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Chapter 76
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Clinical Methods in ENT
EQUIPMENT, HISTORY TAKING
AND GENERAL SETUP
Evaluation of the patient with disease of ear, nose and
throat requires skill in eliciting a meaningful history and
masterly dexterity in the examination of darker cavities
of the ear, nose, pharynx and larynx. A student is expected to learn this by regular practice in ENT clinics.
EQUIPMENT FOR ENT EXAMINATION
(FIGURE 76.1)
The requirements of equipment in a clinic may vary but
the essential instruments for routine examination are
listed here.
1. Bull’s eye lamp. It provides a powerful source of
light. The lamp can be tilted, rotated, raised or lowered according to the needs (Figure 76.1).
2. Head mirror. It is a concave mirror used to reflect
light from the Bull’s eye lamp onto the part being examined. It has a focal length of approximately 25 cm.
The examiner sees through the hole in the centre of
the mirror. Diameter of the mirror is 89 mm (3½“)
and that of the central hole is 19 mm (3/4”).
Sources of illumination include electric headlights
connected to a main power source through a stepdown transformer or chargeable batteries (Figure 76.2).
The latter have the advantage for bedside examination.
3. Tongue depressors. Different sizes for children and
adults should be available. It is used in the examination of oral cavity and oropharynx.
4. Nasal specula. Two types are commonly used, namely Thudicum and Vienna types. The size of the nasal
speculum is selected according to the age of the patient and size of the nostril.
5. Laryngeal mirrors. They are used to examine the
larynx and laryngopharynx. Various sizes, from 6 to
30 mm diameter, are available. To prevent fogging, a
mirror is always warmed over a spirit lamp or by dipping it in hot water and then tested on the back of
hand before insertion into the mouth.
6. Postnasal mirror. It is used to examine the nasophar-
ynx and posterior part of nasal cavity. Like laryngeal
mirror, it is also warmed and tested on the back of
hand before use.
7. Ear specula. Various sizes are available to suit different sizes of the ear canal. The largest speculum which
can be conveniently inserted in the ear canal should
be used.
8. Siegle’s speculum. Essential in examination of tym-
panic membrane; it gives magnified view of tympanic
membrane and helps to test its mobility. It is also
used to elicit the fistula sign.
9. Tuning forks. Commonly used tuning fork has a fre-
quency of 512 Hz. Forks of other frequencies, e.g. 256
and 1024 Hz should also be available.
10. Jobson–Horne’s probe. One end of the probe is used
to form a cotton bud to clean the ear of discharge and
the other end (with ring curette) is used to remove
the wax.
11. Blunt probe. It is used for palpation in the nasal cavity or ear canal.
12. Tilley’s or Hartman’s forceps. It is used in packing of
ear canal or nasal cavity.
13. Eustachian catheter. It is used to test patency of
the eustachian tube and can also be used to remove
foreign bodies from the nose. To test the patency
of eustachian tube, the nose is first anaesthetized,
the catheter is then passed along the floor of nose
into the nasopharynx, turned medially and then
slightly withdrawn till it engages on the posterior
free border of the nasal septum. At this point, it is
rotated 180° laterally to lie against the opening of
eustachian tube. A bulb is attached and air insufflated. If the tube is patent, air enters the middle
ear and can be detected by an auscultation tube
which connects patient’s ear to that of the examiner (see p. 63).
14. Otoscope. It is an electric or battery operated device
with a magnifying glass. Sometimes it has an arrangement to attach a bulb to function as Siegel’s speculum. It is useful for detailed examination of the ear.
It is an essential instrument to examine the ear of an
infant, a child or a bedridden patient.
15. Spirit lamp. It is used to warm the laryngeal or postnasal mirror (Figure 76.3).
16. Gloves. They are essential for intraoral palpation.
17. Spray. It is used to apply local anaesthetic to abolish
the gag reflex.
