Ear, nose and throat examination and how to present it

• An ear, nose and throat (ENT) examination is a focused head and neck examination: ears and hearing, nose and sinuses, mouth and tonsils, voice and swallowing, and neck masses, thyroid and lymph nodes.
• It is done with the person seated, in good light and a quiet room, after a general inspection, using the simplest tools that do the job.
• Most of the work is looking and listening; the parts that need practice are otoscopy and interpreting the tympanic membrane.
• The common abnormalities you should be able to recognise and present are acute otitis media, otitis externa, tonsillitis and peritonsillar infection, and a neck lump.
• The part others remember is how you present: lead with the main finding, summarise, give a short differential, and state the important negatives.

By the end of this page you should be able to:

1. Set up and perform a complete ENT examination in a sensible order at the bedside.
2. Inspect the pinna and perform otoscopy in an adult and a child, and describe a normal tympanic membrane.
3. Carry out whispered voice and tuning fork testing for hearing, and know when they are enough.
4. Examine the nose, mouth and tonsils, the neck including thyroid and nodes, and screen voice, swallowing and cranial nerves.
5. Recognise the patterns of otitis media, otitis externa, tonsillitis and a neck mass.
6. Turn a list of ENT findings into a clear spoken and written presentation.

An ENT examination answers a small set of questions. Is the upper airway open and safe? Is there infection or obstruction in the ears, nose or throat? Is there a lump in the neck that needs explaining? Is there a threat to hearing, smell, voice or swallowing?

The examination sits inside the general medical examination. Introduce it after the history. The person is seated at your eye level in good light, with face and neck fully visible. Begin with the general impression: mouth breathing (suggests nasal obstruction), hoarse voice, stridor, facial symmetry, nutrition, hydration and any visible neck mass.^[1]

Red flags change the pace of the examination: an unstable airway, epiglottitis, peritonsillar abscess with airway risk, stridor, a hard, fixed or progressive neck mass, or sudden cranial nerve deficit. When one of these is possible, keep the examination targeted and involve senior help rather than completing every step.

• Introduction and consent. Explain that you are going to examine the ears, nose and throat, why, and what it involves, including that you will look inside the nose and mouth. Obtain consent and agree that the person may pause or stop. Reassure them that you will explain what you find.
• Chaperone. Offer a trained chaperone whenever the examination is sensitive or when the patient requests one, and record the offer and the response. Even in a routine clinic, a curtain, a gown and attention to privacy matter.
• Hand hygiene and safety. Clean your hands before and after. Use disposable gloves where there is drainage, infection or blood. Do not reuse tongue depressors or specula. Warn the person before you insert anything.
• Exposure and position. Seat the person upright in good light, at eye level. Remove spectacles, hearing aids, head covering and jewellery that block the view. Have tissues and a receiver ready. Examine children on a parent's lap, or with a parent holding the head still.
• Environment. A quiet room matters for hearing tests. A headlight or bright focused light makes otoscopy, rhinoscopy and oropharyngeal inspection reliable.
• Equipment. Otoscope with tips of several sizes, a nasal speculum or large otoscope tip, tongue depressor, pen torch, 512 hertz tuning fork, cotton wool, gloves, tissues, water and a receiver.

Work from the general to the local, and from top to bottom. Inspect before touching, and do not put anything into the ear, nose or mouth until you have looked at the outside. This sequence keeps the cooperative tests together.

1. General inspection. Look at the face for asymmetry or swelling, at the mouth (open or closed breathing), at the voice (hoarse, muffled or nasal), at the breathing, and at the neck for visible masses. Listen for stridor. Ask the person to say "ah" and watch for symmetrical rise of the soft palate in the midline.

2. Pinna and external ear (inspection and palpation). Inspect both auricles from the front and side. Look for asymmetry, prominence, scars, lesions, crusts, erythema and swelling. Palpate the pinna and the mastoid process: the normal pinna is smooth and painless. Drainage in the concha or meatus is abnormal. In a child, asymmetry or deformity of cartilage may hint at a middle ear problem.^[1]

3. Otoscopy in the adult. Choose the largest speculum that fits easily. Reassure the person and warn before you insert it. Insert the speculum with a gentle twisting motion under direct vision, avoiding contact with the easily injured skin of the canal. Examine the canal for narrowing, erythema, oedema, exudate, foreign body or wax. Then focus on the tympanic membrane (eardrum). The normal membrane is translucent, with fine vascularity along the part of the malleus attached to it, and a light reflex may be seen at its anterior-inferior part. It should be inspected for dullness, erythema, retraction, bulging, perforation, scars, crystals or a white mass.^[1] If middle ear effusion is suspected, perform pneumatic otoscopy by sealing the canal with a slightly larger or soft tip and applying a small amount of positive and then negative pressure with a bulb or tube; the normal membrane moves with this pressure.^[1]

