I would wash my hands, introduce myself to the patient and gain consent for the examination and ensure adequate exposure. I would ask if the patient was in any pain.
I would begin with general inspection using a headlight looking at the better ear first. I would examine the pre-auricular region the pinna and post-auricular region looking for pinna abnormalities, scars, pits and lymph nodes and palpate the overlying skin for mastoid deformity, swelling or tenderness,
If available, I would perform microscopic evaluation of the ear assessing the bony and cartilaginous external canal for skin conditions, infection, scars, haematoma, polyps, stenosis or exostoses and osteomas. I would examine all four quadrants of the tympanic membrane and any visible middle ear structures. I would grade any retractions and size perforations.
I would then perform the fistula test looking for nystagmus, free-field hearing test, tuning fork testing and assessment of the facial nerve.
Fistula test: Findings are dependent on the affected canal and location of the fistula. If affecting the lateral canal, then a positive fistula test is where there is nystagmus towards the affected ear with deviation of the eyes away. A false positive test may be seen in congenital syphilis (due to hypermobile stapes footplate) and Ménière disease (due to fibrous bands connecting utricle to the stapes).
Free field test: I would explain the procedure to the patient and place myself behind the patient shielding my mouth. I would test the better hearing ear first whilst masking the contralateral ear with tragal rub (around 50dB). I would start with a whisper at arms length (60cm). If the patient is unable to hear this (~25dB) then it would suggest a hearing deficit. I would then move to a conversational voice (~50dB) and loud voice (~75dB) and moving closer to the patient until they achieved 50% correct responses. This would allow me to estimate the hearing threshold of the patient. I would repeat this exam on the other side.
Tuning fork test: I would explain the procedure to the patient. I would begin with Weber test placing a 512Hz tuning fork on the vertex and asking the patient to tell me which side this was heard loudest. This would indicate a conductive hearing loss on that side or a contra-lateral sensorineural hearing loss. I would then perform Rinne's test by striking the tuning fork and placing this on the mastoid process whilst asking the patient to cover the contralateral ear. I would ask the patient to report when the sound can no longer be heard. I would move the tuning fork to adjacent to the ear canal and ask if the patient can still hear the tuning fork. If air conduction is better than bone conduction then this is considered a normal (positive) Rinne's test.
I would complete my examination with formal hearing testing (PTA, play audiometry, VRA), tympanometry and complete cranial nerve examination and the balance system. I would also perform flexible nasoendoscopy looking at the post nasal space and examine the neck for lymph nodes.
I would wash my hands, introduce myself to the patient and gain consent for the examination and ensure adequate exposure. I would ask if the patient was in any pain and in particular neck pain on movement.
I would begin with assessment of eye movements (CN III, IV,VI) checking for double vision and looking for nystagmus, saccadic eye movements and smooth pursuit and test of skew.
I would then test for the vestibular ocular reflex with head impulse test, post head shake nystagmus and a fistula test.
Post head-shake test: The patient is asked to close their eyes and look down at a 30 degree angle. The patients head is moved side to side reasonably quickly 20 times. Freznel glasses are then placed over the eyes to avoid fixation and the nature and duration of the nystagmus is assessed. Nystagmus occurs in the direction of the better ear and is due to asymmetric input from the vestibular end organs. This implies a poorly compensated vestibular system though is of poor specificity.
I would carry out a cerebellar examination looking for dysdiadochokinesis, past pointing, assessment of gait including heel--to-toe walking and a full cranial nerve examination. With the patient stood up, I would perform Romberg and Untunberger stepping test (balance)
Romberg & Untunberger: The Romberg test is an assessment of proprioceptive impairment (damage to the dorsal column) or may indicate uncompensated vestibular deficit. The test is positive when the patient sways and loses balance with both eyes closed (towards the side of the deficit). The Untunberger stepping test removes proprioceptive input and requires the patient to walk on the spot for 50 steps (or 60 seconds) with eyes closed. A rotation of greater than 30 degrees suggests asymmetrical labyrinthine function with the weaker side identified by the direction of rotation. In isolation, these tests cannot determine the cause of the imbalance.
Finally I would I carry out position testing with a Dix-Hallpike and a supine head roll test.
Dix-Hallpike & Supine head roll test: These test for BBPV in the posterior and superior canal or the lateral canal respectively.
