ENT NEW

1. PRESENTER: DR. ADITI GHORAI
1ST YEAR PG RESIDENT
DEPT. OF ENT
TMMC & RC
Examination of NOSE &
THROAT

2. EXAMINATION OF
NOSE
PART A

3. INTRODUCTION
 Full nose examinations assess the function,
airway resistance and occasionally sense of smell.
It includes looking into the mouth and pharynx.
Common symptoms of nasal disease include:
 Airway obstruction.
 Rhinorrhoea (runny nose).
 Sneezing.
 Loss of smell (anosmia).
 Facial pain caused by sinusitis.
 Snoring (associated with nasal obstruction).

4. Plan of Examination
 Introduce yourself
 Position patient
 Examination of external nose
 Inspect the nasal tip, vestibule, and nasal airway.
 Anterior rhinoscopy
 Posterior rhinoscopy
 Post nasal examination

5. Examination of External Nose
INSPECTION :
 The external is observed from a distance from the
front as well as side for any signs such as:
 Nasal bridge deformity- Saddle Nose/ Hump deformity
 Swelling
 Ulcers
 Sinuses
 Growths on skin
 Scars
 Broadening of nose
 Inflammation/ cellulites

6. Contd..
 External deformities of the nose like external deviation of
nose, nasal hump, depressed nasal bridge, nasal injury,
congenital anomaly, any inflammation or swelling, benign
conditions like rhinophyma are observed.
 Depressed Nasal Bridge : occurs in leprosy, syphilis or
tuberculosis of nose and also in cretinism, thalassemia major.
 Nasal Injury : common after road vehicular accident. Deviated
Nose : common in boxers.
 Congenital Swelling : glioma is present since birth.
 Benign Condition : Rhinophyma (Potato nose) is due to
hypertrophy of sebaceous glands.
 Broadening of Nose : seen in antrochoanal polyp.
 Frog Face Deformity : seen in juvenile nasopharyngeal
angiofibroma.
 Crepitus : felt in fracture nasal bone.

7. Contd..
PALPATION : Following thorough inspection, we
proceed to palpation, where our inspectory
conclusions are verified and additional assessment is
performed.
 Crepitation
 Tenderness

8. Cold Spatula Test
Tongue depressor is kept about a cm. below the nostril and
the amount of fogging on the spatula is observed. If fogging is
less on one side, it indicates obstruction of that side of nasal
cavity. In summers fogging is not appreciated so this test
should be carried out in an air-conditioned room or after
dipping the spatula in cold water. The amount of fogging can
also be measured on the graphic chromium plate.

9. Anterior Rhinoscopy
THUDICUM NASAL SPECULUM
A Thudicum or Vienna type of nasal speculum is held in the left
hand and assists in widening the vestibule (Figs 6A and B). The
blades of speculum are inserted into the less sensitive skin line
vestibule and should not touch the septal mucosa which is very
sensitive and vascular. The nasal speculum is closed while introducing
and opened during examination and remains partially
open when removing from the nose (avoid picking vibrissae).
The size of the nasal speculum should be chosen according to
the age of patient and size of the nose.

10. Nasal Septum

11. Nasal Cavity
Examination:
Patient’s head needs to be tilted in different directions to examine
different sites in the nose: septum, inferior turbinate and meatus, middle
turbinate and meatus and floor of the nose (Box 1).
1. Septum: It is rarely straight and mild deviations are not
significant. In some cases, even gross looking deviations do
not cause any functional problem. Note for any perforations,
granulations, deviations.
2. Inferior and middle turbinates: Compensatory hypertrophy
of middle and inferior turbinates is common on the concave side of
deviated nasal septum. In cases of chronic and allergic rhinitis, there can
occur hypertrophy of inferior margins and posterior ends of middle and
inferior turbinates. Middle turbinate concha bullosa (contains air cells),
paradoxical shape (convex lateral surface) and polypoidal changes are
common findings.

12. Contd..
3. Inferior and middle meatuses: Inferior meatus is rarely
visible. Most nasal polyps first appear in middle meatus.
Purulent secretions in middle meatus can come from
infections of anterior paranasal sinuses (maxillary, anterior
ethmoid and frontal) as they all drain in it.
4. Floor of nose: A swelling in the floor of nose may extend
from hard palate and alveolar process of maxilla. A floor
ulcer may communicate with oral cavity. Foreign bodies are
usually seen between septum and inferior turbinate.
Topical nasal decongestant:
The solution of xylocaine with adrenaline brings about vasoconstriction
(shrinkage of mucous membrane) and local anesthesia and facilitates the
proper nasal examination.

