What does instrumental examination mean in otolaryngology? Endoscopic examination of ENT organs

This is an examination of the ear, throat, and nose using a special video camera with additional lighting and an enlarged image displayed on a screen on which both the otolaryngologist and his patient or the patient’s relative can see all the structures of the examined organ from the inside.

For this purpose special otoscopic And rhinoscopic nozzles are thin, cylindrical tubes with a diameter of less than 3 millimeters with a video channel and a light guide. The attachments do not heat up during the examination and their insertion is painless. Special training research is not required. If there is swelling in the nose, vasoconstrictor drops are instilled into the nose before diagnosis. age dosage to make examination of the posterior parts of the nose and nasopharynx unobstructed.

Why is it important to conduct an endoscopic examination of ENT organs?

When examining ENT organs in the usual way with the “naked eye”, using only a light source directed to the nose, throat, ears, unfortunately, most of the structures of the nose, as well as the nasopharynx and the mouths of the auditory tubes located in it and adenoid vegetations in children remain inaccessible to the doctor’s eye, and the picture of the ear examination is far from complete. When examined by eye, the pathology of the external ear canal and availability inflammation eardrum , but the pathology of the tympanic cavity, often hidden behind a completely intact (healthy) eardrum, is not visible, just as small defects of the eardrum can be invisible - this pathology can only be examined in detail under magnification.

There is also a significant difference in quality endoscopic examination all parts of the larynx, vocal cords and their mobility.

It is almost impossible to make accurate conclusions about normality or pathology without having a complete picture. Even the absence of pathology in that part of the ENT organs that the doctor did not see can only be assumed, but not confirmed.

Videoendoscopy of ENT organs in children

Endoscopic examination of ENT organs: patient fears

Cost of consultation with an ENT doctor

Of course, including an otolaryngologist in your appointment endoscopic examination increases its cost, but at the same time the quality and reliability of diagnosis, the accuracy and detail of the diagnosis increases disproportionately, and, as a result, the doctor will prescribe more correct treatment.

Due to the fact that “ENT Clinic No. 1” specializes in otorhinolaryngology, and therefore must provide decent professional competence, our otorhinolaryngologists have extensive experience in performing endoscopicexamination of ENT organs adults and children from birth, which allows it to be performed efficiently, quickly and painlessly.

The influence of the quality of initial consultation on the cost of treatment of ENT diseases

Comprehensive consultation RUB 3,500 at ENT Clinic No. 1 (with video endoscopic examination)

• The cost of consultation is 2,000 rubles higher.
• The consultation includes a video endoscopic examination (average cost in Moscow is RUB 2,000 and above).
• Examination of hard-to-reach parts of the nasopharynx and tympanic cavity significantly improves the quality of diagnosis.
• Timely detection of “hidden pathology”. Possibility of detecting pathology on early stages, including neoplasms and developmental anomalies.
• The accuracy of diagnosis ensures an individual, rational approach to prescribing therapy. The unnecessary prescription of expensive antibiotics on the “just in case” principle is eliminated.
• Comprehensive (comprehensive) examination of ENT organs.
• More effective and timely treatment.
• As a result, the overall cost of treatment is lower.

Simple consultation 1,500 rubles in other clinics (without video endoscopic examination)

• The cost of consultation is RUB 2,000 lower.
• A superficial analysis of the state of the ENT organs “the old fashioned way.” Examination of the patient with the naked eye.
• The inability to thoroughly examine hard-to-reach parts of the nasopharynx and tympanic cavity significantly reduces the quality of diagnosis.
• The reliability of diagnosis is significantly lower. It is almost impossible to draw unmistakable conclusions without having the full picture.
• Unreasonable prescription of antibacterial therapy on the “just in case” principle.
• Pathology not detected in a timely manner leads to chronicity of the process, and in some cases to significant complications and the need for surgical treatment.
• Additional costs for reliable diagnosis and to more effective medications.
• As a result, the overall cost of treatment is higher.

Rules for using the frontal reflector

Examination of the ENT organs is effective only with the help of reflected light and provided that the direction of the light beam coincides with the visual axis of the researcher. Inspection in daylight is considered uninformative. For effective research, a 150-200 W light bulb is used as a light source; the reflector is round,

a slightly concave mirror with a diameter of 8-9 cm with a focal length of 20 cm. The light source is placed at the level of the patient’s head on the right and slightly behind. The reflector must be mounted on the examiner's head in front of the left eye so that the eye, the hole in the reflector and the area being examined are in one straight line. When examining small children, the presence of an assistant is required. The child is seated in the arms of an assistant, and with one hand he firmly holds the child's head, pressing it to his chest, and with the other hand he holds his hands. The child's legs should be sandwiched between the helper's legs.

Examination of the nasal cavity (rhinoscopy)

The nasal cavity is examined under artificial light using a frontal reflector and a nasal dilator (Hartmann's speculum). The nasal dilator, held in the left hand, is carefully inserted in a closed state into the patient’s nose, then, gradually spreading the jaws, widen the nostril and slightly lift it upward. The examination should be carried out carefully so as not to press the dilator on the nasal septum, as this causes pain and may cause nose bleed. Upon examination, the inferior and middle turbinates, the inferior and middle nasal passages, and the anterior portion of the nasal septum are visible. To examine different parts of the nasal cavity, the patient needs to change the position of his head. Inspection of the inferior turbinate can be carried out with the patient's head in the usual position; to examine the middle turbinate, the patient needs to tilt his head slightly back. Using lateral movements of the head, the results of the study are clarified.

Inspection oral cavity and pharynx (pharyngoscopy)

To examine the oral cavity and the middle part of the pharynx, an artificial light source, a frontal reflector, is required. When examining the oral cavity, pay attention to the condition of the tongue, teeth, hard and soft palate. Next, the palatine tonsils and the back wall of the pharynx are examined. When examining a child, you should not recommend sticking out your tongue, as this is incorrect. To ensure free inspection of the oral cavity, the tongue should remain in the mouth without any tension and in a flattened state. Use a spatula to lightly press the front third of the tongue, without touching the root of the tongue, so as not to cause a gag reflex.

Ear examination (otoscopy)

After examining the auricle and the entrance to the external auditory canal, you need to take the ear funnel by the widened part with your thumb and forefinger. Carefully, with light rotational movements, insert it into the ear canal to a depth of 1-1.25 cm, if possible without touching the bone part. At the same time, to straighten the patient's ear canal auricle pulled upward and backward, and in children younger age- downwards and backwards. Using light movements of the inside of the ear funnel, the internal parts of the ear canal and the entire surface of the eardrum are examined in parts.

Carrying out medical procedures

Caring for patients with ear diseases involves cleaning the ear and introducing various medicinal substances into it. Often, before examining the eardrum, it is necessary to clean the external auditory canal from wax, pus or crusts.

Cleaning the external auditory canal

Cleaning the external auditory canal is one of the stages of ear treatment. It is carried out wet or dry. The wet cleaning method (ear rinsing) is performed in cases of acute or chronic purulent inflammation of the middle ear, when the suppuration is so profuse that removing the pus by drying with cotton wool cannot be complete or takes a lot of time.

Ear rinsing

Ear rinsing is carried out using a 100-gram ear syringe or an ordinary rubber balloon with a plastic tip. The ear is washed with warm disinfectant solutions, often with a 3% solution of boric acid. The patient himself holds the kidney-shaped coxa, pressing it tightly to the side of the neck. To better cleanse the ear canal, the auricle in adults is pulled back and upward with the left hand, and the tip of the balloon is inserted into the patient’s ear with the right hand, but not deeper than 1 cm. The nurse should direct a stream of warm water in separate portions with moderate force along back wall ear canal. When filling a rubber balloon with liquid, all air should be removed from it, since air bubbles, mixing with water, cause noise during rinsing that is unpleasant for the patient. After rinsing, the patient's head is tilted to the side so that the water flows out of the ear. Remaining water from the depths of the ear canal is removed with cotton wool wrapped around the probe. This method of cleaning the ear canal requires care and caution, since washing can introduce a secondary infection into the ear.

Dry ear cleaning

Dry cleaning involves drying or wiping the ear canal with cotton wool. This method is used to remove pus from the ear canal in cases where the suppuration is small or when rinsing is contraindicated due to irritation of the skin of the ear canal (for example, with dermatitis, eczema, boils).

To wipe and dry the ear, use thin probes with a screw thread at the end. Smooth and button-shaped probes are not suitable for this purpose. Before the procedure nurse should thoroughly wash your hands with soap, wrap cotton wool tightly around the probe, cover the sharp end of the probe well with cotton wool to prevent injury to the walls of the ear canal or eardrum. Absorbent sterile cotton wool should be used. Wiping the ear should be carried out according to the following mechanism: hold the ear funnel with your left hand and pull the auricle backwards and upwards, and with your right hand carefully insert a probe with cotton wool wrapped at the end to a depth of 2.5 cm or to the eardrum itself. Light rotational movements of the probe contribute to better absorption of moisture by the cotton wool. Wiping the ear is repeated until the cotton wool removed from the ear is completely dry. Only when the ear canal is completely dry, drops are introduced, if necessary.

Inserting ear plugs

The insertion of ear tampons is carried out according to the following scheme:

To straighten and expand the ear canal, pull the auricle backwards and upwards with your left hand;

Using cranked tweezers, grab the end of the ear swab, which is a narrow, specially folded gauze strip no more than 5 cm long, and carefully move it along the ear canal to a depth of no more than 2.5 cm;

Having taken out the tweezers, they again grab the gauze swab, stepping back 1 - 1.5 cm from its end, and carefully move it until it comes into contact with the eardrum.

Ear swabs are placed loosely in the ear canal so as not to cause retention of pus in the depths. With profuse suppuration, ear swabs should be changed 5-6 times a day, with light or scanty - 1-2 times a day. To prevent the development of complications or secondary infections, all ear care techniques should be performed gently, observing the strictest asepsis.

Washing the wax plug

Washing of the sulfur plug is carried out warm water(37 °C) so as not to cause irritation of the vestibular apparatus and associated discomfort for the patient (dizziness, nausea, vomiting, etc.). To rinse the ear, use a 100 ml syringe. The stream of liquid is directed in pushes along the back wall of the ear canal, pulling the auricle backwards and upwards. To avoid damaging the walls of the ear canal and the eardrum with the tip of the syringe, use the fingers of your left hand to create a support for the syringe, preventing sudden penetration of the tip into the ear canal. With sufficient jet strength sulfur plug washed away entirely or in parts in separate small lumps. After rinsing, the ear canal should be dried with cotton wool wrapped around the probe. If after repeated washings the sulfur plug is not removed, they resort to softening it. To do this, pour alkaline drops into the ear for 10-15 minutes for 2-3 days. After infusion of drops, as a result of swelling of the plug, even greater blockage of the ear may occur, about which the patient should be warned.

Ear blowing

Blowing the ear according to the Politzer method is carried out using a rubber balloon (capacity 300-500 ml) connected to a rubber tube ending in an olive. The olive is inserted into one or another nostril (or both in turn), with the fingers of the left hand firmly pressing both wings of the nose (one to the olive, the other to the nasal septum). This achieves fixation of the olive and the necessary tightness. Then, in order to raise the soft palate, the patient is asked to take a sip of water, or an empty sip, or to say some word (“steamboat”, “cuckoo”), and at the moment of sipping or pronouncing the word, the balloon must be gently squeezed with the right hand. If the blowing is successful, the patient feels a blowing noise, the feeling of ear congestion disappears and hearing is restored.

The use of medicinal substances for ear diseases

Medicinal substances for diseases are used in the form of drops, ointments and powders. Most common medical procedure for ear diseases is the introduction of drops into the ear. If there is purulent discharge in the ear canal, then before introducing drops it is carefully removed by repeated wiping with cotton wool wound around the probe. All drops must be preheated to body temperature so as not to cause irritation of the vestibular system. When putting drops into the ear, the patient should tilt his head in the opposite direction. Pulling the auricle backwards and upwards with her left hand, the nurse instills 5-10 drops of medicine with a pipette. Drops are put into the ear 2-3 times a day, holding them for 10-15 minutes each time, then tilt the head towards the sore ear so that the drops flow out of it. After removing the drops, you need to dry the ear canal and, if prescribed by a doctor, loosely pack it with a sterile gauze swab.

