History Taking in Patients with Ear Disease:

The most common symptoms referable to the ear are:
1. Deafness
2. Ear discharge
3. Pain
4. Itching
5. Tinnitus
6. Vertigo

In taking a history the presence or absence of the commoner symptoms and their duration should be  noted.

Deafness:
Deafness is the most common symptom of ear disease; it may vary from a degree so slight as to escape the patient's notice to complete loss of hearing.  Often  someone else notes the deafness.   Deafness may be caused by occlusion of the external auditory meatus by wax or discharge, a perforation of the tympanic membrane,  an effusion in the middle ear cavity, defects of the ossicles or damage to the inner ear.

There are four questions-
1.  Was the onset sudden or gradual?
Sudden hearing loss may occur in a number of circumstances, for example following barotrauma(flying or diving), upper respiratory tract infection, exposure to excessive noise, drug administration(e.g. gentamicin), or head injury.

2.  Is it unilateral or bilateral?
Unilateral losses are more likely to have a specific cause.  Deafness due to age or noise exposure is not unilateral.

3. Is the loss progressive, fluctuating or improving?
Deafness due to age or continued noise exposure is often progressive.  Meniere's disease and serous otitis media typically present with fluctuating hearing.  An acute middle ear effusion following an upper respiratory infection usually shows steady improvement

4. What is the hearing like in group conversation?
Generally patients with conductive loss manage well in group conversation.  Patients with sensorineural hearing loss have poor speech discrimination in noise and usually hear better in one to one conversation.

Children with reduced hearing:
Questions should be asked about a family history of deafness, problems associated with pregnancy or delivery and past  history such as meningitis .  Inquiry about behaviour and language development should also be made.

Discharge:
Discharge from the ear may arise from the external meatus in otitis externa or the middle ear cavity in chronic otitis media.  Discharge of the external ear usually produces a scanty discharge. Copious discharge is always from the middle ear. Smelly discharge suggests cholesteatoma. Bloody discharge follows ear trauma, severe acute infection or tumour. Watery discharge may be CSF after a head injury.

Pain:
The ear has a rich and varied sensory innervation.  Pain in the ear may arise from the auricle, the external meatus, the middle ear, the mastoid or referral from other sources.  Earache usually indicates an inflammatory process in the external or middle ear.  It is important to take a good history of the pain; description, site, relieving and aggravating factors.   The ear receives sensory branches from the facial, trigeminal, glossopharyngeal, and vagus nerves and branches from the upper cervical roots C2 and C3.  When otoscopy is normal the cause of the pain must be sought in the scalp, neck, nose, nasopharynx, pharynx, teeth, temperomandibular joint and larynx.

Itching:
Generally, itching or irritation in the ear is associated with a mild otitis externa.

Tinnitus:
Tinnitus or a subjective sensation of sound in the ear is very common and sometimes the only symptom of ear disease.  Tinnitus may be regarded as an irritation of the cochlear mechanism.  The sounds may be continuous or intermittent.  The patient is sometimes conscious of tinnitus during the whole of his waking hours, or he may hear the noises only when in a quiet room or when in bed at night.  This is due to absence of background noise  Tinnitus is a common accompaniment of hearing impairment of any cause.

Vertigo:
This term describes the hallucination of movement of the environment about the patient.  Vertigo may occur in certain ear diseases, and is a symptom of vestibular apparatus irritation. It is important to take a history of

1.  The onset of the first attack
If the symptom started following barotrauma (flying or diving), acoustic trauma or head injury, rupture of the inner ear membrane (perilymph fistula) should be considered.  Acute fulminant vertigo in an otherwise healthy young adult is likely to be due to vestibular neuronitis.  If the symptom lasts a few seconds on adopting a sudden change of posture without any hearing loss, consider benign paroxysmal positional vertigo(BPPV).

2.  Duration of Attack
In Meniere's disease, the vertigo lasts for only a few minutes up to several hours.  In BPPV,  the vertigo lasts only a few seconds.  In vestibular neuronitis it lasts several days and the patient is unsteady for several weeks.

