Examination by an ENT doctor. Methods for the study of ENT organs Study of the functions of the auditory analyzer
I.Methods of examination of the nose and paranasal sinuses.
Examination of patients is carried out in a specially equipped room, protected from bright sunlight. The patient is placed on a chair next to the instrument table to the right of the light source. The examiner puts a forehead reflector on his head and illuminates the nose area with a beam of reflected light.
Stages of examination of the patient:
1. Anamnesis
2. Examination of the external nose - shape, skin color, palpation: soft tissue swelling, bone crepitus
3. Anterior rhinoscopy - performed using a nasal mirror. Attention is drawn to the shape of the septum, the condition of the turbinates, the color of the mucosa, the presence of mucus, pus, crusts.
4. Posterior rhinoscopy - a nasopharyngeal mirror and a spatula are required for carrying out. The nasopharynx, choanae, mouths of the auditory tubes, vomer are examined.
Respiratory function is examined using the Woyachek test - a piece of fluffy cotton wool is brought to one nostril, closing the other and watching its movement.
Olfactory function is determined using four standard solutions. These can be: 0.5% solution of acetic acid (low odor); pure wine alcohol (medium smell); valerian tincture (strong); ammonia (ultrastrong).
The paranasal sinuses are examined using radiography, diaphanoscopy (in a dark room, transillumination with a light bulb - the method has historical value), sinus puncture using a Kulikovsky needle, as well as trepanopuncture of the sinuses (frontal).
General treatments:
Treatment is divided into two groups - conservative and surgical.
Conservative treatment includes: toileting the nose with cotton wicks (or rinsing with soda-salt solution, infusions of medicinal herbs), infusing drugs into the nose with drops (3-5 drops for adults, 1-3 drops for children), ointment administration (cotton is wound on a probe , also medicinal substances are administered with the help of turundas), insufflation of powders (using a special powder blower), inhalations, warming thermal procedures.
Surgical treatments include: cutting of the turbinates (conchotomy), resection of deviated nasal septum, ultrasound of the inferior turbinates, galvanocaustics (cauterization of the mucosa with electric current), cryotherapy (cauterization of the mucosa with liquid nitrogen), cauterization of the mucosa with chemicals
II.Methods for the study of the auditory analyzer.
・Anamnesis collection
External examination and palpation
Otoscopy - determines the condition of the external auditory canal and the condition of the tympanic membrane. It is carried out with the help of an ear funnel.
· Functional studies of the ear. Includes the study of auditory and vestibular functions.
Auditory function is examined using:
1. Whispered and colloquial speech. Conditions - a soundproof room, complete silence, the length of the room is at least 6 meters. (norm whispered speech - 6m, colloquial - 20m)
2. Air conduction is determined with tuning forks - they are brought to the external auditory canal, bone - tuning forks are placed on the mastoid process or on the parietal region.
3. Using an audiometer - the sounds entering the headphones are recorded in the form of a curve called an audiogram.
Methods for studying vestibular function.
The rotational test is carried out using a Barani chair
Caloric test - warm water (43g) is injected into the external auditory canal using a syringe, and then cold water (18g)
Pressor or fistula test - air is injected into the external auditory canal with a rubber balloon.
These tests allow you to identify autonomic reactions (pulse, blood pressure, sweating, etc.), sensory (dizziness) and nystagmus.
The human ear perceives the pitch of sound from 16 to 20,000 hertz. Sounds below 16 hertz are infrasound, above 20,000 hertz are ultrasounds. Low sounds cause oscillations of the endolymph, reaching the very top of the cochlea, high sounds - at the base of the cochlea. With age, hearing deteriorates and shifts towards lower frequencies.
Approximate boundary for the location of the volume of sounds:
Whispered speech - 30db
Conversational speech - 60db
Street noise - 70db
Loud speech - 80db
Scream at the ear - up to 110 dB
Jet engine - 120 dB. In humans, this sound causes pain.
Methods for the study of auditory function:
1. Whispering and colloquial speech (norm - 6 meters whispering, colloquial - 20 meters)
2. Tuning forks
3. Audiometry - the resulting curve is called an audiogram
Methods for studying vestibular function:
1. Rotational test in the Barani chair
2. Color test (warm and cold water is injected into the external auditory canal with a Janet syringe)
3. Pressor or fistula test (air is blown into the external auditory canal with a rubber balloon)
Reactions of the body are detected: pulse, blood pressure, sweating, dizziness, nystagmus (involuntary movements of the eyeballs).