Lubrication with ointment is used only for diseases of the external auditory canal and auricle (dermatitis, eczema). The walls of the ear canal are lubricated with ointment using cotton wool wrapped around the probe. Sometimes a tampon with ointment is left in the ear canal for 15-30 minutes.

Insufflation of powdered drugs

Insufflation of the powder should be preceded by thorough cleaning of the ear canal from existing pus with dry or wet method. Insufflation is carried out using various types of powder blowers (insuflators). When blowing in the powder, it is necessary to straighten the ear canal, pulling the auricle backwards and upwards, and make sure that the powder lays down in a thin, even layer, without forming lumps that can interfere with the outflow of pus. Applying a warm compress to the ear, a rubber bag with ice to the mastoid process, and ear bandages is done according to general rules patient care.

Lubricating the pharyngeal mucosa with medicinal substances

Lubricate the mucous membrane of the pharynx with a cotton swab dipped in medicinal solution prescribed by a doctor. This procedure should be carried out under vision control using a frontal reflector. The tongue is pressed with a spatula. Using a cotton swab, you should quickly lubricate first the anterior palatine arches, then the palatine tonsils, then the back wall of the pharynx. If there is an urge to vomit, the procedure should be interrupted and the patient should be allowed to calm down, and then continue lubricating the pharyngeal mucosa.

In system human organs throat plays important role. IN healthy condition The laryngeal mucosa looks clean and pink, without inflammation or enlarged tonsils. For various diseases of a cold, nervous, tumor, traumatic nature, tissues react certain changes. For their diagnosis they use various examinations. The most informative of them is endoscopy of the larynx, which allows you to clarify and record any deviations from the norm, as well as take a tissue sample if a biopsy is needed.

What is endoscopy used for?

The endoscopy method belongs to the field diagnostic studies using flexible tubes equipped with light-fiber optics devices. The larynx area is part of the ENT system, the problems of which are dealt with by the branch of medicine - otolaryngology. In addition to a visual examination, an ENT doctor has an endoscopic diagnostic method in his arsenal, which is prescribed for problems with the voice, swallowing, and injuries. There are several types of examination, depending on the area being examined:

• pharyngoscopy is used to visualize the oral cavity and the condition of the pharynx;
• during laryngoscopy, the laryngeal cavity is examined;
• rhinoscopy is used to view the nasal passages;
• Otoscopy is necessary to view the auditory canal along with the outer ear.

Interesting fact: doctors have been examining the internal surfaces of the ear, larynx and nose for more than a hundred years. However, at the dawn of the era of endoscopic diagnostics, routine instruments were used - special mirrors. Modern diagnostics performed with perfect devices equipped with high-precision optics with the ability to record results.

Advantages of endoscopic diagnosis

If you have problems with your voice, ear and throat pain, hemoptysis, or injuries to the larynx, it becomes necessary to examine the larynx and vocal cords using laryngoscopy. A diagnostic examination of the larynx is performed with a rigidly fixed or flexible endoscope, which allows you to see the internal area of ​​the organ in different projections on the monitor screen. Thanks to the capabilities of the video system, the doctor can examine problem areas in detail, recording the results of the endoscopic examination on a disk.

This type of diagnosis, popular in otolaryngology, has a number of advantages:

• harmlessness of manipulation due to the absence of electromagnetic influence;
• absence pronounced signs discomfort and pain syndrome;
• endoscopy provides a reliable result and the ability to collect a tissue sample.

Diagnostic examination is performed in modern conditions medical centers using various tools. Depending on the type of laryngoscopy, a vibrating fiber endoscope or laryngoscope is used for direct diagnosis. Visual inspection is performed with a system of mirrors that reflect the light of a lamp to illuminate the larynx during indirect endoscopy. Microlaryngoscopy is carried out with a special operating microscope to identify tumor lesions of the larynx.

Endoscopic examination techniques

The examination is carried out by a doctor who treats diseases of the ears, nose and throat. Opportunity instrumental research allows you to accurately determine the diagnosis to prescribe the correct treatment regimen for people of different ages. What types of larynx diagnostics are prescribed?

Indirect view of laryngeal endoscopy

For the study, which is carried out in a darkened room, the patient should sit with his mouth wide open and his tongue protruding as much as possible. The doctor examines the oropharynx using a laryngeal mirror inserted into the patient’s mouth, which reflects the light of the lamp refracted by the frontal reflector. It is attached to the doctor's head.

To prevent the viewing mirror in the throat cavity from fogging up, it must be heated. To avoid gagging, the examined surfaces of the larynx are treated with an anesthetic. However, the five-minute procedure has long been outdated and is rarely performed due to the low information content of the semi-reverse image of the larynx.

Important condition: before appointment modern way diagnosing the condition of the larynx, the patient should be convinced of the need for endoscopy and familiarized with the features of preparation for it. It is also necessary to find out information about the health problems of the person being examined, it is useful to reassure the person that he will not be hurt, there is no danger of lack of air. It is advisable to explain how the manipulation is carried out.

Direct method of research

This type of laryngoscopy is flexible when a movable fiber laryngoscope is used. In the case of using a rigidly fixed apparatus, the technique is called rigid, and is used mainly for surgical intervention. The introduction of modern equipment makes it easier to make a diagnosis and allows you to achieve the following goals:

• identify the causes of changes or loss of voice, pain in the throat, difficulty breathing;
• determine the degree of damage to the larynx, the causes of hemoptysis, as well as problems with the respiratory tract;
• delete benign tumor to save a person from foreign body, caught in the larynx.

If the information content of indirect diagnostics is insufficient, examination by the direct method is relevant. Endoscopy is performed on an empty stomach, but under local anesthesia after taking medications to suppress mucus secretion, as well as sedatives. Before starting the procedure, the patient must warn the doctor about heart problems, blood clotting characteristics, a tendency to allergies, and possible pregnancy.

Features of direct endoscopy of the larynx

• Direct flexible endoscopy method

Diagnosis is carried out under the supervision of a group of health workers. During the manipulation, the doctor uses a fiber-optic fiber endoscope equipped with a movable distal end. The optical system with adjustable focusing and illumination provides a wide range of viewing of the laryngeal cavity. To avoid gagging, the throat is treated with an anesthetic spray. To prevent injuries to the nasal mucosa, the nose is instilled vasoconstrictor drops, because the endoscopic procedure performed by inserting a laryngoscope through the nasal passage.

• Complexity of rigid endoscopy

The study allows, together with examining the condition of the larynx, as well as the vocal cords, to remove polyps and take material for a biopsy. The diagnostic procedure, which lasts approximately 30 minutes, is considered particularly complex. Therefore, they are conducting research in the operating room of a hospital. When the patient, lying on the operating table, falls asleep under anesthesia, the beak of a rigid laryngoscope equipped with a lighting device is inserted into his larynx through the mouth.

An important point: during the procedure, swelling of the larynx is possible, so after the examination the patient’s throat is covered with ice. If the vocal cords have been interfered with, the person will have to remain silent for a long time. Eating and liquids are allowed no earlier than two hours after the endoscopy was performed.

Possibility of complications

The use of modern medical technology for endoscopic diagnosis helps the doctor to detect pathology and determine the degree of its development, which is especially important for drawing up a treatment program. In addition, this is an excellent opportunity for the patient and his relatives to visually familiarize themselves with the problem and understand the need for treatment.

If cancer is suspected, the results of autofluorescence endoscopy become the most reliable diagnosis of the problem. However, it is worth considering that any type of endoscopic diagnosis is associated with possible risk for the patient's condition.

1. The consequence of treatment with an anesthetic may be difficulty swallowing, a feeling of swelling of the root of the tongue, as well as the posterior pharyngeal wall. A certain risk of swelling of the larynx cannot be excluded, which results in impaired respiratory function.
2. For a short time after endoscopy of the larynx, symptoms of nausea, signs of hoarseness and painful sensations sore throat, muscle soreness. To alleviate the condition, regularly rinse the throat walls with a soda solution (warm).
3. If a biopsy sample was taken, a cough with bloody clots in the sputum may begin after it. The condition is not considered pathological; unpleasant symptoms will go away in a few days without additional treatment. However, the risk of bleeding, infection, injury respiratory tract exists.

The risk of developing complications after endoscopy increases due to blockage of the airways by polyps, possible tumors, and inflammation of the cartilage of the larynx (epiglottis). If a diagnostic examination provokes the development of airway obstruction due to spasms in the throat, it is necessary emergency help– tracheotomy. To perform it, a longitudinal dissection of the tracheal area is required to ensure free breathing through a tube inserted into the incision.

When research is prohibited

In modern otolaryngology, laryngoscopy is considered one of the most productive ways of studying susceptible to disease larynx. Although the direct diagnostic method provides the ENT doctor with comprehensive information about the condition of the organ, the procedure is not prescribed in the following situations:

• with a confirmed diagnosis of epilepsy;
• injury to the cervical vertebrae;
• for heart disease, myocardial infarction in the acute phase;
• in case of severe stenotic breathing;
• during pregnancy, as well as allergies to medications to prepare for endoscopy.

Interesting: for a detailed overview of the vocal cords, as well as general condition larynx using microlaryngoscopy. A delicate examination is performed using a rigid endoscope equipped with a camera. The instrument is inserted through the mouth without an additional incision in the cervical area. The manipulation usually accompanies laryngeal microsurgery and is performed under general anesthesia.

Fluorescent microlaryngoscopy will require injection additional drug. Sodium fluorescein allows you to assess the condition of the laryngeal tissues by to varying degrees absorption of fluorescent substance. Thanks to innovative technologies appeared new method endoscopy – fibrolaryngoscotch. The procedure is carried out with a fiberscope with a movable flexible end, providing an overview of all parts of the larynx.

Labor omnia vincit.Labor conquers everything.

Methods of examination and research of ENT organs have a number of general principles.

1. The subject sits down so that the light source and the table with instruments are to his right.

2. The doctor sits opposite the person being examined, placing his feet on the table; The subject's legs should be outward.

3. The light source is placed at the level of the subject’s right ear, 10 cm from it.

4. Rules for using the frontal reflector:

a) strengthen the reflector on the forehead using a forehead bandage. The reflector hole is placed opposite the left eye (Fig. 1.1).

b) the reflector should be removed from the organ under study at a distance of 25-30 cm ( focal length mirrors);

c) using a reflector, direct a beam of reflected light onto the subject’s nose. Then close the right eye, and look through the reflector hole with the left and turn it so that the beam is visible

Ris. 1.1. Position of the frontal reflector on the doctor's head

light (“bunny”) on the nose. Open the right eye and continue examining with both eyes.

1.1. TECHNIQUE FOR STUDYING THE NOSE AND PARONAL SINUSES

Stage 1. External examination and palpation.

1) Examination of the external nose and places of projection of the paranasal sinuses on the face.

2) Palpation of the external nose: the index fingers of both hands are placed along the back of the nose and with light massaging movements they feel the area of ​​the root, slopes, back and tip of the nose.

3) Palpation of the anterior and lower walls of the frontal sinuses: the thumbs of both hands are placed on the forehead above the eyebrows and gently press on this area, then the thumbs are moved to the area of ​​the upper wall of the orbit to the inner corner and also apply pressure. The exit points of the first branches are palpated trigeminal nerve(n. ophthalmicus). Normally, palpation of the walls of the frontal sinuses is painless (Fig. 1.2).

4) Palpation of the anterior walls of the maxillary sinuses: the thumbs of both hands are placed in the area of ​​the canine fossa on the anterior surface of the maxillary bone and apply gentle pressure. The exit points of the second branches of the trigeminal nerve (n. infraorbitalis). Normally, palpation of the anterior wall of the maxillary sinus is painless.