13. Contd..
Probe test:
It is done under topical anesthesia. A probe is passed on all
surfaces of mass and helps in ascertaining the site of
attachment, consistency, mobility, vascular nature and
sensitivity of the growth. Ulcers should be probed to know the
exposed underlying bone. Probing of an ulcer in the floor of nose
can exclude or confirm its oral cavity communication. Rhinolith
gives a grating sensation on probing.
Posture test:
Drainage of purulent discharge from various sinuses depends
upon the posture of patient. After wiping out, the purulent
discharge from the middle meatus note the timings of discharge
and the posture of patient

14. Contd..
 Frontal sinus: Pus reappears immediately if thepatient is
sitting in upright position (Head forward chin down
position).
 Ethmoidal sinus: Pus reappears after some time (10–15
minutes) if the patient is sitting in upright position.
 Maxillary sinus: Pus reappears if the head is so bent that
the affected maxillary sinus is in upward position.

15. Patency of Nasal Cavities
 „
Spatula test (Fig): A clean cold tongue depressor is
held below the nose while patient exhales. Each area of
mist formation on either side is compared.
 Cotton-wool test: A fluff of cotton is held against each
nostril and its movements indicate the nasal blow of air
while the patient inhales or exhales.
 „
Alae nasi movements: In cases of inspiratory
obstruction, alae nasi collapse onto the septum.
 Cottle test: In this test, which is done for the
abnormality of the nasal valve, cheek is drawn laterally
while patient breathes quietly. If there is subjective
improvement in nasal airway, the test is positive, which
indicates nasal valve compromise. The test also can be
performed by lateralizing the ULC with a cotton-tipped
applicator or cerumen curette.

16. Posterior Rhinoscopy
 It consists of examining the nasopharynx and posterior part of nasal
cavity by the postnasal mirror (Fig.). The patient opens his mouth and
breathes quietly. Postnasal mirror is warmed but should not be hot. It is
always better to test on the back of hand before introducing. The
examiner depresses the patient’s tongue with a tongue depressor that is
held in left hand and introduces posterior rhinoscopic mirror (postnasal
mirror). The mirror should be held in right hand like a pen and carried
behind the soft palate, along the tongue but without touching the
posterior third of tongue (to avoid gag reflex). The reflected light from
the head mirror illuminates the area of nasopharynx and the examiner
sees the reflected image of the postnasal space in the postnasal mirror. If
the patient is quiet and relaxed, then usually soft palate does not
contract and hide the view. This procedure especially needs
concentration, patience and practice.

17. Contd..
 Structures seen in Posterior Rhinoscopy:
 Anteriorly
1. Posterior end of Nasal septum.
2. Posterior end of middle and inferior turbinate
3. Posterior end of superior turbinate
4. Posterior part of superior & middle meatus
5. Nasal Surface of the soft palate & the uvula on tilting the mirror
further anteriorly.

18. Contd..
 Laterally:
1. Eustachian tube opening on either side with Tubal
Elevations seen behind the posterior end of inferior
turbinate.
2. Fossa of Rosenmuller behind the eustachian tube
orifice.
 Superiorly:
1. Roof of Nasopharynx.
2. Superior part of posterior pharyngeal wall.

19. Contd..
 The structures visualized on posterior rhinoscopy
are:

20. Examination of Paranasal Sinuses

21. Contd..
 They are examined by inspection, palpation and
transillumination. The anterior group of sinuses
(maxillary, frontal and anterior ethmoid) drains in
middle meatus. The posterior ethmoid drains into
superior meatus. The sphenoid sinus opens into
sphenoethmoidal recess.
 All the structures, which are adjacent to the different
walls of these sinuses, need attention of the examiner.
Sphenoid sinus, which opens in the sphenoethmoidal
recess, lies deep and is not easy to examine directly.
Frontal sinus has three walls: anterior, posterior and
floor but only the anterior wall can be examined
externally.

22. Contd..
Tenderness:
Tenderness of the sinuses can be
elicited by pressure or percussion with a
finger on their walls.
„
 Frontal sinus: Anterior and inferior walls
above the medial part of eyebrow and above
the medial canthus.
 Maxillary sinus: Anterior wall over the
cheek lateral to nose.
 Anterior ethmoids: Medial wall of orbit just
behind the root of nose.