III.Methods for examining the pharynx
1. Anamnesis
2. External examination - submandibular lymph nodes are palpated.
3. Inspection of the middle part of the pharynx - pharyngoscopy. Done with a spatula. The oral mucosa, soft palate and uvula, anterior and posterior arches, the surface of the tonsils, and the presence of lacunae are examined.
4. Inspection of the laryngopharynx - hypopharyngoscopy. It is carried out with the help of a laryngeal mirror.
5. Finger examination of the nasopharynx is performed in children to determine the size of the adenoids
General principles of therapy and care
1. Gargling.
2. Inhalation
3. Irrigation of the mucous membrane
4. Washing the lacunae of the tonsils with a special syringe with nozzles.
5. Lubrication of the mucosa with antiseptic solutions (Lugol's solution) using a long threaded probe, on which cotton wool is wound.
6. A warming compress on the neck or submandibular region for sore throats.
IV.Larynx examination begin with examination and palpation of the cartilage of the larynx and soft tissues of the neck. During an external examination, it is necessary to establish the shape of the larynx by palpation to determine the cartilages, their mobility, the presence of pain, crepitus.
Indirect and direct laryngoscopy.
Other methods for examining the larynx include: stroboscopy, giving an idea of the movement of the vocal folds, radiography, tomography, endoscopy with fiberglass optics endophotography.
For effective treatment of diseases of the ear, throat, nose, high-quality diagnostics are necessary. To identify the cause of the pathology, you need a full range of examinations. At the beginning, the doctor interviews the patient, clarifies information about the operations performed earlier, diseases that occur in a chronic form. Next, the patient is examined with the help of instruments, and if necessary, the doctor can additionally refer to instrumental methods of examination.
Inspection Methods
The consultation of an ENT doctor differs from doctors of a different profile in that the ENT learns surgical and conservative treatment. He does not need to “transfer” the patient to other specialists if surgical intervention is needed in the upper respiratory tract and hearing organs. The doctor himself offers the best treatment option. For diagnosis, the following methods are used:
Palpation
The doctor looks at the presence of defects and the color of the skin, the symmetry of the face. Determines the state of the lymph nodes (cervical and submandibular).
Endoscopy
From the Greek language, the word "Endoscopy" is translated as how to look from the inside. An endoscope is an optical tube based on a lens system. The drug is connected to an endovideo camera and a light source.
- If rigid optics are used, the otolaryngologist inserts the endoscope into the ear, nose, or larynx. A multiple image of the examined organ is transmitted to the monitor
- Through the nasal cavity, fibroendoscopy allows assessing the condition of the throat, auditory tubes, and tonsils. Its advantage is that the airways are examined in one insertion of the endoscope.
Laryngoscopy
Consultation with an otolaryngologist during the examination of the larynx includes indirect (mirror) laryngoscopy. A round mirror is inserted into the oral cavity. Inspection occurs at a time when the patient pronounces the sounds "E", "I"; on exhalation
People who have a pronounced gag reflex are given anesthesia (superficial) of the pharynx.
Oropharyngoscopy
When examining the oral cavity and pharynx, the specialist focuses on the condition of the tongue, cheeks, teeth, mucous membranes of the gums, lips. Examining the throat to determine the tone and symmetry of the palate, he invites the patient to pronounce the sound "A".
Otoscopy
The word is translated from Greek as "I explore the ear." Using medical instruments (ear funnel and forehead light), the specialist examines the ear canal and eardrum, skin.
The procedure for examining the nasal cavity:
- The otolaryngologist determines the state of the nasal septum, the "vestibule" of the nose, raising the tip of the nose with a finger
- Using a dilator, examines the mucous membrane, nasal passages
- The posterior parts of the nasal cavity are examined using an endoscope.
Microlaryngoscopy and microotoscopy
An ENT doctor is a specialist who treats diseases of the throat, ear, and nose. If necessary, for bacteriological examination - takes a swab from the ear, nose, pharynx.