Rice. 1.2. Palpation of the walls of the frontal sinuses

5) Palpation of the submandibular and cervical lymph nodes: submandibular The lymph nodes palpate with the head of the person being examined slightly tilted forward with light massaging movements using the ends of the phalanges of the fingers in the submandibular region in the direction from the middle to the edge of the lower jaw.

The deep cervical lymph nodes are palpated first on one side, then on the other. The patient's head is tilted forward (when the head is tilted backward, the front cervical lymph nodes and the main vessels of the neck are also displaced posteriorly, which makes them difficult to feel). When palpating the lymph nodes on the right, the doctor’s right hand lies on the crown of the subject, and with the left hand they make massaging movements with a soft deep immersion into the tissue with the ends of the phalanges of the fingers in front of the anterior edge of the sternocleidomastoid muscle. When palpating the lymph nodes on the left, the doctor’s left hand is on the crown of the head, and palpation is performed with the right hand.

Normally, the lymph nodes are not palpable (cannot be felt).

Stage 2. Anterior rhinoscopy. Inspection of the nasal cavity is carried out under artificial lighting (frontal reflector or autonomous light source), using a nasal speculum - a nasal dilator, which must be held in the left hand as shown in Fig. 1.3.

Rice. 1.3. Anterior rhinoscopy: a - correct position of the nasal dilator in the hand; b - position of the nasal dilator during examination

Rhinoscopy may be front, middle and back.

1) Inspection of the nasal vestibule (first position during anterior rhinoscopy). Using the thumb of the right hand, lift the tip of the nose and examine the vestibule of the nose. Normally, the vestibule of the nose is free and there is hair.

2) Anterior rhinoscopy is performed alternately - one and the other half of the nose. A nasal dilator is placed on the open palm of the left hand with its beak down; The thumb of the left hand is placed on top of the nasal dilator screw, the index and middle fingers are placed outside under the jaw, IV and V should be between the jaws of the nasal dilator. Thus, the II and III fingers close the jaws and thereby open the beak of the nasal dilator, and the IV and V fingers push the jaws apart and thereby close the beak of the nasal dilator.

3) The elbow of the left hand is lowered, the hand with the nasal dilator should be mobile; The palm of the right hand is placed on the parietal region of the patient to give the head the desired position.

4) The beak of the nasal dilator in a closed form is inserted 0.5 cm into the vestibule of the right half of the patient’s nose. The right half of the nasal dilator beak should be in the lower inner corner of the vestibule of the nose, the left half should be on the upper third of the wing of the nose.

5) Using the index and middle fingers of the left hand, press the jaw of the nasal dilator and open the right vestibule of the nose so that the tips of the beak of the nasal dilator do not touch the mucous membrane of the nasal septum.

6) Examine the right half of the nose with the head in a straight position; normally the color of the mucous membrane is pink, the surface is smooth, moist, the nasal septum is in the midline. Normally, the nasal turbinates are not enlarged, the common, lower and middle nasal passages are free. The distance between the nasal septum and the edge of the inferior turbinate is 3-4 mm.

7) Examine the right half of the nose with the patient’s head slightly tilted downwards. In this case, the anterior and middle sections of the lower nasal passage and the bottom of the nose are clearly visible. Normally, the lower nasal meatus is free.

8) Examine the right half of the nose with the patient’s head slightly tilted back and to the right. In this case, the middle nasal meatus is visible.

9) With fingers IV and V, push back the right branch so that the nose of the beak of the nasal dilator does not close completely (and does not pinch the hairs) and remove the nasal dilator from the nose.

10) Inspection of the left half of the nose is carried out in a similar way: the left hand holds the nasal dilator, and the right hand lies on the crown, while the right half of the beak of the nasal dilator is located in the upper-inner corner of the vestibule of the nose on the left, and the left - in the lower-outer corner.

III stage. Study of the respiratory and olfactory functions of the nose.

1) Exists a large number of methods for determining the respiratory function of the nose. The simplest method is V.I. Vojacek, which determines the degree of air passage through the nose. To determine breathing through the right half of the nose, press the left wing of the nose to the nasal septum with the index finger of the right hand, and with the left hand bring a fluff of cotton wool to the right vestibule of the nose and ask the patient to take a short breath and exhale. Defined similarly nasal breathing through the left half of the nose. The respiratory function of the nose is assessed by the deviation of the cotton wool. Breathing through each half of the nose can be normal, difficult or absent.

2) Definition olfactory function Perform one by one on each half of the nose with odorous substances from an olfactometric kit or using a device - an olfactometer. To determine the olfactory function on the right, press the left wing of the nose to the nasal septum with the index finger of the right hand, and with the left hand take a bottle of an odorous substance and bring it to the right vestibule of the nose, ask the patient to inhale with the right half of the nose and determine the smell of this substance. Most often, substances with odors of increasing concentration are used - wine alcohol, valerian tincture, acetic acid solution, ammonia etc. Determining the sense of smell through the left half of the nose is done in a similar way, only the right wing of the nose is pressed with the index finger of the left hand, and the odorous substance is brought to the left half of the nose with the right hand. The sense of smell may be normal(normosmia), reduced(hyposmia), absent(anosmia), perverted(cocasmia).

IV stage. Radiography. It is one of the most common and informative methods examination of the nose and paranasal sinuses.

The following methods are most often used in the clinic. With nasofrontal projection (occipito-frontal) in the supine position, the patient's head is placed so that the forehead and tip

noses touched the cassette. The resulting image best shows the frontal and, to a lesser extent, the ethmoid and maxillary sinuses (Fig. 1.4 a).

With a nasomental projection (occipitomental) the patient lies face down on the cassette with his mouth open, touching it with his nose and chin. This image clearly shows the frontal as well as the maxillary sinuses, cells of the ethmoidal labyrinth and sphenoid sinuses (Fig. 1.4 b). In order to see the level of fluid in the sinuses on an x-ray, the same positions are used, but in an upright position of the patient (sitting).

With lateral (bitemporal) or profile projection the subject's head is placed on the cassette so that the sagittal plane of the head is parallel to the cassette, the x-ray beam passes in the frontal direction slightly in front (1.5 cm) from the tragus of the auricle. In such a photograph there are clearly

Rice. 1.4. The most common radiological positions used in the study of the paranasal sinuses: a - nasofrontal (occipital-frontal); b - nasomental (occipitomental);

Rice. 1.4. Continuation.

c - lateral (bitemporal, profile); g - axial (chin-vertical); d - computed tomogram of the paranasal sinuses

the frontal, sphenoid and, to a lesser extent, ethmoid sinuses are visible in their lateral image. However, in this projection, the sinuses on both sides overlap each other and one can only judge their depth, and diagnosing lesions of the right or left paranasal sinuses is impossible (Fig. 1.4 c).

With axial (chin-vertical) projection the patient lies on his back, tilts his head back and places his parietal part on the cassette. In this position, the chin area is in a horizontal position, and the X-ray beam is directed strictly vertically to the thyroid notch of the larynx. In this arrangement, the sphenoid sinuses are well differentiated separately from each other (Fig. 1.4 d). In practice, as a rule, two projections are used: nasomental and nasofrontal; if indicated, other projections are also prescribed.

In the last decade, computed tomography (CT) and magnetic nuclear resonance imaging (MRI) methods, which have much greater resolution capabilities, have become widespread.

V stage. Endomicroscopy of the nose and paranasal sinuses. These methods are the most informative modern diagnostic methods using optical systems visual inspection, rigid and flexible endoscopes with different viewing angles, microscopes. The introduction of these high-tech and expensive methods has significantly expanded the horizons of diagnostics and surgical capabilities of an ENT specialist. Detailed description methods, see section 2.8.

1.2. TECHNIQUE FOR RESEARCHING THE PHARYN

1. Examine the neck area and the mucous membrane of the lips.

2. Regional lymph nodes of the pharynx are palpated: submandibular, in the retromandibular fossae, deep cervical, posterior cervical, in the supraclavicular and subclavian fossae.

Stage II. Endoscopy of the pharynx. Oroscopy.

1. Take a spatula in left hand so that the thumb supports the spatula from below, and the index and middle (or ring) fingers are on top. The right hand is placed on the patient's crown.

2. Ask the patient to open his mouth, use a spatula to pull back the left and right corners of the mouth alternately and examine the vestibule of the mouth: mucous membrane, excretory ducts of the parotid salivary glands located on the buccal surface at the level of the upper premolar.

3. Examine the oral cavity: teeth, gums, hard palate, tongue, excretory ducts of the sublingual and submandibular salivary glands, floor of the mouth. The floor of the mouth can be examined by asking the subject to lift the tip of the tongue or by lifting it with a spatula.

MESOPHARINGOSCOPY

4. Holding a spatula in your left hand, press the front 2/3 of the tongue downwards without touching the root of the tongue. The spatula is inserted through the right corner of the mouth, the tongue is pressed not with the plane of the spatula, but with its end. When you touch the root of the tongue, gagging immediately occurs. The mobility and symmetry of the soft palate is determined by asking the patient to pronounce the sound “a”. Normally, the soft palate is well mobile, the left and right sides are symmetrical.

5. Examine the mucous membrane of the soft palate, its uvula, anterior and posterior palatine arches. Normally, the mucous membrane is smooth, pink, and the arches are contoured. Examine the teeth and gums to identify pathological changes.

The size of the palatine tonsils is determined by mentally dividing into three parts the distance between the medial edge of the anterior palatine arch and the vertical line passing through the middle of the uvula and soft palate. The size of the tonsil protruding up to 1/3 of this distance is classified as degree I, protruding up to 2/3 - as degree II; protruding to the midline of the pharynx - to the III degree.

6. Examine the mucous membrane of the tonsils. Normally, it is pink, moist, its surface is smooth, the mouths of the lacunae are closed, and there is no discharge in them.

7. Determine the contents in the crypts of the tonsils. To do this, take two spatulas, in the right and left hands. With one spatula, press the tongue downwards, with the other, gently press through the front arch onto the tonsil in the area of ​​its upper third. When examining the right tonsil, the tongue is squeezed out with a spatula in the right hand, and when examining the left tonsil, with a spatula in the left hand. Normally, there is no content in the crypts or it is scanty, non-purulent in the form of minor epithelial plugs.

8. Examine the mucous membrane of the posterior pharyngeal wall. Normally, it is pink, moist, smooth, and rare, up to 1 mm in size, lymphoid granules are visible on its surface.

EPIPHARYNGOSCOPY (POSTERIOR RHINOSCOPY)

9. The nasopharyngeal speculum is strengthened in the handle, heated in hot water up to 40-45 °C, wipe with a napkin.

10. Using a spatula, taken in the left hand, press down the front 2/3 of the tongue. Ask the patient to breathe through the nose.

11. The nasopharyngeal speculum is taken into right hand, like a pen for writing, is inserted into the oral cavity, the mirror surface should be directed upward. Then place the mirror behind the soft palate, without touching the root of the tongue and the back wall of the pharynx. Direct a beam of light from the frontal reflector onto the mirror. With slight turns of the mirror (1-2 mm), the nasopharynx is examined (Fig. 1.5).

12. During posterior rhinoscopy, you need to examine: the vault of the nasopharynx, choanae, the posterior ends of all three nasal conchae, the pharyngeal openings of the auditory (Eustachian) tubes. Normally, the vault of the nasopharynx in adults is free (there may be a thin layer of pharyngeal tonsil), the mucous membrane is pink, the choanae are free, the vomer is

Rice. 1.5. Posterior rhinoscopy (epipharyngoscopy):

a - position of the nasopharyngeal mirror; b - picture of the nasopharynx during posterior rhinoscopy: 1 - vomer; 2 - choanae; 3 - posterior ends of the lower, middle and upper nasal concha; 4 - pharyngeal opening of the auditory tube; 5 - tongue; 6 - pipe roller

midline, mucous membrane of the posterior ends of the turbinates Pink colour with a smooth surface, the ends of the shells do not protrude from the choanae, the nasal passages are free (Fig. 1.5 b).

