ORL603 — Clinic, Theatre and Ward Round Teaching: Lecture Note

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la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Course code: ORL 603 Course title: Clinic, Theatre and Ward Round Teaching Course credit load: 1 Unit Series 1: Bedside ENT Examination Skills • Part 1.1: The Headlight and General ENT Examination Setup o Sub Part 1.1.1: Use and adjustment of the headlight o Sub Part 1.1.2: General setup and positioning for ENT bedside examination o Sub Part 1.1.3: Examination of the oral cavity and oropharynx • Part 1.2: Otoscopic Examination o Sub Part 1.2.1: Correct otoscope handling technique o Sub Part 1.2.2: Systematic otoscopic assessment o Sub Part 1.2.3: Common pitfalls in otoscopic examination • Part 1.3: Tuning Fork Tests and Minor Bedside Examination o Sub Part 1.3.1: Performing the Rinne test o Sub Part 1.3.2: Performing the Weber test o Sub Part 1.3.3: Minor bedside examination of the nose and neck Introduction Competent otorhinolaryngological practice depends fundamentally on confident, systematic bedside examination skills, correctly using the headlight, otoscope, and tuning fork, and performing a structured minor examination of the nose, throat, and neck. These practical skills, refined through repeated clinic, theatre, and ward round exposure, form the essential foundation for every subsequent diagnostic and investigative skill examined throughout this course. The aim of this Series is to equip you with a thorough, practical understanding of basic clinical bedside examination in otorhinolaryngology, including correct use of the headlight, otoscope, and tuning fork, and minor examination technique. This Series begins with the headlight and general ENT examination setup, before turning to otoscopic examination. It concludes with tuning fork tests and minor bedside examination.

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Series Learning Outcomes At the end of this Series, you should be able to: • SLO 1.1: correctly set up and adjust a headlight for ENT bedside examination • SLO 1.2: perform a systematic examination of the oral cavity and oropharynx • SLO 1.3: demonstrate correct otoscope handling technique and systematic otoscopic assessment • SLO 1.4: recognise and avoid common pitfalls in otoscopic examination • SLO 1.5: perform and interpret the Rinne and Weber tuning fork tests, and • SLO 1.6: perform minor bedside examination of the nose and neck. 1.1 The Headlight and General ENT Examination Setup 1.1.1 use and adjustment of the headlight Achieving a stable, coaxial light source for hands-free examination The headlight provides a hands-free, coaxial light source essential to virtually every subsequent ENT bedside examination technique, discussed throughout this Series, and should be secured firmly at an appropriate head strap tension, neither so loose that it slips during examination nor so tight as to cause examiner discomfort during prolonged clinic sessions. Correct headlight adjustment requires aligning the beam so that it converges with the examiner's own line of sight at the approximate working distance to the patient, generally achieved by focusing the light onto one's own outstretched palm before beginning examination, ensuring the illuminated field and the examiner's direct view remain precisely coincident throughout the examination. Fill in the blank: Correct headlight adjustment requires aligning the beam so that it converges with the examiner's own line of sight at the approximate working ________ to the patient. 1.1.2 general setup and positioning for ent bedside examination Effective ENT bedside examination requires appropriate patient positioning, generally seated upright facing the examiner at a comfortable, matched eye level, with the examiner's own seated

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS or standing position adjusted to avoid awkward posture that could compromise steady, prolonged examination technique. Essential equipment should be arranged within easy reach before beginning examination, including an appropriately sized otoscope speculum, discussed further in the next Part of this Series, nasal speculum, tongue depressor, and tuning fork, discussed later in this Series, minimising unnecessary interruption or repositioning once the examination itself has begun. Fill in the blank: Essential equipment should be arranged within easy reach before beginning examination to minimise unnecessary interruption once the examination has ________. 1.1.3 examination of the oral cavity and oropharynx Examination of the oral cavity proceeds systematically, assessing the lips, buccal mucosa, gingivae, teeth, and tongue, including its lateral borders and undersurface, before using a tongue depressor to gently displace the tongue and directly visualise the oropharynx, including the tonsils, soft palate, and posterior pharyngeal wall. Asking the patient to say "ah" during this examination elevates the soft palate, improving visualisation of the oropharynx and additionally allowing basic assessment of palatal movement, relevant to identifying possible vagal or glossopharyngeal nerve dysfunction where clinically indicated. Fill in the blank: Asking the patient to say "ah" during oral cavity examination elevates the soft palate, improving visualisation of the ________.