Additional examination methods
Reception of an ENT doctor is necessary to identify the causes, factors in the development of the disease and treatment. The otolaryngologist uses a variety of research methods.
- Puncture of the maxillary sinuses, treatment of sinusitis using the sinus catheter YAMIK-3
- rengen
- CT scan
Saint Petersburg State University
Nakatis Ya.A., Tunyan N.T., Konechenkova N.E.
RESEARCH METHODS
ENT
Methodological guide for students, interns
and clinical residents and general practitioners.
St. Petersburg
2009 Methods of examination of ENT organs
The doctor and the patient sit opposite each other at a distance of 30-50 cm. The legs of the doctor and the patient should be closed and directed in different directions (it is possible that the patient's legs are closed together between the legs of the doctor). The instrument table is to the left of the doctor. The light source is placed on it on the right side of the patient, at the level of his ear, somewhat posterior to him. The greatest lighting effect is achieved when the light source, the patient's ear and the doctor's eyes are in the same plane. To direct light to the area being examined, a frontal reflector is used, fixed on the forehead so that the hole in its center is opposite the doctor's left eye (Fig. 1).
Rice. one. The position of the forehead reflector on the doctor's head
Examination of the nose and paranasal sinuses
Before the study, you should carefully ask the patient about his complaints at the moment: pain in the nose, difficulty in nasal breathing, the presence of an abnormal discharge, a disorder of smell. Then they find out the time and conditions for the onset and course of the disease (acute or chronic process). Further, considering that some diseases of the nose can be the result of a number of both infectious diseases and diseases of the internal organs, it is necessary to find out all previous diseases of the nose and determine their relationship with former or present general diseases. Before examining the nasal cavity, attention should be paid to the shape of the external nose (deformity), the state of the vestibule of the nose (atresia), the skin of this area (furunculosis, eczema, sycosis) and the projection of the paranasal sinuses on the face. The study of the entrance to the nose is performed with the patient's head tilted back.
Anterior rhinoscopy. Inspection of the nasal cavity is carried out under artificial lighting using a frontal reflector and a nasal mirror. Anterior rhinoscopy is performed alternately on one and the other half of the nose.
On the open palm of the left hand, a nasal mirror is placed with the beak down. The first finger of the left hand is placed on top of the screw of the nasal mirror, II, III, IV, V fingers should wrap around the jaws of the nasal mirror from the outside. The doctor places his right hand on the forehead or crown of the patient to give the head the desired position during anterior rhinoscopy. The nasal mirror is carefully inserted in the closed state into the right vestibule of the patient's nose to a depth of 0.5 cm, then, gradually, expanding the branches, the nostril is expanded. To avoid trauma to the nasal septum and the occurrence of nosebleeds from the Kisselbach plexus, the nasal speculum should only be inserted into the movable part of the nose up to the apertura periformis. First, the lower sections of the nasal cavity are examined: the bottom of the nasal cavity, the nasal septum, the lower nasal concha (lower nasal passage). To do this, the patient's head is slightly lowered downwards, and the nostril is raised to the top with a nasal mirror (first position). Then they examine the middle nasal concha and the rest of the nasal septum (middle nasal passage) with the patient's head slightly tilted backwards (second position). For a more convenient examination of the nasal cavity, it is necessary to slightly turn the patient's head in one direction or another. Removal of the nasal planum from the vestibule of the nose is performed in a semi-closed state, which prevents the hair from being pinched in the vestibule of the nose.
Inspection of the left half of the nose is carried out in a similar way - the nasal mirror is held in the left hand, and the right one lies on the forehead or crown of the patient. For anterior rhinoscopy in young children, an ear funnel can be used instead of a nasal speculum.
For examination of the nasopharynx and posterior parts of the nose, a mandatory examination is posterior rhinoscopy (Fig. 2). It is carried out in the following way: with a spatula, taken in the left hand, the front two-thirds of the patient's tongue is moved downwards, offering him to breathe calmly through his nose.
The spatula is held with the left hand so that the I finger supports it from below, and the II, III, IV, V fingers are on top. A warmed nasopharyngeal mirror, with its mirror surface up, is inserted into the patient's oropharynx to the posterior pharyngeal wall, without touching the latter, the soft palate and the root of the tongue, as this causes a gag reflex and interferes with examination.
