Right Eardrum

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Inspect the eardrum, noting its color and contour. The cone of light—usually easy to see—helps to orient you.

Identify the handle of the malleus, noting its position, and inspect the short process of the malleus.

Gently move the speculum so that you can see as much of the drum as possible, including the pars flaccida superiorly and the margins of the pars tensa. Look for any perforations. The anterior and inferior margins of the drum may be obscured by the curving wall of the ear canal.

Mobility of the eardrum can be evaluated with a pneumatic otoscope.

Auditory Acuity. To estimate hearing, test one ear at a time. Ask the patient to occlude one ear with a finger or, better still, occlude it yourself. When auditory acuity on the two sides is different, move your finger rapidly, but gently, in the occluded canal. The noise so produced will help to prevent the occluded ear from doing the work of the ear you wish to test. Then, standing 1 or 2 feet away, exhale fully (so as to minimize the intensity of your voice) and whisper softly toward the unoccluded ear. Choose numbers or other words with two equally accented syllables, such as "nine-four," or "baseball." If necessary, increase the intensity of your voice to a medium whisper, a loud whisper, and then a soft, medium, and loud voice. To make sure the patient does not read your lips, cover your mouth or obstruct the patient's vision.

Air and Bone Conduction. If hearing is diminished, try to distinguish between conductive and sensorineural hearing loss. You need a quiet room and

In chronic otitis externa, the skin of the canal is often thickened, red, and itchy.

Red bulging drum of acute purulent otitis media, amber drum of a serous effusion

An unusually prominent short process and a prominent handle that looks more horizontal suggest a retracted drum.

See Table 5-18, Abnormalities of the Eardrum (pp. 194-195).

A serous effusion, a thickened drum, or purulent otitis media may decrease mobility.

a tuning fork, preferably of 512 Hz or possibly 1024 Hz. These frequencies fall within the range of human speech (300 Hz to 3000 ^—functionally the most important range. Forks with lower pitches may lead to overestimating bone conduction and can also be felt as vibration.

Set the fork into light vibration by briskly stroking it between thumb and index finger —or by tapping it on your knuckles.

■ Test for lateralization (Weber test). Place the base of the lightly vibrating tuning fork firmly on top of the patient's head or on the midforehead.

Weber Test

Ask where the patient hears it: on one or both sides. Normally the sound is heard in the midline or equally in both ears. If nothing is heard, try again, pressing the fork more firmly on the head.

■ Compare air conduction (AC) and bone conduction (BC) (Rinne test). Place the base of a lightly vibrating tuning fork on the mastoid bone, behind the ear and level with the canal. When the patient can no longer hear the sound, quickly place the fork close to the ear canal and ascertain whether the sound can be heard again. Here the "U" of the fork should face forward, thus maximizing its sound for the patient. Normally the sound is heard longer through air than through bone (AC > BC).

Image Cone Light Normal Eardrum

In unilateral conductive hearing loss, sound is heard in (lateralized to) the impaired ear. Visible explanations include acute otitis media, perforation of the eardrum, and obstruction of the ear canal, as by cerumen.

In unilateral sensorineural hearing loss, sound is heard in the good ear.

In conductive hearing loss, sound is heard through bone as long as or longer than it is through air (BC = AC or BC > AC). In sensori-neural hearing loss, sound is heard longer through air (AC > BC). See Table 5-19, Patterns of Hearing Loss (pp. 196-197).

The Nose and Paranasal Sinuses

Inspect the anterior and inferior surfaces of the nose. Gentle pressure on the tip of the nose with your thumb usually widens the nostrils and, with the aid of a penlight or otoscope light, you can get a partial view of each nasal vestibule. If the tip is tender, be particularly gentle and manipulate the nose as little as possible.

Note any asymmetry or deformity of the nose.

Tenderness of the nasal tip or alae suggests local infection such as a furuncle.

Deviation of the lower septum is common and may be easily visible, as illustrated below. Deviation seldom obstructs air flow.

Test for nasal obstruction, if indicated, by pressing on each ala nasi in turn and asking the patient to breathe in.

Inspect the inside of the nose with an otoscope and the largest ear speculum available.* Tilt the patient's head back a bit and insert the speculum gently into the vestibule of each nostril, avoiding contact with the sensitive nasal septum. Hold the otoscope handle to one side to avoid the patient's chin and improve your mobility. By directing the speculum posteriorly, then upward in small steps, try to see the inferior and middle turbinates, the nasal septum, and the narrow nasal passage between them. Some asymmetry of the two sides is normal.

Normal Eardrum ColorNasal Vestibule CancerEdematous Nasal Mucosa


■ The nasal mucosa that covers the septum and turbinates. Note its color In viral rhinitis the mucosa is and any swelling, bleeding, or exudate. If exudate is present, note its char- reddened and swollen; in allergic acter: clear, mucopurulent, or purulent. The nasal mucosa is normally rhinitis it may be pale, bluish, or red. somewhat redder than the oral mucosa.