3. Associated symptoms
Auditory symptoms strongly suggests a labyrinthine cause.  Nausea and vomiting are typical of labyrinthine vertigo.  Central causes of vertigo are associated with other neurological symptoms(e.g. dysarthria, visual disturbance) and are not typically accompanied by auditory symptoms.  Neck and shoulder pain may indicate cervical vertigo.

Ear Examination :

The examination of the ear starts with an examination of the external ear itself.  Examination behind the ear may indicate evidence of acute inflammation or inflammatory nodes or a scar from previous surgery. 

This is a cross section or slice through the middle of the head. On the left can be seen the external ear which connects to the ear canal. At the end of the canal, the ear drum can be seen. This vibrates with sound and the pressure wave is then transmitted through tiny bones in the middle ear to the cochlea. Sound is converted here to electrical signals which are then transmitted through the cochlea nerve to the brain. The soft tissue of the external ear canal is relatively pain free. However the skin over the bone is very sensitive. If a speculum touches the bone examination becomes painful.

The ear canal is examined with an otoscope.  Hold the otoscope delicately like a pencil.  In choosing an otoscope choose the biggest speculum that will fit in the ear.  If the speculum pushes against bone the examination becomes painful. Make sure the light source is as bright as possible.  When you next look at an ear,  change the intensity of the light source.  The appearance of the tympanic membrane  change with brightness levels.  In adults, traction on the pinna backwards and upwards helps the straighten the canal and facilitate vision. With practice one can learn use your right hand to examine the right ear and the left hand to examine the left ear. Always steady the hand that holds the instrument on the patient's cheek. 

Tympanic membrane:
It is essential to know the normal anatomy of the tympanic membrane.  If possible, the whole of the tympanic annulus should be seen as well as  the handle and the lateral part of the malleus.  A  prominent anterior wall often obscures the anterior part of the tympanic membrane.  The attic region should be visualised.  Any crusts there should be removed. This is only practical with a microscope. The mobility of the tympanic membrane is assessed by using the pneumatic bulb on the otoscope. 

Clinical tests of hearing:
During history taking and examination the clinician should be assessing hearing.  An estimate of the hearing thresholds in each ear may be made with masking of the opposite ear by gently rubbing the orifice of the external auditory meatus with a finger and asking the patient to repeat what you have said.  Whispering is approximately 30 dB.  Talking is approximately 60 dB.

Tuning Fork Tests:
The tuning fork most commonly used to test hearing has a frequency of 512 Hz.  Higher frequency forks tend to decay quicker and do not allow sufficient time for the Rinne test to be performed.  A lower frequency fork may be detected by vibration alone.

Rinne Test:
The tuning fork is struck gently against your elbow or knee cap so as not to produce overtones and disharmonics.  In a true Rinne test the fork is placed firmly on the mastoid with the observer's hand steadying the head.  Care is taken to have the fork firmly placed on bone and not sternomastoid muscle.

In routine clinical practise, the patient is asked to compare the sound intensity  of the fork on the mastoid process with that by the meatus.  If there is significant sensorineural deafness the fork will not be heard by bone conduction at all, but only by air conduction.  A conductive deafness of greater than 20 dB usually gives a negative Rinne with a 512 Hz fork.  It is important to press the base of the fork firmly against the mastoid process.  Check the sound intensity changes on yourself as you vary the pressure.

False Negative Rinne:
This is an important concept.  If the patient has no hearing in the test ear, the bone stimulus may be perceived by the contralateral (nontest) ear, although the patient says that he/she hears it in the test ear.  This mistaken impression of function in a non functioning ear is called a false negative Rinne.  One can check the diagnosis by masking the nontest ear or using the Weber test.  If the patient can still hear the sound with masking in the other ear it is a true negative Rinne.

Weber test:
The tuning fork is struck and the base is placed on  the forehead.   The patient is asked where the sound is heard the loudest.  In a normal hearing person and people with an equal degree of hearing loss in each ear, the sound is related to the midline.  In a patient with unilateral sensorineural deafness, it is referred to a good ear and in a patient with a conductive deafness to the affected ear. 

