• unilateral or bilateral discharge (rhinorrhoea)
• anterior discharge or postnasal drip.
Clear, bilateral watery discharge suggests allergic or non-allergic
rhinitis. Purulent discharge can point to acute bacterial rhinosinusitis
or chronic rhinosinusitis. A unilateral, purulent discharge in a child
raises the possibility of a foreign body in the nose. Following a
head injury, unilateral clear rhinorrhoea suggests a possible CSF
leak secondary to an anterior skull-base fracture.
Epistaxis (bleeding from inside the nose)
• unilateral or bilateral bleeding
• frequency and duration of episodes
The paranasal sinuses are air-filled spaces in the skull. There
are paired frontal, sphenoid, maxillary and anterior and posterior
ethmoid sinuses. The anterior nasal sinuses (frontal, maxillary
and anterior ethmoid) drain into the middle meatus (between
the middle turbinate and lateral wall of the nose). The posterior
ethmoid and sphenoid sinuses drain into the sphenoethmoidal
recess (between the superior turbinate and nasal septum).
• unilateral or bilateral obstruction
• associated symptoms (bleeding, swelling, pain).
Unilateral nasal obstruction may be caused by anatomical
blockage, such as a deviated septum possibly secondary to
A Frequency in hertz (Hz) Hearing level in decibels (dB)
-10 125 250 500 1000 2000 4000 8000
Hearing level in decibels (dB)
-10 125 250 500 1000 2000 4000 8000
B Frequency in hertz (Hz) Hearing level in decibels (dB)
-10 125 250 500 1000 2000 4000 8000
C Frequency in hertz (Hz) Hearing level in decibels (dB)
-10 125 250 500 1000 2000 4000 8000
conduction, Left air conduction, Bone conduction)
If bleeding is unilateral and associated with nasal obstruction
and pain, the possibility of sinonasal malignancy should be
considered. In adolescent males with unilateral nasal obstruction
and epistaxis, the rare diagnosis of juvenile angiofibroma should
be excluded on nasendoscopy by an ear, nose and throat
• whether symptoms occur all year round, only during
certain seasons, or during contact with allergens.
Sneezing is a protective sudden expulsive effort triggered by
local irritants in the nose and is most commonly due to allergy
• complete loss of smell (anosmia)
• reduced sense of smell (hyposmia)
• unpleasant smells (cacosmia)
• associated nasal symptoms such as obstruction
and rhinorrhoea, which may suggest rhinitis or nasal
A sudden onset of anosmia can occur following a significant
head injury or viral URTI due to damage to the olfactory
epithelium. Inflammation and swelling in the nasal mucosa as
a result of rhinitis, chronic rhinosinusitis or nasal polyps usually
cause hyposmia. Cacosmia is usually caused by infection in the
nose or sinuses, or occasionally by a foreign body in the nose.
Phantosmia describes olfactory hallucinations, which may occur
Nasal pain is rare, except following trauma. Facial pain can
be caused by a number of problems but is often incorrectly
attributed to sinusitis. The key to identifying the cause of facial
• provoking factors such as trauma, sneezing, or blowing or
• bleeding from the front or back of the nose.
The nasal septum has a very rich blood supply, particularly in
Little’s area (anterior septum), which is a common site for bleeding.
Fig. 9.13 The nose and paranasal sinuses.
182 • The ear, nose and throat
• use of anticoagulants, including warfarin, apixaban or
• use of antiplatelet drugs (aspirin, clopidogrel).
Intranasal cocaine use can cause septal perforation, epistaxis,
A family history of atopy is relevant in rhinitis. In patients with
epistaxis it is important to establish a family history of hereditary
haemorrhagic telangiectasia or inherited bleeding disorders.
Occupation is relevant because exposure to inhaled allergens,
occupational dusts and chemicals may exacerbate rhinitis.
Exposure to hardwood dust is associated with an increased
risk of sinonasal cancers. Atopic patients should be asked
Heavy alcohol intake, leading to liver disease, can affect
coagulation and is relevant for epistaxis. Smoking impedes
mucociliary clearance and can contribute to nasal problems.
• Assess the external appearance of the nose, noting
swelling, bruising, skin changes and deformity.
• Stand above the seated patient to assess any external
• Ask the patient to look straight ahead. Elevate the tip of
their nose using your non-dominant thumb to align the
nostrils with the rest of the nasal cavity.
• Look into each nostril and assess the anterior nasal
septum (Fig. 9.16); note the mucosal covering, visible
vessels in Little’s area, crusting, ulceration and septal
perforation. In trauma, a septal haematoma should be
• Using an otoscope with a large speculum in an adult,
assess the inferior turbinates. Note any hypertrophy and
swelling of the turbinate mucosa.
• You may see large polyps on anterior rhinoscopy. To
distinguish between hypertrophied inferior turbinates and
nasal polyps, you can lightly touch the swelling with a
cotton bud (polyps lack sensation).
• Palpate the nasal bones to assess for bony or
• In trauma, palpate the infraorbital ridges to exclude a step
deformity and also to check infraorbital sensation. Eye
movements should be assessed to rule out restriction of
movement related to ‘orbital blowout’.
• Place a metal spatula under the nostrils and look for
condensation marks to assess airway patency.
• Palpate for cervical lymphadenopathy (p. 32).
