Page 7 of 44
EN2.2 | Headlamp Based ENT Examination Workflow — SDL Guide (Part 3)
Self-Assessment: ENT Examination Competency Check
Use these questions to confirm your readiness before your skills laboratory session. Each question tests a specific technique-knowledge element required for the EN2.2 OSCE station.
Q1: In which direction do you pull the pinna to straighten the adult external auditory canal, and why does this direction differ in infants?
Expected answer: In adults: upward and backward (the cartilaginous canal curves upward and forward relative to the bony canal — pulling up and back straightens this curve). In infants and young children: downward and backward (the canal and TM are nearly in the same plane, more horizontal — downward pull aligns them). Getting this backwards in the OSCE = TM not visible.
Q2: What is the difference between a Thudichum speculum and a Vienna/Killian speculum?
Expected answer: Thudichum speculum = short-bladed, spring-loaded, used for bedside anterior rhinoscopy (inserted 1 cm). Vienna/Killian speculum = longer-bladed, not self-retaining, used in operative or formal anterior rhinoscopy, and for epistaxis packing. For EN2.2 bedside examination, the Thudichum is the correct instrument.
Q3: What is the significance of absent laryngeal crepitus in a patient with dysphagia?
Expected answer: Laryngeal crepitus (crunching as the larynx is displaced against the vertebral column) is normally present. Its absence indicates obliteration of the space between the larynx and the vertebral column by a postcricoid or hypopharyngeal mass — classically postcricoid carcinoma in an older patient with dysphagia. This is Muller's (Chevalier Jackson's) sign.
| Examination step | Correct technique | Common error and consequence |
|---|---|---|
| Headlamp positioning | Central hole over dominant eye; reflected beam converges at patient | Mirror angled wrong → shadow, not light, on examination field |
| Pinna traction (adult) | Upward and backward | Downward → canal not straightened, TM not visible |
| Nasal speculum insertion | Blades horizontal, 1 cm depth | Blades vertical → hits septum; too deep → epistaxis |
| Tongue depressor placement | Anterior 2/3 of tongue, midline | Posterior third → gag reflex, examination terminated |
| Laryngeal crepitus | Lateral displacement of larynx against vertebrae | Too forceful → patient pain; not performed → Muller's sign missed |
SELF-CHECK
During oropharyngeal examination, you notice the right tonsil is enlarged to Grade III, the right soft palate is bulging, and the uvula is displaced to the left. The most likely diagnosis is:
A. Infectious mononucleosis with bilateral tonsillar hypertrophy
B. Peritonsillar abscess (quinsy) on the right side
C. Tonsillar malignancy
D. Acute follicular tonsillitis
Reveal Answer
Answer: B. Peritonsillar abscess (quinsy) on the right side
The combination of unilateral tonsillar displacement medially, bulging of the adjacent soft palate, and deviation of the uvula to the contralateral side is the classical examination triad of a peritonsillar abscess (quinsy). Pus accumulates in the peritonsillar space between the tonsil capsule and the superior pharyngeal constrictor muscle, pushing the tonsil medially. This is a clinical emergency requiring needle aspiration or incision and drainage plus antibiotics. Bilateral symmetric enlargement without uvular deviation is seen in infectious mononucleosis or chronic tonsillar hypertrophy.