Methods of examination and research of ENT organs. Presentation of ENT organs diseases in old and senile age Presentation of ENT organs diseases

17.06.2020

Pharynx floors The pharynx is the site of the intersection of the respiratory and digestive tract... The lower border of the pharynx is the place of its transition into the esophagus at the level of the 6th cervical vertebra. There are three sections of the pharynx: Upper - nasopharynx Middle - oropharynx Lower - laryngopharynx The pharynx connects the nasal cavity and mouth from above, with the larynx and esophagus below. The pharynx is formed by muscles, fibrous membranes and is lined with mucous membranes inside. The length of the pharynx of an adult from its vault to the lower end is 14 cm (12-15), transverse dimension on average it is 4.5 cm.

Sagittal incision of the pharynx 1. Hard palate; 2. Soft palate; 3. Uvula; 4. The pharyngeal opening of the auditory tube 5. The pharyngeal tonsil; 6. Palatine tonsil; 7. The palatine and palatopharyngeal arch; 8. Lingual tonsil; 9. Pear-shaped pockets; 10.The epiglottis;

Pirogov-Valdeyer Lymphadenoid pharyngeal ring of Pirogov-Valdeyer. I and II - palatine tonsils III - nasopharyngeal IV - lingual V and VI - tubal In addition, there is an accumulation of lymphadenoid tissue on the posterior wall of the pharynx, in the region of the lateral ridges and the lingual surface of the epiglottis.

Classification of sore throats according to B.S. Preobrazhensky Catarrhal Catarrhal Follicular Follicular Lacunar Lacunar Fibrinous Fibrinous Herpetic Herpetic Ulcerative-necrotic (gangrenous) Ulcerative-necrotic (gangrenous) Phlegmonous abscess intratonzylarny forms

Pharyngoscopy with catarrhal angina With pharyngoscopy, the tonsils are somewhat swollen, strongly reddened, their surface is covered with mucous discharge. The mucous membrane around the tonsils is more or less hyperemic, but there is no diffuse hyperemia of the oropharynx, which is typical for acute pharyngitis... In more severe cases, there are punctate hemorrhages in the mucous membrane.

Pharyngoscopy for lacunar angina On the swollen and reddened mucous membrane of the tonsils, white or yellow plugs are formed from the depths of the tonsils of new lacunae, consisting of bacteria, rejected epithelial cells and a large number of leukocytes. A yellowish-white coating often forms on the surface of the tonsils that does not extend beyond the tonsils. With lacunar sore throat, the entire tissue of the tonsil is affected, which, due to this, swells and increases in volume. The formation of plaque in the lacunae distinguishes this form from diphtheria, in which, in addition to the lacunae, the convex places of the tonsil mucosa are also affected.

Pharyngoscopy for follicular tonsillitis On the reddened and swollen mucous membrane of both tonsils, a significant number of pinhead-sized, slightly raised yellowish or yellowish-white dots, which represent suppurative tonsil follicles, appear. The yellowish-white dots gradually increase and fester and open.

Pharyngoscopy with phlegmonous sore throat Sharp bulging of the tonsil, palatine arches and soft palate to the midline (spherical formation on one side of the pharynx), the uvula is displaced in the opposite direction, tension and bright hyperemia of the bulging, in the area of \u200b\u200bgreatest protrusion with pressure - fluctuation, the tongue is coated with a thick coating and viscous saliva.

Retropharyngeal abscess When examining the posterior pharyngeal wall or palpating it with a finger, a vaporous protruding fluctuating tumor is determined. An abscess can spread to the region of large vessels of the neck or descend along the prevertebral fascia into the chest cavity and cause purulent mediastinitis.

Classification of chronic tonsillitis (according to Preobrazhensky - Palchun) Chronic tonsillitis Simple form Concomitant diseases Toxico-allergic form I - degree Concomitant diseases II - degree Concomitant diseases Concomitant diseases

ABSOLUTE CONTRAINDICATIONS TO TONZILECTOMY - serious diseases of cardio-vascular system with circulatory failure II-III degree - renal failure with the threat of uremia - severe diabetes with the danger of developing a coma - high degree hypertension with possible development crises - hemorrhagic diathesis not treatable - hemophilia - acute common diseases - exacerbation of common chronic diseases

Degrees of adenoid growths (vegetation) I degree - adenoids cover the choans 1/3 of the opener II degree - adenoids cover the choans up to 2/3 of the opener III degree - adenoids cover the choanas completely Methods for the diagnosis of adenoid growths (vegetation) - Digital examination of the nasopharynx - Posterior rhinoscopy

INDICATIONS FOR ADENOTOMY - Nasopharyngeal obstruction with impaired nasal breathing, leading to episodes of sleep apnea, the development of alveolar hypoventilation and pulmonary heart, orthodontic defects, violation of the act of swallowing and voice - Chronic suppurative otitis media, which does not respond conservative treatment - Recurrent otitis media in children - chronic adenoiditis, accompanied by frequent respiratory infections.

