Clinical Skills

Question 1

What clinical skills do I need for ENT?

Answer 1

Examination of a neck lump
Otoscopy
Hearing assessment
Nasal examination
Dix-Hallpike and Epley Manoeuvres
Oral cavity examination

Question 2

What is the first step to a neck examination?

Answer 2

As usual, set the scene:

Wash hands, introduce self, confirm patient details, explain examination, gain consent, and expose appropriately.

Question 3

What do we look for in the inspection step of a neck examination?

Answer 3

Voice changes (weak/hoarse)
Breathing changes (dyspnoea/stridor)
Scars
Masses

Systemic signs (cachexia/exophthalmos/proptosis)

Look from front and both sides

Question 4

What equipment is needed to examine the oral cavity?

Answer 4

Gloves, a headlight and 2 tongue depressors

Question 5

How should an oral cavity examination begin?

Answer 5

As usual with hand washing, introductions, and obtaining consent. Ask about any pain, and if they have dentures that should be removed.

Question 6

What is examined first in an oral cavity examination?

Answer 6

General inspection with pts mouth open (“say “aaahhhh””)

Question 7

What might a pt experience on opening their mouth?

Answer 7

Pain, or not.

Question 8

What structures in the mouth should we examine?

Answer 8

Hard palate, soft palate, tonsils, uvula, tongue, gingiva, and vestibule of mouth.

Question 9

What could be wrong with the lips on examination?

Answer 9

Discolouration, ulceration, swelling, angular stomatitis

Question 10

What could be wrong with the tongue on examination?

Answer 10

Candida, glossitis, ulceration, swelling, other (black hairy tongue -> Kaposi’s sarcoma)

Question 11

What could be wrong with the palate or uvula?

Answer 11

Swelling, ulceration, papillomas, deviation.

Question 12

What could be wrong with the tonsils?

Answer 12

Enlargement, asymmetry, peritonsillar swelling, ulceration, inflammation.

Question 13

A pt is experiencing facial pain when they start eating. You suspect a stone. Where do you need to look?

Answer 13

The ducts of the salivary glands.

Question 14

What signs might you see on the teeth?

Answer 14

Missing teeth, poor dentition, nicotine stains, swelling, leucoplakia, gingivitis, tooth decay

Question 15

What is the Dix-Hallpike test?

Answer 15

Diagnostic manoeuvre used to identify BPPV.

Question 16

What is the Epley manoeuvre?

Answer 16

A treatment for BPPV once it has been diagnosed.

Question 17

When is Dix-Hallpike test indicated?

Answer 17

For pts with paroxysmal vertigo if BPPV is considered a differential. I.e hx of vertigo when they get up from bed, or change head position which lasts one minute then subsides.

Question 18

How should the Dix-Hallpike test be explained to a pt?

Answer 18

I’ve been asked to assess you in relation to the dizziness you’ve been experiencing. The first stage involves me moving you from sitting to lying position briskly on the examination couch. The second stage involves me holding your head whilst asking you to roll onto your side then to sit upright.

Question 19

What do you need to check before performing the D-H test?

Answer 19

If the pt has any back or neck problems, or pain on movement.

Question 20

Do a step by step of the Dix-Hallpike test.

Answer 20

1. Sit pt upright on couch so that when they lie down their head will hang over the edge of the couch. Ask pt to keep their eyes open throughout 2. Standing behind the pt, turn pts head 45 degrees to one side. 3. Whilst supporting their neck, move pt briskly and smoothly into supine position with head hanging at 30 degrees below plane of couch. 4. Inspect pts eyes for nystagmus for at least 30 seconds. 5. If none observed, pt can sit slowly up, and after a short break the test can be repeated on the other side.

Question 21

What is a positive Dix-Hallpike test?

Answer 21

The pt will complain of vertigo and nystagmus should be observable in the eyes.

Question 22

What features of nystagmus should be noted?

Answer 22

Direction, duration, and latency.

Question 23

How long does nystagmus usually last in BPPV?

Answer 23

20-40 seconds

Question 24

When does nystagmus start following the Dix-Hallpike test?

Answer 24

2-20 seconds after the manoeuvre is performed.

Question 25

What direction does BPPV nystagmus generally go in?

Answer 25

Torsional or rotatory nystagmus is usually seen, but horizontal nystagmus can also occur.

Question 26

In what position should a pt undergoing the Epley manoeuvre be?

Answer 26

Lying flat, head turned from midline at 45 degrees, head hanging over the bed edge.

Question 27

How should the Epley manoeuvre be performed?

Answer 27

Turn pts head 90 degrees to other side i.e. so their head is at 45 degrees from midline on the other side. Stay there for 30 seconds. Maintaining the head position, ask pt to roll onto their shoulder on the side they are facing. Then rotate their head so they are looking directly at the floor and maintain for 30 seconds. Then sit pt up while maintaining head position. Then rotate head back to midline, and put chin to chest and maintain for 30 seconds.

Question 28

How many times can the Epley manoeuvre be performed if needed?

Answer 28

2 or 3 times.

Question 29

What external changes might be seen on the nose?

Answer 29

Skin changes, deformity, or deviation.

Question 30

What elements of the internal nose should be visualised?

Answer 30

Nasal vestibule, the nasal septum, and the inferior turbinates.

Question 31

What should you palpate on examination of a nose?

Answer 31

Nasal bones and cartilage, assessing for pain, alignment or irregularity.

Question 32

Other than inspection and palpation, what can be assessed on examination of the nose?

Answer 32

Airflow

Question 33

What are the aspects of an ear examination?

Answer 33

Visualise the outer and inner ear, and perform some hearing tests.

Question 34

What hearing tests can be performed?

Answer 34

Gross hearing test (whisper a word for them to hear), Weber's test, Rinne's test, and further audiometry.

Question 35

Describe Rinne's test.

Answer 35

512Hz tuning fork is used. Tap fork, then place it firmly on mastoid process behind the ear. Get pt to tell you if they can hear it and when it goes away. Once it has gone, hold it in front of the ear canal to test air conduction, and ask if they can hear it again now. Air conduction should usually be better than bone conduction.

Question 36

Describe Weber's test.

Answer 36

512Hz tuning fork is used. Tap fork then place it firmly in the midline of the forehead. Ask pt where they hear the sound, i.e. if they hear it equally in both sides or more in one side than the other. A normal test will come out as equal in both ears.

Question 37

How can we work out if someone has sensorineural or conductive hearing loss?

Answer 37

By using the results of Rinne's and Weber's tests together.

Question 38

If a pt has ear discomfort, which ear should be examined first?

Answer 38

The non-painful ear.

Question 39

What is examined first in an otoscopy?

Answer 39

The pinnae.

Question 40

What might be seen on examination of the pinnae?

Answer 40

Asymmetry, deformity, piercings, signs of active infection, scars, discharge.

Question 41

What areas around the pinna should be examined?

Answer 41

Behind the pinna (mastoid process) for skin changes, erythema, and scars, as well ask about about pain here.

Question 42

What might be seen in the pre-auricular area?

Answer 42

Pits, sinuses, or fistulae.

Question 43

How should the pinna be positioned for best examination of the ear canal?

Answer 43

Pulled upwards and backwards by the clinicians other hand to straighten the canal out.

Question 44

How should an otoscope be held?

Answer 44

Like a pen, in right hand for right ear and left hand for left ear.