Fig.2. Posterior rhinoscopy technique.
With slight turns of the mirror, the vomer, which is located along the midline, is mirrored. On both sides of it there are choanae with the ends of the lower and middle turbinates lying in their lumen, normally not leaving the choanae. The vault and side walls with the pharyngeal openings of the auditory tubes, which are located at the level of the posterior ends of the inferior turbinates, are also examined.
Normally, the choanae are free, the mucous membrane of the upper pharynx is pink and smooth. In the vault of the nasopharynx is the III nasopharyngeal tonsil, normally it is located on the posterior upper wall of the nasopharynx and does not reach the upper edge of the vomer and choanae. In some cases, in adults, if a tumor process is suspected, they resort to a palpation method for examining the nasopharynx.
Nasal breathing study . To determine nasal breathing, first of all, observe the face of the subject: an open mouth is a sign of difficult nasal breathing. For a more accurate determination, the patient is asked to breathe through the nose, while alternately bringing a nostril cotton fluff to one and the other, the gauze thread, the movement of which in the stream of inhaled air will indicate the degree of patency of one and the other half of the nose. At the same time, according to the amplitude of the "fluff" movement, nasal breathing can be regarded as "free", "satisfactory", "difficult" or "absent".
To study nasal breathing, you can use a mirror or a polished metal plate with a handle (Glyatsel's mirror). Exhaled warm air, condensing on the cold surface of a plate or mirror, forms fogging spots (right and left). According to the size of the absence of fogging spots (right and left). The degree of nasal breathing is judged by the size or absence of sweat spots.
To accurately determine the permeability of air through the nose during scientific work, he uses (rhinopneumometry): for this, manometers of various modifications are taken, with the help of which the air pressure in the nose and pharynx during breathing is determined. To determine the resistance to exhaled air of the upper respiratory tract and nose, a method for determining the function of external respiration (RF) is used using computer programs to determine the "flow-volume" loop. Normal indicators of nasal resistance are 8–23 mm of water. Art., 0.5 l / s. These numbers are higher in children than in adults.
In this case, the subject should be sitting in a comfortable position and be at rest without any previous even the most minimal physical or emotional stress. The nasal breathing reserve value is expressed as the resistance of the nasal valve to air flow during nasal breathing and is measured in SI units as kilopascal per liter per second - kPa / (l s).
Modern rhinomanometers are complex electronic devices, the design of which uses special microsensors - converters of intranasal pressure and airflow rate into digital information, as well as special programs for computer mathematical analysis with the calculation of nasal breathing indices, means of graphic display of the studied parameters (Fig. 3). The presented graphs show that during normal nasal breathing, the same amount of air (y-axis) passes through the nasal passages in a shorter time at half or three times less air jet pressure (abscissa).
Fig.3. Graphical display of air flow parameters
in the nasal cavity during nasal breathing (according to A.S. Kiselev, 2000):
a - with difficulty in nasal breathing; b - with normal nasal breathing.
Acoustic rhinomanometry. In recent years, the method of sound scanning of the nasal cavity has become increasingly widespread to determine some metric parameters related to its volume and total surface.
S.R. Electronics (Denmark) has created a commercially available acoustic rhinometer "RHIN 2000", designed for both everyday clinical observations and scientific research. The device consists of a measuring tube and a special nasal adapter attached to its end. An electronic sound transducer at the end of the tube sends out a continuous broadband sound signal or a series of intermittent sound bursts and registers the sound reflected from the endonasal tissues returning to the tube. The measuring tube is connected to an electronic computer system for processing the reflected signal. Contact with the measuring object is made through the distal end of the tube using a special nasal adapter. One end of the adapter conforms to the contour of the nostril; contact sealing to prevent "leakage" of the reflected sound signal is carried out using medical vaseline. In this case, it is important not to apply force to the tube so as not to change the natural volume of the nasal cavity and the position of its wings. Adapters for the right and left half of the nose are removable and can be sterilized. Acoustic probe and measuring system provide interference delay and output only undistorted signals to recording systems (monitor and built-in printer). The unit is equipped with a mini-computer with a standard 3.5-inch disk drive and a high-speed, non-volatile permanent memory disk. Optional is a 100 MB permanent memory disk. Graphical display of the parameters of sound rhinometry is carried out continuously. The display in stationary mode shows both single curves for each nasal cavity, and a series of curves that reflect the dynamics of changing parameters over time. In the latter case, the curve analysis program provides for both curve averaging and display of probability curves with an accuracy of at least 90%.