Dix-Hallpike Check for neck pain and ask the patient to keep their eyes open throughout the procedure. Position the patient sitting upright on the couch. Stand behind the patient and turn the head 45° to one side and extended 30°. Supporting the head, lower the patient quickly to a supine position and observe for any abnormal eye movements for at least 30 seconds. If positive, then proceed to the Epley manouevre. This now involves turning the head 90° to the other side with the head still turned 45°. After 30 seconds move the patient on to their shoulder and hold for another 30 seconds. Finally ask the patient to sit up and they can slowly begin to move their head up to the neutral position.
Supine head roll test The patient begins by lying supine with head in neutral position. The head is turned 90° to the right side with observation of nystagmus for 30 seconds and then turned back to neutral. Then the head is then turned 90° to the left side. The direction of nystagmus in each position is noted. If positive, then proceed to the Lempert roll manouevre. The patient is moved in a series of step-wise 90° rolls away from the affected side holding each position for 30 seconds until the patient is lying supine again. The patient is then sat up rapidly. In canalithiasis, nystagmus/symptoms are on the affected side. In cupulolithiasis, nystagmus/symptoms are on the the unaffected ear during the roll test
I would complete my examination with otoscopy, formal hearing assessment along with VHIT and caloric tests.
I would wash my hands, introduce myself to the patient and gain consent for the examination and ensure adequate exposure. I would ask if the patient was in any pain.
CN I - I would ask the patient if they had noticed any change in smell and formally test this with the University of Pennsylvania smell identification test (UPSIT).
CN II - I would then test visual acuity with a Snellen chart and Ishihara chart to test colour discrimination. I would also test for both direct and consensual response to light and assess for relative afferent pupillary defect (RAPD).
The ‘swinging light test’ is used to detect a RAPD. In healthy eyes, the reaction of the pupils in the right and left eyes are linked by an afferent sensory limb (II) and efferent motor limb (III).
CN III, IV, VI - Next, I would test eye movements with the 'H Test' looking for diplopia and ptosis.
III, IV, VI: Isolated III palsy results in ptosis due to paralysis of levator palpebrae superioris muscle, eye deviated 'down and out' and a fixed, dilated pupil due to paralysis of sphincter pupillae. Ciliary muscle paralysis also leads to loss of accommodation. However, in ischemic lesions, the pupil is spared with no loss of accommodation. IV palsy results in the pupil looking inferomedially whilst VI palsy leads to a failure in abduction of the eye.
CN V - I would then test for the corneal reflex, sensation in all 3 divisions and assess the motor function with jaw opening against resistance.
Cavernous sinus pathology: This leads to palsies of III, IV, V (opthalmic and maxillary) and VI.
CN VII - I will ask about taste disturbance, assess the face at rest and then sequential facial expressions looking at assymetry.
CN VIII - This can be tested with head impulse testing along with tuning fork and whisper test but can be formally measured with pure tone audiometry and VHIT.
CN V, VI, VII & VIII: These nerves can be affected by cerebelopontine angle lesions and necrotising otitis externa complicated by skull base osteomyelitis.
CN IX & X - I would test these together looking at the afferent (IX) and the efferent (X) limb of the gag reflex and palatal movement. I would perform flexible nasoendoscopy if available.
CN XI - I would test the function of the sternocleidomastoid and trapezius muscles on both sides with a head turn and shoulder shrug against resistance.
CN IX, X & XI: These nerves all exit through the jugular foramen and can be affected in tumours that compress this area.
CN XII - Finally, I would inspect and assess movement of the tongue.
I would wash my hands, introduce myself to the patient and gain consent for the examination and ensure adequate exposure. I would ask if the patient was in any pain.
I would begin with general inspection of the patient's face and nose looking for any gross deformity or assymetry and closely inspecting the skin for any scars (rhinotomy/bicoronal), swelling, bruising or rashes.
I would then assess the patient in the frontal view looking at the brow-tip aesthetic line down to the tip defining point and estimating the nasal width and length by dividing the face into vertical fifths and horizontal thirds. I would confirm my findings by assessing the patient from above.
The Tip-defining point provides highlights on the frontal view, created by the dome of the lower lateral cartilage. Normally consists of symmetrical reflections 5-6mm apart.
I would then assess the patient in the right and left lateral positions at the Frankfort horizontal plane. This would allow me to assess the starting point of the nose, along the dorsum down to the tip. I would also estimate the nasofrontal and nasolabial angles (tip rotation) as well as nasal projection.
Frankfort horizontal plane: The plane from the superior border of the external auditory meatus to the infraorbital rim.
Columella show: Normal is 2-3mm below alar rim. Excess is referred to as 'hanging' and can be due to overly long nasal septum.
