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2.1 How toDo Examination ofEar, Nose, Throat, Head, Neck andSkull Base
57
3. Examination of face, maxillofacial area,
orbit and eye
(a) Clinical anatomy—The front of human
head is known as face. It is bounded superiorly by hairline, inferiorly by chin and
laterally by preauricular area and temporal area. Anatomically, face is divided
into upper face, middle face and inner
face. The face is covered by skin, supercially, while the deep anatomy contains
muscles, fat pads, nerves, vessels and
bones.
(b) Position of patient—The patient can be
examined in a sitting, supine position
depending on the general condition of
patient.
(c) Examination of face and maxillofacial
area
• Inspection
– Facial features—Normal varia-
tions of face: oval face, square face,
round face, rectangular face, diamond face and heart-shaped face.
Oval face—Oval faces are the
most proportional out of all the
shapes.
Square face—With a square
face, the sides of face are straight
and jawline is more angled with
a slightly rounded chin. Face is
nearly as wide as it is long
(hence the square shape) with a
square forehead.
Round face—Round faces are
very similar to square-shaped
faces, just with softer more
rounded angles. The sides of
face curve outwards slightly
instead of being straight. The
chin is rounded, and cheekbones
are slightly wider than the other
features of face.
Rectangle/oblong face—
Rectangular faces are characterized by a much longer and
narrower face structure. The
chin has a very slight curve, with
forehead, cheeks and jawline
being about the same width.
Diamond face—Diamondshaped faces are characterized
by having much higher and
wider cheekbones with a more
pointed and narrower chin with
narrower hairline (which is the
main difference when compared
to the heart-shaped face).
Heart-shaped face—Heartshaped faces are very similar to
the diamond face with one main
difference, the hairline (forehead)
is much wider. The cheekbones
are still the widest feature of the
face, with the chin having being
more pointed and narrower.
– Facial features in various disease
Hypothyroid face—Facial
expressions become dull, eyelids droop, and the eyes and face
become puffy.
Thyrotoxic face—Facial expression of excitement tension, nervousness or agitation with or
without exophthalmos.
Acromegalic face—Pronounced
brow protrusion, often with ocular distension (frontal bossing),
pronounced lower jaw protrusion (prognathism) with attendant macroglossia (enlargement
of the tongue) and tooth
spacing.
Cushing face—Fatty deposits,
especially in the midsection, the
face (causing a round, moonshaped face).
Thalassaemic face—
Enlargement of the cheekbones
and forehead in people with
thalassaemia major.
Down face—A attened face,
especially the bridge of the nose.
Almond-shaped eyes that slant
up and short neck.
58
2 Local Examination ofORL: Head andNeck Surgery
Anaemic face—Pale skin of
face, itchy skin with pale lips
and can be easily bruised.
Scleroderma face—Facial
involvement is common and
may be mild, or it can reduce
facial movements, including
decreasing the mouth opening.
Sturge-Weber face—A port- wine
birthmark is most often on the
face, typically on the forehead,
temple or eyelid usually only on
one side of the face but can be on
both sides. Over time, the skin
within the port-wine birthmark
can darken and thicken.
Ageing face—Face appears
abby and dropping due to loss
of muscle tone and thinning
skin.
– Skin of face and head—This part
has been discussed in Chap. 14.
– Symmetry of face
Whole face symmetry
Inspection for asymmetry
Laceration—The site, depth and
size are noted
Trismus
Ecchymosis
Step defect in occlusion—It can
be localized or generalized
Bucket handle fracture
Pan facial fracture
Lengthening of face
Shortening of face
Swelling of face
Oedema of face
Parade ground fracture—B/L
parasymphyseal with B/L condylar fracture
Moon face—B/L circumorbital
ecchymosis, gross oedema
caused by Le Fort type 2 fracture, Le Fort type 3 fracture
Dish face deformity—
Lengthening of middle third of
face is caused by Le Fort type 3
deformity
Panda facies—B/L circumorbital ecchymosis is localized
to orbicularis oculi region
Horizontal third of face
Upper part of face—The
inspection of upper part of face
for forehead, supraorbital rim,
frontal eminence, frontal
depression.
Mid part of face—The midface
is inspected for malar depression, subcutaneous, emphysema,
orbital rim step deformity,
altered relative pupil position,
subconjunctival haemorrhage,
nasal depression or deviation of
nasal dorsum.
Lower part of face—The lower
part of face is inspected for
abnormal occlusion, haematoma, laceration, step deformities, symmetry of angle of
mouth.
