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Local Examination ofORL: Head
andNeck Surgery
2
2.1 How toDo Examination
ofEar, Nose, Throat, Head,
Neck andSkull Base
1. Examination of ear—Ear examination can
be divided into structural examination and
functional examination.
(a) Clinical anatomy—Ear is divided into
external ear, middle ear and inner ear.
(b) Instruments for ear examination (Fig.
2.1)—Figure 2.1 shows the instruments
needed for examination of ear.
(c) Position of patient
• Position of child—The attender holds
the child in his/her leap, keeping in a
straight and sitting position. The legs
of the child should be between legs of
the attender. The attender will hold
both the hands of the child with the left
hand and head with the right hand. The
examining ear should be facing
towards the examiner (Fig.2.2a).
• Position of adult—The examiner sits
facing the patient with his knees
together and to one side of the patient’s
legs. After positioning of the patient,
the examiner puts the head mirror or
headlight for illumination, then turns
the head to the opposite side of the
examined ear.
(d) Examination of ear—After positioning,
the examination of ear starts with inspec-
tion of pinna, preauricular area and postaural area followed by palpation of these
areas. Now, the examiner has to pull
pinna posteriorly, superiorly and laterally (backwards, upwards and outwards)
in adult and laterally and posteriorly in
children to make EAC straight for examination of the external auditory canal
(EAC) and tympanic membrane. In this
part, we will discuss what to examine
and how to examine. The examination of
ear has been subcategorized into examination of external ear, middle ear and
inner ear, as well as audiological tests,
vestibular tests and facial nerve function
tests.
Examination of external ear
It includes the examination of preauricular
area, pinna, postauricular area and EAC.
• Examination of postaural area
– Inspection of postaural area—After
positioning of the patient, pinna is
retracted anteriorly to examine the
postaural area, and the postaural
area is extended from the postaural
sulcus anteriorly to the posterior
border of the mastoid bone posteriorly. The inspection of this area
should be done for:
Scar—If present, site, size and
shape of the scar should be
noted.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2025
S. K. Kashyap, S. Sagar, Clinical Methods of Otorhinolaryngology, Skull Base & Head Neck
Surgery, https://doi.org/10.1007/978-981-96-1765-4_2
47
48
2 Local Examination ofORL: Head andNeck Surgery
a
b c
d
e f
Fig. 2.1 (a) Bull’s lamp, (b) head mirror, (c) headlight, (d) otoscope, (e) tuning forks and (f) instruments
Fig. 2.2 (a) Position of
the child for ear
examination and (b)
position of pinna in
adult
Sinus/stula—If present, site,
size, any discharge or swelling
should be noted.
Discoloration of skin.
Bluish discoloration (Battle’s
sign)—Bluish discoloration of
mastoid is indicative of fracture
a
b
of middle cranial fossa and basilar skull fracture.
Reddish discoloration—It is
present in inammation.
Swelling/mass/growth—If present, inspect for site, side, size,
overlying skin, etc.
2.1 How toDo Examination ofEar, Nose, Throat, Head, Neck andSkull Base
49
Oedema (Griesinger’s sign)—
Oedema and tenderness over
posterior part of the mastoid
bone are due to thrombosis of
the mastoid emissary vein. It is a
sign of lateral sinus
thrombophlebitis.
– Palpation of postaural area
Mastoid tenderness—The tenderness is elicited by pressing
over specied point and watching for grimacing over patient’s
face. It is a cardinal sign of
inammation. It is elicited by
applying gentle pressure over
various sites of postaural area
(Table2.1).
Swelling on mastoid area—To
conrm the ndings of inspection (Table2.2).
• Examination of preauricular area
– Inspection—Preauricular area is
inspected for
Sinus/opening—If present, the
exact location should be noted.
Tag—Present/absent.
Swelling—As described in
examination pinna.
Scar—If present, the site and
size should be noted.
Trismus—If present, the disease
affects the TM joint.
Deformities—Any congenital or
acquired deformity is noted.
– Palpation
Tenderness
Tragal tenderness—The examiner presses the tragus medially
towards the EAC; check grimacing over patient’s face.
Tenderness over swelling—It is
suggestive of inammation of
underlying tissues due to either
infection or trauma.
Tenderness over TM joint—It
is suggestive of inammation
of TM joint and tested by
pressing over TM joint during
chewing.