4. Otoscopy in a child. The same principles apply, but cooperation is often poor and the canals are small. Because crying can cause erythema of the tympanic membrane and obscure a diagnosis of acute otitis media, the otological examination should be done first in a child, before anything else has upset them. Get help from the parent or assistant. An otoscope tip often works better than a nasal speculum in a child. Keep the pinna pulling technique age-appropriate: pull down and slightly back in an infant, up and back once the cartilage is firmer.^[1]

5. Hearing (only if hearing loss is suspected or reported). Start with the whispered voice test: with the opposite ear blocked, whisper something familiar and ask the person to repeat it; move closer if there is no response. Suspected loss should lead to formal audiometry. Then, when you suspect conductive or sensorineural loss, use a 512 hertz tuning fork. Weber: place the vibrating fork at the centre of the forehead or vertex and ask which side sounds louder; central (equal on both sides) is normal, and lateralisation on one side is abnormal. Rinne: compare air conduction (fork held in front of the ear) with bone conduction (fork on the mastoid); air louder than bone is normal and is also seen in sensorineural loss, while bone louder than air suggests a conductive loss. A 512 hertz tuning fork usually suffices, with additional forks of 256 and 1024 hertz increasing sensitivity and specificity.^[1]

6. Nose and anterior rhinoscopy. Look first at the external nose for shape, symmetry, swelling or deformity, and ask whether one side feels more blocked. Then examine the inside with a bright headlight and a nasal speculum; an otoscope with a large tip is often preferable in children. Inspect the appearance of the nasal mucosa, the septum for deviation or a haematoma, the inferior and middle turbinates, and any polyps, crusting, foreign body or mass. Note the colour of the mucosa and any rhinorrhoea. The face should also be inspected for stigmata of allergic rhinitis before you look inside.^[1]

7. Nasal patency and septum. Test each nostril separately by occluding the other and asking the person to sniff in; a marked difference suggests obstruction. Look at the anterior septum for a C- or S-shaped deviation, and for a swollen, bluish-red septal haematoma after trauma. Inspect the inferior turbinates low in the cavity (they can be mistaken for a mass, especially when asymmetric because of the normal nasal cycle) and the middle turbinate higher up. Ask about bleeding, crusting, smell and taste.^[1]

8. Mouth and oropharynx. Inspect the lips, teeth, gums and buccal mucosa for lesions, ulcers, pallor or bleeding. Ask the person to stick out the tongue and move it: look at its size, surface, fissures and any coating. Inspect the hard and soft palate, the uvula and the gag reflex. Have the person say "ah" so you can see palatal movement and symmetry; watch the uvula for deviation. Look at the salivary duct openings. Note any odour, drooling or difficulty managing saliva. Ask whether swallowing is painful or difficult.

9. Tonsils. Inspect the tonsils for size, colour, crypts, exudate and symmetry. Mild asymmetry can be normal, but new asymmetry with fever and pain matters. The peritonsillar area should be examined for swelling or erythema, and the uvula for deviation away from a swollen side. The anterior cervical nodes should be palpated at the same time, because tenderness there supports tonsillitis. The typical symptoms of streptococcal tonsillitis are a sudden sore throat, pain on swallowing, fever and chills, and the examination shows a purulent white exudate on the tonsils with tender anterior cervical lymphadenopathy.^[1] Centor screening criteria are tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough, and history of fever; when three or four are present, a rapid antigen test is reasonable.^[1] The features most suggestive of a peritonsillar abscess are fever, sore throat for 3 to 5 days, dysphagia, odynophagia and a muffled "hot potato" voice, with trismus; the examination shows asymmetric tonsils with peritonsillar swelling and erythema and a swollen uvula.^[1]