*A nasal illuminator, equipped with a short wide nasal speculum but lacking an otoscope's magnification, may also be used, but structures look much smaller. Otolaryngologists use special equipment not widely available to others.

■ The nasal septum. Note any deviation, inflammation, or perforation of the septum. The lower anterior portion of the septum (where the patient's finger can reach) is a common source of epistaxis (nosebleed).

■ Any abnormalities such as ulcers or polyps.

Make it a habit to place all nasal and ear specula outside your instrument case after use. Then discard them or clean and disinfect them appropriately. (Check the policies of your institution.)

Palpate for sinus tenderness. Press up on the frontal sinuses from under the bony brows, avoiding pressure on the eyes. Then press up on the maxillary sinuses.

Fresh blood or crusting may be seen. Causes of septal perforation include trauma, surgery, and the intranasal use of cocaine or amphetamines.

Polyps are pale, semitranslucent masses that usually come from the middle meatus. Ulcers may result from nasal use of cocaine.

External Lumps The Superior MeatusSinus Transillumination Technique

Local tenderness, together with symptoms such as pain, fever, and nasal discharge, suggests acute sinusitis involving the frontal or maxillary sinuses. Transillumination may be diagnostically useful. For this technique, see p. 169.

H The Mouth and Pharynx

If the patient wears dentures, offer a paper towel and ask the patient to remove them so that you can see the mucosa underneath. If you detect any suspicious ulcers or nodules, put on a glove and palpate any lesions, noting especially any thickening or infiltration of the tissues that might suggest malignancy.

Inspect the following:

The Lips. Observe their color and moisture, and note any lumps, ulcers, cracking, or scaliness.

The Oral Mucosa. Look into the patient's mouth and, with a good light and the help of a tongue blade, inspect the oral mucosa for color, ulcers,

Bright red edematous mucosa underneath a denture suggests denture sore mouth. There may be ulcers or papillary granulation tissue.

Cyanosis, pallor. See Table 5-20, Abnormalities of the Lips (pp. 198-199).

white patches, and nodules. The wavy white line on this buccal mucosa developed where the upper and lower teeth meet. Irritation from sucking or chewing may cause or intensify it.

An aphthous ulcer on the labial mucosa is shown by the patient.

An aphthous ulcer on the labial mucosa is shown by the patient.

Patchy Tongue Causes

The Gums and Teeth. Note the color of the gums, normally pink. Patchy brownness may be present, especially but not exclusively in black people.

Inspect the gum margins and the interdental papillae for swelling or ulceration.

Inspect the teeth. Are any of them missing, discolored, misshapen, or abnormally positioned? You can check for looseness with your gloved thumb and index finger.

See p. 207 and Table 5-21, Findings in the Pharynx, Palate, and Oral Mucosa (pp. 200-202).

Redness of gingivitis, black line of lead poisoning

Swollen interdental papillae in gingivitis. See Table 5-22, Findings in the Gums and Teeth (pp. 203-205).

The Roof of the Mouth.


Inspect the color and architecture of the hard

The Tongue and the Floor of the Mouth. Ask the patient to put out his or her tongue. Inspect it for symmetry—a test of the hypo-glossal nerve (Cranial Nerve XII).

Note the color and texture of the dorsum of the tongue.

Bump Behind Tongue Near Tonsil Pillar

Inspect the sides and undersurface of the tongue and the floor of the mouth. These are the areas where cancer most often develops. Note any white or reddened areas, nodules, or ulcerations. Because cancer of the tongue is

Torus palatinus, a midline lump (see p. 201)

Asymmetric protrusion suggests a lesion of Cranial Nerve XII, as shown below.

Asymmetrical Tongue Protrusion

Cancer of the tongue is the second most common cancer of the mouth, second only to cancer of more common in men over age 50, especially in those who use tobacco and drink alcohol, palpation is indicated for these patients. Explain what you plan to do and put on gloves. Ask the patient to protrude his tongue. With your right hand, grasp the tip of the tongue with a square of gauze and gently pull it to the patient's left. Inspect the side of the tongue, and then palpate it with your gloved left hand, feeling for any induration (hardness). Reverse the procedure for the other side.

The Pharynx. Now, with the patient's mouth open but the tongue not protruded, ask the patient to say "ah" or yawn. This action may let you see the pharynx well. If not, press a tongue blade firmly down upon the midpoint of the arched tongue—far enough back to get good visualization of the pharynx but not so far that you cause gagging. Simultaneously, ask for an "ah" or a yawn. Note the rise of the soft palate—a test of Cranial Nerve X (the vagal nerve).

Inspect the soft palate, anterior and posterior pillars, uvula, tonsils, and pharynx. Note their color and symmetry and look for exudate, swelling, ulceration, or tonsillar enlargement. If possible, palpate any suspicious area for induration or tenderness. Tonsils have crypts, or deep infoldings of squamous epithelium. Whitish spots of normal exfoliating epithelium may sometimes be seen in these crypts.

