Otorhinolaryngology (ENT)
Clinical Examination of the Ear, Nose and Throat
ENT clinical examination for MBBS: otoscopy, Rinne and Weber tuning fork tests, rhinoscopy, indirect laryngoscopy and audiogram interpretation, mapped to NMC codes EN2.
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Clinical Examination of the Ear, Nose and Throat
ENT clinical examination for MBBS: otoscopy, Rinne and Weber tuning fork tests, rhinoscopy, indirect laryngoscopy and audiogram interpretation, mapped to NMC codes EN2.
This chapter teaches the bedside skills that make ENT diagnosis possible. It covers otoscopy, tuning fork tests and their interpretation, anterior rhinoscopy, indirect laryngoscopy and neck examination, along with basic audiometry and tympanometry, so that clinical signs can be read confidently.
High-yield: Clinical Examination of the Ear, Nose and Throat
- Otoscopy assesses the external canal and tympanic membrane; the normal drum is pearly grey with a cone of light anteroinferiorly.
- The Rinne test compares air conduction with bone conduction; air greater than bone (Rinne positive) is normal or sensorineural loss.
- A negative Rinne, bone greater than air, indicates conductive hearing loss in that ear.
- The Weber test lateralises to the affected ear in conductive loss and to the better ear in sensorineural loss.
- A tuning fork of 512 hertz is preferred for clinical tuning fork tests as it balances audibility and duration.
- Anterior rhinoscopy uses a nasal speculum to inspect the septum, turbinates and any polyp or discharge.
- Indirect laryngoscopy with a warmed mirror lets you view the vocal cords and their movement.
- Tuning fork tests can be misleading with a false negative Rinne in severe unilateral sensorineural loss, where the sound crosses to the opposite cochlea.
- Pure tone audiometry plots hearing thresholds against frequency and objectively grades and typifies hearing loss.
- The fistula test looks for nystagmus or vertigo on pressing the tragus, suggesting a labyrinthine fistula.
- Tympanometry measures middle ear compliance; a flat (type B) trace suggests fluid or perforation.
- The tuning fork must be struck gently and placed correctly, on the mastoid for bone conduction and near the meatus for air conduction.
- Examination of the neck for lymph nodes and the postnasal space completes a full ENT assessment.
- A cotton wisp or the patient's own breath on a mirror can confirm nasal airway patency at the bedside.
Tuning fork tests, at a glance
- **Rinne positive (AC > BC):** Normal hearing or sensorineural loss in that ear.
- **Rinne negative (BC > AC):** Conductive hearing loss in that ear.
- **Weber to the poor ear:** Conductive hearing loss on that side.
- **Weber to the better ear:** Sensorineural hearing loss on the opposite side.
NMC competencies in this chapter
- **EN2.1:** Elicit and record a history in a patient with ENT complaints
- **EN2.2:** Examination of the ear including otoscopy
- **EN2.3:** Examination of the nose and paranasal sinuses
- **EN2.5:** Examination of the throat, oral cavity and neck
- **EN2.6:** Perform and interpret tuning fork tests
- **EN2.9:** Interpret an audiogram in common types of hearing loss
- **EN2.11:** Indirect laryngoscopy and posterior rhinoscopy technique
- **EN2.14:** Choose and interpret basic ENT investigations
Frequently Asked Questions
How do I interpret Rinne and Weber together?
In conductive loss the affected ear is Rinne negative and Weber lateralises to it. In sensorineural loss the ear is Rinne positive and Weber lateralises away, to the better ear.
Why use a 512 hertz tuning fork?
It gives a good balance of loudness and duration. Lower forks are felt as vibration and higher forks decay too fast, so 512 hertz is the clinical standard.
What is a false negative Rinne?
In severe one-sided sensorineural loss, bone-conducted sound crosses to the opposite normal cochlea, so the ear seems Rinne negative although the loss is sensorineural. Masking clarifies it.
What does a flat tympanogram mean?
A flat type B trace suggests reduced middle ear mobility, usually from fluid (effusion) or a perforation, and supports a conductive picture on the audiogram.
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