Clinical Tests of Balance:
Normal body position is a function of neural input into the cerebellum and brainstem from the receptors in the semicircular canals, the macula of the utricle, the proprioceptive and joint position sensors and the eyes. Thus in clinical examination each component of the system should be tested individually.  If hypofunction of one input occurs, then compensation by the other usually occurs. However when such compensation is removed, for example by closing the eyes, the resultant deficiency usually becomes obvious.

Romberg's test:
The patient is stands erect looking forwards with the feet together.  If the patient is stable, he/she closes their eyes.  With a labyrinthine lesion the patient will often sway to the side of the lesion, a feature that is accentuated by closing the eyes.  A central lesion in the cerebellum results in symmetrical swaying that is less affected by eye closure.  If the patient falls backward but is able to regain balance before falling to the ground, suspect malingering or hysteria.

The gait test:
The patient  walks in a straight line between two points and then quickly turns to return on a straight line.  Patients with labyrinthine lesions deviate to the side of the lesion whereas marked imbalance on turning indicates a cerebellar lesion.

Facial Nerve:
The facial nerve is motor nerve to the face muscles and to the stapedius muscle in the middle ear.  It also carries taste to the anterior two thirds of the tongue.  Always check facial nerve function in diseases of the ear.

Temporomandibular joint
In ear pain particularly in the adult and even in children think about the jaw joint.  The pain is characteristically made worse with a cold wind and there may be a history of nocturnal bruxism and clicking of the jaw joint.  This is common in females aged 20-30 particularly those who work typing or on a computer

Look at the way the jaw moves.  It may deviate on opening.  It should open three finger breadths.  Palpate the medial pterygoid, and temporalis muscles internally.  Palpate the temporalis muscles externally. 

Speech Audiometry:
This test is designed to test how the ear is able to interpret pure tones mixed together. The patient is presented with phonetically balanced words and is scored on the number of correct responses at different loudness levels.

Tympanometry:
Tympanometry is a technique used extensively in clinical practice.  It is based on the fact that pressure in the external ear can be raised or lowered, thus stiffening the ear drum.  A tympanometer presents a low frequency sound to the ear and measures the sound energy reflected from the ear drum.  While this sound is being presented the pressure in the external ear is altered. The ear drum is most floppy when the pressure on both sides of it is equal.  If fluid is present in the middle ear, the ear drum is unresponsive to changes in pressure of the external ear canal and a flat tracing is observed.

The four most common types of tympanogram are
1. Normal (Type A): occurs when pressures on both sides of the ear drum are equal at 0 on the pressure scale.
2. Increased:when the ear drum is floppy, ossicular chain disrupted
3. Decreased (Type C):occurs when the pressure in the middle ear is negative relative to the external ear
4. Flat(Type B):occurs in middle ear effusions and is due to the fact that fluid in the middle ear is non compressible.

Tympanometry is used in screening children with otitis media with effusion.  It is also frequently used in general practice. It is important to realise that there is an error rate associated with the measurement(as there is with many measurements). 90% of children with a Type B tympanogram have a middle ear effusion whereas 10% of children with normal ears will also have a Type B tympanogram.

Hearing Aids:
Hearing aids function by selectively amplifying sound.  They work best for conductive losses(hearing losses associated with the ear drum and bones of hearing)because inner ear function is usually normal and the problem is purely one of sound amplification.  Usually  the better the inner ear function, the more efficiently the hearing aid will work.  Thus given a choice between two ears with hearing impairment, it is usually best to fit the aid to the good ear.

Components: 1. The microphone picks up the incoming sound 2. The amplifier makes the sound louder 3. The receiver feeds the sound into the ear 4. The mould is worn in the external ear

Limitations of Hearing Aids:
Hearing aids amplify sounds.  Background noise (usually low frequency) is also amplified and can interfere significantly with speech intelligibility.  Patients with good low frequency but poor high frequency hearing are most troubled.  Some patients with poor cochlea function are exquisitely sensitive to noise and getting these patients to benefit from a hearing  aid may be difficult.

