Physical Examination in ENT: General, Systemic and Local Guide

ENT physical examination is a structured assessment of the ears, nose, oral cavity, pharynx, face and neck, interpreted alongside the patient’s symptoms and general condition. This guide gives medical students a practical sequence for the general survey, relevant systemic examination and focused local examination, with normal landmarks, documentation tips and findings that should prompt urgent review.

1. Preparation and approach

2. General examination and systemic context

Start broadly before focusing on one organ. The general survey can reveal severity, chronic illness, hydration, nutrition or clues to systemic disease. Record relevant vital signs using local standards and interpret them in context.

Systemic review matters in ENT. Fever and toxicity may accompany infection; facial weakness may reflect cranial nerve involvement; and persistent symptoms or weight loss can change the urgency of a head-and-neck assessment. Let the history guide the scope: see our systematic guide to ENT history taking.

3. Focused local ENT examination

A useful sequence is face and cranial nerves → ears → nose and sinuses → mouth and oropharynx → neck. The order can vary with the complaint and patient comfort, but a consistent routine helps reduce omissions. Examine the symptomatic area carefully and compare both sides.

3.1 Face, facial movement and cranial nerves

Inspect the face at rest for symmetry, swelling, scars, skin change, trauma, facial expression and abnormal movements. Look for periorbital swelling, nasal deformity, parotid-region swelling or asymmetry. Palpate tender or swollen areas gently, explaining each step.

Screen cranial nerves relevant to the presentation. A brief screen is not a substitute for a complete neurological examination when indicated.

Weber and Rinne: quick interpretation

• Rinne: compare air conduction at the ear with bone conduction on the mastoid. Air conduction normally remains louder/longer than bone conduction (“Rinne positive”). Bone conduction louder than air conduction (“Rinne negative”) suggests a conductive component in that ear.
• Weber: place the vibrating 512-Hz fork on the midline forehead or vertex and ask where sound is heard. Lateralisation to the poorer ear can suggest conductive loss; lateralisation to the better ear can suggest unilateral sensorineural loss.

These are simplified teaching rules. Technique, degree and type of loss, bilateral disease and other factors can affect results. Record what the patient reports on each side; tuning-fork tests do not replace audiometry.

3.2 Ear examination

1. Inspect externally: compare pinnae for position, shape, lesions, discharge, scars, swelling or deformity. Inspect the preauricular and postauricular areas and mastoid region for tenderness, erythema or swelling.
2. Palpate gently: assess the pinna, tragus and mastoid only as appropriate to the symptoms. Ask before touching a painful area and stop if the patient has marked pain.
3. Otoscopy: explain the instrument, choose a suitable speculum and brace your hand against the patient’s head. Gently straighten the canal as taught for the patient’s age and insert only under direct vision; never force the speculum. Inspect the canal and tympanic membrane, noting wax, inflammation, discharge, foreign material, perforation, retraction, colour, landmarks and visible fluid.
4. Hearing screen: assess conversational hearing or perform a simple bedside screen, then Weber/Rinne when indicated. Ask about hearing aids and remove them only with permission.

Describe the right and left ears separately. A normal-looking tympanic membrane is not enough to document a complete ear assessment if the canal was not visualised. If wax, pain or anatomy prevents a safe view, record that limitation rather than repeatedly probing.

3.3 Nose and paranasal sinus region

• Inspect the external nose for symmetry, deformity, skin changes, swelling and evidence of trauma.
• Check nasal airflow one side at a time if appropriate, without obstructing both nostrils. Ask about obstruction, discharge, bleeding and smell symptoms.
• Inspect the vestibule and anterior nasal cavity with a light. If trained and equipped, use a nasal speculum gently under direct vision; do not insert it deeply or force it against the septum.
• Describe septal position, mucosal appearance, crusting, discharge, bleeding, polyps or visible masses where you can assess them. A limited anterior view cannot exclude disease deeper in the nose or nasopharynx.
• Assess facial or sinus tenderness only when indicated; tenderness alone is not diagnostic. Examine the eyes and cranial nerves if orbital or neurological symptoms are present.

Persistent unilateral obstruction, recurrent epistaxis, facial numbness, eye symptoms or a visible mass deserves careful assessment and an appropriate referral pathway.

3.4 Oral cavity and oropharynx

With good light and the patient’s consent, inspect the lips, oral mucosa, gums and teeth, buccal surfaces, hard palate, floor of mouth, tongue and visible oropharynx. Ask the patient to remove dentures if comfortable; inspect them and the mucosa beneath them when relevant. Use a tongue depressor gently and explain what you are doing.