10. Neck masses (inspection and palpation). Inspect both sides of the neck from the front and side, with the chin slightly raised and then turned. Palpate systematically from behind or in front, covering the midline (thyroid, thyroglossal), the anterior and posterior triangles, and the supraclavicular fossae. Note each mass's site, size, shape, consistency, tenderness, mobility, fixation to skin or underlying structures, and whether it moves with swallowing or tongue protrusion. Remember the normal structures that can be mistaken for a mass: a low-lying submandibular gland, a calcified carotid artery and the transverse processes of the cervical spine. Masses in the neck may be inflammatory, congenital or neoplastic. In adults, a neck mass should be assumed malignant until proved otherwise, and the mucosal surfaces of the upper airway and the skin should be examined as well.^[1][2]

11. Thyroid and neck nodes. Inspect the lower neck for a goitre. Ask the person to swallow water and watch the thyroid isthmus and lobes rise; a thyroglossal cyst rises with swallowing and also with tongue protrusion, while a diffuse goitre rises with swallowing only. Palpate from behind with the neck bent slightly to relax sternocleidomastoid, determining extent, size, consistency and tenderness. A clinically palpable thyroid nodule is generally more than 1 cm in size. Check for regional cervical lymphadenopathy, tracheal deviation and retrosternal extension, and auscultate for a bruit. Pemberton's sign is positive when, after raising both arms for a minute or longer, the person develops facial plethora, respiratory depression, stridor or distension of the neck veins, implying thoracic inlet obstruction. Check the regional lymph node chains at the same time: size, consistency, tenderness, mobility and fixation are the useful descriptors.^[3]

12. Voice, swallowing, stridor and cranial nerve screen. Listen to the voice (hoarse, breathy, nasal or muffled), the cough and the swallow. Ask about choking, nasal regurgitation and pain. Stridor is noisy breathing produced by turbulent airflow through a narrowed airway, usually at or above the larynx: inspiratory stridor typically comes from obstruction at or above the true vocal cords, expiratory stridor from the more distal tracheobronchial tree, and biphasic stridor from obstruction at the cords or immediate subglottic level.^[1] Remember that a child may have stridor with airway obstruction yet not look distressed. Screen the cranial nerves that matter for ENT: facial movement and taste (VII), facial sensation and jaw strength (V), hearing (VIII), palatal movement and gag (IX and X), and tongue movement and wasting (XII). Voice change after neck surgery can point to recurrent laryngeal nerve injury. Examine the facial nerve carefully in otitis externa or otitis media, since a malignant or severe infection can spread.^[1]

• Stridor or any sign of an unstable airway, drooling or a muffled voice with a swollen peritonsillar area (airway at risk).
• A hard, fixed, enlarging or supraclavicular neck mass, or one with unexplained weight loss.
• Severe otalgia with an immunocompromised patient and an inflamed external canal, suggesting malignant otitis externa.
• Facial nerve palsy developing during otitis externa or otitis media.
• A haematoma or mass behind the tympanic membrane in an adult after trauma.
• A septal haematoma, because it can lead to septal necrosis if not drained.
• Progressive dysphagia, hoarseness beyond three weeks, or unilateral ear pain with a normal drum in an adult (refer).
• Epiglottitis is a clinical diagnosis; do not pass an instrument or tongue depressor if it is strongly suspected.

The presentation is a summary, not a replay of every test. Lead with the most important finding or the absence of one, then nerve-by-nerve style completeness without listing every subtest, then the negatives that matter, a summary sentence, a short differential and the plan.

1. Start with the headline. "The cranial nerves..." becomes "The ENT examination is normal" or "There is a right otitis externa with ..." If there is one standout abnormality, name it first.
2. Group the normal parts. "Ears: canals clear, drums normal and mobile; hearing normal to whisper and tuning fork." Do not list every subtest you performed; state the exception, not the whole normal.
3. State the relevant negatives. If you say "tonsillitis" but the uvula is central, the peritonsillar area flat and there is no trismus, say so; those negatives exclude an abscess. If the neck mass moves with swallowing, say that it does; if it does not, that is equally informative.
4. One summary sentence. Say what level or diagnosis you favour: "I think this is an acute otitis externa on the right."
5. A differential in one sentence. Two or three plausible causes in order of likelihood and danger, not a textbook list.
6. Plan in one sentence when you present to a senior: "I would like to treat with a topical antibiotic and review in 48 hours."

In the written note, use the same order but more briefly: "ENT: ears R O.E. with tender tragus and inflamed canal, drum obscured; other ear normal; nose clear; throat normal; neck no lumps. ? acute otitis externa. Plan: topical drops." Only use abbreviations after you have explained them once.

All the following patients are invented and illustrative.