Some patients find hearing aids either cosmetically or socially unacceptable.  They feel it draws attention to their disabilit

Hearing aids need a mould in the ear canal and this may cause otitis externa.  The precise fitting of an ear mould is of crucial importance and requires considerable care

Hearing Therapy:
Frequently a patient needs counselling to help with a hearing disability.  This is all too often neglected.  Advice on using hearing aids, lip reading skills, environmental aids should all be sought.

Hearing Aid Types:
Behind the Ear:
These aids are quite powerful and are cosmetically acceptable.  Adjusting settings requires a certain amount of dexterity and can be a problem in the elderly, especially those with arthritis or a neurological disability

Body Aid:
These aids are used in people with profound hearing losses or those who do not have the manipulative skills to mange a behind the ear hearing aid.  The microphone is on the device and the patient's clothing may impair the sound uptake.  Friction between the clothes and the microphone can be annoying.

In the Ear Aids:
These aids are accommodated entirely in the external ear.  They are suitable for mild or moderate hearing loss.  They are more cosmetically acceptable than the behind the ear aids.

History taking in Nasal Disease:

History taking requires elucidation of the related facts about these symptoms, their degree, duration and laterality, any associated systemic upset and any factor that aggravates them.

Nasal Obstruction:
Nasal obstruction is a non specific symptom; swelling of the mucosal lining due to infection, allergy, vasomotor changes, polyps and crusting may cause bilateral nasal obstruction.  Deviation of the septum or the growth of a benign or malignant neoplasm may cause unilateral nasal obstruction.  In children adenoid enlargement is a common cause of obstruction and usually presents with persistent mouth breathing.

Infective nasal conditions will give  rise to general malaise and raised temperature if caused by a virus, and there will also be evidence of purulent secretions if caused by  bacteria.

A patient suffering from an allergy may have repeated short episodes of fairly acute symptoms, and may have noticed the precipitating effect of a particular  allergen.

In elucidating unilateral symptoms, it is important to establish whether they are totally unilateral, or whether they are bilateral, but more prominent on one side.  Very few individuals have a completely straight nasal septum and therefore many people with generalised nasal disease will tend to have their symptoms more markedly on one side.

A deviated nasal septum is the principal cause of unilateral obstruction;  in S-shaped deviation there can be bilateral obstruction.  Tumours are rare but always start on one side.  The malignant ones are frequently infected and associated with a purulent serosanguinous discharge.

Increased nasal secretion:
The nasal mucosal glands and goblet cells are constantly producing a thin film of mucus, which covers and protects the underlying respiratory mucosa.  Secretion is stimulated by irritation of the mucosa by infection or allergy or by increased parasympathetic tone. Rarely increased secretion may be mimicked by leakage of CSF.  Excessive thin secretions run anteriorly, and give rise to rhinorrhoea.  If the consistency of the secretion changes, or if its slow but steady movement towards the nasopharynx is interrupted, stasis occurs and the presence of a thicker mucus is noted in the pharynx.

Watery rhinorrhoea is a symptom of virus infection, allergic rhinitis, vasomotor rhinitis.  Thick mucus, especially if purulent, is suggestive of chronic rhinosinusitis. Beware of the persistent unilateral discharge.  A unilateral blood stained discharge is likely to come from a tumour.  A unilateral nasal discharge in a child originates from a foreign body.

A number of patients complain of "post nasal mucus". This can be a difficult symptom to elucidate as we all have at least a litre of mucus travelling postnasally a day and most patients are unable to cough up any of this mucus.

Bleeding: At some stage in their lives 10% of the population suffer from epistaxis.  It can be due to a number of causes.  Acute inflammation, trauma and bleeding disorders are common causes.  The most common site is in the area of Kiesselbach's plexus on the anterior nasal septum(seen on accompanying picture).  After  40, bleeding from the posterior part of the nasal cavity is more prevalent;  hospital admission  may  be necessary.