23. Contd..
Transillumination
 Maxillary sinus: A specially made light source is placed
in the mouth and the mouth is closed. Normally, a crescent
of light in the inferior fornix and glow in the pupil, which
are equally bright on either side can be seen. The affected
side maxillary sinus will not transmit light if there is pus,
thickened mucosa or a neoplasm.
 Frontal sinus: A small light source is placed in the
superomedial angle of the orbit. The transmission of light
from the anterior wall of the both side frontal sinuses is
compared.

24. Contd..

25. EXAMINATION OF
ORAL CAVITY & THROAT
PART B

26. EXAMINATION OF ORAL CAVITY
A. INSPECTION:
Examine all the different parts of oral cavity by both inspection,
as well as palpation (Box 1). Tongue depressors (Fig. 3) are
used in the examination of oral cavity and oropharynx and are
available in different sizes for children and adults.
o „
„
Lips: Lips have an outer (cutaneous), an inner (mucosal) surface
and a vermilion border.
o Buccal mucosa: is examined by asking the patient to open the
mouth and then retracting the cheek with a tongue depressor.
o „
„
Vestibule of mouth: Examine the complete vestibule of mouth.
Look for not only the change in color but also change in surface
appearance. Parotid duct opening may be red, swollen and
discharging. It can be seen opposite the crown of upper second
molar tooth. Examine the skin of the cheek because carcinoma of
buccal mucosa can invade the same.

27. Contd..
 Teeth and gums: Examine gums and teeth of both upper and lower jaws.
Cheeks and lips are retracted with the help of tongue depressor for
examining the outer surface of gums while tongue is pushed away for
examining the inner surface of gums.
 Hard palate: See for any swelling (Fig. 5), ulcer and cleft.
 Anterior two-third tongue: Only anterior two-third tongue, which consists
of the tip, dorsum, lateral borders and undersurface, is included in the oral
cavity. Tongue should be examined in its natural position and then patient is
asked to protrude it and move it in different directions (Figs 6 to 11).
 Floor of mouth: The floor of mouth consists of the area that lies under the
tongue and two lateral gutters (Fig. 12). The latter are examined by two
tongue depressors that retract tongue and cheek. The submandibular duct
opens on the summit of raised papilla on either side of the tongue frenulum.
The swellings in the floor of mouth are examined by bimanual palpation,
which help in differentiating between submandibular salivary gland and
submandibular lymph nodes.

28. Contd..

29. Tongue Depressor
One blade of Lack’s tongue depressor is slightly bent at the
end. The bent end is used for holding the depressor and
supports the little finger of the examiner. The other blade
depresses the tongue and is used like a lever to depress
anterior two-thirds of the tongue with the fulcrum over the
lower teeth.
 Uses: It is used for examining the oral cavity and
thepharynx. In addition to the depressing of tongue it
canalso be used for:
 Squeezing the tonsil
 Retraction of cheek
 Test for gag reflex
 Checking nasal air blast (cold spatula test)
 Spatula test for suspected case of tetanus

30. Contd..
B. PALPATION:
1. Tongue:
Ideally the tongue should be kept in the oral cavity to keep the tongue
muscle relaxed. To look for induration, ulcers, swelling.
2. Palate:
Any ulcer or cyst (nasoalveolar or nasopalatine cyst) is examined
in theusual way. Alveolar abscess causes tender fluctuating
swelling close to the alveolar process.
3. Floor of Mouth:
It should be palpated bimanually. Translucency is tested if there
is anycystic swelling. Ranula is translucent but sublingual
dermoid cyst is nottranslucent. The submandibular duct is
palpated for any stone.

31. Contd..
4. Buccal Mucosa:
The mucus membrane and the cheek should be carefully palpated
to know involvement of skin of cheek by malignant growth.

32. Examination of Throat
Comprises of:
 Salivary Glands.
 Tonsil & Pharynx
 Larynx

33. Examination of Salivary Glands
A. INSPECTION:
 Swelling:
 Parotid swelling appears below, in front, and behind the lobule of ear
causing usually lifting of the lobule. It also obliterates the normal fissure
behind the ramus of mandible.
 Submandibular gland swelling is present in the submandibular triangle.
 Duct:
 The Stensen’s duct (parotid duct) is seen on the buccal surface, opposite
to the upper 2nd molar tooth. In suppurative parotitis, pus may come out
of the duct on pressing the gland while in malignant growth, blood may
come out. We ask the patient to touch the palate by the tip of tongue, the
opening of submandibular duct (Wharton’s duct) on either side of
frenulum linguae or sublingual duct (Bartholian's duct) is seen. It may be
inflamed or swollen.

