AAO-HNSF Primary Care Otolaryngology Handbook

INTRODUCTION TO CLINICAL ROTATION AND PHYSICAL EXAM

A binocular microscope provides an enlarged, three-dimensional image, giving the physician a superior view of the ear canal and tympanic membrane. The microscope also permits the bimanual removal of wax and foreign bodies. Indirect mirror exam with a headlight permits exami- nation of the larynx, hypopharynx, and nasopharynx. Fiberoptic instru- ments provide a similar ability to examine these regions, but with superior optics. The Ear Assess the external auricle for congenital deformities, such as microtia or preauricular pits. The external auditory canal (EAC) should be examined by otoscopy after being thoroughly cleaned if it is blocked by cerumen. The canal should be assessed for swelling, redness (erythema), narrowing (stenosis), discharge (otorrhea), and masses. The tympanic membrane (TM) is normally pearly gray, shiny, translucent, and concave. Changes in the appearance of the eardrummay indicate pathology in the middle ear, mastoid, or Eustachian tube. White patches, called tympanosclerosis , are often clearly visible and provide evidence of prior significant infection. An erythematous, bulging, opacified TM indicates acute bacterial otitis media. A dull, retracted, amber eardrum can be a sign of serous otitis. If a perforation is present, then the middle ear mucosa may be viewed directly. Healed perforations are often more transparent than the surrounding drum and may be mistaken for actual holes. Pneumatic otoscopy should be performed to observe the mobility of the TMwith gentle insufflation of air. Mobility may be limited by scarring, middle ear effusion, or perforation. Eustachian tube function may be assessed by watching the eardrum as the patient executes a gentle Valsalva maneuver. Tuning forks can be used to grossly assess hearing and to differentiate between conductive and sensorineural hearing loss. A tuning fork placed in the center of the skull (Weber test) will normally be perceived in the midline. The sound will lateralize and be perceived as louder on the affected side in cases of conductive hearing loss. If a sensorineural loss exists, the sound will be perceived in the better or normal hearing ear. The tuning fork is then placed just outside the EAC for the Rinne’s test of air conduction hearing. Placing the base of the tuning fork over the mastoid process allows bone conduction hearing to be assessed. In conductive hearing loss, the tuning fork is heard louder behind the ear (bone conduction is better than air conduction in cases of conductive hearing losses). A proper, complete assessment of hearing requires audiometry. This is indicated in any patient with chronic hearing loss, or with acute loss that

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