18. Suction apparatus. To clear the ear or nose of discharge or blood for detailed examination.
HISTORY TAKING
1. History of present illness. A patient presents with cer-
tain presenting complaints. They are asked in detail,
with particular reference to the duration of symptoms,
their onset, progression, severity and other accompanying complaints. Inquiry should also be made of any
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Figure 76.1A. (a) Bull’s eye lamp. (b) Left to right: (1) tuning fork, (2) Siegel’s speculum, (3) otoscope, (4) head mirror and (5) Barany’s noise box.
SECTION IX — Clinical Methods in ENT and Neck Masses
Figure 76.1B. (1) Jobson–Horne’s probe. (2) Vienna nasal
speculum. (3) Hartmann’s packing forceps. (4) Wilde’s packing forceps. (5) Eustachian tube catheter. (6) Thudicum nasal
speculum. (7) Laryngeal mirror. (8) Postnasal mirror. (9) Blunt
probe. (10) Ear specula. (11) Lacks tongue depressor.
Figure 76.2. Head light.
systemic disease the patient may be suffering from,
e.g. diabetes, hypertension, coronary artery disease,
liver or kidney disease, or a bleeding disorder. Also find
out about the treatment patient has taken or is still
taking for the present ailment.
2. History of past illness. It includes history of similar
complaints in the past, treatment taken, history of any
operation which the patient has undergone and allergy to any drug.
3. Personal history. Inquire about the patient’s pro-
fession and nature of job, personal habits (smoking,
chewing pan or tobacco, use of alcohol) and food habits (excessive use of tea or coffee). It is also important
to know about his activities, exercise, or sedentary
habits.
4. Family history. Some diseases have a genetic basis,
e.g. otospongiosis, certain types of sensorineural hearing loss and autoimmune disorders while others are
the result of close contact between different members
of the family, e.g. tuberculosis, syphilis, pediculosis,
scabies, etc.
Figure 76.3. Warming a laryngeal mirror over a spirit lamp. Warm
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only the glass side of the mirror.
GENERAL SETUP AND POSITION
OF PATIENT
The patient is examined in a semi-dark room. He is seated
on a stool or chair opposite the examiner and is made to
sit erect leaning slightly forward towards the examiner.
He should not slump in the seat. Bull’s eye lamp is kept
on the left at the level of his shoulder. The examiner uses
a head mirror to reflect light from the Bull’s eye lamp on
to the area of examination.
A head mirror gives good illumination and permits
freedom to use both hands for other activities. Some prefer to use a head light in place of Bull’s eye lamp and a
head mirror.
I. EXAMINATION OF EAR
SYMPTOMATOLOGY
A patient with ear disease presents with one or more of
the following complaints:
1. Hearing loss.
2. Tinnitus.
3. Dizziness or vertigo.
4. Ear discharge.
5. Earache.
6. Itching in the ear.
7. Deformity of the pinna.
8. Swelling around the ear.
The details of history of these symptoms particularly
in reference to the onset, duration, progression and severity
should be noted.
EXAMINATION
It includes both physical and functional examination.
Chapter 76 — Clinical Methods in ENT
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A. Physical Examination
It includes examination of:
1. Pinna and the surrounding area.
2. External auditory canal
(a) Without speculum
(b) With speculum
3. Tympanic membrane.
4. Middle ear.
5. Mastoid.
6. Eustachian tube.
7. Facial nerve and other cranial nerves.
1. pinna and the surrounding area. The pinna is ex-
amined by inspection and palpation. Both of its surfaces,
the lateral and the medial, should be examined.
Look for size (microtia, macrotia); shape (abnormalities
of contour, cauliflower ear); position (bat ear). Also look
for redness (furuncle or abscess); swelling (haematoma, abscess); vesicles in concha and retroauricular groove (herpes
zoster); scars (trauma or operation); ulceration or neoplasm.
Also examine the area above, in front, below and be-
hind the pinna and look for a swelling (mastoid or zygomatic abscess, neoplasm or lymph nodes); sinus (preauricular sinus); fistula (mastoid fistula) scar (endaural or
postaural scar due to previous operation).