Table 2.1 Sites for mastoid tenderness
Sites for mastoid tenderness
Cymba concha—This is an area on pinna
corresponding to MacEwen’s triangle of mastoid bone
and thus antrum. Tenderness over cymba concha is
elicited by pressing over the cymba concha area on
pinna medially towards the mastoid bone (Fig.2.3a)
Mastoid tip—The examiner presses over the mastoid
tip to elicit the tenderness. This is suggestive of
infection/inammation/pus collection in mastoid tip
air cells (Fig.2.3b)
Mastoid process—This is elicited by pressing over the
centre mastoid bone (Fig.2.3c)
Table 2.2 Components of examination of swelling during palpation
Size of swelling—The size of swelling is noted in
transverse, vertical and anteroposterior direction
Consistency—The examiner presses the swelling by
ngers or in between the ngers and thumbs to know
it is either hard, rm or soft. The hard swelling can
also be classied into stony hard, bony hard and
rubbery hard
Tenderness—The examiner presses over the swelling
to conrm that tenderness is present or absent
Surface—The surface of the swelling should be
palpated with to know it is either smooth or irregular
Overlying skin—The examiner should hold the skin
with pinch to check he is either able to do so or not, to
know the xity of skin to swelling
Mobility—The examiner should hold the swelling and
move it side by side, or superior to inferior direction to
check it is either mobile or xed to underlying
structures
Translucency—Present or absent
Pulsation—The examiner holds the swelling and asks
the patient to cough to see either there is any
transmission of pulsation
Translucency—The examiner puts the light on one
side of swelling to check the light can be either seen
on other side or not
Swelling—Size, consistency,
tenderness over swelling
Movement of TM joint
• Examination of pinna
– Inspection—site, shape, size, posi-
tion, curvature, deformity, swelling
– Palpation—tenderness, consistency
of pinna, consistency of swelling
• Examination of EAC—For inspec-
tion of EAC, the pinna should be
pulled laterally, posteriorly and superiorly to make EAC straight.
50
2 Local Examination ofORL: Head andNeck Surgery
a
Fig. 2.3 Sites for mastoid tenderness. (a) Cymba concha, (b) mastoid tip and (c) mastoid process
– Inspection—Inspection of EAC
should be done with the help of
head mirror or headlight and
otoscope.
b
pinna should be pulled laterally, posteriorly and superiorly to make EAC
straight for visualization of TM and
middle ear.
Examining with head mirror or
headlight—size of EAC, shape
of EAC, curvature of EAC, type
of collection, swelling and size
of EAC opening.
Otoscopic examination—All
parts of EAC should be inspected
to conrm the ndings of head
mirror examination and additional nding. The pinna is
retracted laterally; now, the otoscope should be held like pen in
left hand for left ear examination
and right hand for right ear
examination. The ring nger
should be placed anterior to tragus to avoid any accidental
trauma.
– Examination with otoscope (otos-
copy/otoscopic examination)—The
otoscopic examination of ear is per-
formed to conrm the ndings of
inspection under head mirror as men-
tion below:
– Palpation
Tragal tenderness—Tenderness
on palpation of tragus or moving
the pinna
Tympanic membrane and middle ear
• Examination of tympanic membrane
and middle ear
– Examination with headlight or head
mirror—For examination of TM, the
c
Tympanic membrane examination—
Tympanic membrane should be
inspected for colour, cone of light,
curvature, perforation, retraction,
cholesteatoma, granulations, bulging, tympanosclerosis, etc.
Middle ear—If patients are having
large perforation in tympanic membrane, the middle ear can be examined through perforation colour of
mucosa, ossicles and cholesteatoma;
granulation can be visualized.
Perforation of tympanic membrane
Cholesteatoma, granulation, reservoir signs, blebs
Colour of tympanic membrane
Position of tympanic membrane
Ossicular status—If perforation is
large or posterior perforation
Middle ear diseases like cholesteatoma, granulation, etc.
2.1 How toDo Examination ofEar, Nose, Throat, Head, Neck andSkull Base
51
Procedure of otoscopy (Fig. 2.4a, b)—
Firstly, hold the otoscope like a pan horizontally in left hand for left ear and in right
hand for right ear. Now, gently pull the
auricle outwards, upwards and backwards
in adult; the auricle should be pulled outwards and backwards to make EAC straight.