• Note that rigid nasendoscopy and tests of olfaction are
confined to specialist clinics.
• quality of pain: for example, throbbing, aching, sharp,
• location of pain: unilateral or bilateral
• duration and frequency of pain
• associated nausea, photophobia or aura (migraine)
• relieving and exacerbating factors.
rhinosinusitis, trigeminal neuralgia (severe, sharp pain in a
trigeminal distribution), tension headache (band-like, tight pain)
and cluster headaches (unilateral nasal discharge, eye watering).
The most common cause of nasal deformity is trauma, resulting
in swelling, bruising and deviation of the nose. The swelling
following trauma will settle over a couple of weeks but residual
deviation may remain if the nasal bones were fractured and
displaced. It is important to establish the impact of the nasal
injury on function (nasal breathing, sense of smell) and cosmetic
Nasal septal destruction or perforation can result in ‘saddle
deformity’ of the nasal bridge. Causes include granulomatosis
with polyangiitis, trauma, cocaine abuse, congenital syphilis and
iatrogenic factors (septal surgery, Fig. 9.14B).
The nose can appear widened in acromegaly or with advanced
nasal polyposis (Fig. 9.14C). Rhinophyma can also result from
chronic acne rosacea of the nasal skin (Fig. 9.15).
• asthma (around one-third of patients with allergic rhinitis
• prior nasal trauma or surgery
• history of bronchial infection (cystic fibrosis or ciliary
disorders may affect the nose and lower airways).
For patients with epistaxis it is important to identify any history
of bleeding diathesis or hypertension.
Fig. 9.15 Rhinophyma as a complication of rosacea.
9.7 Investigations in nasal disease
Investigation Indication/comment
Plain X-ray Not indicated for nasal bone fracture
Only required if associated facial fracture is suspected
Nasal endoscopy Inflammatory sinus disease, malignancy
Computed tomography Inflammatory sinus disease, trauma and malignancy
enabling planning of endoscopic surgical procedures (see Fig. 9.17)
Tests of olfaction Used in specialist clinics only
Include the UPSIT smell test and Sniffin’ Sticks
RAST, radioallergosorbent test; UPSIT, University of Pennsylvania smell identification test.
The mucosa of the inferior turbinate on anterior rhinoscopy is
pale, moist and hypertrophied in allergic rhinitis (see Fig. 9.14A).
In chronic rhinitis the mucosa is swollen and red. Large polyps
may be seen on anterior rhinoscopy as pale yellow/grey swellings
A septal haematoma will appear as a soft, red, fluctuant swelling
of the anterior septum. The septal cartilage receives its blood
supply from the overlying perichondrium; a septal haematoma
interrupts this supply and can result in cartilage necrosis, septal
perforation and ‘saddle deformity’. It must therefore be identified
and referred for early drainage.
Facial swelling is not usually seen in chronic sinusitis but can
occur with dental abscesses and cancer of the maxillary antrum.
Initial investigations are summarised in Box 9.7 and Fig. 9.17.
184 • The ear, nose and throat
In children the 20 deciduous teeth erupt by 3 years. There are 32
secondary teeth, erupting from ages 6 to 16 or later (Fig. 9.20).
Anatomically the neck is divided into anterior and posterior
triangles (Fig. 9.21). The anterior triangle is bounded by the
midline, the anterior border of the sternocleidomastoid muscle
and the body of the mandible. The posterior triangle of the neck
is bounded by the posterior border of sternocleidomastoid, the
trapezius muscle and the clavicle. The cervical lymph nodes
drain the head and neck (see Fig. 3.26). Examination of these
nodes is described on page 33 and shown in Fig. 3.27. Palpable
lymphadenopathy is most commonly due to URTI but may be
caused by atypical infection, inflammation, lymphoma or metastatic
malignancy. The neck can also be subdivided further into different
levels that are used to describe the location of enlarged lymph
nodes in the neck (Fig. 9.22).
• how long pain has been present and any progression
Aphthous ulcers are small, painful, superficial ulcers on the
tongue, palate or buccal mucosa. They are common and usually
heal spontaneously within a few days. Oral ulcers can be caused
by trauma, vitamin or mineral deficiency, cancer, lichen planus
or inflammatory bowel disease.
The mouth extends from the lips anteriorly to the anterior tonsillar
pillar posteriorly and is divided into the vestibule, between the
buccal (cheek) mucosa and the teeth, and the oral cavity internal
to the teeth. The oral cavity contains the anterior two-thirds of
the tongue, the floor of the mouth, the hard palate and the inner
surfaces of the gums and teeth (Fig. 9.18). The tongue anteriorly
has filiform papillae containing taste buds, giving the tongue its
velvet texture. The circumvallate papillae are groups of taste
buds marking the boundary between the anterior two-thirds
and posterior third of the tongue.
Saliva is secreted into the mouth from the parotid, submandibular
and sublingual salivary glands (Fig. 9.19). The parotid gland is
situated anterior to the ear and has a superficial and deep lobe
relative to the facial nerve that runs through it. The parotid duct
opens into the buccal mucosa opposite the second upper molar.
The submandibular gland lies anterior and medial to the angle
of the mandible and its duct opens into the floor of the mouth
next to the frenulum of the tongue (see Fig. 9.18).
