ENT Examination OSCE — Otoscopy, Rinne and Weber, Nasal and Throat Examination

Why ENT Is Tested

ENT examination appears in OSCE circuits assessing ear, nose and throat pathology — commonly as a combined head and neck station or as individual components. Otoscopy and hearing tests are tested most frequently, followed by nasal and oropharyngeal examination.

Systematic ENT Examination

1. General Inspection

• Ears: pinna deformity, scars (previous surgery), pre-auricular pits/sinuses/tags, erythema, swelling, discharge
• Nose: deviation, swelling, discharge, skin changes
• Face: facial nerve palsy (asymmetry, drooping corner of mouth, inability to close eye)

Ear Examination

External Ear

Inspect the pinna, tragus (tender in otitis externa), post-auricular region (mastoid tenderness in mastoiditis), and pull the pinna upward and backward to straighten the canal.

Otoscopy

1. 1Hold otoscope like a pen, with your wrist resting on the patient's cheek for stability
2. 2Straighten the canal: adults — pull pinna upward, backward, and laterally; children — pull pinna down and back
3. 3Insert speculum gently along the canal floor
4. 4Systematically inspect: canal (erythema, swelling, wax, discharge, foreign body), then tympanic membrane

Tympanic membrane assessment:

Hearing Tests

Tuning Fork Tests (512 Hz)

Weber Test: Place vibrating tuning fork on the vertex of the skull (midline).

• Lateralises to the affected/deaf ear → conductive hearing loss
• Lateralises to the normal/good ear → sensorineural hearing loss
• Central (heard equally bilaterally) → normal or symmetric loss

Rinne Test: Place vibrating tuning fork on the mastoid (bone conduction), then move to 1 cm in front of ear canal (air conduction).

• Rinne positive (AC > BC): normal or sensorineural loss
• Rinne negative (BC ≥ AC): conductive hearing loss (≥25 dB)
• False negative Rinne: in profound sensorineural loss, the patient "hears" BC via the opposite cochlea (cross-hearing)

Nasal Examination

• Inspect externally: deviation, skin lesions, swelling
• Anterior rhinoscopy: use an auroscope or nasal speculum — inspect mucosa, turbinates, septum, nasal polyps (grey, insensate), discharge
• Assess patency: occlude one nostril, ask patient to sniff

Oropharyngeal Examination

1. 1Adequate lighting (pen torch or head light)
2. 2Ask patient to open mouth wide and say "ahh" — depresses posterior tongue, lifts soft palate
3. 3Inspect: tonsils (size, erythema, exudate, peritonsillar bulge suggesting quinsy), posterior pharynx, uvula (central?)
4. 4Palatal movement: "ahh" — uvula should move centrally upward; deviation away from lesion in CN X palsy

Voice Assessment

• Hoarse voice: laryngeal/vocal cord pathology (cancer, cord palsy, laryngitis)
• Nasal/hyponasal: nasal obstruction, adenoids
• Hypernasal: palatal insufficiency (cleft palate, post-adenoidectomy)
• Dysphonia: CN X (vagus) or recurrent laryngeal nerve palsy — ask about neck surgery, thoracic pathology

Frequently Asked Questions

"How do you interpret the Rinne and Weber tests together?"

The Rinne and Weber tests must always be interpreted together. In conductive hearing loss (e.g., wax, otitis media with effusion, ossicular chain disruption), bone conduction exceeds air conduction on the affected side (Rinne negative), and the Weber test lateralises to the affected ear (because the conductive loss reduces ambient noise masking, making BC seem louder on that side). In sensorineural hearing loss (e.g., noise-induced, presbycusis, acoustic neuroma), air conduction is still better than bone conduction (Rinne positive) but the Weber lateralises away from the affected ear (to the normal side). Normal hearing gives Rinne positive bilaterally and a central Weber.

"What is the technique for holding an otoscope and why does it matter?"

The correct technique is to hold the otoscope like a pen, with the handle between the thumb and index finger, and rest the dorsum of your hand against the patient's cheek. This creates a rigid unit between your hand and the patient's head — if the patient moves suddenly, your hand moves with them, preventing the speculum from injuring the canal. Alternatively, grip the otoscope from below with the handle pointing upward. In children, always pull the pinna downward and backward (not upward as in adults) to straighten the naturally more horizontal canal. Failure to demonstrate correct holding technique and canal straightening consistently loses marks in ENT OSCE stations.

"What are the features of acute otitis media on otoscopy?"

In acute otitis media (AOM), the tympanic membrane appears erythematous (red, injected) and bulging outward due to middle ear effusion and pressure. The light reflex is absent or distorted, and the normal landmarks (malleus handle, lateral process) may be obscured by the bulging membrane. There may be purulent discharge if spontaneous perforation has occurred — in this case, the ear pain typically resolves after perforation as the pressure is relieved. The canal may show mild erythema, but the drum is the main finding. Distinguish from myringitis bullosa (bullae on the TM surface), which causes severe otalgia and is associated with viral or Mycoplasma infection.

"What is a quinsy and how does it present on examination?"

A quinsy (peritonsillar abscess) is a collection of pus between the tonsillar capsule and the superior pharyngeal constrictor muscle. On examination: trismus (difficulty opening the mouth — diagnostic clue before even examining), a bulging of one tonsillar pillar with medial displacement of the ipsilateral tonsil and uvula deviation away from the affected side, muffled or "hot potato" voice, drooling, and significant ipsilateral cervical lymphadenopathy. The patient appears unwell with fever and severe throat pain, often worse on one side, and difficulty swallowing. Management: IV antibiotics, aspiration or incision and drainage, and IV fluids. Distinguish from a retropharyngeal abscess (midline bulge, stridor, neck stiffness).

"What causes a hoarse voice and how do you approach this systematically?"

Hoarseness (dysphonia) results from disruption of normal vocal cord vibration. Causes are best categorised as: local (laryngitis, laryngeal carcinoma, benign vocal cord lesions such as nodules or polyps), neurological (recurrent laryngeal nerve palsy from thyroid surgery, lung apical tumour — Pancoast, mediastinal lymphadenopathy, aneurysm of the aortic arch), and functional (muscle tension dysphonia). Any hoarseness lasting more than 3 weeks in an adult requires referral for flexible laryngoscopy to exclude malignancy — this is a 2-week wait red flag. When examining, assess the voice quality, look for neck swellings or scars, and examine the chest and thyroid gland.

"What is the significance of unilateral nasal polyps?"

Nasal polyps are typically bilateral in allergic rhinitis, aspirin sensitivity, and cystic fibrosis — they appear pale/grey, insensate (painless to touch), and polypoid on anterior rhinoscopy. A unilateral polyp is always suspicious and should prompt urgent specialist review to exclude inverted papilloma (premalignant) or sinonasal malignancy (squamous cell carcinoma, olfactory neuroblastoma, lymphoma). Other unilateral nasal masses include: antrochoanal polyp (originates from the maxillary sinus, extends to the nasopharynx), rhinoscleroma, and encephalocele (in children). Unilateral nasal symptoms (obstruction, discharge, bleeding) warrant the same degree of suspicion.

Related guides: Ear Examination OSCE · Lymph Node Examination OSCE · Cranial Nerve Examination OSCE · Thyroid Examination OSCE · Head and Neck History OSCE