Palpation of pinna is essential to look for raised tem-
perature (perichondritis or abscess); thickness of tissues
(perichondritis); fluctuation (seroma or abscess) and ten-
derness. Movement of pinna is painful in furunculosis of
the external canal.
2. Examination oF external auditory canal
(a) Examination without a speculum. This is an im-
portant part of the examination and precedes introduction of speculum. The pinna is pulled upwards and backwards while the tragus is pulled
forwards to spread open the meatus. Look for the
size of meatus (narrow or wide), contents of lumen
(wax, debris, discharge or polyp) or swelling of its
wall (furuncle, neoplasm).
(b) Examination with a speculum. Once the size of
the meatus is known, proper speculum is selected and introduced (Figure 76.4). Use the largest
speculum that can easily enter the canal. Look for
wax, debris, discharge, polyp, granulations, exostosis, benign or malignant neoplasm, sagging of
posterosuperior area (coalescent mastoiditis).
3. examination oF tympanic membrane. Normal
tympanic membrane is pearly white in colour and semitransparent and obliquely set at the medial end of the
meatus. It has two parts—pars tensa and pars flaccida,
both of which should be carefully examined. Its various
landmarks are shown in Figure 76.5. A tympanic membrane is examined for:
(a) Colour. Red and congested in acute otitis media, blu-
ish in secretory otitis media or haemotympanum. A
chalky plaque is seen in tympanosclerosis.
(b) Position. Tympanic membrane may be retracting or
bulging. General retraction is seen in tubal occlusion,
retraction pockets are seen in attic or posterosuperior
region and may collect epithelial flakes. Sometimes,
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SECTION IX — Clinical Methods in ENT and Neck Masses
Figure 76.4. Examination of ear with a speculum. (A) Right ear. (B) Left ear.
Figure 76.5. Landmarks of a normal tympanic membrane (right
side).
tympanic membrane is very thin, deeply retracted and is fixed to promontory as in adhesive otitis
media.
1. Bulging tympanic membrane is seen in acute otitis
media, haemotympanum or neoplasm of middle
ear which has not yet perforated the drum.
(c) Surface of tympanic membrane. It may show vesicles
or bullae (herpes zoster or myringitis bullosa), a
perforation (acute or chronic otitis media). A perforation may be central (in pars tensa) or attic (in pars
flaccida) or marginal (at the periphery involving
the annulus). A central perforation may be small,
medium, subtotal or total.
(d) Mobility. It is tested with a Siegle’s speculum
(Figure 76.6). A normal tympanic membrane is mobile. Restricted mobility is seen in the presence of
fluid or adhesions in the middle ear. An atrophic segment of tympanic membrane may be hypermobile.
4. examination oF middle ear. Normally, middle ear
cannot be examined directly. When tympanic membrane is semi-transparent, some structures can be seen
through it. In the presence of a perforation, it is possible
to know the condition of middle ear mucosa and any
in-growth of squamous epithelium from the edges of the
perforation.
Figure 76.6. Use of Siegel’s speculum to see the mobility of the
tympanic membrane.
5. examination oF mastoid. Look for a swelling
(abscess or enlarged nodes), obliteration of retroauricular
groove (furuncle), fistula (burst abscess), scar (previous
operation).
Normally, mastoid surface feels irregular on palpation.
These irregularities are “ironed out” and surface feels
smooth in periosteal inflammation as in subperiosteal
abscess.
Tenderness of mastoid is seen in mastoiditis. It is elicited by pressure at three sites:
(a) Over the antrum (just above and behind the meatus).
(b) Over the tip.
(c) Over the part between the mastoid tip and mastoid
antrum.
6. examination oF eustachian tube. Tympanic orifice
of eustachian tube can be seen in the anterior part of middle
ear if there is perforation of tympanic membrane. Pharyngeal opening of tube can be seen by posterior rhinoscopy.
