeling in the affected ear.

• Hearing Loss: Conductive hearing loss caused by canal swelling and/or debris blocking the ear canal.

• Systemic Symptoms: In more severe or advanced cases, patients may experience mild to moderate fever and general malaise. [1, 2, 3, 4, 5, 6, 7]

signs and symptoms of strep pharyngitis on assessment

Key physical signs and reported symptoms on assessment include:

• Throat and Tonsils: Bright red, inflamed pharynx with swollen tonsils, frequently accompanied by white, yellow, or patchy exudate (pus). [1, 2]

• Palate: Petechiae, which are tiny, bright red spots localized on the soft or hard palate. [1, 2]

• Lymph Nodes: Anterior cervical lymphadenopathy (tender, swollen lymph nodes in the front of the neck). [1, 2]

• Onset and Systemic Signs: Sudden throat pain and difficulty swallowing, accompanied by fever, chills, and headache. [1, 2, 3]

• Associated Symptoms: Gastrointestinal complaints such as nausea, vomiting, and abdominal pain are common, especially in younger children. [1, 2]

  • The "Absence" Clue: A critical differentiator is the lack of cough, runny nose (rhinorrhea), or hoarseness. The presence of these symptoms typically points to a viral etiology

signs and symptoms of viral pharyngitis on assessment

Localized Throat and Neck Findings

• Throat: Mild to moderate redness (erythema) and swelling of the pharynx and tonsils.

• Exudate: Generally minimal or absent (unlike the thick, patchy exudate common in strep throat).

• Lymph nodes: Swollen anterior cervical lymph nodes are possible but are usually smaller, softer, and less tender than in bacterial infections.

• Voice: Hoarseness (laryngitis) is a common accompanying symptom.

signs and symptoms of bacterial sinusitis

Cardinal Symptoms and Physical Findings

A focused clinical assessment for bacterial rhinosinusitis heavily relies on the PODS mnemonic:

• Pain, pressure, or fullness (often radiating to the teeth, ears, or forehead)

• Obstruction or blockage of the nasal passages

• Discharge that is purulent/discoloured (anterior or posterior)

• Smell disorder (hyposmia or anosmia)

Objective Findings on Physical Exam

• Nasal Mucosa: Redness, swelling, and edema.

• Discharge: Presence of thick, discolored (yellow or green) purulent mucus.

• Tenderness: Palpation or percussion over the frontal and maxillary sinuses may elicit localized tenderness.

• Transillumination: Shining a light against the sinuses (in a darkened room) may reveal diminished illumination, suggesting fluid-filled or congested sinuses.

• Throat and Pharynx: Evidence of post-nasal drip and pharyngeal inflammation.

Systemic Signs

• Fever: More common in acute bacterial sinusitis than in viral upper respiratory infections.

• Halitosis: Bad breath due to the presence of pus and bacterial buildup.

• Fatigue: Generalized malaise and tiredness.

Differentiating Criteria to distinguish a bacterial infection from a standard viral cold or allergy

Bacterial sinusitis is generally suspected if: [1, 2]

1. Symptoms persist without improvement for at least 10 days.

2. Symptoms suddenly worsen ("double worsening" or "double sickening") within the first 10 days after a brief period of feeling better.

3. Symptoms are initially severe (fever over 38.9°C / 102°F and purulent discharge) lasting 3-4 consecutive days. [1, 2, 3, 4, 5]

signs and symptoms of viral sinusitis

Subjective Signs (Patient Report)

• Nasal Obstruction: A feeling of stuffiness, congestion, or difficulty breathing through the nose.

• Facial Pain/Pressure: A feeling of fullness or aching, commonly radiating to the forehead, cheeks (maxillary sinuses), or between the eyes. This pain often intensifies when leaning forward or bending down.

• Nasal Discharge: Anterior runny nose or posterior drip down the throat (postnasal drip). The mucus can be clear, cloudy, yellow, or greenish.

• General Malaise: Fatigue, mild body aches, and a low-grade fever.

• Other Indicators: Reduced sense of smell, ear fullness/popping, and a mild non-productive cough.

Objective Assessment Findings (Physical Exam)

• Rhinoscopy: The nasal mucosa appears erythematous (red) and edematous (swollen).

• Discharge: Visible presence of clear or purulent (colored/cloudy) secretions in the nasal cavity or posterior pharynx.

• Palpation & Percussion: Tenderness or pain when tapping or pressing firmly over the frontal and maxillary sinus areas.

• Oral Examination: Evidence of postnasal drip in the back of the throat, or reddened tonsils/pharynx.

signs and symptoms of allergic rhinitis

1. Nasal & Upper Respiratory Signs

• The "Allergic Salute": Repetitive upward rubbing of the nose.

• Transverse Nasal Crease: A visible line across the bridge of the nose, commonly seen in children who exhibit the allergic salute.

• Mucosal Swelling: Pale, bluish, or boggy (swollen) nasal turbinates with thin, clear secretions.

• Postnasal Drip: Mucus dripping down the back of the throat, often causing chronic throat clearing or a cough.

• Anosmia: Decreased or absent sense of smell due to severe congestion.

2. Ocular (Eye) Symptoms

• Allergic Conjunctivitis: Itchy, red, and watery eyes.

• Periorbital Edema: Puffiness and swelling around the eyes.

• Dennie-Morgan Lines: Prominent creases under the lower eyelids.

3. Oral & Throat Findings

• Palatal Itching: Persistent itching in the roof of the mouth or throat.

• Cobblestoning: A granular, bumpy appearance of the posterior pharynx caused by chronic inflammation.

• Mouth Breathing: Persistent mouth breathing and snoring due to nasal blockage.

4. Ear Symptoms

• Eustachian Tube Dysfunction: Clogged ears, a popping sensation, or a feeling of fullness.

• Serous Otitis Media: Accumulation of fluid behind the eardrum, which is frequently evaluated during pediatric assessments.

5. Constitutional & Systemic Symptoms

• Fatigue & Malaise: Extreme tiredness, often resulting from poor, interrupted sleep due to nasal congestion.

• Headaches & Sinus Pressure: Dull frontal headaches resulting from blocked sinus cavities.

When would you do sinus transillumination

to check for maxillary or frontal sinusitis