Illustrative normal. "Mr Chen, 34, with a sore throat: the external ears are normal and both drums are translucent with a normal light reflex; hearing is normal to whispered voice and tuning fork; the nasal mucosa and septum are normal and both nostrils are patent; the tonsils are symmetric and small, the uvula rises in the midline and there is no exudate; the neck has no masses and the thyroid and nodes are normal. In summary, the ENT examination is normal."

Illustrative otitis externa. "This is a 22-year-old woman with two days of right ear pain. The right pinna is normal but the tragus is tender, and the canal is oedematous and exquisitely tender with scant discharge; the drum is obscured. The left ear is normal and hearing is normal to whisper. The throat and neck are normal. In summary, this is an acute otitis externa on the right, and I would distinguish otitis media by the absence of a middle ear effusion and by the tenderness of the tragus. Plan: topical ear drops and dry-ear advice."

Illustrative acute otitis media. "This is a 5-year-old boy with fever and pulling at his right ear. The right drum is bulging and erythematous with loss of the light reflex and no movement on pneumatic otoscopy; the left drum is normal and mobile. The nose and throat look normal. There is no neck mass and the nodes behind the ear are mildly tender. My conclusion is acute otitis media of the right ear, and I would exclude otitis externa because the canal is normal and the tragus is not tender."

Illustrative tonsillitis. "This is a 19-year-old student with three days of sore throat and fever. The ears are normal and hearing is normal. The tonsils are enlarged and erythematous with a white exudate, and there is tender enlargement of the anterior cervical nodes on both sides. There is no peritonsillar swelling, the uvula is central and he opens his mouth fully. I think this is acute tonsillitis; with three of four Centor criteria a rapid antigen test is reasonable and the main diagnoses to exclude are infectious mononucleosis and a peritonsillar abscess."

Illustrative neck mass. "This is a 62-year-old smoker with a six-week-old lump on the right side of the neck. The ears, nose and throat are otherwise normal with no mucosal lesion. There is a 3 cm, firm, non-tender, fixed mass in the right anterior triangle, and it does not move with swallowing or tongue protrusion; the thyroid is normal. My localisation is a cervical lymph node rather than thyroid, and the serious possibilities are a metastatic head and neck cancer and lymphoma. He needs urgent ENT examination of the upper airway and cross-sectional imaging."

The separate red-flag list above applies; in presentation terms, any of those findings belongs in the first sentence of your report.

• Peering into the ear before you have looked at the outside: a pinna problem or obvious canal obstruction is missed.
• Using a speculum that is too small, or forgetting pneumatic otoscopy when effusion is the question.
• Saying "drums normal" when you did not inspect both and did not record mobility.
• Diagnosing acute otitis media from a red drum alone, without middle ear effusion and without considering myringitis or otitis externa.
• Forgetting that erythema of the drum can be caused by crying in a child, or by manipulation.
• Calling every neck swelling a lymph node: the thyroid, a salivary gland and the sternomastoid can all be palpable.
• Pressing on an obviously infected canal so hard that the person will not let you near them again.
• Presenting a checklist of negatives and burying the main finding.
• Not stating what you could not test, for example when a child would not let you look in the second ear.
• Forgetting to say "the relevant negatives are normal" when they help exclude an important diagnosis.

• Perform the examination in a fixed order: general, ears, nose, mouth and tonsils, neck, then voice and cranial nerves.
• Otoscopy: largest speculum; adult canal straightened by pulling up and back; inspect canal then drum; pneumatic otoscopy tests mobility.
• A normal drum is translucent with a light reflex; document dullness, erythema, bulging, retraction, perforation and scars.
• Acute otitis media needs acute onset, middle ear effusion and signs of inflammation; myringitis and otitis externa are different. ^[1]
• Otitis externa inflames the canal skin and makes the tragus tender; the drum is often hidden.
• Hearing screening is by whispered voice, supported by 512 hertz tuning forks and formal audiometry when needed.
• Nasal examination looks at mucosa, septum, turbinates, polyps and patency; turbinates are often mistaken for masses.
• Tonsillitis shows exudate and tender anterior cervical nodes; peritonsillar abscess adds trismus, muffled voice and a deviated uvula.
• A neck mass is described by size, consistency, mobility, fixation and movement with swallowing or tongue protrusion.
• Thyroid examination includes swallowing, tracheal position, auscultation and Pemberton's sign.
• Present with the headline first, then a concise normal list, then relevant negatives, a summary, a short differential and the plan.
• State what you could not test and always record enough to allow comparison later.