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431
Function of tube can be tested by Valsalva manoeuvre.
In the presence of a perforation, air can be felt to escape
from the ear when patient tries to blow with mouth and
nose closed.
7. examination oF Facial nerVe. Paralysis of facial
nerve may coexist with disease of the ear, e.g. acute or
chronic suppurative otitis media, herpes zoster oticus,
malignant otitis externa, tumours of external or middle
ear and trauma. It is essential to test for facial nerve in
every case of ear disease.
B. Functional Examination
1. Auditory function
(a) Voice test
(b) Tuning fork tests
• Rinne test
• Weber test
• Schwabach test
• Absolute bone conduction test.
2. Vestibular function
(a) Spontaneous nystagmus
(b) Fistula test (p. 43)
(c) Positional tests (p. 44).
II. EXAMINATION OF NOSE
AND PARANASAL SINUSES
A detailed history of these symptoms with special regard to their onset, duration, progression, severity should
be asked. They are discussed in the relevant sections of
the book.
A. EXAMINATION OF NOSE
Nasal examination includes:
1. Examination of external nose.
2. Examination of vestibule.
3. Anterior rhinoscopy.
4. Posterior rhinoscopy.
5. Functional examination of nose.
1. External Nose
Examine the skin and osteocartilaginous framework of
nose both by inspection and palpation.
Skin is examined for signs of inflammation (furuncle,
septal abscess), scars (operation or trauma), sinus (congenital dermoid), swelling (dermoid or glioma) or a neoplasm
(basal cell or squamous cell carcinoma).
Osteocartilaginous framework is examined for deformity,
e.g. deviated or twisted nose, hump, depressed bridge, bifid or pointed tip, destruction of nose (trauma, syphilis,
cancer).
Palpation of nose is done to find raised temperature,
fixity of skin, thickening of soft tissues, tenderness, fluctuation or crepitation.
SYMPTOMATOLOGY
A patient with disease of the nose and paranasal sinuses
presents with one or more of the following complaints:
1. Nasal obstruction.
2. Nasal discharge.
3. Postnasal drip.
4. Sneezing.
5. Epistaxis.
6. Headache or facial pain.
7. Swelling or deformity.
8. Disturbances of smell.
9. Snoring.
10. Change in voice (hyper- or hyponasality).
2. Vestibule
It is the anterior skin-lined part of nasal cavity having
vibrissae and can be easily examined by tilting the
tip of nose upwards. It is examined for a furuncle, a
fissure (chronic rhinitis), crusting, dislocated caudal
end of the septum, and tumours (cyst, papilloma or
carcinoma).
3. Anterior Rhinoscopy
Technique. Patient is seated facing the examiner. A
Thudicum or Vienna type of speculum is used to open
the vestibule. The speculum is held in the left hand
(by a right-handed person) (Figure 76.7). It should be
fully closed while introducing and partially open when
Figure 76.7. (A) Anterior rhinoscopy. (B) Technique of holding a Thudicum nasal speculum.
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removing from the nose to avoid catching the hair. Light
is focussed at different sites in the nose to examine the
nasal septum, roof, floor and the lateral wall. For this, patient’s head may need to the tilted in different directions.
Look for the following points:
(a) Nasal passage. Narrow (septal deviation or hyper-
(b) Septum. Deviation or spur, ulcer, perforation, swelling
(c) Floor of nose. Defect (cleft palate or fistula), swelling
(d) Roof. Usually not seen except in cases of atrophic
(e) Lateral wall. Look at the turbinates and meatuses.
SECTION IX — Clinical Methods in ENT and Neck Masses
Figure 76.8. Technique of posterior rhinoscopy.
trophy of turbinates, growth) and wide (atrophic
rhinitis).
(haematoma or abscess) and growth (rhinosporidiosis, haemangioma).
(dental cyst), neoplasm (haemangioma) or granulations (foreign body or osteitis).
rhinitis.