Discard your tongue blade after use.

the lip. Any persistent nodule or ulcer, red or white, must be suspect. Induration of the lesion further increases the possibility of malignancy. Cancer occurs most often on the side of the tongue, next most often at its base.

A carcinoma on the left side of a tongue:

(Photo reprinted by permission of the New England Journal of Medicine, 328: 186, 1993—arrows added)

See Table 5-23, Findings In or Under the Tongue (pp. 206-207).

In Cranial Nerve X paralysis, the soft palate fails to rise and the uvula deviates to the opposite side.

Failure Deviated to rise to left

Failure Deviated to rise to left

Vagus Nerve Palate Palsy Facial

See Table 5-21, Findings in the Pharynx, Palate, and Oral Mucosa (pp. 200-202).

Pallor Oral Mucosa

B The Neck_

Inspect the neck, noting its symmetry and any masses or scars. Look for en- A scar of past thyroid surgery may largement of the parotid or submandibular glands, and note any visible be the clue to unsuspected thyroid lymph nodes. disease.

Lymph Nodes. Palpate the lymph nodes. Using the pads of your index and middle fingers, move the skin over the underlying tissues in each area. The patient should be relaxed, with neck flexed slightly forward and, if needed, slightly toward the side being examined. You can usually examine both sides at once. For the submental node, however, it is helpful to feel with one hand while bracing the top of the head with the other.

Feel in sequence for the following nodes:

1. Preauricular—in front of the ear

2. Posterior auricular—superficial to the mastoid process

3. Occipital—at the base of the skull posteriorly

4. Tonsillar—at the angle of the mandible

5. Submandibular—midway between the angle and the tip of the mandible. These nodes are usually smaller and smoother than the lobulated sub-mandibular gland against which they lie.

A "tonsillar node" that pulsates is really the carotid artery. A small, hard, tender "tonsillar node" high and deep between the mandible and the sternomastoid is probably a styloid process.

6. Submental—in the midline a few centimeters behind the tip of the mandible

7. Superficial cervical—superficial to the sternomastoid

8. Posterior cervical—along the anterior edge of the trapezius

9. Deep cervical chain—deep to the sternomastoid and often inaccessible to examination. Hook your thumb and fingers around either side of the sternomastoid muscle to find them.

10. Supraclavicular—deep in the angle formed by the clavicle and the ster-nomastoid

External Lymphatic Drainage

External lymphatic drainage

Internal lymphatic drainage (e.g.,from mouth and throat)

External lymphatic drainage

Internal lymphatic drainage (e.g.,from mouth and throat)

Enlargement of a supraclavicular node, especially on the left, suggests possible metastasis from a thoracic or an abdominal malignancy.

Note their size, shape, delimitation (discrete or matted together), mobility, consistency, and any tenderness. Small, mobile, discrete, nontender nodes, sometimes termed "shotty," are frequently found in normal persons.

Tender nodes suggest inflammation; hard or fixed nodes suggest malignancy.

Using the pads of the 2nd and 3rd fingers, palpate the preauricular nodes with a gentle rotary motion. Then examine the posterior auricular and occipital lymph nodes.

Using the pads of the 2nd and 3rd fingers, palpate the preauricular nodes with a gentle rotary motion. Then examine the posterior auricular and occipital lymph nodes.

Can Preauricular Lymph Nodes Cancer

Palpate the anterior cervical chain, located anterior and superficial to the sternomastoid. Then palpate the posterior cervical chain along the trapezius (anterior edge) and along the sternomastoid (posterior edge). Flex the patient's neck slightly forward toward the side being examined. Examine the supraclavicular nodes in the angle between the clavicle and the ster-nomastoid.

Supraclavicular Nodes

Enlarged or tender nodes, if unexplained, call for (1) reexamination of the regions they drain, and (2) careful assessment of lymph nodes elsewhere so that you can distinguish between regional and generalized lymph-adenopathy.

Occasionally you may mistake a band of muscle or an artery for a lymph node. You should be able to roll a node in two directions: up and down, and side to side. Neither a muscle nor an artery will pass this test.

The Trachea and the Thyroid Gland. To orient yourself to the neck, identify the thyroid and cricoid cartilages and the trachea below them.

Diffuse lymphadenopathy raises the suspicion of infection from human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS).

■ Inspect the trachea for any deviation from its usual midline position. Then feel for any deviation. Place your finger along one side of the trachea and note the space between it and the sternomastoid. Compare it with the other side. The spaces should be symmetric.

Tracheal Deviation

Masses in the neck may push the trachea to one side. Tracheal deviation may also signify important problems in the thorax, such as a mediastinal mass, atelectasis, or a large pneumothorax (see p. 243).

■ Inspect the neck for the thyroid gland. Tip the patient's head back a bit. Using tangential lighting directed downward from the tip of the patient's chin, inspect the region below the cricoid cartilage for the gland. The lower, shadowed border of each thyroid gland shown here is outlined by

The lower border of this large thyroid gland is outlined by tangential lighting. Goiter is a general term for an enlarged thyroid gland.


Enlarged Thyroid Picture

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