In children and adolescents, in the posterior part of the nasopharyngeal vault there is a third (pharyngeal) tonsil, which normally does not cover the choanae.

On the lateral walls of the nasopharynx at the level of the posterior ends of the inferior turbinates there are depressions - the pharyngeal openings of the auditory tubes, in front of which there are small ridges - the pharyngeal edges of the anterior cartilaginous walls of the auditory tubes.

FINGER EXAMINATION OF THE NASOPHARYNX

13. The patient sits, the doctor stands behind to the right of the patient. Using the index finger of the left hand, gently press the patient’s left cheek between the teeth while open mouth. Index finger the right hand quickly passes behind the soft palate into the nasopharynx and feels the choanae, the arch of the nasopharynx, and the lateral walls (Fig. 1.6). In this case, the pharyngeal tonsil is felt with the end of the back of the index finger.

Hypopharyngoscopy is presented in section 1.3.

Rice. 1.6. Digital examination of the nasopharynx:

a - position of the doctor and the patient; b - position of the doctor’s finger in the nasopharynx

1.3. TECHNIQUE FOR STUDYING THE LARYNX

Stage I. External examination and palpation.

1. Examine the neck and the configuration of the larynx.

2. Palpate the larynx and its cartilages: cricoid, thyroid; determine the crunch of the cartilage of the larynx: with the thumb and forefinger of the right hand, take the thyroid cartilage and gently move it to one side and then to the other. Normally, the larynx is painless and passively mobile in the lateral direction.

3. Regional lymph nodes of the larynx are palpated: submandibular, deep cervical, posterior cervical, prelaryngeal, pretracheal, paratracheal, in the supra- and subclavian fossae. Normally, the lymph nodes are not palpable (cannot be felt).

Stage II. Indirect laryngoscopy (hypopharyngoscopy).

1. The laryngeal mirror is strengthened in the handle, heated in hot water or over an alcohol lamp for 3 s to 40-45 ° C, wiped with a napkin. The degree of heating is determined by applying a mirror to the back surface of the hand.

2. Ask the patient to open his mouth, stick out his tongue and breathe through his mouth.

3. Wrap the tip of the tongue from above and below with a gauze napkin, take it with the fingers of your left hand so that the thumb is located on the upper surface of the tongue, middle finger- on the lower surface of the tongue, and the index finger raised upper lip. Slightly pull the tongue towards you and downwards (Fig. 1.7 a, c).

4. The laryngeal mirror is taken in the right hand, like a pen for writing, and inserted into the oral cavity with a mirror plane parallel to the plane of the tongue, without touching the root of the tongue and the back wall of the pharynx. Having reached the soft palate, lift the tongue with the back of the mirror and place the plane of the mirror at an angle of 45° to the median axis of the pharynx; if necessary, you can slightly lift the soft palate upward; the light beam from the reflector is directed exactly at the mirror (Fig. 1.7 b). The patient is asked to make prolonged sounds “e”, “and” (at the same time the epiglottis will move anteriorly, opening the entrance to the larynx for inspection), then take a breath. Thus, one can see the larynx in two phases of physiological activity: phonation and inspiration.

Correction of the position of the mirror must be done until the picture of the larynx is reflected in it, but this is done with great care, with very subtle small movements.

5. Remove the mirror from the larynx, separate it from the handle and immerse it in a disinfectant solution.

Rice. 1.7. Indirect laryngoscopy (hypopharyngoscopy): a - position of the laryngeal mirror (front view); b - position of the laryngeal mirror (side view); c - indirect laryngoscopy; d - picture of the larynx during indirect laryngoscopy: 1 - epiglottis; 2 - false vocal folds; 3 - true vocal folds; 4 - arytenoid cartilage;

5 - interarytenoid space;

6 - pear-shaped pocket; 7 - fossae of the epiglottis; 8 - root of the tongue;

9 - aryepiglottic fold;

IMAGE AT INDIRECT LARYNGOSCOPY

1. In the laryngeal mirror you can see an image that differs from the true one in that the anterior parts of the larynx in the mirror are at the top (they appear behind), the rear parts are at the bottom (they seem to be in front). The right and left sides of the larynx in the mirror correspond to reality (do not change) (Fig. 1.7 d).

2. In the laryngeal mirror, first of all, the root of the tongue with the lingual tonsil located on it is visible, then the epiglottis in the form of an unfolded petal. The mucous membrane of the epiglottis is usually pale pink or slightly yellowish in color. Between the epiglottis and the root of the tongue, two small depressions are visible - the pits of the epiglottis (valleculae), bounded by the median and lateral lingual-epiglottic folds.

4. Pink vestibular folds are visible above the vocal folds; between the vocal and vestibular folds on each side there are depressions - laryngeal ventricles, inside of which there may be small accumulations of lymphoid tissue - laryngeal tonsils.

5. Below in the mirror the posterior parts of the larynx are visible; The arytenoid cartilages are represented by two tubercles on the sides of the upper edge of the larynx, have a pink color with a smooth surface, the posterior ends of the vocal folds are attached to the vocal processes of these cartilages, and the interarytenoid space is located between the bodies of the cartilages.

6. Simultaneously with indirect laryngoscopy, indirect hypopharyngoscopy is performed, and the following picture is visible in the mirror. From the arytenoid cartilages upward to the lower lateral edges of the lobe of the epiglottis there are aryepiglottic folds; they are pink in color with a smooth surface. Lateral to the aryepiglottic folds are pear-shaped pouches (sinuses) - the lower part of the pharynx, the mucous membrane of which is pink and smooth. Tapering downward, the pear-shaped pouches approach the esophageal sphincter.

7. During inhalation and phonation, the symmetrical mobility of the vocal folds and both halves of the larynx is determined.

8. When inhaling, a triangular space is formed between the vocal folds, which is called the glottis, through which the lower part of the larynx is examined - the subglottic cavity; It is often possible to see the upper rings of the trachea, covered with pink mucous membrane. The size of the glottis in adults is 15-18 mm.

9. When examining the larynx, you should make general review and assess the condition of its individual parts.

1.4. EAR EXAMINATION METHOD

Stage I. External examination and palpation. The examination begins with the healthy ear. The auricle, the external opening of the auditory canal, the postauricular area, and in front of the auditory canal are examined and palpated.

1. To examine the external opening of the right auditory canal in adults, it is necessary to pull the auricle backwards and upwards, grasping the helix of the auricle with the thumb and forefinger of the left hand. To examine on the left, the auricle must be pulled back in the same way with the right hand. In children, the auricle is pulled not upward, but downward and posteriorly. When the auricle is retracted in this manner, the bony and membranous cartilaginous parts of the auditory canal are displaced, which makes it possible to insert the ear funnel up to bone department. The funnel holds the ear canal in a straight position, and this allows otoscopy.

2. To examine the area behind the ear, turn the right auricle of the person being examined anteriorly with the right hand. Pay attention to the postauricular fold (the place where the auricle attaches to the mastoid process), normally it is well contoured.

3. Thumb With the right hand, gently press on the tragus. Normally, palpation of the tragus is painless; in an adult, it is painful with acute external otitis; in a young child, such pain also appears with secondary otitis.

4. Then, with the thumb of the left hand, the right mastoid process is palpated at three points: the projection of the antrum, the sigmoid sinus, and the apex of the mastoid process.

When palpating the left mastoid process, pull the auricle with your left hand, and palpate with your right finger

5. Using the index finger of your left hand, palpate the regional lymph nodes of the right ear anteriorly, inferiorly, posteriorly from the external auditory canal.

Using the index finger of your right hand, palpate the lymph nodes of your left ear in the same way. Normally, the lymph nodes are not palpable.

Stage II. Otoscopy.

1. Select a funnel with a diameter corresponding to the transverse diameter of the external auditory canal.

2. Pull the patient’s right ear backwards and upwards with your left hand. Using the thumb and index fingers of the right hand, the ear funnel is inserted into the membranous-cartilaginous part of the external auditory canal.

When examining the left ear, pull the pinna with your right hand, and insert the crow with the fingers of your left hand.

3. The ear funnel is inserted into the membranous-cartilaginous part of the ear canal to hold it in a straightened position (after pulling the auricle upward and backward in adults); the funnel cannot be inserted into the bony part of the ear canal, as this causes pain. When inserting the funnel, its long axis must coincide with the axis of the ear canal, otherwise the funnel will rest against its wall.

4. Lightly move the outer end of the funnel in order to sequentially examine all parts of the eardrum.

5. When inserting the funnel, there may be a cough, depending on irritation of the ends of the branches vagus nerve in the skin of the ear canal.

Otoscopic picture.

1. Otoscopy shows that the skin of the membranous-cartilaginous region has hair, and there is usually earwax here. The length of the external auditory canal is 2.5 cm.

2. The eardrum has grey colour with a pearlescent tint.

3. Identification points are visible on the tympanic membrane: the short (lateral) process and the handle of the malleus, the anterior and posterior malleus folds, the light cone (reflex), the navel of the tympanic membrane (Fig. 1.8).

4. Below the anterior and posterior malleus folds, the tense part of the tympanic membrane is visible; above these folds, the loose part is visible.

5. There are 4 quadrants on the eardrum, which are obtained by mentally drawing two lines that are mutually perpendicular. One line is drawn down the handle of the hammer, the other - perpendicular to it through the center (umbo) of the eardrum and the lower end of the handle of the hammer. The quadrants that arise in this case are called: anterosuperior and posterosuperior, anterioinferior and posteroinferior (Fig. 1.8).

Rice. 1.8. Diagram of the eardrum:

I - anterosuperior quadrant; II - anterioinferior quadrant; III - posteroinferior quadrant; IV - posterosuperior quadrant

Cleaning the external auditory canal. Cleaning is done by dry method or washing. When dry cleaning, a small piece of cotton wool is wound onto a threaded ear probe so that the tip of the probe is fluffy, in the form of a brush. The cotton wool on the probe is slightly moistened with petroleum jelly, inserted into the external auditory canal during otoscopy and the earwax contained in it is removed.

To rinse the ear canal, warm water at body temperature is drawn into the Janet syringe (to avoid irritation of the vestibular apparatus), a kidney-shaped tray is placed under the patient’s ear, and the tip of the syringe is inserted into the initial part of the external auditory canal.

passage, having previously pulled the auricle upward and backward, and direct a stream of liquid along the postero-superior wall of the auditory canal. The pressure on the syringe plunger should be gentle. If the rinsing is successful, pieces of earwax along with water fall into the tray.

After rinsing, it is necessary to remove the remaining water; this is done using a probe with a cotton wool wrapped around it. If there is a suspicion of perforation of the eardrum, ear lavage is contraindicated due to the risk of causing inflammation in the middle ear.

Study of the function of the auditory tubes. The study of the ventilation function of the auditory tube is based on blowing through the tube and listening to the sounds of air passing through it. For this purpose, you need a special elastic (rubber) tube with ear plugs at both ends (otoscope), a rubber bulb with an olive at the end (Poltzer balloon), and a set of ear catheters of various sizes - from number 1 to number 6.

5 methods of blowing the auditory tube are performed sequentially. The possibility of performing one or another method allows you to determine I, II, III, IV or V degrees of pipe patency. When performing the study, one end of the otoscope is placed in the external auditory canal of the subject, and the second - in the doctor. Through an otoscope, the doctor listens to the sound of air passing through the auditory tube.

Empty sip test allows you to determine the patency of the auditory tube during the swallowing movement. When the lumen of the auditory tube is opened, the doctor hears a characteristic slight noise or crackling sound through the otoscope.

Toynbee's method. This is also a swallowing movement, but performed by the subject with his mouth and nose closed. During the examination, if the tube is passable, the patient feels a push in the ears, and the doctor hears a characteristic sound of air passing.