The following parameters are estimated (in graphical and digital display): the transverse area of the nasal passages, the volume of the nasal cavity, the difference between the areas and volumes between the right and left halves of the nose. To the possibility of RHIN 2000, an electronically controlled adapter and stimulator for olfactometry and an electronically controlled stimulator for performing allergic provocation tests and histamine tests by injecting the appropriate substances are expanded.
The value of this device lies in the fact that with its help it is possible to accurately determine the quantitative spatial parameters of the nasal cavity, their documentation and research in dynamics. In addition, the unit provides ample opportunities for conducting functional tests, determining the effectiveness of the drugs used and their individual selection.
The study of smell (odorimetry). All methods of researching the sense of smell are divided into qualitative and quantitative. A qualitative study is carried out with the exposure of odorous substances in close proximity to one, then to the other nostril, during which the patient is asked to actively sniff and answer if he feels any smell, and if so, what kind of smell. The following standard solutions can be used for this purpose, in ascending order of odor strength:
Solution No. 1 - 0.5% acetic acid solution (low odor).
Solution No. 2 - wine alcohol 70% (medium strength smell). Solution No. 3 - tincture of valerian (strong smell).
Solution No. 4 - ammonia (super strong smell).
Solution No. 5 - distilled water (control).
The above standard solutions must be stored in glass vials with ground stoppers, marked with the appropriate numbers. One nostril is closed with a finger and allowed to sniff the other half of the nose from each vial. With the perception of all odors - the sense of smell of the 1st degree, of medium and more strong odors - the sense of smell of the 2nd degree, of strong and super-strong odors - the sense of smell of the 3rd degree. When perceiving only the smell of ammonia, it is concluded that there is no olfactory function of the trigeminal nerve, since ammonia causes irritation of the branches of the latter. The inability to perceive the smell of ammonia indicates both anosmia and the absence of excitability of the endings of the trigeminal nerve. A bottle of water is used to detect dissimulation.
A quantitative study of the olfactory function involves the determination of the threshold of perception and the threshold of recognition. For this, olfactory, trigeminal and mixed odorants are used. The principle of the technique consists in dosing the volume of air containing odorous substances in a constant concentration, or in a gradual increase in the concentration of odorous substances until a threshold of perception is obtained.
The method of quantitative study of the sense of smell is called olfactometry, and the devices with which this method is implemented are called olfactometers.
Endomicroscopy of the nose and paranasal sinuses. These methods are the most informative modern diagnostic methods using optical visual control systems, rigid and flexible endoscopes with different viewing angles, microscopes (Fig. 4.5).
Indications for diagnostic endoscopy are very wide: impaired nasal breathing, nasal discharge, impaired sense of smell, recurrent epistaxis, tumors of the nasal cavity, polypous maxillary etmoiditis, dysfunction of the auditory tube, headaches of unknown origin, preoperative examination and postoperative monitoring of therapy, the need for photo- and video documentation, etc., i.e. almost the entire spectrum of pathology of the nasal cavity and paranasal sinuses. The most commonly used endoscope is a rigid endoscope with zero optics.
Fig.4. Rhinoscopes (hard).
Fig.5. Rhinoscope (flexible).
During endoscopic examination, it is necessary to recall the main identification points and landmarks in the nasal cavity, primarily the concept « aboutWiththiomeatal toomplex". This is the space formed by the uncinate process, the ethmoid bladder, the anterior end of the middle turbinate and the nasal septum. In the space formed by these anatomical structures, the anterior group of the paranasal sinuses opens, therefore it is a key zone that determines the state of the anterior group of the paranasal sinuses.
Endoscopic examination of the nasal cavity consists of three main points.
Istage - a general panoramic view of the vestibule of the nose and the common nasal passage. Then the endoscope moves along the bottom of the nasal cavity towards the nasopharynx. The state of the mucous membrane of the inferior nasal concha is assessed, sometimes it is possible to see the mouth of the lacrimal canal; with a previously operated sinus, the anastomosis with the maxillary sinus in the lower nasal passage is controlled. With further advancement of the endoscope posteriorly, the condition of the posterior ends of the inferior turbinate, the mouth of the auditory tube, the nasopharyngeal arch, and the presence of adenoid vegetations are assessed.