34. Contd..
B. PALPATION:
 The parotid duct may be palpated on the masseter muscle by rolling
the finger across it while patient clinches the teeth by making the
muscle taut. The terminal part of duct is palpated bidigitally between
index finger in the mouth and thumb over the cheek.
 The submandibular gland and duct is palpated bidigitally. A finger is
inserted inside the mouth along the groove between the alveolus and
the tongue and pressed on the floor of mouth. The finger of the other
hand is placed under the jaw. The gland and duct are palpated from
behind. This bidigital palpation helps to differentiate it from the
enlarged submandibular lymph node. The finger inside the mouth
can feel the deeper part of salivary gland but not the lymph node (as
salivary gland is situated above the mylohyoid muscle while lymph
node is situated below the muscle.)

35. Contd..
 Saliva Flow Test : Test the flow of saliva by asking the
patient to suck lemon. In absence of any stone or
obstruction in the duct, saliva flows freely from the duct. If
duct is obstructed by the stone, the salivary outflow is
markedly obstructed and there is obvious swelling of the
gland.

36. EXAMINATION OF TONSIL AND PHARYNX
TONSILS
We ask the patient to open the mouth and Lack’s tongue
depressor is introduced to press the tongue. The tongue
depressor should never press the posterior part of tongue as
this causes gag reflex (due to the glossopharyngeal nerve).
Examination of the tonsil for its size, crypts, anterior pillar
and posterior pillar is done.

37. Contd..
Tonsillitis can be acute or chronic:
1. Acute Tonsillitis :
a. Acute Follicular Type: There is acute inflammation of crypts
and exudation from the crypts marks the reddened surface
with white or yellow spots.
b. Acute Parenchymatous type: There is inflammation of whole
tonsil.
c. Acute Membranous type: Another variant of follicular
tonsillitis in which exudation from the crypts may coalesce to
form the confluent membrane over the tonsil. It should be
differentiated from diphtheric tonsillitis, in which membrane
bleeds on removal. (while membranous tonsillitis does not
bleed.)

38. Contd..
2. Chronic Tonsillitis : It is the complication of acute
tonsillitis. It can be chronic follicular or chronic
parenchymatous tonsillitis.
Cardinal Signs of chronic tonsillitis :–
1. Flushing of anterior pillar
2. On pressing the anterior pillar, cheesy material comes out of
tonsil
3. Enlarged tender jugulodigastric lymph node, when there is
no other reason for it.
Out of these 3 signs, if 2 signs are present it is suggestive of
chronic tonsillitis.

39. Contd..
 Chronic Fibroid Tonsillitis :
It is the condition where tonsils are buried between the
pillars. They are innocent looking, though they are not as
repeated inflammation causes more fibrosis and reduction in
size. It tends to bleed more during tonsillectomy.

40. NASOPHARYNX
Examination of Nasopharynx can be carried out by the
following ways:
A. Anterior Rhinoscopy
B. Posterior Rhinoscopy
C. Digital Examination
D. Endoscopy.

41. Contd..
A. Anterior rhinoscopy:
Some part of the nasopharynx can be seen in decongested nose
(with vasoconstrictors); even on anterior rhinoscopy.
B. Posterior rhinoscopy:
Posterior rhinoscopy provides fragmented view of nasopharynx,
which is mentally reconstituted by the examiner. The examiner
has to tilt the mirror in different directions to visualize the
structures present on different walls of the nasopharynx.
 Retraction of soft palate with catheters: It facilitates postnasal mirror
examination in some difficult cases and requires good local or general
anesthesia. In this method, a soft rubber catheter is passed through each
nostril and then taken out from the mouth through the oropharynx. Both
ends of catheter are held together, and pulled forward. Retraction of soft
palate makes the mirror examination easy. This method has been becoming
obsolete with the advent of sinuscope and flexible
nasopharyngolaryngoscopy.

42. Contd..
C. Digital examination:
Digital examination though uncomfortable for the patient, is a simple
method to palpate the nasopharynx. Examiner, standing behind and right
to the patient invaginates patient’s cheek with his left finger and
introduces right index finger behind and above the soft palate into the
nasopharynx. This method is usually avoided in cases of angiofibroma.
D. Endoscopy:
Endoscopy gives a bright and magnified view of the nose and
nasopharyngeal structures. It can be performed by either rigid or flexible
fiber-optic scope.
 Rigid nasal endoscope (sinuscope or rhinoscope): They are available
in different sizes and angles and introduced through the nose after instilling
or spraying local anesthetic and decongestant. See details of sinuscopy
examination in chapter Operations of Nose and Paranasal Sinuses.
 Flexible nasopharyngolaryngoscope: It offers views of nose, pharynx
and larynx. See chapter Laryngeal symptoms and Examination in
section of larynx, trachea and bronchus.