In children, the attender should hold the
head to avoid movement. The ring nger
should be placed over preauricular area
anterior to tragus as fulcrum to protect from
any accidental trauma if patients move or
turn head suddenly. Slowly insert around
1–1.5cm just past the hair of the ear canal—
be careful! This may cause the patient discomfort if they have inammation in their
EAM.Inspect EAC for discharge, scaling,
inammation, foreign bodies, stenoses,
cerumen and exostoses. Inspect the tympanic membrane (Fig. 2.5) for retraction,
perforation, bulging, colour, translucency,
discharge and cholesteatoma.
Special clinical examination
Pneumatic otoscopy—This test is
performed to check the mobility of
tympanic membrane by applying
positive and negative pressures with
the rubber squeeze bulb.
Siegel’s test/Siegalization—It is
performed to check the mobility of
the tympanic membrane with help of
Siegel speculum by varying the pressure in EAC (detail in Chap. 3).
Procedure of Siegel’s test—The speculum
should be snuggly tting for this test to be
performed. The speculum should be introduced in such a manner that the eye piece is
oriented towards the anteroinferior slant of
the eardrum. Pressure at the external canal
is applied by pressing the bulb. The eardrum could be seen moving inwards. On
releasing the pressure in the bulb, negative
pressure is created pulling the eardrum
towards the speculum. Normally, this to
and fro movement of the eardrum can be
observed during this procedure.
Examination of inner ear
– Hearing tests—The tuning fork tests
provide information about the type of
hearing loss. The sensorineural hearing
loss is indicative of cochlear or retroco-
chlear pathology, and conductive hear-
ing loss is indicative of disease of
middle ear, tympanic membrane or
EAC.
– Balance test—These tests have been
discussed in detail in Chap. 3.
– Facial nerve tests—These tests have
been discussed in Chap. 3.
– Hennebert’s sign—It is dened as a
false-positive stula test because it is
present in patient without clinical evi-
dence of middle ear or mastoid disease
or stula on lateral semicircular canal.
It can be elicited either by pressure
changes exerted on the EAC with tra-
Fig. 2.4 (a) Showing
how to hold otoscope
and (b) showing
otoscopy
a
b
52
malleolar f
ld
Fig. 2.5 Labelled
diagram of right
tympanic membrane
Posterior
old
2 Local Examination ofORL: Head andNeck Surgery
Pars flaccida
Anterior
malleolar fo
Handle of
malleus
Umbo
Tympanic
annulus
Cone of light
gal compression or a Politzer bulb, or
by increasing intracranial/middle ear
pressure through Valsalva manoeuvres.
It is present in hypermobile stapes syndrome in congenital syphilis and may
also be in Meniere’s disease due to
dilatation of utricle. It has been postulated that the vestibular stimulation is
mediated by brous bands between
footplate of stapes and the vestibular
membranous labyrinth in Meniere’s
disease, and in congenital syphilis, it is
due to excessively mobile footplate
which touches utricle and vestibular
stimulation.
– Fistula tests.
Procedure—The pressure changes in the
EAC stimulate the labyrinth to produce the
nystagmus and vertigo. The intermittent tragal pressure or Siegel’s speculum is used to
increase the pressure.
– Interpretation
Fistula test negative—normal
Fistula test positive—labyrinthine
stula, perilymph stula, poststapedectomy stula
False-negative stula test—cholesteatoma covering stula
False-positive stula test (it is a
positive stula test in the absence of
stula, Hennebert’s sign)—
Meniere’s disease, congenital syphilis, hypermobile stapes footplate
syndrome
• Nystagmus (discussed in Chap. 3)
• Tuning fork test for audiological assess-
ment (discussed in Chap. 3)
Rinne’s test, Weber’s test, ABC test, Bing’s
test, Gillie’s test, Stranger’s tests, etc.
• Vestibular function tests (detail in Chap. 3)
Nystagmus, Romberg’s test, Unterberger’s
test, etc.
• Examination/clinical tests for facial
nerve function (detail in Chap. 3)
Frowning over forehead, whistling, blowing, taste on anterior 2/3 of tongue, forceful closure of eyes, test for taste, tests for
lacrimation
2. Examination of nose, paranasal sinus and
nasopharynx
(a) Clinical anatomy—Nose is located in
central part of face, and for examination
purpose, nose can be divided into external
nose and internal nose.
(b) Instruments (Fig. 2.6).
(c) Position of patients—Sit facing the
patient with your knees together and to
one side of the patient’s legs. It is not
pleasant for the patient to be straddled.
Ask the patient to look forward, keeping
2.1 How toDo Examination ofEar, Nose, Throat, Head, Neck andSkull Base
Fig. 2.6 Instruments for examination of nose
53
their head in a neutral position. The external nose should be examined rst followed by internal nose.