Nasofrontal angle: The angle between a line tangent to the nasal dorsum and a line tangent to the glabella through the nasion Normal range: 115° to 145°
Nasolabial angle: The angle between a line tangent to the upper lip and a line tangent to the columella through the subnasale. Normal male: 90°- 95°. Normal female: 95°- 105°.
Nasal projection: This can be measured with Goode's method by drawing a line from the alar crease to the tip perpendicular to the Frankfort horizontal line and another line from the tip to the nasion. The ratio of the two lines should be between 0.55 and 0.6.
I would then assess the patient from below looking at the apex of the nose, columella width and symmetry of the nostrils.
I would then move on to palpating the skin, looking at tip recoil, thumb lift to assess for columella dislocation and test for misting as a marker of patency. I'd also perform a modified Cottle maneuver.
I would now perform anterior rhinoscopy looking at the nasal mucosa, position of the septum and appearance of the inferior turbinates and presence of any gross nasal massess.
I would complete my examination with an examination of the oral cavity, neck and rigid endoscopy with a 3 pass technique
I would wash my hands, introduce myself to the patient and gain consent for the examination and ensure adequate exposure. I would ask if the patient was in any pain.
I would begin with topicalisation of the nose for 10mins with co-phenylcaine spray and use a 3-pass technique with a 4mm 30º Hopkins Rod endoscope.
- 1st Pass - floor of nose + inferior meatus to the post nasal space.
- 2nd Pass - middle meatus
- 3rd Pass - superior meatus + sphenoethmoidal recess and anterior skull base
Throughout, I would be looking for any massess, polyps or pus and asessing the nasal mucosa.
I would complete my examination with an examination of the oral cavity, neck and otoscopy.
I would wash my hands, introduce myself to the patient and gain consent for the examination and ensure adequate exposure. I would ask if the patient was in any pain.
I would begin with general inspection around the patient looking for any scars, sinuses, lumps or evidence of previous radiotherapy. I would ask the patient to swallow and protrude their tongue looking for lumps intimiately related to the thyroid.
I would sequentially palpate all lymph node compartments of the neck including the thyroid, salivary glands and scalp.
I would complete my examination with an examination of the oral cavity and oropharynx, flexible nasoendoscopy and otoscopy.
I would wash my hands, introduce myself to the patient and gain consent for the examination and ensure adequate exposure. I would ask if the patient was in any pain.
I would use a headlight and two tongue depressors to thoroughly examine the oral cavity including buccal and gingival mucosa as well as alveolar ridges and teeth. I would check for lesions of the dorsal, lateral or ventral surfaces of the tongue and floor of mouth. I would then depress the tongue and inspect hard and soft palate, any parapharyngeal swelling or medial displacement of the tonsils and both retromolar trigones.
I would then perform bimanual palpation of the sublingual, submandibular and parotid glands and ducts as well as the tongue base and tonsils if tolerated.
I would complete my examination with flexible nasendoscopy to evaluate the nasal cavity, PNS, larynx and pharynx.
I would wash my hands, introduce myself to the patient and gain consent for the examination and ensure adequate exposure. I would ask if the patient was in any pain.
I would offer the patient co-phenylcaine nasal spray. I would pass the nasoendoscopy along the floor of the nose to the post nasal space looking for any lesions or signs of pathology. I would inspect the eustachian tube orifice and fossa of Rosenmüller. I would pass the scope through the choana to inspect the hypopharynx and supraglottis looking at the lingual and laryngeal surfaces of the epiglottis, vallecula and aryepiglottic folds followed by assessment of the glottis. I would ask the patient to phonate and perform a chin tuck to assesss the subglottis followed by a breath hold to inspect the post-cricoid and pyriform fossae. Whilst withdrawing the nasoendoscope I would inspect the nasopharynx and nasal cavity and repeat this on the other side.
I would complete my examination with an examination of the head and neck, oral cavity and oropharynx and otoscopy.
I would wash my hands, introduce myself to the patient and gain consent for the examination and ensure adequate exposure. I would ask if the patient was in any pain.
I would begin with general inspection all around the patient checking for thinning of hair, proptosis, exophthalmos or chemosis. I would then check eye movements for lid lag or ophthalmoplegia.
I would then ask the patient to extend their hands checking for a tremor, palmar erythema, sweating, dry skin or tachycardia (indicating sympathetic system overactivity). I would assess for thyroid acropachy or onchylosis.
I would also examine for pretibial myxoedema and deep tendon reflexes.
I would complete my assessment with an examination of the head and neck including the thyroid gland and vocal cord assessment. I would arrange for thyroid function tests, thyroid autoantibody screen and an ultrasound neck with fine needle aspiration cytology.