43. Contd..

44. OROPHARYNX
 The examination begins by asking the patient to open the mouth widely. Tongue
depressor is used to examine tonsillolingual sulcus, and to express contents of
tonsillar crypts. The base of tongue is examined by laryngeal mirror. The structures
of oropharynx and their common lesions are mentioned in Box added up next.
„
1. Tonsils and pillars: For expressing the material from tonsil crypts,
pressure on the anterior pillar is applied with the edge of tongue depressor.
Palpation should always be performed with a gloved finger to know the
consistency of the mass. There is uniform congestion of the pillars, tonsils
and pharyngeal mucosa in acute tonsillitis; however, congestion of only
anterior pillars indicates chronic tonsillitis. Ulcer and proliferative growth
may extend to or from the tonsil, base of tongue, and the retromolar
trigone.
2. „
Soft palate: In cases of peritonsillar abscess, uvula becomes edematous,
and displaced to the opposite side. To note the movement of soft palate,
patient is asked to say “AA”. Deviation of the uvula and soft palate occurs
to the healthy side in cases of vagus palsy, which may be associated with
paralysis of posterior pharyngeal wall that manifests as a “curtain effect”
(the paralyzed side moves like a sliding curtain to the healthy side). In
cases of submucous cleft palate, in addition to bifid uvula, a notch can be
palpated in the midline of the posterior part of hard palate.

45. Contd..

46. Contd..
3. Base of tongue: Posterior one-third of tongue is best examined by
indirect laryngoscopy and finger palpation. It lies between the V-
shaped row of circumvallate papillae and the valleculae. Valleculae
are two shallow depressions that lie between the base of tongue and
the epiglottis.
„
 Palpation:
Palpation of oropharynx including base of tongue is very important, as
it helps in locating the infiltrative growth and its extension which is
usually missed during inspection. If the patient fails to relax, and does
not cooperate even after 4% xylocaine spray, palpation must be
conducted under general anesthesia. The examiner must insert his/her
finger in patient’s cheek (especially in children) between the upper and
lower teeth to prevent biting on the examiner’s finger.

47. Examination of Larynx
 EXTERNAL EXAMINATION:
 It includes inspection (Figs 1 and 2) and palpation (Box 2) of area
of hyoid bone, thyroid cartilage, thyroid notch, cricoid cartilage
and the tracheal rings for redness of skin, bulging or swelling,
widening of larynx, surgical emphysema, change in contour or
displacement of larynx, movements of larynx with deglutition and
breathing and post laryngeal crepitus.
 Laryngeal Crepitus: We move the larynx from side to side. A
crepitus sound is felt. It is a normal sound produced by the
movement of laryngeal cartilage against the cervical spine but
absence of this sound (Boaca’s sign) may be due to the
possibility of growth between the laryngeal framework and the
cervical spine (postcricoid carcinoma).

48. Contd..
 INTERNAL EXAMINATION :
Indirect Laryngoscopy:
 Laryngeal mirror: It is used for the indirect examination of oropharynx,
laryngopharynx and larynx. It is available in various sizes from 6 mm to 30 mm
diameter.
 Method: For indirect laryngoscopy (Figs 3 to 5), patient sits erect with the head
and chest leaning slightly towards the examiner. Patient protrudes out the tongue,
which is wrapped in a piece of gauze cloth and then held by the examiner between
the thumb and middle finger. Index finger of the examiner retracts out the patient’s
upper lip and moustache. To prevent fogging, a laryngeal mirror is always warmed
over a spirit lamp or in hot water. It is advisable to test mirror’s warmness on the
back of hand before inserting into the mouth, because hot mirror can damage the
mucosa. The warmed laryngeal mirror is introduced into the mouth and held firmly
against the uvula and soft palate while the light is focused on the laryngeal mirror.
Patient is asked to breathe quietly. Then the systematic examination begins from the
oropharynx, laryngopharynx and larynx. Movements of both the cords are observed
when patient takes deep inspiration (abduction of cords) and say “Aa” (adduction of
cords) and “Eee” (for adduction and tension).