Only the inferior and middle turbinates and their
corresponding meatuses can be visualized. Examine
the colour of mucosa (congested in inflammation and
pale in allergy), size of turbinates (enlarged and swollen in hypertrophic rhinitis, small and rudimentary
in atrophic rhinitis), discharge (discharge in the middle meatus indicates infection of maxillary, frontal
or anterior ethmoidal sinuses), mass (polyp, rhinosporidiosis, carcinoma). A probe test should be done.
It ascertains the site of attachment, consistency,
mobility and sensitiveness of the mass. Attachment
of the mass is found by passing the probe on all its
surfaces. Bleeding during probing indicates vascular
nature of the mass.
4. Posterior Rhinoscopy
Technique. Patient sits facing the examiner, opens his
mouth and breathes quietly from the mouth. The examiner depresses the tongue with a tongue depressor
and introduces posterior rhinoscopic mirror, which
has been warmed and tested on the back of hand
( Figure 76.8). The mirror is held like a pen and carried
behind the soft palate. Without touching it on the posterior third of tongue to avoid gag reflex, light from
the head mirror is focussed on the rhinoscopic mirror which further illuminates the part to be examined.
Figure 76.9. Structures seen on posterior rhinoscopy.
Figure 76.10. Testing the patency of the nose. Note the area of mist
formation on the tongue depressor when patient exhales from the nose.
Patient’s relaxation is important so that soft palate does
not contract.
Structures normally seen on posterior rhinoscopy are
shown in Figure 76.9. Look for the following:
(a) Choanal polyp or atresia.
(b) Hypertrophy of posterior ends of inferior turbinates.
(c) Discharge in the middle meatus. It is seen in infec-
tions of maxillary, frontal or ethmoidal sinuses. Discharge above the middle turbinate indicates infection
of the posterior ethmoid or the sphenoid sinuses.
5. Functional Examination of Nose
Test for patency of the nose and sense of smell.
(a) Patency of nose. (i) Spatula test. A clean cold tongue
depressor is held below the nostrils to look for
the area of mist formation, when patient exhales
( Figure 76.10), the two sides are compared.
(ii) Cotton-wool test. A fluff of cotton is held against
each nostril and its movements are noticed when
patient inhales or exhales.
(b) Sense of smell. A simple test is to ask the patient to
identify the smell of a solution or substance held before the nostril while keeping the eyes closed. Each
nostril is tested separately. Common substances used
are the clove oil, peppermint, coffee and essence of
rose. Ammonia stimulates the fibres of CN V and is
not used to test the sense of smell.
B. EXAMINATION OF PARANASAL SINUSES
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1. Maxillary sinus
2. Frontal sinus
3. Ethmoid sinuses
4. Sphenoid sinus
1. Maxillary Sinus
It is examined by inspection, palpation and trans-illumination.
Maxillary sinus has five walls and except for the poste-
rior, all other walls can be examined directly.
Examine:
(a) the soft tissues of cheek, lip, lower eye lid and the
molar region,
(b) the orbit and its contents, and the vision,
(c) the vestibule of mouth by everting the lip,
(d) upper alveolus, teeth and palate,
(e) the nose by anterior and posterior rhinoscopy,
(f) tenderness by pressure over the canine fossa
(Figure 76.11).
Transillumination of maxillary sinus is done by placing a specially made light source centrally in the mouth
and closing the lips. Normally, a crescent of light in the
inferior fornix and glow in the pupil, equally bright on
both sides, can be seen. In the presence of pus, thickened
mucosa or a neoplasm, the affected side does not transmit
light. This test has limited value and has practically been
abandoned in favour of X-rays.
Chapter 76 — Clinical Methods in ENT
Figure 76.11. Testing for tenderness of maxillary sinus by pressure
on the canine fossa.
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2. Frontal Sinus
It is also examined by inspection, palpation and transillumination.
Frontal sinus has three walls: anterior, posterior and
floor. Only the anterior wall and floor lend themselves to
external examination.