Sneezing:
Sneezing is the normal nasal reflex to clear secretion from the nose.  Irritation within the nose, infection or allergy, or inhalation of noxious gases or polluted air are common stimuli. 

Itch:
Irritation within the nose causes itch.  It is a common feature particularly in allergy. In allergic rhinitis the eyes and soft palate  as well as the nose may also be affected.

Pain:
Facial pain can be a multifaceted problem.  It is important to take a good history of the pain: type, periodicity, site, relieving and aggravating factors

Pus:
Sinusitis can lead to the development of increased nasal discharge.  Enquire as to the colour of the discharge(clear, yellow or green)  and the frequency of attacks.

Deformity:
Appearance is important to many people.  The nose is a dominant facial feature.  A deformed exterior often reflects internal functional problems.

Disturbances of Olfaction:
Hyposmia is a reduction of the sense of smell.  It occurs in many nasal diseases, when the air stream is unable to reach the olfactory area.  Anosmia is a complete loss of sense of smell.  It occurs in severe upper nasal airway obstruction or when the olfactory epithelium is damaged (as by the influenza virus or by long standing rhinitis).  It can also follow head injuries - particularly occipital ones. The olfactory nerves are severed at the cribriform plate.

Family History:
The patient is asked about the presence of allergic rhinitis, bronchial asthma and atopic dermatitis in first degree relatives

Social and Environmental factors:
Occupational and working environment should be asked about.  The home environment is discussed with particular reference to the bedroom ( feather pillows, age and type of mattress).  Exposure to animals in the home or elsewhere is  also important.

Examination of the nose and sinuses:

The external nose is examined by observation and palpation.  If a person has a fractured nose he/she should be tender over the affected nasal bone.

Examination of the interior of the nose needs good lighting,  the topical use of a vasoconstrictor to shrink the nasal  mucosa.  Use the speculum for examining "elephants ears".  In children, where the use of instruments is best avoided simple upward pressure on the tip of the nose allows examination of the vestibule and beyond. 

In ant evidence of septal deflections, the presence of nasal polyps, the size of the inferior turbinates and the state of the overlying mucosa. Gentle palpation with a probe distinguishes a  turbinate from a polyp.  A polyp is insensitive and swings back and forth on its stalk.   A turbinate is a fixed sensitive structure. Little's area lies against the anterior part of the caudal septum and is easily seen in epistaxis.  Think about the semispinalis capitis muscle with  frontal pain.

History taking in Pharynx, Larynx and Neck:

When assessing a patient with problems of the upper aerodigestive tract and neck remember the surgical sieve.  Is the problem congenital or acquired?  If acquired is it infectious, inflammatory, endocrine or neoplastic? 

A patient may present because of a problem  - i.e. a mass in the neck or lesion in the mouth.

Symptoms are likely to be

Pain:
It is important to take a good history of the pain; description, site, relieving and aggravating factors.  It is important to ask about referred pain particularly to the ear.  A sore throat is usually acute and associated with viral or bacterial infections. 

Hoarseness:
This  is primarily a symptom of laryngeal disease.  Occasionally it is a manifestation of distant disease such as hypothyroidism or lung cancer.  A patient with hoarseness lasting more than three weeks should be referred to an Otolaryngologist.

Dysphagia:
This may vary from mild discomfort to inability to swallow solid food. Symptoms of weight loss should alert the clinician to the possibility of malignancy.  Patients with pharyngeal pouch commonly regurgitate old food.  Nasal regurgitation of food suggests an underlying neurological problem.

Stridor:
The larynx is the only part of the respiratory tract that contains an entire ring of cartilage.  In children, the area below the vocal cords - the subglottis is the narrowest part of the airway.  Obstruction leads to diminished airflow and this leads to turbulence. The turbulent airflow flowing through the narrowed larynx causes a musical noise called stridor.  This is usually inspiratory stridor when the blockage is at or above the level of the vocal cords.

Lump in the Neck
A lump in the neck in an adult is malignant until proved otherwise and needs an otolaryngological opinion.  A patient should be asked about size, site and duration of the mass.  Further questioning will depend on the site of the mass.  It is generally important to ask about associated symptoms such as hoarseness or dysphagia.  In patients with a suspected secondary node in the neck it is important to ask questions looking for the primary site - e.g. nasopharynx  in people of Chinese descent.

