History, Physical Examination, and the Preoperative Evaluation

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CHAPTER 8 History, Physical Examination, and the Preoperative Evaluation

Key Points

A physician is privileged when requested to evaluate a person and render an opinion and diagnosis. The importance of obtaining an accurate, detailed patient history cannot be overemphasized because it is the framework upon which the otolaryngologist places all available information. Without this, the evaluation may be incomplete and the diagnosis flawed. Unnecessary testing may ensue, and at a minimum, a delay in symptom management may result. In the worst scenario, a misdiagnosis may occur. Therefore the energy expended in obtaining a complete history is always worthwhile.

Preoperative evaluation of surgical patients is, in its broadest sense, an extension of the diagnostic process. The surgeon should (1) strive to determine the extent of disease, (2) prove the necessity of surgery or clearly demonstrate its benefit to the patient, (3) optimize the choice of surgical procedure, and (4) minimize the risk to the patient by defining concomitant health problems and instituting appropriate therapy or precautionary measures. Integral to each of these goals is an appreciation of the ideal set forth in the Hippocratic Oath—above all else, do no harm. It is the surgeon’s responsibility to ensure that an appropriate patient assessment has been completed before entering the surgical suite. Surgical complications can often be avoided by recognizing the physiologic limitations of the patient preoperatively. Documentation of findings, decision making, and discussion between surgeon and patient regarding surgical risks and benefits have become medicolegal imperatives.

Gathering a Patient History

The otolaryngologist should always try to request that previous medical records pertaining to the patient’s current problem be sent to the office before the visit. If previous operations have been performed, operative reports can be important sources of information. In addition, pertinent radiographic imaging is helpful to obtain for review. Reports of computed tomography (CT) or magnetic resonance imaging (MRI) scans are valuable but cannot substitute for actual review of the imaging by the otolaryngologist. For head and neck cancer patients, any pathologic slide specimens from past biopsies should be sent to the pathology department for review so that a second opinion may be rendered. This is especially helpful when patients are referred with an unusual pathologic diagnosis. Finally, laboratory values can provide much information and should be carefully reviewed.

The physician should address the patient’s chief complaint by determining its duration, intensity, location, frequency, factors that make the problem worse or better, any past therapy, and related symptoms. Whether the complaint is vertigo, pain, sinusitis, hearing loss, allergies, or a neck mass, the approach should entail asking many of the same basic questions followed by more specific ones designed to elucidate the full scope of the problem.

A discussion of the patient’s medical history not only leads the otolaryngologist to a better understanding of the patient, but also often reveals pertinent information. For instance, a patient with an otitis externa who also is diabetic requires a high level of concern for malignant otitis externa, which may be reflected in the management plan. If the patient requires surgery, complete knowledge of the patient’s medical problems is necessary before the operative procedure.

The surgical history is equally valuable. All the past operations of the head and neck area are important to note, including surgery for past facial trauma, cosmetic facial plastic surgery, otologic surgery, and neoplasm. However, full disclosure of all past operations may be critical. The otolaryngologist needs to know whether a patient scheduled for surgery has had adverse reactions to anesthetic agents or a difficult intubation.

Any known drug allergies and side effects are crucial to note prominently in the medical chart. True allergies should be distinguished from side effects of a medication. In addition, all medications and current dosages should be accurately recorded. Often it is valuable to inquire whether the patient has been compliant with the prescribed medication regimen because the physician needs to know what dose the patient actually is taking.

It is also advantageous to assess for risk factors associated with certain disease states. Tobacco use is important to note. It is helpful to specifically ask about cigarette, cigar, and chewing tobacco consumption—either current or past use. Alcohol consumption also is occasionally difficult to quantitate unless the interviewer asks direct questions regarding frequency, choice of beverage, and duration of use. Recreational drug use should be addressed, as should risk factors for communicable diseases such as the human immunodeficiency virus (HIV) and hepatitis virus. For patients being assessed for hearing loss, major risk factors such as exposure to machinery, loud music, or gunfire should be discussed. Finally, past irradiation (implants, external beam, or by mouth) and dosage (either high or low dose) should be ascertained. A history of accidental radiation exposure also is important to document.