• Inspect the tongue at rest, then ask the patient to protrude it; inspect the dorsal and lateral surfaces and floor of mouth as tolerated.
• Assess the soft palate and uvula while the patient says “ah” if safe. Note symmetry, movement, erythema, ulceration, exudate or asymmetry.
• Describe tonsils and visible posterior pharynx using an agreed local grading system if needed; avoid over-interpreting a single finding.
• Look for dental caries, gum disease, oral ulcers, white or red patches, induration, bleeding or a persistent mass. Palpation of a lesion is for a trained clinician and requires explanation, consent, gloves and appropriate technique.

3.5 Neck, lymph nodes, thyroid and salivary glands

Inspect the neck from the front and sides for asymmetry, scars, swelling, skin change and visible pulsation. Note the midline position of the trachea. Palpate systematically and gently, comparing sides:

• Lymph node regions: preauricular, postauricular, occipital, tonsillar/jugulodigastric, submandibular, submental, superficial and deep cervical chains, and supraclavicular fossae. For any node, record site, approximate size, tenderness, consistency, mobility and whether nodes are matted or multiple.
• Thyroid: inspect and palpate while the patient swallows if indicated and within your training; describe enlargement, nodules, tenderness and movement. Do not massage a mass.
• Salivary glands: inspect and palpate parotid and submandibular regions for swelling or tenderness. Intraoral duct examination is performed only if indicated and trained.
• Other structures: assess neck range of movement, tenderness and any mass. Relate findings to the history and examine the oral cavity, scalp, skin and other likely primary sites where relevant.

Document a neck lump precisely instead of writing “neck normal.” A persistent or suspicious adult neck mass, especially one that is hard, fixed, enlarging or associated with mucosal symptoms, warrants timely medical assessment according to local referral guidance.

3.6 Nasopharynx and larynx

Routine student examination usually documents voice, swallowing symptoms and visible oral/pharyngeal findings. Examination of the nasopharynx or larynx with a mirror or flexible endoscope is a specialised procedure requiring appropriate training, equipment, consent and supervision. Refer when symptoms or findings warrant it rather than attempting an unfamiliar procedure.

4. Findings that need urgent attention

Escalate promptly under local pathways when the examination or overall picture suggests:

• Stridor, respiratory distress, drooling, inability to swallow secretions or rapidly worsening airway symptoms.
• Rapidly enlarging neck or floor-of-mouth swelling, severe trismus, spreading facial/neck infection or systemic toxicity.
• Sudden hearing loss, new facial weakness, significant postauricular swelling, severe ear/temporal-bone trauma or concerning neurological signs.
• Orbital swelling with visual symptoms, painful/restricted eye movements, proptosis or severe headache with neurological features.
• Uncontrolled epistaxis, major facial trauma, suspected foreign body with airway or oesophageal risk, or a persistent suspicious oral lesion/neck mass.

This list supports clinical learning; urgency depends on the patient, examination and local resources. Use the local emergency, ENT and referral pathways and involve a senior clinician early.

5. How to document an ENT examination

Prefer precise observable language: “left tympanic membrane not visualised because of impacted cerumen” is more useful than “left ear abnormal.” Record laterality, measurements when feasible, and both positive and important negative findings. Never chart a normal finding for a structure you did not examine.

6. OSCE checklist and common pitfalls

7. Short practice cases

8. Study resources

The American Academy of Otolaryngology–Head and Neck Surgery ENT Exam Video Series demonstrates systematic ear, oral cavity/neck, face/nose and nasopharynx/larynx examinations, including Weber and Rinne. The University of Iowa head and neck examination protocol provides an additional clinical outline and normal anatomical landmarks.

Class notes coming soon

Quick self-check

1. Which findings should make you pause a routine throat examination and seek urgent senior help?
2. What does a negative Rinne test suggest, and why should it still be followed by appropriate hearing assessment?
3. What details should be recorded when you find a cervical lymph node or neck lump?

Suggested answers: Airway symptoms such as stridor, drooling, respiratory distress or rapidly progressive swelling; a negative Rinne suggests bone conduction is heard better than air conduction and may indicate a conductive component, but tuning-fork tests are not definitive; document site, size, tenderness, consistency, mobility and relevant associated findings.

References and further reading

1. American Academy of Otolaryngology–Head and Neck Surgery. ENT Exam Video Series.
2. University of Iowa, Iowa Head and Neck Protocols. Physical Examination of the Head and Neck.
3. University of Iowa. Otolaryngology Medical Student Clerkship Objectives and Exam Topics.
4. MSD Manual Professional Edition. Evaluation of Ear Disorders.
5. MSD Manual Professional Edition. Evaluation of the Patient with Nasal and Pharyngeal Symptoms.