Vertical fth of face—The vertical fth describes the ideal
transverse proportion of face to
comprise equal fth. The face is
divided by vertical lines drawn
from medial canthus of eye, lateral canthus of eye and preauricular area of face. Each fth is
roughly equal to one eye or
width of alar base.
Intraoral inspection—The oral
cavity is inspected for type of
dental occlusion, laceration, loss
of teeth, bleeding, fracture of
palate, step deformities of dentition, buccolabial sulcus, tongue,
soft palate movement, buccal
and lingual sulcus for laceration,
hard palate—palatal haematoma/laceration/step ladder
deformity.
ab c
2.1 How toDo Examination ofEar, Nose, Throat, Head, Neck andSkull Base
59
• Palpation of face and maxillofacial
area
– Extraoral palpation
Step ladder deformity of orbit
margins—This is a sign of
orbital wall fracture, frontozygomatic suture, zygomatic buttress, zygomatic arch, inferior
orbital rim, zygomatic maxillary
suture (Fig.2.8).
Crepitation—Abnormal crepitation felt on palpation.
Abnormal movement of maxilla,
mandible, nose.
Bow string test—Hold the eyelid skin with nger or forcep and
pull laterally, while the tendon
area is palpated to detect movement of fracture segment. A lack
of resistance or movement of
underlying bone is found indicative of a fracture.
Palpation of nose—Nose is palpated for tenderness and abnormal movement and crepitation.
Infraorbital area—Infraorbital
area is palpated for anaesthesia,
hypoesthesia.
Nasoethmoid area—crepitation
over nasoethmoid area and maxillary region.
Area of tenderness.
Step deformity—Orbital rim
and mandibular margin are palpated for step deformities.
Abnormal mobility—Nose,
maxilla and mandible are palpated for abnormal mobility.
Inferior border continuity.
– Intraoral palpation
Tenderness—Site is noted.
Abnormal movement of nose.
Mobility of upper or lower or
both alveolus.
Mobility of maxilla—It is tested
by grasping the anterior alveolar
arch and forward while stabilizing head with other hand.
Le Fort type 1—Palate moves,
which is known as oating palate.
Le Fort type 2—Maxilla and
base of nose move, which is
known as oating maxilla.
Le Fort type 3—Whole face
moves, which is known as oating face.
Fig. 2.8 (a–c) Examination of orbital margin for step ladder deformity, crepitation, tenderness and abnormal
movement
60
2 Local Examination ofORL: Head andNeck Surgery
(d) Examination of orbit and eye
• Inspection of orbit and eye
– Inspection of eyeball
Exophthalmos—It is also known
as proptosis, or bulging or protruding eyeballs. It can affect
one or both eyes.
Enophthalmos—It is also known
as shrunken eye due to posterior
displacement of the eyeball
within the orbit due to changes
in the volume of the orbit (bone)
relative to its contents (the eyeball and orbital fat), or loss of
function of the orbitalis muscle.
Movement of eyeball—Adduction, medial, lateral upward and
downward movement.
Vision/visual acuity/visual eld
testing.
– Inspection of conjunctiva
Palpebral conjunctiva
Pallor—anaemia, shock, heart
failure, hypopituitarism
Plethoric—polycythaemia,
superior vena cava obstruction
Haemorrhage—trauma, hypertension, bleeding disorder
Bulbar conjunctiva
Yellow—jaundice
Blue—osteogenesis imperfecta
– Inspection of cornea and pupil
Pupillary reex/light reex
(this part has been discussed in
Chap. 1).
• Palpation of eye
– Palpation of eyeball
Forced duction test—The
forced duction test is performed
in order to determine whether
the absence of movement of the
eye is due to a neurological disorder or a mechanical restriction. The anaesthetized
conjunctiva is grasped with forceps, and an attempt is made to
move the eyeball in the direction
where the movement is
restricted.
Intercanthal distance—It is
referred to distance between
medial canthi of the eye. The
increased distance is called
telecanthus.
– Palpation of cornea
Corneal reex—First explain
the procedure to patient, then
take wisp of cotton and approach
the eye from lateral side to
lightly touch to his cornea. The
examiner should take care to
remain out of his line of vision.
Observe for blinking and tearing
in that eye (direct corneal reex).
At the same time, observe
whether his other eye blinks
(consensual corneal reex).
Now repeat the test on patient
for opposite eye.
– Palpation of orbital wall—step
ladder deformity of orbit margins—
This is a sign of orbital wall fracture, frontozygomatic suture,
zygomatic buttress, zygomatic
arch, inferior orbital rim, zygomatic maxillary suture.