The patient’s social history should not be overlooked because it may often reveal more occult risk factors for many diseases. For instance, a retired steel worker may have an extensive history of inhaling environmental toxins, whereas a World War II veteran may have noise-induced hearing loss from his or her military service. Family history often is equally revealing, and asking patients questions about their familial history of such conditions as hearing loss, congenital defects, atopy, or cancer may uncover useful information that they had not previously considered.

Finally, a review of systems is part of every comprehensive history. This review includes changes in the patient’s respiratory, neurologic, cardiac, endocrine, psychiatric, gastrointestinal, urogenital, cutaneous skin, or musculoskeletal systems. The otolaryngologist often may derive more insight into the patient’s problem by inquiring about constitutional changes such as weight loss or gain, fatigue, heat or cold intolerance, rashes, and the like (Box 8-1).

Physical Examination

The otolaryngologist must develop an approach to the head and neck examination that allows the patient to feel comfortable while the physician performs a complete and comprehensive evaluation. Many of the techniques used by the otolaryngologist, such as fiberoptic nasopharyngolaryngoscopy, may leave a patient feeling alienated if not done correctly. Thus, it is essential to establish a rapport with a patient before proceeding with the examination.

A word of caution is necessary. The head and neck examination should only be done with the examiner wearing gloves and, in some instances, protective eye covering. Universal precautions are mandatory in today’s practice of medicine. This has the added benefit of showing the patient that the examiner is concerned about not transmitting any diseases, which builds trust between the patient and physician.

Neck

The neck, an integral part of the complete otolaryngology examination, is best approached by palpating it while visualizing the underlying structures (Fig. 8-1). The midline structures such as the trachea and larynx can be easily located and then palpated for deviation or crepitus. If there is a thyroid cartilage fracture, tenderness and crepitus may be present. In thick, short necks, the “signet ring” cricoid cartilage is a good landmark to use for orientation. The hyoid bone can be inspected and palpated by gently rocking it back and forth.

Triangles of the Neck

Most physicians find it helpful to define the neck in terms of triangles when communicating the location of physical findings (Fig. 8-2). The sternocleidomastoid muscle divides the neck into a posterior triangle—whose boundaries are the trapezius, clavicle, and sternocleidomastoid muscles—and an anterior triangle—bordered by the sternohyoid, digastric, and sternocleidomastoid muscles. These triangles are further divided into smaller triangles. The posterior triangle houses the supraclavicular and the occipital triangles. The anterior triangle then may be divided into the submandibular, carotid, and muscular triangles.

Lymph Node Regions

Another classification system for neck masses, endorsed by the American Head and Neck Society and the AAO-HNS, uses radiographic landmarks to define six levels to depict the location of adenopathy (Fig. 8-3). Level I is defined by the body of the mandible, anterior belly of the contralateral digastric muscle, and the stylohyoid muscle. Level IA contains the submental nodes, and level IB consists of the submandibular nodes. They are separated by the anterior belly of the digastric muscle.

The upper third of the jugulodigastric chain is level II, whereas the middle and lower third represent levels III and IV, respectively. More specifically, the jugulodigastric lymph nodes from the skull base to the inferior border of the hyoid bone are located in level II. Sublevel IIA nodes are located medial to the plane defined by the spinal accessory nerve and sublevel IIB nodes are lateral to the nerve.

Level III extends from the inferior border of the hyoid bone to the inferior border of the cricoid cartilage, and level IV includes the lymph nodes located from the inferior border of the cricoid to the superior border of the clavicle. For levels III and IV, the anterior boundary is the lateral border of the sternohyoid muscle and the posterior limit is the lateral border of the sternocleidomastoid muscle.

Level V is the posterior triangle, which includes the spinal accessory and supraclavicular nodes, and encompasses the nodes from the lateral border of the sternocleidomastoid muscle to the anterior border of the trapezium muscle. Sublevel VA (spinal accessory nodes) is separated from sublevel VB (transverse cervical and supraclavicular nodes) by a plane extending from the inferior border of the cricoid cartilage. Of note, the Virchow node is not in the VB region but is located in level IV.

The pretracheal, paratracheal, precricoid (Delphian), and perithyroidal nodes are contained in level VI, which extends from the hyoid bone to the suprasternal region. The lateral borders are the common carotid arteries.