History of Alcohol and Tobacco Intake:
Patients with malignancies of the upper aerodigestive tract commonly abuse alcohol and tobacco.

Sleep Disturbance:
The patient history in adults is  conducted best with the bed partner in attendance.  Information should be asked about whether snoring occurs every night in every position, whether there are periods of apnoea as well as the quality of sleep.  The patient is frequently a restless sleeper and usually awakes tired as if he /she hasn't slept much.  The patient should be asked about inappropriate day time snoring and somnolence.

Persistent ulcer or growth:

The patient should be asked about size, duration of the lesion and any associated symptoms such as bleeding, otalgia, etc.

Examination of the Mouth and Oropharynx
These should be examined with a headlight and both hands free.

Lips
The lips should be examined for pallor, mucosal lesions and angular stomatitis

Buccal cavity, teeth and tongue
An orderly examination of the mouth is essential.  Dentures should be removed for a thorough examination of the oral cavity.  The mouth should be examined in a systematic fashion.

The following is recommended:
Examination of the lower buccogingival sulcus as far  back as the last molar tooth on that side follows examination of the buccal surface of the lower lip.  The cheek is then retracted superolaterally to allow inspection of the buccogingival sulcus from posterior to anterior.  Examination then proceeds to the other side of the mouth.  The opening of the parotid duct is seen opposite the second upper molar tooth.  The examiner now turns his attention to the teeth and the surrounding structures of the lower and upper jaw.  Malocclusion of the upper and lower jaw should be noted.  Next the patient is asked to move the tongue.  The patient is then asked to raise the tip of the tongue to expose its ventral surface.   This step naturally leads to examination of the anterior floor of the mouth.  On either side of the frenulum may be seen the opening of the submandibular salivary duct.  The examiner then asks the patient to move the tongue and now retracts the tongue to one side to view the glossogingival sulcus as far back as the lateral border at the base of the tongue and the last molar.  This examination is repeated on the other side of the tongue. Finally the hard palate is inspected.

A tongue spatula is then placed in the midline of the dorsum of the tongue and gentle pressure is applied so that the tonsillar pillars, tonsils, soft palate and uvula can be seen.  After observing the mucosa, the main concern is usually the oropharyngeal tonsil.  The soft palate and the movement of the soft palate is now assessed. 

In children, merely opening the mouth wide with the tongue fully protruding will usually give an excellent view without the need for a spatula

The Neck and Salivary Glands

A thorough neck examination of course includes evaluation of the parotid and submandibular glands, the thyroid gland, and the lymph glands. Each of these areas demands a specific examination when indicated. Masses in any region are noted for:

1. position
2. size
3. contour/ definition
4. texture - soft, firm, hard, fluctuant
5. mobility/ attachment to surrounding structures
6. tenderness
7. transillumination if fluctuant

Nodes
The most important chain of nodes is the jugular chain which has a surface marking roughly from the ear lobe to the sternoclavicular joint. This chain receives lymphatics from the other areas. Nodes in the upper part of this chain are called "upper deep cervical nodes", lower nodes are "lower deep cervical nodes", and nodes in between are "mid deep cervical nodes".

Other important regions are

1. the submandibular triangle (nodes drain the oral cavity, maxillary   sinus, and face)
2. the posterior triangle (nodes drain the nasopharynx and posterior scalp   in particular)
3. the muscular triangle or central compartment (nodes drain the thyroid gland)
4. the supraclavicular fossa (nodes drain the lung, chest wall, abdomen, as well as the more superior cervical nodes)

The full neck examination

The neck is inspected from the front for any unusual scars or masses.  The examiner  then stands slightly behind the patient who  remains comfortably seated with the head slightly flexed.

Enough clothing is removed so that the supraclavicular fossae and the tips of the shoulder are seen.