4. Examination of lip and oral cavity
Examination of lip
(a) Examination of lip—The patient should
be examined in their natural sitting position, in order to assess the lips in an
upright manner. The lips should also be
examined while they are relaxed and
when they are in motion. This is to assess
the natural position of the lips, as well as
symmetry of muscle movement, and to
check for action and hyperactivity of
muscle groups. All of these aspects will
be discussed further in the following
sections.
• Inspection of upper and lower lips
including skin and vermillion borders:
Normally, the lip tissue should be resilient and smooth and have a homoge-
2.1 How toDo Examination ofEar, Nose, Throat, Head, Neck andSkull Base
61
neous pink colour, and vermillion
border should be distinct and even. The
lips should be inspected for:
– Symmetry, colour, tissue consis-
tence and texture.
– Pigment change.
– Keratosis.
– Atrophy.
– Subsurface abnormalities like
swelling, ulceration, blistering,
discoloration.
– Deformities—Cleft or non-cleft
deformities.
– Lip position—Lip position will be
affected by changes in the position-
ing of the teeth and alveolar, both of
which tend to increase in retrusion
relative to the chin and bony facial
plane with age.
– Lip shape—Full, thin or in between.
– Lip height—The characteristics
that should be measured in order to
assess lip height include the upper
and lower lips, lower lip/chin
height, ratio of upper lip to lower
lip/chin height, interlabial gap (the
gaps between the lips at rest), and
the upper and lower lip vermillion
height.
– Lip thickness—An important con-
sideration when assessing the lips
as it is directly affecting lip
prominence and is inuenced by
ethnic background. Thinner lips are
more capable of following the teeth
and jaw movements, which makes
any loss of movement or other aes-
thetic effects more apparent.
– Lip contour—The contour should
be assessed in both front and side
views to evaluate the curvature, curl
and inclination of the lip. The lip
curl is affected by the position and
strength of dentoskeletal support of
the lips. One such instance is the
occurrence of a at upper lip due to
maxillary dentoalveolar retrusion.
– Lip posture—The posture of the lip
should be evaluated when the lips
are at rest (relaxed with normal
muscle tone), in a natural head position in repose. Also assess lip seal
(ability of the lips to close) at this
point. In certain cases, lip seal is not
achieved when the lips are at rest,
due to particular characteristics of
the lip posture, and adaptive postures are used instead. In these
cases, the patient is undergoing
continuous contraction of circumoral musculature.
– Lip inclination—As mentioned
before, support of the lips is dentoalveolar. Thus, the structure of the
underlying bone and teeth will greatly
inuence how the lips will look. This
is particularly pertinent when it
comes to lip inclination, where protrusion or retrusion of the upper and
lower incisors will change the inclination of the lips accordingly. For
instance, impingement of the upper
incisor teeth onto the lower teeth can
result in eversion of the lower lip.
– Lip prominence—From the side,
assess the prominence of the lips in
relation to the prominence of the
nose and chin. Lip prominence will
vary according to skeletal factors,
soft tissue factors such as lip thickness, or dentoalveolar factors such
as position of the incisor teeth.
– Lip activity and function—Lip
activity is assessed in terms of
hypertonic (high activity or overactivity) or hypotonic (underactive, or
low muscle-toned, lips) lips.
Hypotonic lips appear accid and
may be overstretched to attain lip
seal. This feature is typical in individuals with an increased lower
face height. Hypertonic lips, on the
other hand, may retrocline the lower
incisor teeth (in the case of a hyper-
62
2 Local Examination ofORL: Head andNeck Surgery
tonic lower lip), or result in a
gummy smile (due to a highly toned
upper lip levator muscle).
– Behaviour of lips—The contraction
of perioral musculature indicates
atypical swallowing.
– Shape and aesthetic quality of
lips—The closure line should be
located 2 mm above the incisional
edge of the maxillary anterior teeth.
• Palpation
– Tenderness—Tenderness of palpa-
tion suggests inammation.
– Induration—It is dened as hard-
ness of lip caused either by inammation or by tumours.
– Lip tonicity—The lip tonicity is
assessed by pinching lips between
index nger and thumb. The hypotonic lips give sensation of squeezing a wet cotton roll, while
hypertonic lips offer strong
resistance.
Examination of oral cavity
(b) Examination of oral cavity (Fig.2.9)
• Inspection—There are various sites in
oral cavity to be examined by direct
and indirect visual inspection which is
done with the help of mirror.