Although not part of this classification system, the parotid-preauricular, retroauricular, and suboccipital regions are commonly designated as the P, R, and S regions.

Ears

Auricles

The postauricular region, which is frequently overlooked, often has many hidden physical findings. For instance, well-healed surgical incisions signify that previous otologic procedures have been performed. In children, the postauricular mastoid area may harbor important clues that mastoiditis with a subperiosteal abscess has developed. Finally, in patients with head trauma, postauricular ecchymosis (or Battle’s sign) suggests that a temporal bone fracture may have occurred.

The area anterior to the pinna, at the root of the helix, may have preauricular pits or sinuses, which may become infected. The external auricles also may show abnormalities or congenital malformations, including canal atresia, accessory auricles, microtia, and prominent protruding “bat ears.” The outer ears may have edema with weeping, crusting otorrhea, which may signify an infection. Psoriasis of the auricle or external auditory canal with its attendant flaking, dry skin, and edema is another common finding.

Careful examination of the auricles may reveal conditions that require prompt management. For instance, an auricular hematoma—with a hematoma separating the perichondrium from the underlying anterior auricular cartilage—will present as a swollen auricle with distortion of the normal external anatomy. If not surgically drained, a deformed “cauliflower ear” may result. Another important diagnosis is that of carcinoma of the auricle. Because early diagnosis is important, all suspicious lesions or masses should be judiciously biopsied or cultured. A maculopapular rash on the auricle and the external auditory canal in patients with facial nerve paralysis most likely is a result of herpes zoster oticus or Ramsay-Hunt syndrome. Finally, an erythematous painful pinna may represent many diseases, such as perichondritis, relapsing polychondritis, Wegener’s granulomatosis, or chronic discoid lupus erythematosus. Metabolic disorders also may have manifestations that affect the auricles. Patients with gout may have tophus on the pinna that exudes a chalky white substance if squeezed. Ochronosis is an inherited disorder of homogentisic acid that will cause the cartilage of the auricles to blacken. These examples of various diseases and syndromes illustrate the importance of routinely examining the auricles.

External Auditory Canal

The outer third (approximately 11 mm) of the auditory canal is cartilaginous. The adnexa of the skin contain many sebaceous and apocrine glands that produce cerumen. Hair follicles also are present. The inner two thirds (approximately 24 mm) of the canal is osseous and has only a thin layer of skin overlying the bone. Cerumen is commonly found accumulating in the canal, often obstructing it. When removing cerumen, remember two points. The canal is well supplied with sensory fibers: first, CN V3, the auricular branch of CN X, C3, and CN VII. Second, the canal curves in an S-shape toward the nose. To visualize the ear canal, gently grasp the pinna and elevate it upward and backward. This will open the external auditory canal and allow atraumatic insertion of the otoscopic speculum. Cerumen impaction may be removed with many techniques, such as careful curetting, gentle suctioning, or irrigation with warm water.

Otitis externa, or “swimmer’s ear,” is a painful condition with an edematous, often weeping external canal. If severe, the entire canal may be so edematous and inflamed that it closes, making inspection of the tympanic membrane difficult. Gently tugging on the auricle is painful for many patients. The periauricular lymph nodes may be tender and enlarged. If the patient is immunocompromised or diabetic, the canal should be carefully inspected for the presence of granulation tissue at the junction of the cartilaginous and bony junction. This may signify that a malignant otitis externa is present, which, as an osteomyelitis of the temporal bone, requires aggressive management, including prompt intravenous antibiotics.

In older patients, atrophy of the external auditory canal skin is frequently seen and may be associated with psoriasis or eczema of the canal. If patients attempt to soothe an itch with foreign objects such as keys, hair pins, or cotton-tipped swabs, scabs or areas of ecchymosis may be present in the posterior canal wall.

Children are the most likely patients to insert foreign materials into the ear canal. Although most objects lodge lateral to the narrowest part of the canal, the isthmus, some are found in the anterior recess by the tympanic membrane. This makes it especially difficult for the physician to visualize with an otoscope, so patients should turn their head for this area to be viewed. In adults, cotton plugs are commonly lodged and often are impacted against the tympanic membrane. In patients of all ages, insects may find their way into the canal. An operating microscope allows excellent visualization and enables the physician to use both hands to manipulate the instruments needed to remove the object.