The pharynx is a shared upper aerodigestive channel that runs
from the anterior tonsillar pillar to the laryngeal inlet. The larynx
(‘voice box’) is responsible for phonation and also has a protective
function to prevent aspiration. It consists of two external cartilages,
the thyroid cartilage (Adam’s apple) and the cricoid cartilage
(prominence at the top of the trachea; see Fig. 10.1A). The
membrane between the two is called the cricothyroid membrane;
a cricothyroidotomy may be performed by an experienced
clinician at this site as an emergency procedure to obtain an
airway. The sensory supply to the larynx is via the superior and
recurrent laryngeal branches of cranial nerve X (vagus). The motor
supply is mainly from the recurrent laryngeal nerve, which loops
round the aortic arch on the left side and the subclavian artery
A sore mouth can also be due to conditions of the gums,
including inflammation (gingivitis) or systemic conditions (Box 9.8).
Infections, including candidiasis (caused by Candida albicans),
herpes simplex and herpes zoster, as well as dental sepsis,
can cause a painful mouth. Candidiasis may be secondary to
poorly fitted dentures, the use of inhaled glucocorticoids or
immunodeficiency. Herpes zoster of the maxillary division of
the trigeminal nerve (see Fig. 7.9B) can cause unilateral painful
• unilateral or bilateral pain
• difficulty opening the mouth (trismus, due to spasm of the
• associated fever, malaise, anorexia, neck swelling
• associated red flag symptoms (dysphagia, odynophagia,
Throat pain can radiate to the ear as a result of the dual
innervation of the pharynx and external auditory meatus via the
vagus nerve (referred pain). The most common cause of sore
throat is pharyngitis (inflammation of the pharynx) and is usually
viral. Acute tonsillitis may be viral or caused by streptococcal
bacterial infection (Fig. 9.23A), and cannot be distinguished
Fig. 9.19 The position of the major salivary glands.
Fig. 9.20 Primary and secondary dentition.
Fig. 9.21 Sites of swellings in the neck.
I Submental and submandibular nodes
II Upper third sternocleidomastoid (SCM) muscle
III Middle third SCM (between hyoid and cricoid)
IV Lower third SCM (between cricoid and clavicle)
V Posterior to SCM (posterior triangle)
VI Midline from hyoid to manubrium
Fig. 9.22 Cervical lymph node levels.
9.8 The gums in systemic conditions
Phenytoin treatment Firm and hypertrophied
Acute leukaemia Hypertrophied and haemorrhagic
Cyanotic congenital heart disease Spongy and haemorrhagic
186 • The ear, nose and throat
Globus pharyngeus is a sensation of something in the throat in
the context of a normal clinical examination. Patients classically
describe the feeling of a lump in the throat, usually in the midline,
which fluctuates from day to day and eases when swallowing.
Anxiety, habitual throat clearing and acid reflux are thought to
Stridor is a high-pitched noise produced by turbulent airflow
through a narrowed, partially obstructed upper airway and can
indicate laryngeal or tracheobronchial (p. 79) obstruction. It most
commonly occurs on inspiration but may also be expiratory or
biphasic. The level of obstruction determines the type of stridor.
Inspiratory stridor suggests narrowing at the level of the vocal
cords, biphasic stridor suggests subglottic/tracheal obstruction,
and stridor on expiration suggests tracheobronchial obstruction.
Common causes of stridor include infection/inflammation, trauma,
foreign bodies (particularly in children) and tumours. Stridor should
Stertor differs from stridor. It is a low-pitched snoring or gasping
sound audible during inspiration and is due to obstruction at the
level of the nasopharynx or oropharynx. This can be as a result
of enlarged inflamed tonsils, a peritonsillar abscess or tongue
swelling (trauma, anaphylaxis).
• how long dysphonia (hoarseness) has been present
• whether it is persistent or intermittent
• voice quality (croaky, breathy, weak)
• associated stridor, dysphagia, otalgia or weight loss.
If hoarseness has been present continuously for more than
3 weeks, urgent laryngoscopy is indicated to exclude laryngeal
cancer. If voice quality is breathy and associated with a weak
(bovine) cough (p. 78), a recurrent laryngeal nerve palsy
due to lung or oesophageal cancer should be considered.
Recurrent laryngeal nerve palsy may also be iatrogenic (thyroid
surgery) or secondary to trauma or neurological conditions
The approach to dysphagia is described on page 98.
Neck lumps are common; they may be reported by patients or
found incidentally on physical examination. While many lumps
are benign, there may be a more serious underlying diagnosis
• associated hoarseness or dysphagia
• fever or other systemic symptoms (weight loss, night
Infectious mononucleosis caused by Epstein–Barr virus
(glandular fever) results in tonsil erythema and swelling, a
white pseudomembrane covering the tonsil, palatal petechiae
(Fig. 9.23B), cervical lymphadenopathy and sometimes
hepatosplenomegaly. A peritonsillar abscess (quinsy) can lead
to unilateral throat pain, trismus, drooling of saliva, soft-palate
swelling, deviation of the uvula to the opposite side (Fig. 9.23C)
and ‘hot-potato voice’ (like you were trying to speak with a hot
It is important to establish whether there are any ‘red flag’
symptoms associated with sore throat. Progressive dysphagia or
hoarseness associated with weight loss should raise suspicion
of malignancy. A mass or ulcer on the tonsil associated
with throat pain may be a tonsil squamous cancer. Human
papillomavirus-related oropharyngeal cancer is the now most
common primary head and neck malignancy in young, sexually
Fig. 9.23 Sore throat. A Acute tonsillitis. The presence of pus strongly
suggests a bacterial (streptococcal) aetiology. B Glandular fever showing
palatal petechiae. C A left peritonsillar abscess. (A) From Bull TR. Color
Atlas of ENT Diagnosis. 3rd edn. London: Mosby–Wolfe; 1995.