(d) Functional examination of nose
• Examination of external nose
– Inspection—The external nose is
said to have a pyramidal shape. The
nasal root is located superiorly and
is continuous with the forehead.
The apex of the nose is located
inferiorly and ends in a rounded tip.
The dorsum of the nose spans
between the root and apex. The
examination of nose begins with an
overall inspection of the nose. The
inspection should be done to evaluate the size, shape, deformity, deviation of nose and colour and texture
of the skin of nose.
Type of nose—It varies in different ethnic groups and geographical areas.
Shape of nose—The external
nose is said to have a pyramidal
shape.
Size of nose—Average male has
a nose size of 2.2in., while the
average female nose size is 2in.
Nose is classied into small,
medium and tall.
Skin of nose—Normally, skin
over the bony part of the nose is
thin, in that overlying the cartilaginous part is thicker with
many sebaceous glands. This
skin extends into the vestibule of
the nose via the nares. Here,
there are hairs which function to
lter air as it enters the respiratory system.
Type of skin—thick or thin,
Fitzpatrick type, sebaceous
Discoloration—redness; causes—
rosacea, acne, skin irritation,
windburn, allergic contact dermatitis
Dryness of skin
Hyperpigmentation
Types of lesions, ulcer, growth
Rashes over nose—buttery or
malar rashes, buttery rash over
the nasal bridge, malar rash in
systemic lupus erythematosus
Thickening and coarseness—
hypothyroidism
A large bulbous nose with a
coarse ‘orange skin’-like appearance suggests a rhinophyma.
Check for any telangiectasia on
the face or hands.
Scars or abnormal creases—horizontal nasal creases
Swelling over nose—The differential diagnoses of a midline
nasal mass include inammatory lesions, traumatic deformity, benign neoplasms,
malignant neoplasms and con-
54
2 Local Examination ofORL: Head andNeck Surgery
genital masses. Congenital midline nasal masses include nasal
dermoids, gliomas, and
encephalocoeles.
Tip of nose—type of tip, supratip depression, deviated tip,
bullous tip, thickening and
coarsening of tip of nose.
Deformities of nose.
Base of nose—caudal dislocation, atresia or stenosis of anterior nares, alar collapse,
triangularity of ala, retraction
of ala.
Dorsum of nose—inspected for
any deviation from midline,
hump, depression, swelling.
Lateral wall of nose—deviation,
swelling, bulging.
– Palpation of external nose—
Palpation of nose was done to
assess the crepitation, tenderness,
step ladder deformity, etc.
Palpation of dorsum of nose—
The bridge of nose should be
pressed with index nger to palpate bony and cartilaginous skeleton of nose, tenderness and skin
thickness. Now, the examiner
holds the bony part of nose and
moves side by side for any abnormal movement and crepitation.
Palpation of the nasal bones
(upper 1/3 of nose)—The upper
part of nose is palpated for alignment, tenderness, irregularity
(suggestive of fracture), mobile
nasal bone, step ladder deformity, and crepitation.
Palpation of the nasal cartilage
(middle 1/3 of nose)—The middle part of nose is palpated for
alignment, tenderness, step ladder deformity.
Palpation of the alar cartilage
(lower 1/3 of nose)—The lower
part of nose is palpated for alignment, recoil and tenderness.
Palpation of tip of nose—The
nasal tip is palpated for tenderness, cartilage support and tip
recoil.
• Examination of internal nose—The
examination of the internal nose has
been divided into examination of the
vestibule and examination of nasal
cavity proper.
– Examination of vestibule—This
part of examination is done without
speculum. The examiner carefully
elevates the tip of the nose with
your thumb so that the nasal cavity
becomes visible. This part of nose
should be examined for caudal dislocation of septum, septal haematoma and furunculosis.
– Examination of nasal cavity
proper (anterior rhinoscopy)—
This part of examination of nasal
cavity is done with help of thudicum or Killian nasal speculum for
inspection of nasal cavity proper
for nasal secretion, turbinate hypertrophy, nasal mass, foreign body,
etc. This is known as anterior rhinoscopy (Fig.2.7).
Procedure of anterior rhinoscopy—The
anterior rhinoscopy is carried out after
inspection of vestibule without speculum.
Now, the nasal speculum is introduced into
the nasal vestibule with its blades together.