Otorrhea is commonly seen in the external auditory canal. The characteristics of the aural discharge may reveal the etiology of the otorrhea. For instance, mucoid drainage is associated with a middle ear chronic suppurative otitis media because only the middle ear has mucus glands. In these patients, a tympanic membrane perforation should be present to allow the mucoid otorrhea to escape. Foul-smelling otorrhea may be caused by chronic suppurative otitis media with a cholesteatoma. Bloody, mucopurulent otorrhea frequently is seen in patients with acute otitis media, trauma, or carcinoma of the ear. Otorrhea with a watery component may signify a cerebrospinal fluid leak or eczema of the canal. Black spores in the otorrhea may be present in a fungal otitis externa caused by Aspergillus species. Gentle suctioning is used to thoroughly clean and inspect the canal.

In patients with head trauma, a temporal bone fracture is important to recognize. Bloody otorrhea in conjunction with an external canal laceration or hemotympanum is a very serious finding. Longitudinal fractures often involve the external canal. Because longitudinal fractures may be bilateral, careful inspection of both canals is essential.

Tympanic Membrane

To view the tympanic membrane, the correct otoscope speculum size is used to allow a seal of the ear canal. With pressure from the pneumatic bulb, the tympanic membrane will move back and forth if the middle ear space is well aerated. Perforations and middle ear effusions are common causes for nonmobile tympanic membranes.

The tympanic membrane is oval, not round, and has a depressed central part called the umbo, wherein the handle of the malleus attaches to the membrane. The lateral process of the malleus is located in the superior anterior region and is seen as a prominent bony point in atelectatic membranes. Superior to this process is the pars flaccida, wherein the tympanic membrane lacks the radial and circular fibers present in the pars tensa, which is the remainder of the ear drum. This superior flaccid area is critical to examine carefully because retraction pockets may develop here, which may develop into cholesteatomas. In congenital cholesteatomas, often diagnosed in young children, the tympanic membrane is intact, and a white mass is seen in the anterior superior quadrant. Acquired cholesteatomas in adults are different in that they often are in the posterior superior quadrant and are associated with retraction pockets, chronic otitis media with purulent otorrhea, and tympanic membrane perforations.

To assess the middle ear for effusions, use the tympanic membrane as a window that allows a view of the middle ear structures (Fig. 8-4). Effusions may be clear (serous), cloudy with infection present, or bloody. When the patient performs a Valsalva maneuver, actual bubbles may form in the effusion.

Hearing Assessment

Tuning fork tests, usually done with a 512-Hz fork, allow the otolaryngologist to distinguish between sensorineural and conductive hearing loss (Table 8-2). They also may be used to confirm the audiogram, which may give spurious results because of poor-fitting earphones or variations in equipment or personnel. All tests should be conducted in a quiet room without background noise. Furthermore, one should ensure that the external auditory canal is not blocked with cerumen.

The Weber test is performed by placing the vibrating tuning fork in the center of the patient’s forehead or at the bridge of the nose. If the patient has difficulty with these locations, the mandible or front teeth may be used; however, the patient then should tightly clench his or her teeth. The patient then is asked if the sound is louder in one ear or is heard midline. The sound waves should be transmitted equally well to both ears through the skull bone. A unilateral sensorineural hearing loss causes the sound to lateralize to the ear with the better cochlear function. However, a unilateral conductive hearing loss causes the Weber test to lateralize to the side with the conductive loss because the cochlea are intact bilaterally and because bone conduction causes the sound to be better heard in the ear with the conductive loss (because there is less background noise detected through air conduction). Interestingly, a midline Weber result is referred to as “negative.” “Weber right” and “Weber left” refer to the direction to which the sound lateralized.

To compare air conduction with bone conduction, perform the Rinne test. The 512-Hz tuning fork is placed by the ear canal and then on the mastoid process. The patient determines whether the sound is louder when the tuning fork is by the canal (air conduction) or on the mastoid bone (bone conduction). A “positive test” result is air conduction louder than bone conduction. A conductive hearing loss will make bone conduction louder than air conduction, and this is called “Rinne negative.” When the air and bone conduction are equal, it is called “Rinne equal.”

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