(a) External examination. For this, examine the forehead, root of nose, orbital margins, the orbit and its contents. Look for redness, swelling, fistula, proptosis and
displacement of the eye balls.
Tenderness of the frontal sinus can be elicited by pressure or percussion with a finger on its anterior wall above
the medial part of eyebrow, or by pressing upwards on its
floor above the medial canthus (Figure 76.12).
(b) Examination of nose. Nose should be examined by
anterior as well as posterior rhinoscopy for evidence of
discharge in the middle meatus and for any neoplasm.
Transillumination is done by placing a small light
source in the superomedial angle of the orbit and observing the transmission of light from the anterior wall of the
sinus. It is compared on both sides. Transillumination of
frontal sinus is of limited value and has practically been
abandoned in favour of X-rays.
3. Ethmoid Sinuses
They are divided into two groups: the anterior and posterior. The former drains below the middle turbinate and
the latter above it. They are examined by inspection and
palpation.
(a) External examination. It includes examination of orbit, upper and lower eye lids, root of nose, eye ball and
vision.
Figure 76.12. Testing for tenderness of the frontal sinus.
Tenderness can be elicited only in the anterior ethmoid
sinuses. This is done by gentle pressure applied on the
medial wall of orbit just behind the root of nose. The area
is tender in acute ethmoiditis.
(b) Nasal examination. Anterior rhinoscopy may reveal
pus, polypi, or growth in the middle meatus (anterior
group of ethmoid sinuses) or between the middle turbinate and the septum (posterior group of ethmoid sinuses). Probe test should be done to find the consistency, attachment and friability of the mass.
Posterior rhinoscopy may reveal pus or growth, below
or above the middle turbinate.
4. Sphenoid Sinus
Sphenoid sinus lies deep and is not easy to examine directly. Sometimes, its anterior wall can be seen in atrophic rhinitis or in marked deviation of the septum to the
opposite side.
(a) Anterior rhinoscopy. Sphenoid sinus opens in the
sphenoethmoidal recess. Attention should therefore be
paid to the findings in the olfactory fissure near the roof
of nose. It may show discharge, crusts, polyp or growth. A
probe can be used to palpate the mass.
(b) Posterior rhinoscopy. It may reveal pus in the nasopharynx or the choana, above the middle or superior turbinate. A growth or a polyp may also be seen.
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SECTION IX — Clinical Methods in ENT and Neck Masses
III. EXAMINATION OF NASOPHARYNX
SYMPTOMATOLOGY
A patient with disease of nasopharynx presents with:
1. Nasal obstruction.
2. Postnasal discharge.
3. Epistaxis.
4. Hearing impairment (tubal block).
5. Cranial nerve palsies.
6. Enlargement of lymph nodes in the neck.
A detailed history of these symptoms regarding their
onset, duration, progression and severity should be asked.
(These have been discussed in the relevant sections.)
EXAMINATION
Clinical examination of nasopharynx includes:
1. Anterior rhinoscopy.
2. Posterior rhinoscopy.
3. Other methods.
(a) Digital examination
(b) Endoscopy
(c) Retraction of soft palate with catheters and mirror
examination
4. Cranial nerves.
5. Cervical lymph nodes.
1. Anterior Rhinoscopy
It is possible to see only a small part of the nasopharynx
on anterior rhinoscopy. The view can be facilitated by decongestion of nasal and turbinal mucosa with vasoconstrictors.
2. Posterior Rhinoscopy
The technique is described on p. 431. Structures to be examined are:
(a) Anterior wall. Posterior border of nasal septum, choa-
nae, posterior ends of turbinates and their meatuses.
(b) Lateral walls. Torus tubarius, opening of eustachian
tube, pharyngeal recess.
(c) Floor. Upper surface of soft palate.
(d) Roof and posterior wall.
Only a small part of nasopharynx can be seen in the
mirror at one time. The examiner tilts the mirror in different directions to see all the walls of the nasopharynx and
then mentally reconstitutes the entire picture.
