ENT Exam Study Guide: Structured Breakdown

I. CLINICAL EXAMINATION TECHNIQUES

A. Otoscopic Examination (Ear Assessment)

Master pneumatic otoscopy as your primary diagnostic tool—it achieves 94% sensitivity and 80% specificity when performed correctly. 1

Essential Equipment

Pneumatic otoscope with nasal adapter 2
Indirect mirror 2
Rigid or flexible nasopharyngoscope 2
Impedance tympanometer for assessing tympanic membrane mobility 2

Key Examination Findings to Document

Tympanic membrane characteristics: dullness, erythema, retraction, perforation, mobility (reduced or increased), air-fluid levels 2
External ear: alar collapse, transverse external crease, external deformity (saddle nose) 2
Ear canal: obstructions, discharge amount/color/consistency 2
Topical decongestant response: Apply topical decongestant to differentiate mucosal edema from bony hypertrophy and distinguish severely edematous mucosa from nasal polyps 2

Tympanometry Adjunct

Confirms middle ear effusion with 91% sensitivity and 76% specificity when type B tympanogram is positive 1
Essential for assessing tympanic membrane mobility, especially in children 2

II. NASAL AND SINUS EXAMINATION

A. Nasal Endoscopy Protocol

Perform systematic three-pass nasal endoscopy with the patient upright, using topical decongestant/anesthetic spray as needed. 2

Three-Pass Technique

First pass: Along nasal floor to nasopharynx—assess general anatomy, septum, inferior turbinates, nasal mucosa 2
Second pass: Above inferior turbinate to middle meatus, then medial to middle turbinate into sphenoethmoidal recess 2
Third pass: Withdraw endoscope while rolling laterally into middle meatus 2

Diagnostic Accuracy

Nasal endoscopy correlates highly with CT findings (r=0.85, p<0.0001) 2
Sensitivity: 73% (84% when Lund-Kennedy score ≥2) 2
Specificity: 77% (79% when Lund-Kennedy score ≥2) 2

Critical Findings to Document

Nasal mucosa appearance: pallor, edema, erythema, hyperemia 2
Turbinate status: hypertrophy, edema, crusting 2
Discharge characteristics: amount, color, consistency 2
Structural abnormalities: septal deviation, spurs, ulcers, perforation, prominent vessels 2
Masses: nasal polyps, tumors, foreign bodies 2
Unilateral vs bilateral findings: Unilateral symptoms suggest structural problems (polyp, foreign body, septal deformity, tumor) 2

III. OROPHARYNGEAL EXAMINATION

A. Throat Assessment Technique

Perform firm, thorough sampling of throat and tonsils while avoiding cheeks, gums, and teeth. 2

Key Findings

Tonsillar status: hypertrophy, cobblestoning of oropharyngeal wall 2
Pharyngeal discharge: postnasal drainage 2
Dental findings: halitosis, malocclusion, high arched palate (associated with chronic mouth breathing) 2
Temporomandibular joint: pain or clicking with occlusion 2
Tongue/buccal mucosa: furrowing, coating, ulceration 2

Critical Pitfall

Never swab in suspected epiglottitis—blood cultures are the preferred diagnostic sample; swabbing should only occur in settings with emergency response capability 2

IV. COMPREHENSIVE PHYSICAL EXAMINATION ELEMENTS

A. Vital Signs and General Observations

Record weight and height in all patients 2
Facial features: pallor, elongated facies, preferred mouth breathing, evidence of systemic disease 2

B. Ocular Examination

Excessive lacrimation, conjunctival erythema/swelling 2
Cobblestoning of tarsal conjunctiva 2
Dennie-Morgan lines, "allergic shiners" (venous stasis below lower eyelids) 2
Note: Allergic shiners occur in 38% of nonatopic individuals, so they are supportive but not specific 2

C. Neck Examination

Lymphadenopathy, thyroid enlargement or tenderness 2

D. Chest Examination

Signs of asthma: chest wall deformity, abnormal percussion, egophony, wheezing, abnormal auscultation 2

E. Abdominal Examination

Tenderness, distension, masses, hepatosplenomegaly 2

F. Skin Examination

Rashes (eczematous or urticarial), dermatographism 2

V. DIAGNOSTIC MICROBIOLOGY

A. Specimen Collection Principles

Submit tissue, fluid, or aspirate whenever possible—swabs are not the specimen of choice for head and neck infections. 2

Otitis Media Microbiology

Gold standard: Tympanocentesis (needle aspiration of middle ear fluid) 2
Aspirate both ears in bilateral acute otitis media 2
Critical pitfall: Nose and throat cultures have NO value in diagnosing acute otitis media—they are neither sensitive nor specific for predicting bacteria in middle ear effusion 2

Key Pathogens to Know

Acute otitis media: Streptococcus pneumoniae, nontypeable Haemophilus influenzae, Moraxella catarrhalis 2
Less common: S. aureus, Streptococcus pyogenes, Pseudomonas aeruginosa 2
Note: H. influenzae, S. aureus, N. meningitidis, and S. pneumoniae are NOT etiologic agents of pharyngitis 2

Specimen Transport

Keep tissue specimens moist during transport 2
Use anaerobic transport containers only if anaerobes suspected 2
Anaerobic bacteria are infrequent pathogens in most ENT infections 2

VI. ALLERGY TESTING IN ENT PRACTICE

A. Specific IgE Testing Indications

Determine specific IgE preferably by skin testing to confirm allergic basis, identify suspected allergen causes, or assess sensitivity for avoidance/immunotherapy. 2