IIstage - the endoscope is advanced from the vestibule of the nose towards the middle turbinate. The middle nasal concha and the middle nasal passage are examined. Sometimes subluxation of the middle turbinate in the medial direction is required. The uncinate process, the bulla of the ethmoid bone, the semilunar fissure, the infundibulum, the presence of hyperplasia of the mucous membrane of the middle turbinate and the degree of blockade of the ostiomeatal complex are examined. Sometimes it is possible to differentiate the excretory opening of the sphenoid sinus; the natural opening of the maxillary sinus cannot be seen, as it is usually hidden behind the free edge of the uncinate process.
IIIstage- examination of the upper nasal passage and olfactory fissure. Sometimes it is possible to visualize the superior nasal concha and the excretory openings of the posterior groups of cells of the ethmoid labyrinth.
In addition to endoscopic examination of the nose and paranasal sinuses, additional examination methods can be used to clarify the nature and localization of the pathological process. So, the presence of inflammatory diseases of the paranasal pauses can be suspected indirectly, by palpation determining the presence of pain in the anterior walls of the maxillary and frontal sinuses. Soreness on palpation at the exit site of the branches of the trigeminal nerve indicates neuritis or neuralgia, which may be secondary and depend on the presence of an educational process in the corresponding sinus (usually the frontal). More reliable data on the state of the paranasal sinuses are provided by diaphanoscopy and radiological research methods.
Diaphanoscopy - a relatively simple, fairly informative method of research, on a visual comparative assessment of the intensity of the translucence of the paranasal sinuses. Diaphanoscopy is performed in a completely dark room. An electric bulb in a metal case (diaphanoscope) is inserted into the mouth of the subject strictly along the median plane, pressing against the hard palate.
When the patient's lips close, one can see how both halves of the face are translucent in red of the same intensity. In cases where there are changes in the maxillary or ethmoid sinus, the corresponding side of the face will be darkened, the pupil will not glow, and the patient will not feel in the eye on the affected side. Normally, the patient experiences a sensation of light in both eyes and both pupils will be bright red. When diaphanoscopy of the frontal sinuses, a metal case with a light bulb inside is pressed against the inner corner
The intensity of translucence is observed through the anterior wall of the orbit at the root of the nose (the frontal sinus is translucent through the orbital wall). The intensity of translucence is observed through the anterior wall of the frontal sinus.
Ultrasound procedure carried out in relation to the maxillary and frontal sinuses; using this method, it is possible to establish the presence of air in the sinus (normal), fluid, thickening of the mucous membrane or dense formation (tumor, polyp, cyst, etc.).
The device used for ultrasound examination of SNPs was called "Sinusscan". The principle of operation is based on the irradiation of the ultrasound cavity (300 kHz) and the registration of the signal reflected from the formations located on the path of the beam. The method is based on the property of ultrasound not to penetrate through the air, to penetrate well through liquid media and to be reflected from the boundaries of media with different densities. This means that when ultrasound passes through heterogeneous tissue layers, a partial reflection occurs from each interface. After processing the reflected signal, a special screen (display) displays spatially spaced indication strips, the number of which corresponds to the number of echogenic layers, and the distance on the display from the zero strip (skin surface) reflects the depth of each layer.
X-ray examination of the nose and paranasal sinuses. Routine x-ray examination of the nose and paranasal sinuses may be limited to one panoramic view (chin-nasal view). With purulent inflammation of the paranasal sinuses, an intense shading of one of the sinuses or a group of them is detected on the x-ray. In the presence of exudate of the maxillary or frontal sinus on the radiograph, you can get a line of the horizontal level of the liquid (the x-ray should be taken in the vertical position of the patient).
Lateral x-rays of the bones of the nose are used for injuries of the nose in order to determine the fracture. X-rays show the bones of the external nose forming its back. In the presence of a fracture, the presence of cracks and displacement of bone fragments are noted.