The neck is best examined in triangles and while each surgeon has his preference it is important to do this methodically.  The examination should begin with the posterior triangle superiorly by defining the mastoid tip and then feeling for nodes along the anterior border of the trapezius muscle.  It is also possible to palpate  under the muscle by gently pressing the fingers under the muscle so that  the flesh between the thumb and the muscles can be palpated. The examining fingers will eventually reach the clavicle.  At this point the floor of the posterior triangle can be examined by rolling the tissues between the fingertips and the muscular floor of the triangle gradually moving medially until the sternomastoid is reached.  The contents of the posterior triangle should then be palpated superiorly until the mastoid process is reached.  The mass of the sternomastoid muscle is then palpated inferiorly.   The medial side of the sternomastoid muscle from the suprasternal notch superiorly should then be examined again palpating for pathological lymph nodes.  It is now possible to feel the lymph nodes associated with the internal jugular vein by firmly pressing the fingers beneath the muscle.  It is possible to palpate the muscle mass itself using the thumb and fingers.  The fingers arrive again at the mastoid process.   The clavicle and suprasternal notch are palpated and at this point the trachea can be felt in the midline.

The external features of the larynx should also be assessed.  The most prominent of the cartilages is the cricoid, and it may just be possible to palpate a normal thyroid isthmus overlying the second and third tracheal rings.  The cricothyroid membrane, the alae of the thyroid cartilage, the thyrohyoid membrane, and the hyoid itself should be palpated. Deep in the groove between the sternomastoid muscle and the larynx lie the great vessels of the neck and associated with the internal jugular vein lies the deep cervical plexus of lymph nodes. The examination continues with the submental triangle. In this triangle lies the submandibular gland and as the fingers come gently forward the facial artery crossing the mandible and associated pre and post facial lymph nodes can be felt.  The examiner stands behind the patient, cupping the fingers under the mandibular ramus and palpating the floor of the mouth for other lymph nodes or direct extension of oral tumour.  Palpation is carried forward toward the point of the chin and then the tissues of the anterior triangle are rolled against the muscles of the floor of the mouth.  If swelling of the submandibular gland is felt, it is mandatory to examine the mouth bimanually with a gloved finger. Finally return to the parotid area and roll the gland over the underlying mandible and masseter in order to palpate irregularities within it.

If your history or examination dictates a more complete examination of the thyroid or salivary areas then proceed as outlined under those headings.

Parotid

The parotid gland is first inspected externally and its size and contour compared to the opposite side. If there is parotid swelling, does it involve the whole gland or some part of it?  Palpation is best performed while standing behind the patient and examining both sides at the same time. Remember that the majority of parotid masses occur in the tail  -  i.e. behind the angle of the mandible. Inspect the duct that opens at its papilla opposite the second upper molar tooth. Observe saliva coming from the papilla by "milking" the gland, compressing it against the angle of the mandible externally. Saliva should be clear. White discharge from the duct indicates infection. Deep lobe parotid tumours may cause medial displacement of the pharyngeal wall (parapharyngeal swelling) - the tonsil is pushed medially rather than downward and medially as with a  quinsy.  The soft palate is swollen and palpably firm.

Submandibular

The submandibular gland is similarly inspected and compared to the opposite side. Palpation should be bimanual. Stand in front of the patient. For the right gland, palpate the gland with your left hand while inserting a gloved right index finger into the floor of mouth on that side. Ballot the gland between the fingers of each hand and palpate along the line of the duct for stones. Change hands for the other side. Inspect the papillae opening on either side at the base of the frenulum and milk saliva from the gland. Note any discoloration of the saliva.

Thyroid

Again, first inspect the thyroid externally. Is there a whole gland swelling or an asymmetrical swelling or mass? The thyroid gland is best palpated from behind the patient. The normal thyroid is not palpated easily.  Feel in the region of the isthmus and then each lobe using your right hand to feel the left lobe, and your left hand to feel the right. Ask the patient to swallow - can you feel a nodule elevate beneath your fingers?  One should also note changes that could indicate hyper or hypothyroidism e.g. hair, nails, skin, eyes, tremor, reflexes