Skin Prick Testing

Simplicity, ease, rapidity, low cost, high sensitivity make skin testing preferred 2
Select allergens based on patient age, history, environment, geography, occupation, activities 2
Interpretation: 60% of total sensitizations are clinically relevant 2
Clinical relevance varies by allergen: 40% (cockroach) to 87-89% (grass, mites) 2
Larger wheal sizes (≥3mm) significantly increase risk of allergic symptoms 2

Serum Specific IgE Immunoassays

Sensitivity compared to skin prick tests: 50% to >90%, average 70-75% 2
Similar sensitivity when compared to nasal provocation challenge 2

Advanced Testing (Exceptional Circumstances)

Nasal allergen challenge: For occupational allergies, starting with low doses and increasing until response achieved 2
Conjunctival provocation test: 89% diagnostic efficacy when correlated with nasal challenge 2

VII. HISTORY TAKING ESSENTIALS

A. Rhinitis-Specific History

Document these 13 critical elements systematically: 2

Nature of presenting symptoms (rhinorrhea, congestion, sneezing, ocular symptoms) 2
Duration of symptoms 2
Current and past medications (duration, effectiveness, adverse events) 2
Medications for other conditions and relationship to rhinitis 2
Quality of life impact 2
Seasonality or lack thereof 2
Occupational exposures 2
Detailed environmental history 2
Precipitating factors 2
Other medical conditions 2
Complications (sinusitis, otitis media) or comorbidities (asthma) 2
Family history of allergic rhinitis, asthma, atopic dermatitis 2
Personal/family history of chronic sinus problems 2

B. Pediatric-Specific Questions

Sniffing, snorting, throat clearing 2
Chronic gaping mouth, halitosis, cough 2
Dark circles under eyes, eye rubbing 2
Poor appetite, learning/attention problems 2
Sleep disturbances, malaise, irritability 2

C. Distinguishing Allergic vs Nonallergic Rhinitis

Pruritus and sneezing are much more common in allergic than nonallergic rhinitis. 2

Allergic rhinitis features: Seasonal exacerbations, onset before age 20 2
Nonallergic rhinitis features: Isolated postnasal drainage, symptoms triggered by strong odors (perfume, tobacco smoke) 2
Gustatory rhinitis: Isolated rhinorrhea with eating 2
Rhinitis medicamentosa: Chronic/frequent topical decongestant spray use 2

VIII. ACUTE OTITIS MEDIA (AOM) CLINICAL CRITERIA

A. Diagnostic Definition

AOM is inflammation of the middle ear evidenced by fluid presence accompanied by specific signs (ear pain, drainage, hearing loss) or nonspecific findings (fever, lethargy, irritability, anorexia, vomiting, diarrhea). 2

B. Middle Ear Effusion Confirmation

Pneumatic otoscopy with or without tympanometry or acoustic reflectometry 2
Accuracy limitation: Even experienced otoscopists are accurate in only ~80% of cases 2

C. Age-Specific Considerations

Highest incidence: 6-24 months 2
Newborns/infants ≤6 weeks: Different bacterial pathogens (organisms acquired during delivery) 2
Risk significantly increased in: males, Native Americans, Canadian/Alaskan Eskimos 2
Risk may be lower in Black Americans vs White Americans 2

IX. CHRONIC SUPPURATIVE OTITIS MEDIA (CSOM)

A. Diagnostic Criteria

CSOM is chronic inflammation with polymicrobial infection of middle ear/mastoid cavity, presenting with persistent ear discharge through perforated tympanic membrane. 1

Primary Symptoms

Persistent ear discharge 1
Hearing loss 1

Otoscopic Findings

Perforated tympanic membrane with discharge 1
Tympanic membrane retraction 1
Limitations of membrane motion 1

B. Complications and Impact

CSOM carries 91% absolute risk of permanent hearing loss when occurring in childhood. 1

Impaired auditory skills at ages 8-12 years 1
Serious complications: mastoiditis, meningitis, brain abscesses 1
Global mortality: ~21,000 deaths annually from otitis media complications 1

X. OTITIS MEDIA WITH EFFUSION (OME)

A. Clinical Characteristics

OME is fluid buildup behind the eardrum without acute infection signs, typically self-limiting with spontaneous resolution within 3 months in most cases. 3

Symptoms

Mild discomfort 3
Fullness in ear 3
Mild hearing problems 3

B. Management Approach

Watchful waiting for first 3 months in uncomplicated OME before considering interventions 3
Follow-up every 3-6 months until fluid resolves 3
Ineffective treatments to avoid: Antihistamines, decongestants, antibiotics (unless specifically prescribed) 3
No benefits from alternative therapies (chiropractic, special diets, herbal remedies) 3

C. Prevention Strategies

Avoid secondhand smoke exposure 3
Limit pacifier use during daytime (children >12 months) 3
Proper allergy and upper respiratory infection management 3

XI. COMMON DIAGNOSTIC PITFALLS

A. Specimen Collection Errors

Using swabs instead of aspirates for otitis media 2
Obtaining nose/throat cultures to diagnose AOM 2
Attempting to swab epiglottitis 2

B. Physical Examination Errors

Failing to use pneumatic otoscopy 2, 1
Not applying topical decongestant to differentiate mucosal vs bony hypertrophy 2
Inadequate throat sampling (touching cheeks/gums/teeth instead of throat/tonsils) 2

C. Interpretation Errors

Assuming "allergic shiners" confirm atopy (present in 38% of nonatopic individuals) 2
Believing mucosal appearance distinguishes allergic from nonallergic rhinitis 2
Misinterpreting unilateral symptoms as bilateral disease 2

What are the key points to study for an ENT (Ear, Nose, and Throat) exam?

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