For a more accurate diagnosis of inflammatory diseases of the paranasal sinuses, as well as tumors of the nose and paranasal sinuses, computed and magnetic resonance imaging (Fig. 4), which have much greater resolution capabilities, are successfully used.
Fig.5. Computed tomography of the paranasal sinuses (normal):
a – coronal projection, b – axial projection.
Fig.4. Computed tomography of the paranasal sinuses
(in the right maxillary sinus, a pathological formation of a rounded shape).
Diagnostic puncture of the maxillary sinus is performed through the lower nasal passage under the lower concha at the place of its attachment at a depth of 1.5-2 cm from the anterior end.
The puncture is preceded by thorough anesthesia of the mucous membrane at the puncture site by re-lubricating it with a 10% solution of lidocaine with adrenaline. The middle nasal passage in the area of the natural fistula of the maxillary sinus should also be anemized. For sinus puncture, a Kulikovsky needle specially designed for this is used. During the puncture, after some resistance, the needle is felt to fall into the sinus. Then, at moderate pressure, a washing liquid is introduced into the sinus (a solution of furacilin 1: 5000 or 0.9% saline). If there is pus in the sinus, the washing liquid becomes cloudy or pus is mixed with it in the form of separate lumps. If, with sufficient rinsing, the liquid remains clear all the time, the result is considered negative.
For the study of the nose and paranasal sinuses, cytological and histological examination and the taking of smears to determine the microflora are also used.
At external examination pay attention to the following features:
properties of the skin of the nose and face: density, turgor, color, swelling, soreness;
visible changes in the shape of cartilage and bone structures associated with congenital or acquired pathology: saddle nose, hump nose, wide or scoliotic nose; early or long-term effects of trauma; painful swelling caused by the inflammatory process; painless swelling caused by tumor infiltration;
palpable formations in neighboring anatomical structures, for example, in the frontal and zygomatic regions, in the region of the upper lip, upper eyelids; proptosis, displacement of the eyeball or restriction of its movement;
participation of the wings of the nose in breathing, for example, retraction or, conversely, inflation;
the condition of the vestibule of the nose and the anterior edge of the nasal septum, the roof of the vestibule and the inner part of the nasal cavity, examined when the apex of the nose was raised;
crepitus and pathological mobility of the nasal bones;
soreness at the exit of the nerves to the face;
Sensitivity to pressure on the forehead, calvaria, or cheekbones.
a - Occipital region: 1 - small occipital nerve; 2 - large occipital nerve,
b - Face area: 3 - supraorbital nerve; 4 - infraorbital nerve; 5 - mental nerve.
Anterior rhinoscopy is performed using a nasal speculum, strong light source, head reflector or head light. The technique for using the nasal speculum is shown in the figure below. Usually, when examining both halves of the nose, the mirror is held in the left hand. Currently, anterior rhinoscopy alone is considered insufficient, but it is the first step in the examination of the nose.
Methodology. The mirror is introduced into the vestibule of the nose with closed jaws. The end of the mirror in the vestibule is oriented somewhat laterally.
Branches nasal mirror in anticipation, they are moved apart and fixed to the wing of the nose with the index finger. When removing the mirror, keep it slightly open to avoid pulling out vibrissae, which can be pinched in closed jaws. The right hand is used to give the face and head the desired position.
As shown in figure below, the patient's head at the beginning of the examination is oriented vertically so that the direction of the doctor's gaze is parallel to the floor surface and along the inferior turbinate and inferior nasal passage (position I). If the nasal cavity is wide, the choana and the posterior wall of the nasopharynx can be seen in this position.
To inspect upper part of the nasal cavity, the patient's head is slightly tilted back. This allows you to examine the middle nasal passage and the middle nasal concha, which are of great clinical importance (position II). If the head is tilted back even more, the olfactory fissure can be seen.
In children infants and toddlers anterior rhinoscopy is more appropriate to perform not with the help of a nasal mirror, but using an otoscope.
With the right hand head position, which holds the nasal mirror, at the same time it is possible to fix the head, thus freeing the right hand to manipulate the instruments and aspirate the secret from the nasal cavity.
a - Traditional rhinoscopy with a frontal reflector. b - At present, the use of headlights with a cold light source has largely replaced the frontal reflectors.