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS Figure 1.1: Diagram illustrating correct headlight alignment onto the examiner's outstretched palm to confirm coincident beam and line of sight. Pilot questions 1.1 1. Describe the correct method for confirming a headlight is properly adjusted before examination. (Linked to SLO 1.1) 2. Describe appropriate patient positioning for ENT bedside examination. (Linked to SLO 1.1) 3. List the essential equipment that should be arranged before beginning an ENT examination. (Linked to SLO 1.1) 4. Describe the systematic approach to examining the oral cavity. (Linked to SLO 1.2) 5. Explain the purpose of asking a patient to say "ah" during oropharyngeal examination. (Linked to SLO 1.2)

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS 1.2 Otoscopic Examination 1.2.1 correct otoscope handling technique A stable, controlled grip protecting against sudden patient movement The otoscope should generally be held in a pen grip, with the ulnar border of the examining hand resting gently against the patient's cheek or head, providing a stable point of contact that moves together with the patient's head should sudden, unexpected movement occur, discussed further in relation to safety in this sub-Part. The opposite hand should be used to gently apply pinna traction, discussed in relation to otological examination in an earlier related course, upward and backward in adults, or downward and backward in young children, straightening the external auditory canal to allow clear visualisation of the tympanic membrane. Fill in the blank: The otoscope should generally be held in a pen grip, with the ulnar border of the examining hand resting gently against the patient's cheek or ________. 1.2.2 systematic otoscopic assessment Systematic otoscopic assessment should proceed in a consistent sequence, first inspecting the external auditory canal for wax, discharge, inflammation, or foreign material, before advancing the speculum gently under direct vision to bring the tympanic membrane into clear view. Assessment of the tympanic membrane itself should systematically note its colour, translucency, position, and the presence or absence of the light reflex and visible landmarks, discussed in relation to middle ear examination in an earlier related course, with any abnormal finding described precisely according to its specific location on the membrane. Fill in the blank: Assessment of the tympanic membrane should systematically note its colour, translucency, position, and the presence or absence of the light ________. 1.2.3 common pitfalls in otoscopic examination Common pitfalls in otoscopic examination include inserting the speculum too deeply, risking patient discomfort or canal trauma, particularly in the sensitive bony portion of the canal, and failing to adequately straighten the canal through correct pinna traction, discussed earlier in this Part, resulting in an incomplete or obscured view of the tympanic membrane. A further recognised pitfall involves mistaking impacted cerumen for the tympanic membrane itself, particularly where wax closely approximates the membrane's expected position,

la-NET | ONLINE LEARNING VIDEO PLATFORM FOR POST-SECONDARY & HIGHER INSTITUTION STUDENTS underscoring the importance of confirming genuine visualisation of recognised landmarks, discussed earlier in this Part, before concluding the examination is normal. Fill in the blank: A recognised pitfall in otoscopic examination involves mistaking impacted cerumen for the tympanic ________ itself. Table 1.2: Common otoscopic examination pitfalls and their prevention. Pitfall Consequence Prevention Speculum inserted too deeply Patient discomfort or canal trauma Advance gently under direct vision only Inadequate pinna traction Obscured or incomplete view Apply correct traction before advancing speculum Mistaking cerumen for tympanic membrane Missed abnormality or false reassurance Confirm visualisation of recognised landmarks Pilot questions 1.2 1. Describe the correct grip and hand position for holding an otoscope. (Linked to SLO 1.3) 2. Explain the purpose of resting the examining hand against the patient's cheek during otoscopy. (Linked to SLO 1.3) 3. Describe the systematic sequence of otoscopic examination. (Linked to SLO 1.3) 4. List two common pitfalls in otoscopic examination and describe how to avoid each. (Linked to SLO 1.4) 5. Explain why mistaking impacted cerumen for the tympanic membrane is a recognised risk. (Linked to SLO 1.4) 1.3 Tuning Fork Tests and Minor Bedside Examination 1.3.1 performing the rinne test Comparing air and bone conduction within a single ear The Rinne test is performed by striking a 512 Hz tuning fork and placing its base firmly against the patient's mastoid process,

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