Valsalva method. The subject is asked to take a deep breath, and then perform increased expiration (inflation) with the mouth and nose tightly closed. Under the pressure of exhaled air, the auditory tubes open and air forcefully enters the tympanic cavity, which is accompanied by a slight cracking sound, which is felt by the patient, and the doctor listens to a characteristic noise through an otoscope. If the patency of the auditory tube is impaired, the Valsalva experiment cannot be performed.

Rice. 1.9. Blowing of the auditory tubes, according to Politzer

Politzer method(Fig. 1.9). The olive of the ear balloon is inserted into the vestibule of the nasal cavity on the right and held with the second finger of the left hand, and with the first finger the left wing of the nose is pressed against the nasal septum. One olive of the otoscope is inserted into the patient’s external auditory canal, and the second into the doctor’s ear and the patient is asked to say the words “steamboat”, “one, two, three”. At the moment of pronouncing the vowel sound, the balloon is squeezed with four fingers of the right hand, with the first finger serving as a support. At the moment of blowing when pronouncing a vowel sound, the soft palate deviates posteriorly and separates the nasopharynx. Air enters the closed cavity of the nasopharynx and presses evenly on all walls; At the same time, part of the air passes with force into the pharyngeal openings of the auditory tubes, which is determined by the characteristic sound heard through the otoscope. Then, in the same way, but only through the left half of the nose, the left auditory tube is blown, according to Politzer.

Blowing the auditory tubes through the ear catheter. First, anesthesia of the nasal mucosa is performed with one of the anesthetics (10% lidocaine solution, 2% dicaine solution). Otoscope olives are inserted into the doctor's ear and into the test subject's ear. The catheter is held in the right hand, like a pen for writing. During anterior rhinoscopy, the catheter is passed along the bottom of the strip.

Ti your nose with the beak down to the back wall of the nasopharynx. Then the catheter is turned inward by 90° and pulled towards you until its beak touches the vomer. After this, carefully turn the beak of the catheter downwards and then approximately 120° further towards the ear being examined so that the catheter ring (and therefore the beak) faces approximately the outer corner of the eye of the side being examined. The beak enters the pharyngeal opening of the auditory tube, which is usually felt with the fingers (Fig. 1.10). The olive of the balloon is inserted into the socket of the catheter and lightly compressed. When air passes through the auditory tube, noise is heard.

Rice. 1.10. Catheterization of the auditory tube

If all tests are performed with positive result, then the patency of the auditory tube is assessed as grade I, if it is possible to obtain a positive result only with catheterization, the patency of the tube is assessed as grade V.

Along with the ventilation function of the auditory tube, it is important (for example, when deciding whether to close a defect in the eardrum). drainage function. The latter is assessed by the time of passive entry of various liquid substances from the tympanic cavity into the nasopharynx. The appearance of a substance in the nasopharynx is recorded during endoscopy of the area of ​​the pharyngeal opening of the auditory tube (dyes are used for this).

for example methylene blue); by the patient’s taste sensations (test with saccharin) or by X-ray contrast examination of the auditory tube. If the drainage function of the auditory tube is good, the substance used appears in the nasopharynx after 8-10 minutes, if it is satisfactory - after 10-25 minutes, if unsatisfactory - after more than 25 minutes.

Stage III. Radiation diagnostic methods. X-rays of the temporal bones are widely used to diagnose ear diseases; the most common are three special styling: according to Schüller, Mayer and Stenvers. In this case, radiographs of both temporal bones are taken at once. The main condition for traditional radiography of the temporal bones is image symmetry, the absence of which leads to diagnostic errors.

Lateral plain radiography of the temporal bones, according to Schüller(Fig. 1.11), allows us to identify the structure of the mastoid process. On radiographs, the cave and perianthral cells are clearly visible, the roof of the tympanic cavity and the anterior wall of the sigmoid sinus are clearly defined. From these images one can judge the degree of pneumatization of the mastoid process; destruction of the bone bridges between the cells, characteristic of mastoiditis, is visible.

Axial projection, according to Mayer(Fig. 1.12), allows you to more clearly display the bone walls of the external auditory canal, the supratympanic recess and mastoid cells than in the Schüller projection. An expansion of the atticoantral cavity with clear boundaries indicates the presence of cholesteatoma.

Oblique projection, according to Stenvers(Fig. 1.13). With its help, the apex of the pyramid, the labyrinth and the internal auditory canal are removed. The greatest importance is the ability to assess the condition of the internal auditory canal. When diagnosing neuroma of the vestibulocochlear (VIII) nerve, the symmetry of the internal auditory canals is assessed, provided that the alignment of the right and left ears is identical. Laying is also informative in the diagnosis of transverse fractures of the pyramid, which are most often one of the manifestations of a longitudinal fracture of the base of the skull.

More clear structure temporal bone and ear are visualized using CT and MRI.

Computed tomography (CT). It is performed in axial and frontal projections with a slice thickness of 1-2 mm. CT allows

Rice. 1.11. Survey radiograph of the temporal bones in the Schüller arrangement: 1 - temporomandibular joint; 2 - external auditory canal; 3 - internal auditory canal; 4 - mastoid cave; 5 - perianthral cells; 6 - cells of the apex of the mastoid process; 7 - front surface of the pyramid

Rice. 1.12. Survey radiograph of the temporal bones in position, according to Mayer: 1 - cells of the mastoid process; 2 - antrum; 3 - anterior wall of the auditory canal; 4 - temporomandibular joint; 5 - internal auditory canal; 6 - core of the labyrinth; 7 - border of the sinus; 8 - tip of the mastoid process

Rice. 1.13. X-ray of the temporal bones in position, according to Stenvers:

1 - internal auditory canal; 2 - auditory ossicles; 3 - mastoid

Rice. 1.14. Computed tomography scan of the temporal bone is normal

detect both bone and soft tissue changes. In the presence of cholesteatoma, this study makes it possible to determine with great accuracy its distribution, to establish a fistula of the semicircular canal, caries of the hammer and incus. CT of the temporal bone is increasingly used in the diagnosis of ear diseases (Fig. 1.14).

Magnetic resonance imaging(MRI) has advantages over computed tomography when identifying soft tissue

formations, differential diagnosis inflammatory and tumor changes. This is the method of choice in diagnosing neuroma of the VIII nerve.

1.4.1. Study of the functions of the auditory analyzer

Depending on the tasks facing the doctor, the scope of research performed may vary. Information about the state of hearing is necessary not only for diagnosing ear diseases and deciding on the method of conservative and surgical treatment, but also during professional selection, selection hearing aid. It is very important to examine hearing in children in order to identify early hearing impairments.

Complaints and anamnesis. In all cases, the study begins with clarification complaints. Hearing loss can be unilateral or bilateral, permanent, progressive, or accompanied by periodic deterioration and improvement. Based on complaints, the degree of hearing loss is tentatively assessed (communication is difficult at work, at home, in a noisy environment, during excitement), the presence and nature of subjective tinnitus, autophony, the sensation of iridescent fluid in the ear, etc. are determined.

Anamnesis suggests the cause of hearing loss and tinnitus, changes in hearing in the dynamics of the disease, the presence concomitant diseases affecting hearing, to clarify the methods of conservative and surgical treatment used for hearing loss and their effectiveness.

Hearing research using speech. After identifying complaints and collecting anamnesis, a speech hearing test is performed to determine perception of whispering and colloquial speech.

The patient is placed at a distance of 6 m from the doctor; the ear being examined should be directed towards the doctor, and the assistant closes the opposite one, tightly pressing the tragus to the opening of the external auditory canal with the second finger, while the third finger lightly rubs the second, which creates a rustling sound that muffles this ear, excluding overlistening (Fig. 1.15) .

The subject is explained that he must loudly repeat the words he hears. To eliminate lip reading, the patient should not look in the direction of the doctor. In a whisper, using the air remaining in the lungs after unforced exhalation, the doctor pronounces words with low sounds (number, hole, sea, tree, grass, window, etc.), then

Rice. 1.15. Testing hearing acuity using whispered and spoken speech: a - Weber’s experience; b - Jelle's experiment

words with high sounds are treble (thicket, already, cabbage soup, hare, etc.). Patients with damage to the sound-conducting apparatus (conductive hearing loss) hear low sounds worse. On the contrary, when sound perception is impaired (sensorineural hearing loss), hearing for high-pitched sounds worsens.

If the subject cannot hear from a distance of 6 m, the doctor reduces the distance by 1 m and re-examines the hearing. This procedure is repeated until the subject hears all spoken words. Normally, when studying the perception of whispered speech, a person hears low sounds from a distance of at least 6 m, and high sounds - 20 m.

The study of spoken speech is carried out according to the same rules. The results of the study are recorded in a hearing passport.

Study with tuning forks - next stage of hearing assessment.

Air conduction study. For this purpose, tuning forks C 128 and C 2048 are used. The study begins with a low-frequency tuning fork. Holding the tuning fork by the stem with two fingers,

the impact of the jaws on the tenor of the palms causes it to oscillate. Tuning fork C 2048 is set into vibration by abruptly squeezing the jaws with two fingers or by clicking a nail.

The sounding tuning fork is brought to the external auditory canal of the subject at a distance of 0.5 cm and held in such a way that the jaws oscillate in the plane of the axis of the auditory canal. Starting from the moment the tuning fork is struck, a stopwatch measures the time during which the patient hears its sound. After the subject stops hearing the sound, the tuning fork is moved away from the ear and brought closer again, without exciting it again. As a rule, after such a distance from the ear of the tuning fork, the patient hears the sound for a few seconds. The final time is based on the last answer. A study is carried out similarly with a tuning fork C 2048, the duration of perception of its sound through the air is determined.

Study bone conduction. Bone conductivity is examined with a C 128 tuning fork. This is due to the fact that the vibration of tuning forks with a lower frequency is felt by the skin, and tuning forks with a higher frequency are heard through the air by the ear.

A sounding tuning fork C 128 is placed perpendicularly with its stem on the platform of the mastoid process. The duration of perception is also measured with a stopwatch, counting the time from the moment the tuning fork is excited.

If sound conduction is impaired (conductive hearing loss), the perception of a low-sounding tuning fork C 128 through the air deteriorates; When studying bone conduction, the sound is heard longer.

Impairment of air perception of a high tuning fork C 2048 is accompanied primarily by damage to sound perception.

hearing aid (sensorineural hearing loss). The duration of the sound of C 2048 through air and bone also decreases proportionally, although the ratio of these indicators remains, as normal, 2:1.

Quality tuning fork tests carried out for the purpose of differential express diagnosis of damage to the sound-conducting or sound-perceiving sections of the auditory analyzer. For this purpose experiments are carried out Rinne, Weber, Jelle, Federice, when performing them, use a tuning fork C 128.

Rinne's experience It consists of comparing the duration of air and bone conduction. A sounding tuning fork C 128 is placed with its stem against the area of ​​the mastoid process. After the cessation of perception of sound by the bone, the tuning fork, without stimulation, is brought to the external auditory canal. If the subject continues to hear the sound of a tuning fork through the air, Rinne’s experience is regarded as positive (R+). If the patient, after the tuning fork stops sounding on the mastoid process, does not hear it in the external auditory canal, Rinne’s experience is negative (R-).

With Rinne's positive experience air conduction sound is 1.5-2 times higher than bone, with a negative sound - vice versa. A positive Rinne experience is observed normally, a negative one is observed when the sound-conducting apparatus is damaged, i.e. with conductive hearing loss.

When the sound-receiving apparatus is damaged (i.e., with sensorineural hearing loss), sound conduction through the air, as normal, prevails over bone conduction. However, the duration of perception of the sounding tuning fork by both air and bone conduction is less than normal, so Rinne’s experience remains positive.

Weber's experiment (W). It can be used to evaluate the lateralization of sound. A sounding tuning fork C 128 is placed at the crown of the subject so that the leg is in the middle of the head (see Fig. 1.15 a). The jaws of the tuning fork must oscillate in the frontal plane. Normally, the subject hears the sound of a tuning fork in the middle of the head or equally in both ears (normal<- W ->). With unilateral damage to the sound-conducting apparatus, the sound is lateralized into the affected ear (for example, to the left W -> ), with unilateral damage to the sound-receiving apparatus (for example, on the left), the sound is lateralized to the healthy ear (in this case, to the right<-

With bilateral conductive hearing loss, the sound will be lateralized towards the worse-hearing ear, and with bilateral sensorineural hearing loss - towards the better-hearing ear.