49. Indirect Laryngoscopy Contd..
 Merits:
 Three-dimensional view of larynx with good color resolution.
 Good visualization during phonation.
 Demerits:
 Epiglottis may obstruct the view during respiration.
 Examination is not satisfactory in cases of difficult anatomy
and strong gag reflex.

50. Contd..

51. ENDOSCOPY
 The continuous light of endoscope helps in studying
gross structure and function of larynx, while strobe
light assesses mucosal health and vibration pattern.
 Examiner should keep in mind that reactions to
topical xylocaine or vasovagal attack can occur. Some
of the methods of carrying out endoscopy are as
follows:
 Rigid 90° Fiberoptic Laryngoscope (Telescope).
 Flexible Rhinolaryngoscope (Nasopharyngolaryngoscope).
 Laryngeal Videoendoscopy.

52. Endoscopy Contd..
Patient’s Tasks
 The patient is instructed to perform following tasks during the
endoscopic examination of larynx:
 „
Breathing at rest
 „
Deep breathing
 „
Easy coughing or throat clearing
 „
Laryngeal diadochokinesis: Rapid repetitions of “ee” with glottal stops
between productions. Laryngeal diadochokinesis “hee”.
 „
Sustained “ee”
 „
Quick sniffing through nose
 „
Speaking
 „
Singing
 „
Swallowing
 „
Valsalva maneuver.

53. Contd..
The structures seen on indirect laryngoscopy are :
a) Anterior part of larynx-epiglottis and anterior commissure
(seen towards the top of the mirror).
b) Posterior part of the larynx - the arytenoids and the posterior
commissure (seen at the lower portion of the mirror).

54. Contd..
 The patient’s right vocal cord is seen on the left side of the
mirror as the examiner looks at it. We first examine the
vallecula and the tip of epiglottis and then the ary-epiglottic
fold and the pyriform fossa on each side. Then postcricoid
region, arytenoids, false cords (ventricular folds) and vocal
cords (vocal folds) are inspected. Sometimes it is possible
to see upper few cms. of trachea. Finally movement of vocal
cords are studied by asking patient to phonate ‘ee’ and
breathe gently alternately several times. Also examination
of the colour of mucosa all around is seen.

55. Contd..
The following things are examined :
a. Epiglottis:
 The normal colour of epiglottis is pinkish.
 Bright red, swollen epiglottis is seen in acute laryngitis. X-ray
neck lateral view shows thumb sign.
 Pale, swollen epiglottis is seen in allergic laryngitis.

56. Vocal Cords Contd..
b. Vocal Cords :
 Colour : The normal vocal cords are pearly white in colour. In
acute laryngitis they are congested.
 Oedema : Oedema of vocal cords is seen in Reinke’s oedema (it
is oedema of the Reinke’s space of the vocal cords).
 Edge: Vocal nodules (Singer’s nodules) are seen at the junction
of anterior 1/3rd and posterior 2/3rd of the vocal cords.
 The malignant growth may be seen anywhere in the vocal
cords and requires its removal and histopathological
examination.
 Any solitary nodule can be solitary papilloma.
 Surface : Observe for any cyst, ulcer, leucoplakic patch or
granulations.

57. Vocal Cords Contd..
 Movement :
The movements of vocal cords are examined at :
 gentle breathing during phonation
 forced inspiration
 on coughing
 at rest
The movement of vocal cord is restricted in abductor or adductor
paresis, in infiltration by growth or in arthritis of crico-arytenoid
joint.

58. Vocal Cords Contd..
 Position of Vocal Cords :
There are different positions of vocal cords:
 Median position
 Paramedian position
 Cadaveric position
 Gentle abduction
 Full abduction

59. c. Arytenoids
d. Ary-epiglottic folds
e. Inter-arytenoids area: Congestion of this area occurs in tuberculosis of
the larynx.
f. Glottic chink: Glottic chink is reduced in vocal cord paralysis or any
malignant growth.
g. Postcricoid area: Any growth of this area along with absent laryngeal
crepitus is highly suspicious of malignancy of this area.
h. Pyriform fossa: Fullness of this area is highly suspicious of malignancy.
Pooling of saliva in both the pyriform fossa (Jackson’s sign) is
suspicious of post cricoid malignancy.
i. Upper few cm. of trachea
j. Vallecula, median glosso epiglottic fold and base of tongue is also examined
after completing examination of larynx.

60. Difference between Indirect Laryngoscopy and
Direct Laryngoscopy