– General examination of oral cav-
ity—The oral cavity is examined
for:
Mouth opening—The mouth
opening can be normal or
reduced.
Oro dental hygiene—It can be
classied into poor, average and
good.
– Examination of subsites of oral
cavity—Oral cavity including all
subsites is examined for colour of
mucosa, texture of mucosa, ulceration, growth, swelling, etc. The
subsites of oral cavities are as
follows:
Upper and lower gingiva.
Upper and lower labial mucosa.
Lower and upper gingiva-buccal
sulcus.
Teeth—Upper and lower.
Lower and upper alveolus.
Buccal/cheek mucosa—Cheek
mucosa also contains Stensen’s
duct opening which lies against
the upper second molar.
Tongue—Tongue is examined
for movement, atrophy, fasciculation, taste too.
Hard palate—Hard palate is
examined for its position, any
cleft.
Soft palate and uvula—The soft
palate and uvula are examined
for movements; any deviation is
noted.
Upper and lower gingiva-labial
sulcus.
Floor of mouth—Floor of mouth
contains opening of submandibular duct opening which lies to
side of frenulum. This is examined by asking patient to open
the mouth and elevate the
tongue.
Retromolar trigone—Space
behind the last molar and pterygomandibular raphe (ascending
ramus of mandible).
• Palpation—Oral cavity can be assessed
easily by palpation. The examiner
should wear gloves and use his/her
index nger for palpation of cheek,
hard palate, tongue, oor of mouth.
– Bimanual palpation—The subman-
dibular gland and sublingual
parotid gland can be palpable
bimanually.
Position—The examiner either
stands or sits in front of the patient.
Procedure—The examiner rst
wears gloves. Now ask the patient
to open mouth and not to close
while palpation. For palpation of
submandibular gland, the index nger to be placed on oor of mouth
and ngers of other hand on submandibular area, ngers of second
hand are pushed upwards to feel
2.1 How toDo Examination ofEar, Nose, Throat, Head, Neck andSkull Base
63
a
c
b
d e
f g
h i
Fig. 2.9 Examination of oral cavity. (a) Upper labial
mucosa, (b) lower labial mucosa, (c) examination of gums
and teeth, (d) upper gingivolabial sulcus, (e) lower gingi-
swelling is either palpable with
both hand or not. The sublingual
gland can be palpated behind mandibular canine in oor of mouth.
The parotid gland is bimanually
palpated around the anterior border
of ramus of mandible.
Interpretation
Submandibular gland—It is palpable with both hands because it has
two lobes while submandibular
j
volabial sulcus, (f, g) cheek mucosa, gingiva-buccal sulcus, (h) hard palate, (i) soft palate, and (j) retromolar
trigone
lymph node did not. Bimanual palpation is useful in differentiating
submandibular salivary gland
swellings from enlarged submandibular lymph nodes.
Sublingual gland—The sublingual
glands can be felt behind each mandibular canine. Placing one index
nger within the mouth and the ngertips of the opposite hand outside
it, the compressed gland is manually
64
2 Local Examination ofORL: Head andNeck Surgery
palpated between the inner and
outer ngers.
Parotid gland—This is palpated
mainly externally but also bimanually around the anterior border of
the ramus of the mandible. The
gland extends below and behind the
angle of the jaw, and parotid lumps
in this region may be difcult to
differentiate from lymph nodes or
submandibular gland enlargement.
– Palpation of swelling/growth—The
swelling is palpated for tenderness,
induration, extension, movement,
xation and bleeding.
– Palpation of cheek—The cheek is
hold between nger and thumb and
palpated for tenderness, induration,
swelling, lymph node, etc.
– Palpation of tongue—Tongue is
palpated for induration, tenderness,
wasting, tonicity, etc.
Clinical picture for examination of oral
cavity and lips
5. Examination of oropharynx/throat
(a) Clinical anatomy: location and anatomy of
oropharynx—Oropharynx is located posterior to oral cavity, inferior to nasopharynx and superior to hypopharynx.
Oropharyngeal isthmus separates oral cavity from oropharynx which is formed by
soft palate, anterior tonsillar pillars, and
junction of anterior 2/3 with posterior 1/3
of tongue. The nasopharyngeal isthmus
separates it from nasopharynx. Inferiorly,
it is continuous with hypopharynx.
(b) Instruments (Fig. 2.10).
(c) Position of patient—Patient sits in front
of the examiner with legs to one side of
examiner. The head mirror with bull’s
lamp or headlight is used for illumina-
tion. The patient is asked to open the
mouth keeping tongue inside; a tongue
depressor is used to depress the tongue
for visualization of oropharynx. The
tongue depressor should not touch the
posterior part of tongue to avoid gag
reex.