The physical examination • 187
It is important to establish whether there are any previous dental
problems or systemic disease, particularly those affecting the
gastrointestinal tract, as the mouth is part of this. Neurological
conditions may affect swallowing and cause drooling or dry mouth
with secondary infection. Previous head and neck surgery and
Any prior intubations or admissions to intensive care should
be recorded, as repeated or prolonged intubation can result in
subglottic stenosis and stridor.
Many drugs, including tricyclic antidepressants and anticholinergics,
cause a dry mouth. Multiple, repeated courses of antibiotics
increase the risk of oral candidiasis, as does any prolonged illness.
Risk factors for head and neck squamous cancer include
alcohol and smoking. Oral cancer is more common in those who
experience orogenital contact and in those who chew tobacco
or betel nuts. Any history of head and neck cancer in the family
• Listen to the patient’s voice (rough, breathy, wet, muffled,
• Use a head light to leave both of your hands free to use
• Ask the patient to remove any dentures.
• Look at their lips. Ask them to half-open their mouth and
inspect the mucosa of the vestibule, buccal surfaces and
buccogingival sulci for discoloration, inflammation or
ulceration, then at bite closure. Inspect the parotid duct
opening opposite the second upper molar for any pus or
• Ask the patient to open their mouth fully and put the tip of
their tongue behind their upper teeth. Check the mucosa
of the floor of the mouth and the submandibular duct
• Ask them to stick their tongue straight out, noting any
deviation to either side (XII nerve dysfunction), mucosal
change, ulceration, masses or fasciculation.
• Ask them to deviate their tongue to one side. Retract the
opposite buccal mucosa with a tongue depressor to view
the lateral border of the tongue. Repeat on the other side.
• Inspect the hard palate (Fig. 9.25) and note any cleft,
abnormal arched palate or telangiectasia.
• Inspect the oropharynx. Ask the patient to say ‘Aaah’ and
use a tongue depressor to improve visualisation.
• Assess the soft palate for any cleft, bifid uvula, swelling or
Sudden, painful, unilateral salivary gland swelling (sialadenopathy)
is due to a stone obstructing the duct (sialolithiasis). Other
causes of enlarged salivary glands are mumps (usually bilateral),
sarcoidosis, human immunodeficiency virus-related cysts, bacterial
infection (suppurative parotitis; Fig. 9.24) and cancer. The clinical
features of important neck lumps are summarised in Box 9.10.
9.9 Causes and features of dysphonia
Congenital abnormality Laryngomalacia most frequent cause
More common in preterm neonates
Associated stridor due to immature
larynx folding in on inspiration
Neurological disorder Examples include vocal cord palsy
Unilateral causing weak, breathy cry
Bilateral may cause stridor and airway
Barking cough, stridor, hoarse voice
Trauma Mechanical or chemical injury
Gastro-oesophageal reflux disease
Lung cancer Vocal cord paralysis, breathy voice
Neurological disorder Weak, wet or dysarthric voice
Cancer of the larynx Rough voice, constant, progressive,
Fig. 9.24 Pus discharging from the parotid duct.
188 • The ear, nose and throat
9.10 Causes and features of neck lumps
Location in neck Diagnosis Clinical features
Midline Thyroglossal cyst Smooth, round, cystic lump that moves when patient sticks out
Submental lymph nodes Associated infection of lower lip, floor of mouth, tip of tongue or
Thyroid isthmus swelling Lump moves on swallowing
Dermoid cyst Small, non-tender, mobile subcutaneous lump
Anterior triangle Thyroid lobe swellings:
Thyroid tumours: benign (adenoma) and malignant
(papillary, follicular, medullary, anaplastic)
Lump moves with swallowing but not on tongue protrusion
Infection, stones, autoimmune disease
Swelling below the angle of the mandible. Can be felt bimanually.
Involvement of more than one gland suggests a systemic condition.
A lump within the gland suggests a tumour. Uniform enlargement
with pain suggests infection or stones
Mumps, parotitis, stones, autoimmune disease
Swelling in the preauricular area or just below the ear
Hard, fixed mass with facial nerve weakness suggests a malignant
Branchial cyst Smooth, non-tender, fluctuant mass. Not translucent. Slowly
enlarging, may increase after upper respiratory tract infection
Malignant: lymphoma, metastatic cancer Large, hard, fixed, matted, painless mass suggests malignancy
Infection: bacterial infection of head and neck,
viral infection (e.g. infectious mononucleosis),
human immunodeficiency virus, tuberculosis
Lymph nodes can be reactive to infection and are usually smooth,
Posterior triangle Lymph nodes:
Carotid body tumour Firm, rubbery, pulsatile neck mass, fixed vertically due to attachment
to bifurcation of common carotid. A bruit may be present
Carotid artery aneurysm Rare, present as pulsatile neck mass
Cystic hygroma Soft, fluctuant, compressible and transilluminable mass, usually seen
Fig. 9.25 Torus palatinus. This benign asymptomatic central palatal bony
mass is more common in Asian populations. From Scully C. Oral and
Maxillofacial Medicine. 2nd edn. Edinburgh: Churchill Livingstone; 2008.