Jelle's experiment (G). The method makes it possible to detect disturbances in sound transmission associated with the immobility of the stapes in the window of the vestibule. This type of pathology is observed, in particular, with otosclerosis.

A sounding tuning fork is placed at the crown of the head and at the same time the air in the external auditory canal is condensed using a pneumatic funnel (see Fig. 1.15 b). At the moment of compression, a subject with normal hearing will feel a decrease in perception, which is associated with a deterioration in the mobility of the sound-conducting system due to the pressing of the stapes into the niche of the vestibule window - Jelle’s experience is positive (G+).

If the stapes is immobilized, no change in perception will occur at the moment of air condensation in the external auditory canal - Jelle’s experience is negative (G-).

Federici experiment (F). It consists of comparing the duration of perception of the sounding tuning fork C 128 from the mastoid process and the tragus when it obstructs the external auditory canal. After the sound on the mastoid process stops, the tuning fork is placed with its stem on the tragus.

In normal conditions and in cases of impaired sound perception, Federici’s experience is positive, i.e. the sound of a tuning fork from the tragus is perceived longer, and if sound conduction is impaired, it is perceived negatively (F-).

Thus, Federici's experience, along with other tests, allows us to differentiate between conductive and sensorineural hearing loss.

The presence of subjective noise (SN) and the results of a hearing test using whispered (SH) and spoken speech (SS), as well as tuning forks, are entered into the hearing passport. Below is a sample hearing passport of a patient with right-sided conductive hearing loss (Table 1.1).

Conclusion. There is hearing loss on the right side due to a type of sound conduction disorder.

These methods make it possible to comprehensively assess hearing acuity and, by the perception of individual tones (frequencies), determine the nature and level of its damage in various diseases. The use of electroacoustic equipment makes it possible to dose the strength of a sound stimulus in generally accepted units - decibels (dB), conduct hearing tests in patients with severe hearing loss, and use diagnostic tests.

An audiometer is an electrical sound generator that produces relatively pure sounds (tones) through both air and bone. A clinical audiometer examines hearing thresholds in the range from 125 to 8000 Hz. Currently, audiometers have appeared that allow one to study hearing in an expanded frequency range - up to 18,000-20,000 Hz. With their help, audiometry is performed in an extended frequency range up to 20,000 Hz through the air. By converting the attenuator, the supplied audio signal can be amplified to 100-120 dB when studying air conduction and up to 60 dB when studying bone conduction. The volume is usually adjusted in steps of 5 dB, in some audiometers - in smaller steps, starting from 1 dB.

From a psychophysiological point of view, various audiometric methods are divided into subjective and objective.

Subjective audiometric techniques are most widely used in clinical practice. They are based on

subjective sensations of the patient and on the conscious response, depending on his will. Objective, or reflex, audiometry is based on the reflex unconditioned and conditioned responses of the subject that occur in the body during sound exposure and do not depend on his will.

Taking into account what stimulus is used when studying a sound analyzer, there are such subjective methods as tone threshold and suprathreshold audiometry, a method for studying auditory sensitivity to ultrasound, and speech audiometry.

Pure-tone audiometry there is threshold and suprathreshold.

Tone threshold audiometry performed to determine the thresholds for the perception of sounds of various frequencies during air and bone conduction. Using air and bone telephones, the threshold sensitivity of the hearing organ to the perception of sounds of various frequencies is determined. The results of the study are recorded on a special grid form, called an “audiogram”.

An audiogram is a graphical representation of hearing threshold. The audiometer is designed to show hearing loss in decibels compared to normal. Normal hearing thresholds for sounds of all frequencies by both air and bone conduction are marked by the zero line. Thus, a pure-tone threshold audiogram primarily makes it possible to determine hearing acuity. Based on the nature of the threshold curves of air and bone conduction and their relationship, it is possible to obtain a qualitative characteristic of the patient’s hearing, i.e. determine whether there is a violation sound conduction, sound perception or mixed(combined) defeat.

At sound conduction disorders The audiogram shows an increase in air conduction hearing thresholds, mainly in the range of low and medium frequencies and, to a lesser extent, in high frequencies. Auditory thresholds by bone conduction remain close to normal; between the threshold curves of bone and air conduction there is a significant so-called air-bone gap(cochlear reserve) (Fig. 1.16 a).

At impaired sound perception air and bone conduction are affected to the same extent, the bone-air gap is practically absent. In the initial stages, the perception of high tones mainly suffers, and in the future this disorder

appears at all frequencies; there are breaks in the threshold curves, i.e. lack of perception at certain frequencies (Fig. 1.16 b).

Mixed, or combined hearing loss characterized by the presence on the audiogram of signs of impaired sound conduction and sound perception, but a bone-air gap remains between them (Fig. 1.16 c).

Tone threshold audiometry allows you to determine damage to the sound-conducting or sound-receiving sections of the auditory analyzer only in the most general form, without more specific

Rice. 1.16. Audiogram for impaired sound conduction: a - conductive form of hearing loss; b - sensorineural form of hearing loss; c - mixed form of hearing loss

localization. The form of hearing loss is clarified using additional methods: suprathreshold, speech and noise audiometry.

Pure tone suprathreshold audiometry. Designed to identify the phenomenon of accelerated increase in volume (FUNG - in domestic literature, the phenomenon of recruitment, recruitment phenomenon- in foreign literature).

The presence of this phenomenon usually indicates damage to the receptor cells of the spiral organ, i.e. about intracochlear (cochlear) damage to the auditory analyzer.

A patient with decreased hearing acuity develops increased sensitivity to loud (suprathreshold) sounds. He notes unpleasant sensations in the sore ear if people talk to him loudly or sharply increase his voice. The presence of FUNG can be suspected during a clinical examination. This is evidenced by the patient’s complaints about intolerance to loud sounds, especially with a sore ear, the presence of dissociation between the perception of whispered

and colloquial speech. The patient does not perceive whispered speech at all or perceives it at the sink, while he hears spoken speech at a distance of more than 2 m. When carrying out Weber's experiment, a change or sudden disappearance of the lateralization of sound occurs; during a tuning fork study, the audibility of the tuning fork suddenly stops when it is slowly moved away from the diseased ear.

Methods of suprathreshold audiometry(there are more than 30 of them) allow you to directly or indirectly identify FUNG. The most common among them are the classical methods: Lushera - determination of the differential threshold for perception of sound intensity, Fowler volume equalization(for unilateral hearing loss), small increment index intensity (IMPI, more often referred to as SISI -test). Normally, the differential sound intensity threshold is 0.8-1 dB; the presence of FUNG is indicated by its decrease below 0.7 dB.

Study of auditory sensitivity to ultrasound. Normally, a person perceives ultrasound during bone conduction in the frequency range up to 20 kHz or more. If hearing loss is not associated with damage to the cochlea (neurinoma of the VIII cranial nerve, brain tumors, etc.), the perception of ultrasound remains the same as normal. When the cochlea is damaged, the threshold for ultrasound perception increases.

Speech audiometry in contrast to tonal, it allows one to determine the social suitability of hearing in a given patient. The method is especially valuable in the diagnosis of central hearing lesions.

Speech audiometry is based on determining speech intelligibility thresholds. Understandability is understood as a value defined as the ratio of the number of correctly understood words to the total number of words heard; it is expressed as a percentage. So, if out of 10 words presented for listening, the patient correctly understood all 10, this will be 100% intelligibility; if he correctly understood 8, 5 or 2 words, this will be 80, 50 or 20% intelligibility, respectively.

The study is carried out in a soundproofed room. The results of the study are recorded on special forms in the form of speech intelligibility curves, while the intensity of speech is marked on the abscissa axis, and the percentage of correct answers is marked on the ordinate axis. The intelligibility curves are different for different forms of hearing loss, which has differential diagnostic significance.

Objective audiometry. Objective methods of hearing research are based on unconditioned and conditioned reflexes. Such a study is important for assessing the state of hearing in cases of damage to the central parts of the sound analyzer, during labor and forensic examinations. With a strong sudden sound, unconditioned reflexes are reactions in the form of dilation of the pupils (cochlear-pupillary reflex, or auropupillar reflex), closing of the eyelids (auropalpebral, blink reflex).

Most often, galvanic skin and vascular reactions are used for objective audiometry. The galvanic skin reflex is expressed in a change in the potential difference between two areas of the skin under the influence, in particular, of sound stimulation. The vascular response consists of a change in vascular tone in response to sound stimulation, which is recorded, for example, using plethysmography.

In young children, the reaction most often recorded is when gaming audiometry, combining sound stimulation with the appearance of a picture at the moment the child presses a button. The initially loud sounds are replaced by quieter ones and determine the hearing thresholds.

The most modern method of objective hearing testing is audiometry with recording auditory evoked potentials (AEPs). The method is based on recording potentials evoked in the cerebral cortex by sound signals on an electroencephalogram (EEG). It can be used in infants and young children, mentally disabled persons and persons with normal psyche. Since EEG responses to sound signals (usually short - up to 1 ms, called sound clicks) are very small - less than 1 μV, averaging using a computer is used to register them.

Registration is being used more widely short-latency auditory evoked potentials (SAEP), giving an idea of ​​the state of individual formations of the subcortical pathway of the auditory analyzer (vestibular-cochlear nerve, cochlear nuclei, olives, lateral lemniscus, quadrigeminal tuberosities). But CVEPs do not provide any complete picture of the response to a stimulus of a certain frequency, since the stimulus itself must be short. In this regard, more informative long-latency auditory evoked potentials (LAEPs). They record responses of the cerebral cortex for relatively long periods, i.e. sound having a certain frequency

signals and can be used to infer hearing sensitivity at different frequencies. This is especially important in pediatric practice, when conventional audiometry, based on the patient's conscious responses, is not applicable.

Impedance audiometry- one of the methods for objective assessment of hearing, based on measuring the acoustic resistance of a sound-conducting apparatus. In clinical practice, two types of acoustic impedance measurements are used - tympanometry and acoustic reflexometry.

Tympanometry consists of recording the acoustic resistance that a sound wave encounters when propagating through the acoustic system of the outer, middle and inner ear, when the air pressure in the external auditory canal changes (usually from +200 to -400 mm water column). The curve reflecting the dependence of the resistance of the eardrum on pressure is called a tympanogram. Various types of tympanometric curves reflect the normal or pathological state of the middle ear (Fig. 1.17).

Acoustic reflexometry is based on recording changes in the compliance of the sound-conducting system that occur during contraction of the stapedius muscle. Nerve impulses caused by a sound stimulus travel along the auditory pathways to the superior olivary nuclei, where they switch to the motor nucleus of the facial nerve and go to the stapedius muscle. Muscle contraction occurs on both sides. A sensor is inserted into the external auditory canal, which responds to changes in pressure (volume). In response to sound stimulation, an impulse is generated, passing through the above-described reflex-

Rice. 1.17. Types of tympanometric curves (according to Serger):

a - normal; b - with exudative otitis media; c - when the auditory circuit breaks

seeds

nal arch, as a result of which the stapedius muscle contracts and the eardrum begins to move, the pressure (volume) in the external auditory canal changes, which is recorded by the sensor. Normally, the threshold of the acoustic reflex of the stapes is about 80 dB above the individual sensitivity threshold. With sensorineural hearing loss accompanied by FUNG, reflex thresholds are significantly reduced. With conductive hearing loss, pathology of the nuclei or trunk of the facial nerve, the acoustic reflex of the stapes is absent on the affected side. For the differential diagnosis of retrolabyrinthine lesions of the auditory tract, the acoustic reflex decay test is of great importance.