Abnormal findings in the nasopharynx include:
(a) Discharge. It may be seen below the middle turbinate
(anterior group of sinuses) or above the middle turbi-
nate (posterior group of sinuses).
(b) Crusting. Atrophic rhinitis or nasopharyngitis.
(c) Mass
(i) Smooth pale mass—antrochoanal polyp.
(ii) Pink lobulated mass—angiofibroma.
(iii) Irregular bleeding mass—carcinoma.
(iv) Smooth swelling in the roof—Thornwaldt’s cyst
or abscess.
(v) Irregular mass with radiating folds-adenoids.
(vi) Irregular mass filling the lower part of choana—
mulberry hypertrophy of inferior turbinate.
(d) Bleeding. Due to posterior nasal or nasopharyngeal
pathology.
3. Other Methods
(a) Digital examination. It is a quick method to examine the nasopharynx by palpation but is uncomfortable for the patient. The examiner stands behind and to
the right of the patient, invaginates patient’s cheek with
his left finger and inserts right index finger behind the
soft palate into the nasopharynx. He first examines the
posterior border of the nasal septum, then the choana,
lateral wall and finally the posterior wall of nasopharynx.
Adenoids, antrochoanal polyp and other masses in the
nasopharynx can be examined. Avoid this examination if
angiofibroma is suspected.
(b) Endoscopy. A rigid nasal endoscope zero or zero
degree and 4 mm is passed through the nose after local
anaesthesia and decongestion of nasal mucosa. It gives
a bright and magnified view of the nasopharyngeal
structures. Using endoscopes with different angles of
view, it is possible to examine structures situated at an
angle. Flexible nasopharyngoscope can also be used. It
is also passed through the nose and gives a magnified
view.
(c) Retraction of soft palate with catheters and
mirror examination. This method is reserved for dif-
ficult cases where view of nasopharynx is not obtained
by other methods. It requires good local or general anaesthesia.
A soft rubber catheter is passed through each nostril
and recovered from the oropharynx. Both ends of catheter are held together and clamped. In this way, soft palate
is retracted forwards. Now a mirror can be introduced and
the nasopharynx examined with the advent of the endoscope; this is not required except for biopsy in some cases.
4. Examination of Cranial Nerves
Malignancy of nasopharynx can involve any of the CN II
to XII, more often CN IX, X and XI.
5. Examination of Cervical Lymph Nodes
It is not unusual for nasopharyngeal malignancy to present primarily as a lymph node mass in the neck. Lymph
nodes commonly involved are upper internal jugular and
those along the accessory nerve in the posterior triangle
of the neck.
IV. EXAMINATION OF ORAL CAVITY
Oral cavity extends from the lips to the level of anterior
tonsillar pillars. Structures included in it are:
1. Lips
2. Buccal mucosa
3. Gums and teeth
4. Hard palate
5. Anterior two-thirds of tongue
6. Floor of mouth
7. Retromolar trigone
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435
SYMPTOMATOLOGY
A patient with disease of the oral cavity may present with
one or more of the following complaints:
1. Pain. It may be localized to a particular site in the
oral cavity, e.g. tooth, tongue, buccal mucosa, floor of
mouth, etc. Sometimes, pain is referred to the ear from
pathology in the oral cavity.
2. Disturbance of salivation. Xerostomia (dryness of
mouth) can result from mouth breathing, irradiation
or generalized disease of the salivary glands. Excessive
salivation can result from ulcers of mouth and pharynx, poor orodental hygiene, ill-fitting denture and
iodide therapy.
3. Disturbance of taste. Sweet, sour and salt tastes are
appreciated by taste buds on the anterior two-thirds of
tongue. Patient may complain of unilateral or bilateral
loss of taste, diminished or perverted taste. Lesions in
these cases may be local on the tongue, e.g. heavily
coated tongue, or injury to chorda tympani or the facial nerve.