• Inspect the tonsils, noting size, symmetry, colour and any
• Touch the posterior pharyngeal wall gently with the tongue
depressor to stimulate the gag reflex. Check for
symmetrical movement of the soft palate.
• If any lesion is seen in the mouth or salivary glands,
palpate it (wearing gloves) with one hand outside on the
patient’s cheek or jaw and a finger of your other hand
inside the mouth (bimanual palpation).
• Feel the lesion and identify its characteristics (p. 32).
• If the base of the tongue or the tonsils are asymmetrical,
palpate it using a gloved finger.
• If the parotid gland is enlarged or abnormal on inspection,
examine the facial nerve and check if the deep lobe (tonsil
• Palpate the parotid and submandibular duct, feeling for
• Palpate the cervical lymph nodes (p. 33).
The physical examination • 189
biopsy (Fig. 9.27B). Cancers (usually squamous) may occur at
any site in the mouth. Any painless persistent mass in the mouth
should be assumed to be oral cancer and referred urgently for
biopsy. Similarly, any mouth ulcer persisting for over 3 weeks
requires biopsy to exclude cancer (Fig. 9.27C).
A stone may be felt in the submandibular (or, rarely, the parotid)
duct. Rotten teeth (dental caries) are common in patients with
poor oral hygiene (Fig. 9.27D).
The neck must be examined in all patients with mouth or throat
• With the patient sitting down and their neck fully exposed
(ties and scarves removed and shirt unbuttoned), look at
their neck from in front. Inspect for scars, masses or
• From behind, palpate the neck. Work systematically
around the neck. Start in the midline and gently palpate
the submental, submandibular and preauricular areas,
assessing for the presence of any masses or swelling.
Then palpate down the anterior border of the
sternocleidomastoid muscle to the midline inferiorly.
• Palpate the midline structures of the neck from inferior to
superior up to the submental area, noting any masses.
• If a midline mass is present, ask the patient to swallow
(offer a glass of water if needed) and then instruct them to
stick out their tongue while you palpate the mass.
Movement superiorly on swallowing suggests a thyroid
Cracking of the lips can be the result of cold exposure (‘chapped
lips’), riboflavin deficiency, chronic atrophic candidiasis or iron
deficiency (Fig. 9.26). Squamous and basal cell cancers occur
on the lips and are associated with smoking and sun exposure.
The normal tongue appearance includes areas of smooth
mucosa (‘geographic tongue’) or, conversely, excessive furring.
A smooth red tongue with diffuse papillary atrophy occurs in
iron or vitamin B12 deficiency. Tongue protrusion may be limited
by neurological disease, painful mouth or a tight frenulum.
Macroglossia (enlarged tongue) occurs in Down’s syndrome,
acromegaly (see Fig. 10.9), hypothyroidism and amyloidosis.
Wasting and fasciculation of the tongue are features of motor
White plaques of candidiasis on the tongue or mucosa (Fig.
9.27A) come away easily when scraped but leukoplakia (a
keratotic precancerous condition) does not and requires excision
190 • The ear, nose and throat
swelling (p. 194), while movement on tongue protrusion
suggests a thyroglossal cyst (Fig. 9.28).
• Palpate the posterior triangle of the neck, including the
posterior border of sternocleidomastoid and anterior
border of trapezius. Palpate for occipital lymph nodes
• For any mass, note the size, site, consistency, edge,
fixation to deeper structures, tethering to the skin, warmth,
fluctuance, pulsatility and transillumination (p. 32).
Initial investigations are summarised in Box 9.11.
9.11 Mouth, throat and neck investigations
Investigation Indication/comment
Full blood count Infective causes of mouth, throat or
Monospot Infectious mononucleosis
Hepatosplenomegaly can occur in
infectious mononucleosis so liver
Throat swab Acute tonsillitis and pharyngitis
Patients may carry Streptococcus
pyogenes and have a viral infection
(detected by PCR), so swab does not
PCR may help identify viral causes
Endoscopy and biopsy Cancer of larynx and pharynx, changes
Computed tomography Cancer and metastases
PCR, polymerase chain reaction.
Mr Smith, 65 years old, presents with hoarseness.
Please take a history from the patient
• Introduce yourself and clean your hands.
• Invite the patient to describe the presenting symptoms, using open questioning.
conditions, including neurological problems.
• Ask about social history, including profession (singer, teacher), smoking and alcohol consumption.
• Address any patient concerns.
• Thank the patient and clean your hands.
Suggest initial investigations
Mrs Lewis, 55 years old, presents with a lump just under her left ear at the angle of her jaw.
• Introduce yourself and clean your hands.
ask the patient to swallow and stick out their tongue.
• Ask if the lump is painful and if the patient minds you examining it.
• Palpate the anterior and posterior triangles of the neck, and the parotid region.
• Assess facial nerve function if you suspect a parotid mass.
• Thank the patient and clean your hands.
The most likely diagnosis is a pleomorphic salivary adenoma in the tail of the parotid.