Thus, existing methods of hearing research allow one to navigate the severity of hearing loss, its nature and the location of damage to the auditory analyzer. The accepted international classification of degrees of hearing loss is based on average values ​​of thresholds for the perception of sounds at speech frequencies (Table 1.2).

Table 1.2. International classification of hearing loss

1.4.2. Study of the functions of the vestibular analyzer

The examination of the patient always begins with finding out complaints and anamnesis life and illness. The most common complaints are dizziness, balance disorder, manifested by impaired gait and coordination, nausea, vomiting, fainting, sweating, discoloration of the skin, etc. These complaints may be constant or intermittent, fleeting or lasting several hours or days. They can occur spontaneously, for no apparent reason, or under the influence of

We take into account specific factors of the external environment and the body: in transport, surrounded by moving objects, overwork, physical stress, a certain position of the head, etc.

Usually, with vestibular genesis, there are specific complaints. For example, when dizzy, a patient feels an illusory displacement of objects or his body; when walking, such sensations lead to falling or staggering. Patients often call dizziness the darkening or appearance of spots in the eyes, especially when bending over and when moving from a horizontal to a vertical position. These phenomena are usually associated with various lesions of the vascular system, fatigue, general weakening of the body, etc.

Vestibulometry includes identifying spontaneous symptoms, conducting and evaluating vestibular tests, analyzing and summarizing the data obtained. Spontaneous vestibular symptoms include spontaneous nystagmus, changes in muscle tone of the limbs, gait disturbance.

Spontaneous nystagmus. The patient is examined in a sitting position or in a supine position, while the subject follows the doctor’s finger, which is 60 cm away from the eyes; the finger moves sequentially in horizontal, vertical and diagonal planes. Eye abduction should not exceed 40-45°, since overstrain of the eye muscles may be accompanied by twitching of the eyeballs. When observing nystagmus, it is advisable to use high-magnification glasses (+20 diopters) to eliminate the influence of gaze fixation. Otorhinolaryngologists use special Frenzel or Bartels glasses for this purpose; Spontaneous nystagmus is revealed even more clearly by electronystagmography.

When examining a patient in a supine position, the head and torso are given different positions, while in some patients the appearance of nystagmus, designated as positional nystagmus(positional nystagmus). Positional nystagmus can have a central genesis; in some cases it is associated with a dysfunction of otolith receptors, from which the smallest particles are torn off and enter the ampoules of the semicircular canals with pathological impulses from the cervical receptors.

In the clinic, nystagmus is characterized along the plane(horizontal, sagittal, rotatory), towards(right, left, up, down), by strength(I, II or III degrees), according to the speed of vibration -

body cycles(alive, lethargic), by amplitude(small-, medium- or large-scale), by rhythm(rhythmic or disrhythmic), by duration (in seconds).

The strength of nystagmus is considered I degree, if it occurs only when looking towards the fast component; II degree- when looking not only towards the fast component, but also directly; finally, nystagmus III degree observed not only in the first two eye positions, but also when looking towards the slow component. Vestibular nystagmus usually does not change its direction, i.e. in any position of the eyes, its fast component is directed in the same direction. The extralabyrinthine (central) origin of nystagmus is evidenced by its undulating nature, when it is impossible to distinguish fast and slow phases. Vertical, diagonal, multidirectional (changing direction when looking in different directions), converging, monocular, asymmetrical (not the same for both eyes) nystagmus is characteristic of disorders of central origin.

Tonic reactions of hand deviation. They are examined by performing index tests (finger-nose, finger-finger), Fischer-Wodak test.

Index samples. By doing finger-nose test the subject spreads his arms to the sides and, first with his eyes open and then with his eyes closed, tries to touch the tip of his nose with the index fingers of one and then the other hand. When the vestibular analyzer is in a normal state, it performs the task without difficulty. Stimulation of one of the labyrinths leads to swinging of both hands in the opposite direction (towards the slow component of nystagmus). When the lesion is localized in the posterior cranial fossa (for example, with pathology of the cerebellum), the patient swings with one hand (on the side of the disease) to the “sick” side.

At finger-finger test The patient, alternately with his right and left hand, should touch the doctor’s index finger, located in front of him at arm’s length. The test is performed first with eyes open, then with eyes closed. Normally, the subject confidently hits the doctor’s finger with both hands, both with open and closed eyes.

Fischer-Wodak test. It is performed by the subject sitting with his eyes closed and with his arms extended forward. Index fingers

extended, the rest clenched into a fist. The examiner places his index fingers opposite and in close proximity to the patient's index fingers and observes the deviation of the subject's hands. In a healthy person, deviation of the hands is not observed; when the labyrinth is damaged, both hands deviate towards the slow component of nystagmus (i.e. towards the labyrinth, the impulse from which is reduced).

Study of stability in the Romberg pose. The subject stands with his feet close together so that their toes and heels touch, his arms are extended forward at chest level, his fingers are spread, his eyes are closed (Fig. 1.18). In this position, the patient should be secured so that he does not fall. If the function of the labyrinth is impaired, the patient will deviate in the direction opposite to nystagmus. It should be taken into account that even with cerebellar pathology, there may be a deviation of the body in the direction of the lesion, therefore the study in the Romberg position is supplemented by turning the subject’s head to the right and left. With damage to the labyrinth, these turns are accompanied by a change in the direction of fall; with cerebellar damage, the direction of deviation remains unchanged and does not depend on the rotation of the head.

Gait in a straight line and flank:

1) when studying gait in a straight line, the patient with his eyes closed takes five steps forward in a straight line and then, without turning, 5 steps back. If the function of the vestibular analyzer is impaired, the patient deviates from a straight line in the direction opposite to nystagmus; in case of cerebellar disorders - in the direction of the lesion;

Rice. 1.18. Study of stability in the Romberg pose

2) flank gait is examined as follows. The subject puts his right leg to the right, then puts his left one in and takes 5 steps in this way, and then similarly takes 5 steps to the left. If the vestibular function is impaired, the subject performs the flank gait well in both directions; if the cerebellar function is impaired, he cannot perform it in the direction of the affected cerebellar lobe.

Also, for the differential diagnosis of cerebellar and vestibular lesions, test for adiadochokinesis. The subject performs it with his eyes closed, both arms extended forward, and quickly changes between pronation and supination. Adiadochokinesis - a sharp lag of the hand on the “sick” side due to impaired cerebellar function.

VESTIBULAR TESTS

Vestibular tests make it possible to determine not only the presence of dysfunction of the analyzer, but also to give a qualitative and quantitative description of their features. The essence of these tests is to excite the vestibular receptors with the help of adequate or inadequate dosed influences.

Thus, for the ampullary receptors, angular accelerations are an adequate stimulus; a dosed rotational test on a rotating chair is based on this. An inadequate stimulus for the same receptors is the effect of a dosed caloric stimulus, when the infusion of water of different temperatures into the external auditory canal leads to cooling or heating of the liquid media of the inner ear and this causes, according to the law of convection, the movement of the endolymph in the horizontal semicircular canal, located closest to the middle ear. Also, exposure to galvanic current is an inadequate stimulus for vestibular receptors.

For otolith receptors, an adequate stimulus is rectilinear acceleration in the horizontal and vertical planes when performing a test on a four-bar swing.

Rotational test. The subject is seated in the Barani chair in such a way that his back fits snugly against the back of the chair, his legs are placed on the stand, and his hands are on the armrests. The patient's head tilts forward and down 30°, eyes should be closed. Rotation is carried out uniformly at speed

1/2 revolution (or 180°) per second, for a total of 10 revolutions in 20 s. At the beginning of rotation, the human body experiences positive acceleration, and at the end - negative. When rotating clockwise after stopping, the endolymph flow in the horizontal semicircular canals will continue to the right; therefore, the slow component of the nystagmus will also be to the right, and the direction of the nystagmus (fast component) will be to the left. When moving to the right at the moment the chair stops in the right ear, the movement of the endolymph will be ampulofugal, i.e. from the ampulla, and in the left - ampulopetal. Consequently, post-rotation nystagmus and other vestibular reactions (sensory and autonomic) will be caused by irritation of the left labyrinth, and the post-rotation reaction from the right ear will be observed when rotating counterclockwise, i.e. to the left. After the chair stops, the countdown begins. The subject fixes his gaze on the doctor's finger, while the degree of nystagmus is determined, then the nature of the amplitude and liveliness of the nystagmus, its duration when the eyes are positioned towards the fast component are determined.

If the functional state of the receptors of the anterior (frontal) semicircular canals is being studied, then the subject sits in a Barany chair with his head tilted back 60°; if the function of the posterior (sagittal) canals is being studied, the head is tilted 90° to the opposite shoulder.

Normally, the duration of nystagmus when studying the lateral (horizontal) semicircular canals is 25-35 s, when studying the posterior and anterior canals - 10-15 s. The nature of nystagmus when irritating the lateral canals is horizontal, the anterior canals are rotatory, the posterior canals are vertical; in amplitude it is small or medium in amplitude, grades I-II, lively, quickly fading.

Caloric test. During this test, a weaker artificial stimulation of the labyrinth, mainly of the receptors of the lateral semicircular canal, is achieved than during rotation. An important advantage of the caloric test is the ability to irritate ampullary receptors on one side in isolation.

Before performing a water caloric test, you should make sure that there is no dry perforation in the eardrum of the ear being tested, since the entry of water into the tympanic cavity can cause an exacerbation of the chronic inflammatory process. In this case, air calorization can be carried out.

The caloric test is performed as follows. The doctor draws 100 ml of water at a temperature of 20 ° C into the Janet syringe (with a thermal caloric test, the water temperature is +42 ° C). The subject sits with his head tilted back 60°; in this case, the lateral semicircular canal is located vertically. Pour 100 ml of water into the external auditory canal over 10 s, directing the stream of water along its posterior superior wall. The time from the end of the infusion of water into the ear until the appearance of nystagmus is determined - this is the latent period, normally equal to 25-30 s, then the duration of the nystagmus reaction is recorded, normally equal to 50-70 s. The characteristics of nystagmus after calorization are given according to the same parameters as after the rotational test. During cold exposure, nystagmus (its fast component) is directed in the direction opposite to the test ear, and during thermal calorization - towards the irritated ear (Fig. 1.19 a, b).

Rice. 1.19. Methodology for conducting a caloric test

Pressor (pneumatic, fistula) test. It is carried out to identify a fistula in the area of ​​the labyrinthine wall (most often in the area of ​​the ampulla of the lateral semicircular canal) in patients with chronic purulent otitis media. The test is performed by condensing and rarefying the air in the external auditory canal, or by applying pressure to the tragus, or using a rubber bulb. If nystagmus and other vestibular reactions occur in response to air thickening, then the pressor test is assessed as positive. This indicates the presence of a fistula. It should be noted, however, that a negative test does not allow one to completely deny the presence of a fistula. In case of extensive perforation in the eardrum, direct pressure can be applied with a probe with cotton wool wound onto it onto areas of the labyrinthine wall that are suspected of a fistula.

Study of the function of the otolithic apparatus. It is carried out mainly during professional selection; in clinical practice, methods of direct and indirect otolitometry are not widely used. Taking into account the interdependence and mutual influence of the otolithic and cupular sections of the analyzer V.I. Wojacek proposed a technique he called the “double experiment with rotation” and known in the literature as the “Otolith reaction according to Wojacek.”

Otolithic reaction (OR). The subject sits in a Barany chair and tilts his head and torso 90° forward and down. In this position, it is rotated 5 times for 10 s, then the chair is stopped and waited for 5 s, after which it is asked to open your eyes and straighten up. At this moment, a reaction occurs in the form of tilting the torso and head to the side. The functional state of the otolithic apparatus is assessed by the degrees of deviation of the head and torso from the midline in the direction of the last rotation. The severity of autonomic reactions is also taken into account.