4. Trismus. There are several causes of trismus but the
important ones related to the oral cavity include ulcerative lesions, dental abscess, trauma to mandible
or maxilla, and malignant lesions of tongue, buccal
mucosa and retromolar trigone that have infiltrated
deeply.
5. Lesion or oral cavity. Patient can easily see several
parts of his oral cavity in the mirror and present with
an abnormal growth, coating of tongue, a cleft (lip
or palate) or a fistula (oroantral). It is not unusual for
some patients of cancerophobia to fix their attention
on the circumvallate papillae as cancer.
EXAMINATION
Examine in seriatim the following structures:
1. Lips
Examine both the lips—the upper and lower, by inspection and palpation. Each lip has an outer (cutaneous), an
inner (mucosal) surface and a vermilion border. Look for
any swellings, vesicles, ulcers, crusts, scars, unilateral or
bilateral clefts.
2. Buccal Mucosa
It can be examined by asking the patient to open the
mouth and by retracting the cheek with a tongue depressor. Examine the mucosa of cheek and vestibule of
mouth. Look for:
(a) Change in colour.
(b) Change in surface appearance, e.g. ulceration,
vesicles or bullae (pemphigus), white stria (lichen
planus), blanched appearance with submucosal scars
(submucous fibrosis), leukoplakia, erythroplakia, pigmentation, atrophic change in mucosa, swelling or
growth. Opening of parotid duct is seen opposite the
upper second molar tooth. It may be red and swollen with secretions flowing through it on massage of
parotid gland (viral or suppurative parotitis).
3. Gums and Teeth
Examine the gums and teeth in both the upper and lower
jaws. Outer surface of gums is examined by retracting
the cheeks and lips and the inner surface by pushing the
tongue away with a tongue depressor.
(a) Red and swollen gums. Gingivitis.
(b) Ulcerated gums covered with a membrane. Viral ul-
cers or Vincent infections.
(c) Hyperplasia. Pregnancy or phenytoin therapy for
epilepsy.
(d) Growths. Benign or malignant neoplasms.
(e) Loose teeth. Maxillary or mandibular growth,
periodontitis.
(f) Carious infected tooth or teeth. Cause of maxillary
sinusitis if upper, and Ludwig’s angina, if lower.
(g) Malocclusion. Fractures of mandible or of teeth
maxilla, abnormalities of temporomandibular joint.
4. Hard Palate
Look for:
(a) Cleft palate : Congenital
(b) Oronasal fistula : Trauma or syphilis
(c) High-arched palate : Mouth breathers
(d) Bulge : Tumours of palate,
nose or antrum
(e) Bony growth in midline : Torus palatinus
(f) Mass or ulcer : Cancer
5. Tongue
Only oral tongue (anterior two-thirds) is included in the
oral cavity. First, examine the tongue in its natural position and then ask the patient to protrude it, move it to
the right and left and then up. Examine the tip, dorsum,
lateral borders and undersurface.
(a) Large size. Macroglossia, haemangioma, lymphangi-
oma, cretinism, oedema or abscess.
(b) Inability to protrude. Congenital ankyloglossia,
cancer tongue or floor of mouth, painful ulcer,
abscess.
(c) Deviation on protrusion. Paralysis CN XII on the side
of deviation.
(d) Bald tongue. Iron-deficiency anaemia, median rhom-
boid glossitis (single patch in midline on the dorsum),
geographical tongue.
(e) Fissures. Congenital (Melkersson syndrome), syphi-
litic. A single nonhealing fissure may be malignant.
(f) Ulcers. Aphthous traumatic (jagged tooth or denture),
malignant, syphilitic or tubercular.
(g) White thick patch or plaque. Leukoplakia.
(h) Proliferative growth. Malignancy.
6. Floor of Mouth
Examine anterior part which lies under the tongue and
two lateral gutters. Lateral gutters are better examined by
two tongue depressors; one retracting the tongue and the
other, the cheek.
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