Ultrasound scan with or without fine-needle aspiration.
Integrated examination sequence for ear, nose and throat disease
• Inspect: pinna skin, shape, size, position, deformity, scars.
• Palpate: pinna, tragus, mastoid.
• Otoscopy: external auditory canal (swelling, discharge), tympanic membrane (red, perforated).
• If there is hearing loss: whispered voice test and tuning fork tests.
• If there are balance symptoms: vestibular examination, including Dix–Hallpike.
– External nose (swelling, bruising, skin changes, deformity).
– Inferior turbinates (hypertrophy, swelling, polyps).
– Nasal bones (bony or cartilaginous deformity).
– Airway patency using metal spatula.
• Examine the mouth and throat:
• Listen to the voice (rough, breathy, wet, muffled, nasal escape).
– Hard palate for cleft, abnormal arched palate, telangiectasia.
– Soft palate for cleft, bifid uvula, swelling or lesions.
– Tonsils, noting size, symmetry, colour, pus or membrane.
– Any lesion, identifying characteristics.
– Base of tongue or tonsils if asymmetrical.
– Parotid and submandibular ducts, feeling for stones.
– If there is midline swelling, ask the patient to swallow and stick out their tongue.
– Anterior and posterior triangles of the neck and parotid region.
– If there is a parotid lump, assess the facial nerve.
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Common presenting symptoms 194
Past medical, drug, family and social history 196
Common presenting symptoms 198
Past medical, drug, family and social history 199
Common presenting symptoms 200
Common presenting symptoms 201
Past medical and drug history 202
Common presenting symptoms 204
Common presenting symptoms 205
Past medical, drug, family and social history 205
OSCE example 1: Neck swelling 209
OSCE Example 2: Diabetic feet 209
10.1 Common clinical features in endocrine disease
Symptom, sign or problem Differential diagnoses
Tiredness Hypothyroidism, hyperthyroidism, diabetes mellitus, hypopituitarism
Weight gain Hypothyroidism, PCOS, Cushing’s syndrome
Weight loss Hyperthyroidism, diabetes mellitus, adrenal insufficiency
Diarrhoea Hyperthyroidism, gastrin-producing tumour, carcinoid
Diffuse neck swelling Simple goitre, Graves’ disease, Hashimoto’s thyroiditis
Hirsutism Idiopathic, PCOS, congenital adrenal hyperplasia, Cushing’s syndrome
‘Funny turns’ or spells Hypoglycaemia, phaeochromocytoma, neuroendocrine tumour
Sweating Hyperthyroidism, hypogonadism, acromegaly, phaeochromocytoma
Flushing Hypogonadism (especially menopause), carcinoid syndrome
Resistant hypertension Conn’s syndrome, Cushing’s syndrome, phaeochromocytoma, acromegaly
Amenorrhoea/oligomenorrhoea PCOS, hyperprolactinaemia, thyroid dysfunction
Muscle weakness Cushing’s syndrome, hyperthyroidism, hyperparathyroidism, osteomalacia
PCOS, polycystic ovary syndrome.
Endocrine glands synthesise hormones that are released into
the circulation and act at distant sites. Diseases may result
from excessive or inadequate hormone production, or target
organ hypersensitivity or resistance to the hormone. The main
endocrine glands are the pituitary, thyroid, adrenals, gonads
(testes and ovaries), parathyroids and the endocrine pancreas.
With the notable exception of the pancreatic islet cells (which
release insulin) and the parathyroids, most endocrine glands
are themselves controlled by hormones released from the
Since hormones circulate throughout the body, symptoms and
signs of endocrine disease are frequently non-specific, affecting
many body systems (Box 10.1). Often, endocrine disease is
picked up incidentally during biochemical testing or radiological
imaging. Careful history taking and examination are required to
recognise characteristic patterns of disease. Thyroid disease and
diabetes mellitus are common and frequently familial; establishing
a detailed family history is therefore important. Some less common
endocrine disorders (such as multiple endocrine neoplasia) show
an autosomal dominant pattern of inheritance.
The thyroid is a butterfly-shaped gland that lies inferior to the
cricoid cartilage, approximately 4 cm below the superior notch
of the thyroid cartilage (Fig. 10.1A). The normal thyroid has a
volume of <20 mL and is palpable in about 50% of women and
25% of men. It is comprised of a central isthmus approximately
1.5 cm wide, covering the second to fourth tracheal rings, and
two lateral lobes that are usually no larger than the distal phalanx
of the patient’s thumb. The gland may extend into the superior
mediastinum and can be partly or entirely retrosternal. Rarely, it
can be located higher in the neck along the line of the thyroglossal
duct, an embryological remnant of the descent of the thyroid
from the base of the tongue to its final position. Thyroglossal
cysts can also arise from the thyroglossal duct; they often occur
at the level of the hyoid bone (Fig. 10.1A) and characteristically
move upwards on tongue protrusion. The thyroid is attached to
the pretracheal fascia and thus moves superiorly on swallowing
Thyrotoxicosis is a clinical state of increased metabolism caused
by elevated circulating levels of thyroid hormones. Graves’ disease
is the most common cause (Fig. 10.2 and Box 10.2). It is an
autoimmune disease with a familial component and is 5–10
times more common in women, usually presenting between 30
and 50 years of age. Other causes include toxic multinodular
goitre, solitary toxic nodule, thyroiditis and excessive thyroid
Hypothyroidism is caused by reduced levels of thyroid
hormones, usually due to autoimmune Hashimoto’s thyroiditis,
and affects women approximately six times more commonly
than men. Most other causes are iatrogenic and include previous
radioiodine therapy or surgery for Graves’ disease.