Thus, a deviation by an angle from 0 to 5° is assessed as I degree of reaction (weak); deviation of 5-30° - II degree (medium strength). Finally, a deviation of more than 30° is grade III (strong), when the subject loses balance and falls. The angle of reflex inclination in this reaction depends on the degree of influence of otolith irritation during straightening of the body on the function of the anterior semicircular canals. In addition to the somatic reaction, this experience takes into account vegetative reactions, which can also be of three degrees: I degree - paleness of the face, change in pulse; II degree

(medium) - cold sweat, nausea; III degree - changes in cardiac and respiratory activity, vomiting, fainting. The double rotation experiment is widely used when examining healthy people for the purposes of professional selection.

When selecting in aviation and astronautics for studying the sensitivity of the subject to the cumulation of vestibular irritation, the proposal proposed by K.L. Khilov back in 1933. technique of motion sickness on a four-bar (two-bar) swing. The swing platform does not oscillate like a regular swing - in an arc, but remains constantly parallel to the floor. The subject is located on the swing platform, lying on his back or on his side, and tonic eye movements are recorded using the electrooculography technique. A modification of the method using small dosed amplitude swings and recording compensatory eye movements is called "direct otolitometry".

Stabilometry. Among the objective methods for assessing static equilibrium, the method stabilometry, or posturography (posture - pose). The method is based on recording oscillations of the center of pressure (gravity) of the patient’s body installed on a special stabilometric platform

(Fig. 1.20). Body vibrations are recorded separately in the sagittal and frontal planes, and a number of indicators are calculated that objectively reflect the functional state of the balance system. The results are processed and summarized using a computer. In combination with a set of functional tests, computer stabilometry is

Rice. 1.20. Study of balance on a stabilometric platform

a highly sensitive method and is used to identify vestibular disorders at the earliest stage, when they are not yet subjectively manifested (Luchikhin L.A., 1997).

Stabilometry is used in the differential diagnosis of diseases accompanied by balance disorders. For example, a functional test with head rotation (Palchun V.T., Luchikhin L.A., 1990) makes it possible at an early stage to differentiate disorders caused by damage to the inner ear or vertebrobasilar insufficiency. The method makes it possible to control the dynamics of the development of the pathological process in case of balance function disorder, and to objectively evaluate the results of treatment.

1.5. ESOPHAGOSCOPY

Esophagoscopy is the main method for examining the esophagus. It is performed both as an emergency medical service, for example, when removing foreign bodies of the esophagus, and to examine the walls of the esophagus in case of injuries to the esophagus, suspected tumor, etc.

Before esophagoscopy, a general and special examination is carried out. The patient’s condition and contraindications to esophagoscopy are clarified. A special examination involves an X-ray examination of the hypopharynx, esophagus and stomach with a contrast mass.

Tools. Brunings, Mesrin, Friedel bronchoscopes and fiber optics. In addition, the research room should have an electric suction, a set of forceps for removing foreign bodies and taking pieces of tissue for histological examination.

Preparing the patient. The manipulation is performed on an empty stomach or 5-6 hours after the last meal. 30 minutes before the start of esophagoscopy, an adult patient is injected subcutaneously with 1 ml of 0.1% atropine sulfate solution and 1 ml of 2% promedol solution. Removable dentures must be removed.

Anesthesia. Esophagoscopy for adults and older children can be performed under general anesthesia or local anesthesia; for young children - only under general anesthesia.

Local anesthesia used in cases where there are no local and general aggravating factors (perforation or injury

esophagus, general diseases, etc.). For pain relief in adults, use 10% cocaine solution or 2% dicaine solution with the addition of 0.1% adrenaline solution. After spraying the pharynx twice, the mucous membrane of the pharynx and larynx is sequentially lubricated with the same composition. Anesthesia occurs when the patient does not react by gagging and coughing to lubricate the laryngopharynx and the entrance area to the esophagus.

Anesthesia. Endotracheal anesthesia is always preferable; it is absolutely indicated in cases where esophagoscopy is performed in the presence of local or general aggravating factors. Local factors include a large foreign body, injury or inflammation of the wall of the esophagus, bleeding from the esophagus, a failed attempt to remove a foreign body under local anesthesia, etc. General factors include mental illness, deaf-muteness, dysfunction of the cardiovascular system, general diseases, disrupting certain vital functions of the body.

Rice. 1.21. Esophagoscopy technique

Patient's position. If esophagoscopy is performed under local anesthesia, the patient sits on a special Brunings chair. An assistant stands behind the patient, holding his head and shoulders in the desired position if anesthesia is given, and also in children, esophagoscopy is performed with the patient lying on his back.

Esophagoscopy technique(Fig. 1.21). Before starting esophagoscopy, an appropriate size tube is selected (taking into account the level of damage to the esophagus or stuck foreign body). If esophagoscopy is performed under local anesthesia, the patient opens his mouth wide and sticks out his tongue. Breathing should be smooth. The doctor places a napkin on the protruding part of the tongue and grasps the tongue with the fingers of his left hand in the same way as during indirect laryngoscopy. With his right hand, the doctor inserts the esophagoscope tube from the corner of the mouth into the oropharynx, then transfers it to the laryngopharynx, the end of the tube should be strictly in the midline. At this point, the epiglottis fossae should be examined. By pushing the epiglottis anteriorly with the beak of the tube, the tube is advanced beyond the arytenoid cartilages. In this place, in the lumen of the tube, the entrance to the esophagus is visible in the form of a sphincter. Next, under visual control, the patient is asked to make a swallowing movement, which helps open the mouth of the esophagus. The tube moves lower. An indispensable condition for further advancement of the esophagoscope is the coincidence of the axis of the tube and the axis of the esophagus.

Upon examination, a pink mucous membrane is visible, collected in longitudinal folds. When properly performed esophagoscopy, the narrowing and expansion of the lumen of the esophagus is determined synchronously with respiratory movements. When the tube is immersed in the lower third of the esophagus, it is clear that its lumen becomes narrow, acquiring a slit-like shape as it passes the level of the diaphragm. Remove the tube slowly. At the same moment, directing the distal end along the mucous membrane in a circular motion, a thorough examination is performed.

Esophagoscopy under anesthesia has a number of features. First, the doctor uses the fingers of his left hand to open the mouth of the patient lying on his back wide. An esophagoscopic tube is passed through the corner of the mouth to the entrance to the esophagus. Absolutely effortlessly, the tube is inserted through the mouth of the esophagus into its lumen, but gaping of the lumen, as with esophagoscopy under local anesthesia, does not occur.

1.6. TRACHEOBRONCHOSCOPY

The trachea and bronchi are examined for diagnostic and therapeutic purposes using the same instruments used to examine the esophagus.

A diagnostic examination of the trachea and bronchi is indicated in cases of respiratory dysfunction in the presence of neoplasms; the occurrence of tracheoesophageal fistula, atelectasis (any localization), etc. For therapeutic purposes, tracheobronchoscopy is used in otorhinolaryngology mainly in the presence of foreign bodies and scleroma, when infiltrates or a membrane of scar tissue form in the subglottic cavity. In this case, the bronchoscopic tube is used as a bougie. In therapeutic and surgical practice, tracheobronchoscopy is one of the measures in the treatment of abscess pneumonia and lung abscess.

Instrumental examination of the lungs plays an equally important role in the practice of treating pulmonary tuberculosis. Depending on the level of tube insertion, upper and lower tracheobronchoscopy are distinguished. With upper tracheobronchoscopy, the tube is inserted through the mouth, pharynx and larynx, with lower tracheobronchoscopy, the tube is inserted through a pre-formed tracheotomy opening (tracheostomy). Lower tracheobronchoscopy is performed more often in children and people who already have a tracheostomy.

The anesthesia technique deserves special attention. Currently, preference should be given to general anesthesia (anesthesia), especially since the doctor is armed with special respiratory bronchoscopes (Friedel system). In children, examination of the trachea and bronchi is carried out only under anesthesia. In connection with the above, the introduction of anesthesia is carried out in the operating room with the patient lying on his back with his head thrown back. The advantages of general anesthesia over local anesthesia are the reliability of pain relief, the elimination of mental reactions in the subject, relaxation of the bronchial tree, etc.

Technique for introducing a tracheobronchoscopic tube. The patient is on the operating table in a supine position with the shoulder girdle raised and head thrown back. Holding the lower jaw with the fingers of the left hand with the mouth open, under visual control (through the bronchoscope tube) the bronchoscope is inserted through the corner of the mouth into its cavity. The distal end of the tube is

wives should be located strictly on the midline of the oropharynx. The tube is slowly advanced forward, pressing on the tongue and epiglottis. At the same time, the glottis becomes clearly visible. By rotating the handle, the distal end of the tube is turned 45° and inserted into the trachea through the glottis. The examination begins with the walls of the trachea, then the bifurcation area is examined. Under visual control, the tube is inserted alternately into the main and then into the lobar bronchi. Inspection of the tracheobronchial tree continues when the tube is removed. Foreign bodies are removed and pieces of tissue are taken for histological examination using a special set of forceps. Suction is used to remove mucus or pus from the bronchi. After this manipulation, the patient should be under medical supervision for 2 hours, since during this period laryngeal edema and stenotic breathing may occur.

To identify any disease at an early stage and make an accurate diagnosis, effective research methods are needed.

Diagnosis of ENT organs in modern medicine is carried out in several ways. Depending on the tasks and existing assumptions, the specialist chooses one or another examination. Often, several types of studies are required to complete the clinical picture.

Basic diagnostic techniques

The most widely applicable and effective are the following diagnostic techniques:

• Audioscopy.
• Otoscopy.
• Olfactometry.
• Rhinoscopy.
• Pharyngoscopy.
• Bronchoscopy.

If we talk about general studies aimed at obtaining a detailed profile of a certain area, the following types of diagnostics should be distinguished:

• Ultrasonography.
• Radiography.
• CT scan.
• Fibroscopy.
• Bioresonance diagnostics.

The listed general techniques are prescribed only in a number of cases. Arriving at the otolaryngologist’s office, the patient will not always receive a referral for an ultrasound or x-ray. These types of diagnostics are required to identify severe forms of diseases and their complications. For preventive or initial examination in the presence of complaints, narrowly focused types of research are used.

For example, if there is a suspicion of hearing diseases, each patient must undergo an otoscopy. Using a special diagnostic device - an otoscope (an example can be found on the website http://www.otoscope.ru/), a specialist is able to assess the nature of changes in the area of ​​the eardrum, external auricle and other adjacent areas. If diseases of the nose and nasopharynx are suspected, as well as to assess the condition of these areas in cases of concomitant diseases, rhinoscopy is used.

After the initial examination, if necessary, the patient may be prescribed additional studies aimed at a detailed study of a certain area.

For example, to assess the quality of mucous membranes, identify pathological changes in the form of tumor and inflammatory processes, as well as to detect purulent and cystic accumulations in the area of ​​the nasal and frontal sinuses, the neck, the patient may be prescribed an ultrasound examination or radiography. X-rays of ENT organs are also carried out to identify congenital abnormalities in the structure of bone tissue, changes in soft tissues and detect purulent and inflammatory processes.

To check hearing acuity, patients are prescribed audiometry. Pathologies of the middle ear are successfully determined using tympanometry.

Endoscopy in otolaryngology is also widely used to study the condition of the ENT organs. This is a fairly simple, informative and completely safe diagnostic method that can be used to examine patients of any age category.

With the help of an endoscope, it is possible to carry out several important, narrowly focused studies:

• Endoscopy of the nose.
• Examination of the oropharynx.
• Endoscopy of the ear.
• Examination of the larynx.
• Examination of the nasopharynx.

Laboratory research

It is worth noting that to understand the full picture, instrumental diagnostics, examination and questioning for complaints alone are not enough. If infectious or inflammatory diseases are suspected, laboratory tests are also required. Evaluation of analyzes of biological material in cases of diseases in the field of otolaryngology is most important for identifying the pathogen. Timely determination of the main cause of the development of the inflammatory process makes it possible to select an effective course of therapy and avoid the development of complications or chronicity of the process. Also, timely diagnosis allows you to limit yourself to only conservative treatment methods. In cases of advanced disease, surgery is often required.