Note. The nasal mucosa is often edematous and limits the view of the nasal cavity. Therefore, in such cases, the mucous membrane is irrigated with a decongestant spray and wait 10 minutes, after which the nasal cavity can usually be successfully examined.
At anterior rhinoscopy pay attention to features such as:
the amount and nature of the secret (mucous, purulent), its color, the presence of crusts in the nasal cavity:
place of accumulation of pathological secretion;
swelling of the turbinates, narrowing or expansion of the nasal passages;
mucosal surface properties (including color), such as whether it is wet, dry, smooth, keratinized, or uneven;
the position of the nasal septum, its possible deformation;
the location of large vessels (for example, the Kisselbach plexus);
unusual pigmentation or color of the nasal mucosa;
the presence of pathological tissue;
ulceration and perforation;
foreign bodies.
Clinically important area middle nasal passage may be narrowed and therefore difficult to study. It can be examined using a long Killian nasal speculum after preliminary application of a solution of lidocaine (Xylocaine) or a 1% solution of pantocaine with the addition of a solution of adrenaline in a ratio of 1:1000 at the rate of 1 drop per 1 ml of local anesthetic solution, or by applying a 5% solution of lidocaine in the form spray containing 0.5% phenylephrine.
Gustav Killian developed this mirror for medial rhinoscopy, already 100 years ago realizing the importance of the lateral wall of the nasal cavity in the pathogenesis of its lesions. Relatively recently, the method of anterior rhinoscopy using a nasal endoscope was introduced into clinical practice.
a Position I. b Position II.
Posterior rhinoscopy
On the figure below shows the method of examination of the nasopharynx using a mirror and a combined image of this area. Posterior rhinoscopy is used to examine the posterior nasal cavity; choanae, the posterior end of the turbinates and the posterior edge of the nasal septum, as well as the nasopharynx (including the roof and mouths of the auditory tubes).
Nasal endoscopy, including examination of the nasopharynx, has now become an integral part or additional study in the examination of a patient with a disease of the ENT organs. It has supplanted posterior rhinoscopy and can be accepted as a reference research method (gold standard) that allows assessing the condition of the nasal cavity, regardless of further treatment.
Methodology. Performing a posterior rhinoscopy requires considerable experience from the doctor, as well as good communication with the patient. With a spatula located in the middle of the root of the tongue, slowly press on it and move it downward, increasing the distance between the surface of the tongue, the soft palate and the back wall of the pharynx. Warm the glass surface of a small mirror and test by touching the hand to see if it is too hot. The free hand is used to insert a speculum into the space between the soft palate and the posterior pharyngeal wall.
The mirror should not touch the mucous membrane otherwise it will cause a gag reflex. If the soft palate remains tense, the patient is asked to inhale calmly through the nose, snorting or aspirating “ha” to relax the soft palate and allow an unobstructed view of the nasopharynx. By moving and tilting the mirror in different directions, they examine various parts of the nasopharynx.
Rear upright located edge of the nasal septum used as a guide to identify normal anatomical structures. If due to the gag reflex it is not possible to fully examine the nasopharynx, the study can be successfully performed by applying a local anesthetic solution (for example, 1% lidocaine solution) to the nasopharyngeal mucosa and especially the soft palate and posterior pharyngeal wall.
If it is impossible to explore nasopharynx by this method, either an endoscope or a palatal retractor (or both) can be used, although endoscope examination has now largely supplanted examination with a palatal retractor.
At performing posterior rhinoscopy attention should be paid to the following features:
patency and width of the choanae;
the shape of the posterior end of the lower and middle turbinates;
the presence of scars in the nasopharynx and its deformation, for example, due to trauma;
the shape of the posterior nasal septum;
the presence of polyps;
the shape of both mouths of the auditory tubes and the Rosenmullerian fossa (pharyngeal pocket);
possible obstruction of the nasopharynx by large adenoids in children;
tumors of the nasopharynx;
pathological secret in the choanae;
properties of the mucous membrane of the posterior and nasopharynx (moisture, dryness, thickening, color.
CT used to assess the degree of spread of damage to the paranasal sinus to adjacent anatomical structures, especially the skull base, cranial cavity, retromaxillary space and orbits. CT is also used for trauma; this research method is indispensable for the differentiation of bone structures. MRI complements it and is more informative in the study of soft tissues.