Goitre is enlargement of the thyroid gland (Fig. 10.3). It is not
necessarily associated with thyroid dysfunction and most patients
occult nodules; thus many are found incidentally on neck or
Neck pain is uncommon in thyroid disease and, if sudden in
onset and associated with thyroid enlargement, may represent
with goitre are euthyroid. Large or retrosternal goitres may cause
compressive symptoms, including stridor, breathlessness or
Thyroid nodules may be solitary (Fig. 10.3C) or may present as
a dominant nodule within a multinodular gland. Palpable nodules
(usually >2 cm in diameter) occur in up to 5% of women and
less commonly in men, although up to 50% of patients have
Past medical, drug, family and social history
• prior neck irradiation (risk factor for thyroid malignancy)
• recent pregnancy (postpartum thyroiditis usually occurs in
• drug therapy: antithyroid drugs or radioiodine therapy;
amiodarone and lithium can cause thyroid dysfunction
• family history of thyroid or other autoimmune disease
• residence in an area of iodine deficiency, such as the
Andes, Himalayas, Central Africa: can cause goitre and,
• smoking (increases the risk of Graves’ ophthalmopathy).
bleeding into an existing thyroid nodule. Pain can also occur in
viral subacute (de Quervain’s) thyroiditis.
History suggesting hyperthyroidism
• tremor, heat intolerance, excessive sweating (hyperhidrosis)
• pruritus (itch), onycholysis (loosening of the nails from the
• irritability, anxiety, emotional lability
• dyspnoea, palpitations, ankle swelling
• weight loss, hyperphagia, faecal frequency, diarrhoea
• proximal muscle weakness (difficulty rising from sitting or
• oligomenorrhoea or amenorrhoea (infrequent or ceased
• eye symptoms: ‘grittiness’, excessive tearing, retro-orbital
pain, eyelid swelling or erythema, blurred vision or diplopia
(these symptoms of ophthalmopathy occur in the setting
of autoimmune thyroid disease).
History suggesting hypothyroidism
• fatigue, mental slowing, depression
• symptoms of carpal tunnel syndrome
10.2 Features suggestive of Graves’ hyperthyroidism
• Prior episode of hyperthyroidism requiring treatment
• Family history of thyroid or other autoimmune disease
• Ocular symptoms (‘grittiness’, redness, pain, periorbital swelling)
• Diffuse thyroid enlargement (can be nodular)
• Signs of Graves’ ophthalmopathy (proptosis, redness, oedema)
The physical examination • 197
Many clinical features of hypothyroidism are produced by
myxoedema (non-pitting oedema caused by tissue infiltration
by mucopolysaccharides, chondroitin and hyaluronic acid; Figs
10.4 and 10.5). Other common findings in hypothyroidism include
goitre, cool, dry or coarse skin, bradycardia, delayed ankle reflexes
• Observe the facial appearance, noting signs of dry or
coarse hair and periorbital puffiness (Fig. 10.5).
• Inspect the hands for vitiligo, thyroid acropachy,
onycholysis and palmar erythema.
• Assess the pulse (tachycardia, atrial fibrillation,
bradycardia) and blood pressure.
• Auscultate the heart for a midsystolic flow murmur
• Inspect the limbs for coarse, dry skin and pretibial
• Assess proximal muscle power and deep tendon (ankle)
• Inspect the neck from the front, noting any asymmetry or
scars. Inspect the thyroid from the side with the patient’s
neck slightly extended. Extending the neck will cause the
thyroid (and trachea) to rise by a few centimetres and may
make the gland more apparent. Give the patient a glass of
water and ask them to take a sip and then swallow. The
thyroid rises (with the trachea) on swallowing.
• Palpate the thyroid by placing your hands gently on the
front of the neck with your index fingers just touching,
while standing behind the patient (see Fig. 10.1B). The
patient’s neck should be slightly flexed to relax the
Hyperthyroidism Hypothyroidism
Fig. 10.4 Features of hyper- and hypothyroidism. Fig. 10.5 Typical facies in hypothyroidism.
Look for signs of weight loss or gain (calculate the body mass
index), and assess the patient’s behaviour for signs of agitation,
restlessness, apathy or slowed movements. Patients may have
abnormal speech (pressure of speech suggests hyperthyroidism,
while speech is often slow and deep in hypothyroidism).
Hoarseness is suggestive of vocal cord paralysis and should
raise suspicion of thyroid malignancy.
Features of hyperthyroidism and hypothyroidism on examination
Features of thyrotoxicosis include warm, moist skin, proximal
muscle weakness (due to a catabolic energy state), tremor
and brisk deep tendon reflexes. Hyperthyroidism may also be
associated with tachycardia or atrial fibrillation, and a midsystolic
cardiac flow murmur due to increased cardiac output.