The point of speculum is directed somewhat laterally in nasal vestibule, and then,
the speculum is opened out. Initially,
patient’s head should be kept in vertical
position for visualization of inferior turbinate and inferior meatus; now, head is tilted
backwards for inspection of rest of nasal
cavity, middle turbinate and middle meatus.
After completion of examination, the nasal
speculum is removed and slightly opened
to avoid entrapment of vibrissae.
e
2.1 How toDo Examination ofEar, Nose, Throat, Head, Neck andSkull Base
Nasal septum
Superior meatus
Middle turbinate
Middle meatus
Inferior turbinate
Inferior meatus
Floor of nose
55
Fig. 2.7 Labelled diagram of anterior rhinoscopy and methods of examination of nose
– Probe test—While doing anterior
rhinoscopy, the blunt probe is used
to assess the origin, sensation on
touch, bleed on touch, painful on
touch and consistency of nasal
mass.
– Posterior rhinoscopy—This is the
examination of nasopharynx and
posterior part of nose (choana)
with help of posterior rhinoscopy
During the procedure, the patient is asked to
breathe through nose. If a patient is having
gag reex, 10% Xylocaine can be used to
anaesthetize the oropharynx. The structures
visualized on posterior rhinoscopy are
Eustachian tube opening, fossa of
Rosenmuller laterally, anterior nasal cavity,
posterior end of inferior and middle turbinate and posterior end of nasal septum.
mirror.
Procedure—Posterior rhinoscopy is done
with open mouth, tongue is depressed with
tongue depressor, and mirror is dipped in
antifog solution, hot water or Savlon. Now,
the posterior rhinoscopy mirror is introduced in oropharynx and passed behind the
soft palate with mirror facing upwards.
Middle turbinate
Inferior turbinat
Nasal septum
Eustachian tube
opening
Fossa of
Rosenmuller
56
2 Local Examination ofORL: Head andNeck Surgery
• Special examination of nose
– Clinical tests for assessment of
nasal airow/nasal patency or
functional tests of nose—Nasal
airow can be assessed using several clinical methods (this part has
been discussed in detail in Chap. 4).
Nostril occlusion test
Cold spatula test (misting test)
Cotton wool tests
Cottle’s test (Cottle’s
manoeuvre)
– Clinical tests for ciliary func-
tion—There are few tests for ciliary dyskinesia
Saccharine transit time
Nasal nitric oxide
– Clinical tests for olfactory func-
tion/smell
Snifn—Sticks Smell Test (SS)
Indian Smell Identication Test
Butanol threshold test
University of Pennsylvania
Smell Identication Test
Cross-Cultural Smell
Identication Test
Olfactory-evoked response (usually reserved for research
studies)
(e) Aesthetic assessment/examination of
nose (this part has been discussed in
detail in Chap. 4).
(f) Examination of paranasal sinus
• Inspection of paranasal sinuses—
Stand or sit directly in front of the
patient in good lighting. Inspection of
paranasal sinus area should be done to
look for swelling, skin changes, etc. in
area of maxillary sinus, ethmoid sinus
and frontal sinus, and intercanthal
distance.
• Palpation of paranasal sinuses—The
palpation of paranasal sinus starts with
tenderness.
– Temperature—Raised tempera-
ture is a sign of inammation.
– Tenderness
Maxillary sinus tenderness—
The examiner has to apply gentle pressure over canine fossa
which lies above the canine
tooth, on the anterior wall of
maxillary sinus to elicit pain.
Ethmoid sinus tenderness—The
examiner has to apply gentle
pressure to medial canthus.
Frontal sinus tenderness—The
examiner has to apply gentle
pressure on the oor of frontal
sinus that lies above the medial
canthus of eye.
Sphenoid sinus—This sinus is
located in middle skull base.
– Transillumination test
Maxillary sinus—A bright light
is applied on a hard palate with
lip closed; a crescentic glow is
observed in region of eyelids
and over maxillary sinus. It is
absent or poor in pus and mass,
or thickening in sinus.
Frontal sinus—A light is applied
at the oor of frontal sinus. A
light glow is observed on the
anterior wall of frontal sinus
normally. It is absent or poor in
case of pus, and thickening in
mucosa and mass.
– Postural tests—It is rarely done
now days. In this test, area of middle meatus is observed for appearance of discharge/pus in various
head positions.
Maxillary sinus—Head is bent
to one side so the affected sinus
comes in upright position.
Frontal sinus—In head forward
and chin down position, pus
appears immediately in middle
meatus.
Ethmoidal sinus—If pus takes
10–15 min to appear in middle
meatus in head forward and chin
down position.