(d) Examination of oropharynx
• Inspection of oropharynx—It consists of the inspection of both tonsils,
lateral oropharyngeal wall, posterior
oropharyngeal wall, movement of
uvula and base of tongue.
– Tonsil—It is located in tonsillar
fossa which is bounded anteriorly
by anterior tonsillar pillar and posteriorly by posterior tonsillar pillar.
Tonsil should be looked for hypertrophy (size), congestion, ulceration, growth, membrane.
Hypertrophy of tonsil—Side
(unilateral or bilateral), grade of
hypertrophy.
Congestion of anterior tonsillar
pillar—It is a sign of infection.
Fig. 2.10 Instruments for examination of oropharynx
2.1 How toDo Examination ofEar, Nose, Throat, Head, Neck andSkull Base
65
Membrane—Colour of membrane, is it adherent or not, does
it bleed on removal and site of
membrane.
Pus—Colour, amount, site (tonsil, posterior oropharyngeal
wall).
Debris/stone—Site, consistency
and size should be noted.
Ulcer/growth—The site, size,
numbers.
Bulging—Tonsil is either
pushed medially and inferiorly
or pushed medially.
– Lateral oropharyngeal wall—It is
located posterior to posterior tonsillar pillar up to posterior pharyngeal
wall.
Bulging or swelling—It may be
pushed medially by parapharyngeal tumour and parapharyngeal
abscess.
Growth—It may be either extension of tonsillar growth or de
novo growth of lateral oropharyngeal wall.
– Posterior oropharyngeal wall.
Congestion.
Hypertrophied follicle.
Bulging—It is present in case of
retropharyngeal abscess.
Postnasal drip—It is a sign of
chronic rhinosinusitis.
Ulcer—Ulcer may be painful
or not, cover with membrane or
not.
Growth—The proliferative or
endophytic growth can be found.
– Base of tongue—Hypertrophied
lymphoid follicle, swelling/growth/
ulcer, etc. This part is visualized on
indirect laryngoscopy.
– Soft palate—Soft palate is observed
for movement, symmetry, bulging,
cleft, swelling, etc. The movement
of soft palate is checked by asking
the to say aaa.
– Uvula—Uvula is checked for
movement, size and symmetry.
• Palpation of oropharynx—This is
done to palpate the base of tongue,
tonsil to evaluate the induration, tenderness and pain.
Procedure of palpation—The examiner
wears the gloves, asks patient to open
mouth and protrude tongue, and uses his/
her pulp of index nger for palpation of
base of tongue and tonsil.
6. Examination of larynx and hypopharynx
Clinical anatomy—The larynx is located
between c3 and c6 cervical vertebra. It has
three parts supraglottis, glottis and subglottis.
Superiorly, it is continuous with oropharynx
at the level of vallecula and inferiorly with trachea. Posteriorly, it is related to pyriform
fossa, hypopharynx.
How to examine the larynx—Indirect
laryngoscopy is an OPD procedure for examination of larynx (Fig.2.11).
7. Examination of head and neck—This is dis-
cussed in detail in Chap. 10.
8. Examination of thyroid—Examination of
thyroid has been discussed in Chap. 11.
9. Examination of salivary glands—
Examination of salivary gland has been discussed in Chap. 12.
66
Fig. 2.11 Labelled
diagram of indirect
laryngoscopy
Median
glossoepiglottic
fold
Rima glottis
2 Local Examination ofORL: Head andNeck Surgery
Base of tongue
Vallecula
Epiglottis
False vocal cords
Ventricle
Tr ue vocal cord
Aryepiglottic fold
Pyriform fossa
Arytenoid
Inter arytenoid
area
2.2 Summary ofCase
It should be in few lines, explaining the general
information of patient and then key points.
Always reach four points during medical history
taking:
1. C/C (chief complaints) of patient with
duration
2. Organ system affected
3. Onset of symptoms (acute/chronic)
4. Possible diagnosis
So, it could be like xx-year-old M or F presented with complains of xxx for xx duration. Add only positive history. On
examination, positive nding to be included
is the main focus on local examination. The
provisional diagnosis appears to be xx.
Diagnosis
Provisional diagnosis—The most possible diagnosis
should be made based on history and examination
Differential diagnosis—Make a list of possible
diagnosis and rule out individually to reach to the
exact diagnosis
Relevant diagnosis—This is made on the basis of
history, examination and investigations