Thyroid acropachy is an extrathyroidal manifestation of
autoimmune thyroid disease. It is characterised by soft-tissue
swelling and periosteal hypertrophy of the distal phalanges, and
mimics finger clubbing (see Fig. 10.2C). It is often associated with
dermopathy and ophthalmopathy. Pretibial myxoedema is a raised,
discoloured (usually pink or brown), indurated appearance over
the anterior shins; despite its name, it is specifically associated
with Graves’ disease and not hypothyroidism (see Fig. 10.2D).
• Assess eye movements (see Fig. 8.11). Graves’
ophthalmopathy is characteristically associated with
Lid retraction (a staring appearance due to widening of the
palpebral fissure) and lid lag (see earlier) are common eye signs
associated with hyperthyroidism. Both are thought to be due
to contraction of the levator muscles as a result of sympathetic
hyperactivity. Periorbital puffiness (myxoedema) is sometimes
Graves’ ophthalmopathy occurs in around 20% of patients
and is caused by an inflammatory infiltration of the soft tissues
and extraocular muscles (see Fig. 10.2A,B). Features suggestive
of active inflammation include spontaneous or gaze-evoked
eye pain, and redness or swelling of the lids or conjunctiva.
Proptosis (protrusion of the globe with respect to the orbit) may
occur in both active and inactive Graves’ ophthalmopathy and
is often referred to as exophthalmos. Inflammation of the orbital
soft tissues may lead to other more severe features, including
corneal ulceration, diplopia, ophthalmoplegia and compressive
optic neuropathy (see Fig. 8.8D).
sternocleidomastoid muscles. Ask the patient to swallow
again and feel the gland as it moves upwards.
• Note the size, shape and consistency of any goitre and
• Palpate for cervical lymphadenopathy (see Fig. 3.27).
• Percuss the manubrium to assess for dullness due to
retrosternal extension of goitre.
• Auscultate with your stethoscope for a thyroid bruit. A
thyroid bruit (sometimes associated with a palpable thrill)
indicates abnormally high blood flow and is most
commonly associated with Graves’ disease. It may be
confused with other sounds: bruits from the carotid artery
or those transmitted from the aorta are louder along the
Early simple goitres are relatively symmetrical but may become
nodular with time. In Graves’ disease the surface of the thyroid is
usually smooth and diffuse; in uninodular or multinodular goitre
it is irregular (see Fig. 10.3). Diffuse tenderness is typical of
viral thyroiditis. Localised tenderness may follow bleeding into a
thyroid cyst. Fixation of the thyroid to surrounding structures (such
that it does not move on swallowing) and associated cervical
lymphadenopathy increase the likelihood of thyroid malignancy.
Further investigation of thyroid disorders is summarised in
• Look for periorbital puffiness or oedema, and lid
retraction (this is present if the white sclera is visible
above the iris in the primary position of gaze; see
• Examine for features of Graves’ ophthalmopathy, including
exophthalmos (look down from above and behind the
patient), lid swelling or erythema, and conjunctival redness
• Assess for lid lag: ask the patient to follow your index
finger as you move it from the upper to the lower part of
the visual field. Lid lag means delay between the
movement of the eyeball and descent of the upper eyelid,
exposing the sclera above the iris.
10.3 Investigations in thyroid disease
Investigation Indication/comment
Thyroid function tests To assess thyroid status
Antithyroid peroxidase antibodies Non-specific, high in autoimmune
Antithyroid stimulating hormone
Thyroid scintigraphy (123I, 99mTc) To assess areas of hyper-/
Computed tomography To assess goitre size and aid
Fine-needle aspiration cytology Thyroid nodule
Respiratory flow-volume loops To assess tracheal compression
There are usually four parathyroid glands situated posterior to
the thyroid (see Fig. 10.1A). Each is about the size of a pea
and produces parathyroid hormone, a peptide that increases
polyuria, polydipsia, renal stones, peptic ulceration, tender areas
of bone fracture or deformity (‘Brown tumours’: Fig. 10.6A),
and delirium or psychiatric symptoms. In hypoparathyroidism,
hypocalcaemia may cause hyper-reflexia or tetany (involuntary
muscle contraction), most commonly in the hands or feet.
Paraesthesiae of the hands and feet or around the mouth may
occur. Hypoparathyroidism is most often caused by inadvertent
damage to the glands during thyroid surgery but may also be
caused by autoimmune disease. Patients with the rare autosomal
dominant condition pseudohypoparathyroidism have end-organ
resistance to parathyroid hormone and typically have short stature,
a round face and shortening of the fourth and fifth metacarpal
The physical examination • 199
• Examine the neck for scars. Parathyroid tumours are very
• Measure the blood pressure and assess the state
of hydration (p. 244). Inflating the blood pressure cuff
in a patient with hypocalcaemia may precipitate carpal
muscle contraction, producing a typical picture with
the thumb adducted, the proximal interphalangeal
and distal interphalangeal joints extended and the
metacarpophalangeal joints flexed (‘main d’accoucheur’,
hand of the obstetrician, or Trousseau’s sign;
• Test for muscle weakness and hyper-reflexia (p. 138).
• Look for evidence of recent fractures or bone deformity/
• Perform urinalysis (renal stones may result in
• polyuria, polydipsia (hypercalcaemia)
• abdominal pain or constipation (hypercalcaemia)
• confusion or psychiatric symptoms (hypercalcaemia)
• muscle cramps, perioral or peripheral paraesthesia
Past medical, drug, family and
• recent neck surgery or irradiation
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