Predisposes FACTORS OF ostorov pharyngitis: - hypothermia - REDUCTION GENERAL AND LOCAL AND spetsefichesky NESPETSEFICHESKIH FACTORS protect the body - an inflammatory disease of the mouth, nose and paranasal sinuses - GIPOVITAMINOZNYE condition - affects the lining of the pharynx physical, chemical, thermal factors

PROSPOSING FACTORS OF CHRONIC PHARYNGITIS DEVELOPMENT -Reduction of general and local specific and non-specific factors body protection -Inflammatory diseases oral cavity, nose and paranasal sinuses -Smoking -Using alcoholic beverages -Various occupational hazards (inhalation of dust and gases) -Diseases of metabolism (rickets, diabetes, etc.) -Diseases of other organs and systems of the body (cardiovascular system, gastrointestinal tract, hematopoietic, genitourinary, cardiovascular and other systems). - hypovitaminosis on the mucous membrane of the pharynx of physical, chemical, thermal factors - hypothermia of the body

INDICATIONS FOR TONZILEECTOMY - chronic tonsillitis simple and toxic allergic form II degree in the absence of the effect of conservative therapy - chronic toxic-allergic tonsillitis form III degree of chronic tonsillitis, complicated by paratonsillitis - tonsillogenic sepsis

PRINCIPLES OF TREATMENT OF ACUTE PHARYNGITIS - Elimination of irritating food -Antibacterial therapy - Anti-inflammatory drugs - Inhalation or pulverization of warm alkaline and antibacterial drugs... - Distractions - Elimination of local and general predisposing factors.

Methods of examination and examination of ENT organs

Methods for the treatment of LORorgan_v
ZAPORIZKY DERZHAVNYY MEDICAL UNIVERSITY
Faculty: PISLYADIPLIMNO OSVITI
Department: CHILD FOOD
assistant of the department Shamenko V.O.
2016

The methods of examination and examination of ENT organs have a number of general principles.
The subject sits down so that the source
light and a table with tools was
to the right of him.
The doctor sits down opposite the subject,
putting your feet on the table; legs
the subject should be outward.
The light source is placed at the level
the right auricle of the subject in
10 cm from her.

1) Examination of the external nose and places of projection of the paranasal sinuses
on the face.
2) Palpation of the external nose: index fingers of both hands
placed along the nasal dorsum and lightly massaging
movements feel the area of \u200b\u200bthe root, slopes, back and
tip of the nose.
3) Palpation of the anterior and lower walls frontal sinuses: large
fingers of both hands are placed on the forehead above the eyebrows and gently
press on this area, then thumbs
move to area top wall eye sockets to inner
corner and also press. Palpate the exit points of the first
branches trigeminal nerve (n. ophtalmicus). Normal palpation
the walls of the frontal sinuses are painless (Fig. 1.2).
4) Palpation of the anterior walls of the maxillary sinuses: large
fingers of both hands are placed in the canine fossa on
the anterior surface of the maxillary bone and slightly
press. Palpate the exit points of the second branches
trigeminal nerve (n. infraorbitalis). Normal palpation
the anterior wall of the maxillary sinus is painless.
Palpation of the walls of the frontal sinuses

5) Palpation of the submandibular and cervical lymph nodes:
submandibular the lymph nodes palpate with several
tilted forward head of the subject with light massaging
movements of the ends of the phalanges of the fingers in the submandibular region in
direction from the middle to the edge of the lower jaw.
Deep cervical lymph nodes are palpated first with one
side, then on the other. The patient's head is tilted forward (with
tilting the head backward, the anterior cervical lymph nodes and trunk
the vessels of the neck are also displaced posteriorly, which makes it difficult to feel them).
When palpating the lymph nodes on the right, the doctor's right hand lies on
the vertex of the subject, and with the left hand they massage
movements with soft deep immersion into the tissue by the ends of the phalanges
fingers in front of the anterior edge of the sternocleidomastoid
muscles. On palpation of the lymph nodes on the left, the left hand of the doctor
located on the crown, palpation is performed on the right.

Inspection of the nasal cavity is carried out with
artificial lighting (frontal
reflector or autonomous
light source) using the bow
mirror - nasal dilator,
to be kept on the left
hand as shown
Anterior rhinoscopy:
and - correct position a nasal dilator in the hand;
b - position of the nasal dilator when viewed

Rhinoscopy can be anterior, middle and posterior.
1) Inspection of the vestibule of the nose (first position with anterior rhinoscopy).
With the thumb of the right hand, lift the tip of the nose and examine
vestibule of the nose. Normally, the vestibule of the nose is free, there is hair.
2) Anterior rhinoscopy is performed alternately - one and the other half
nose. Place the nasal dilator on the open palm of the left hand with its beak down;
thumb the left hand is placed on top of the nasal dilator screw,
index and middle fingers - outside under the branch, IV and V should
be between the jaws of the nasal dilator. Thus II and III fingers
close the jaws and thereby open the beak of the nasal dilator, and IV and V
fingers move apart the jaws and thereby close the beak of the nasal speculum.
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 patient's parietal region so that
give the head the desired position.

4) The closed beak of the nasal dilator is inserted 0.5 cm in front of the right half of the nose
sick. The right half of the beak of the nasal dilator should be in the lower-inner corner
vestibule of the nose, left - on the upper third of the wing of the nose.
5) With 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
mucous membrane of the nasal septum.
6) Examine the right half of the nose with a straight head position, normal color of the mucosa
the shell is pink, the surface is smooth, moist, the nasal septum along the midline. Fine
the turbinates are not enlarged, the common, lower and middle nasal passages are free. Distance
between the septum of the nose 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 downward. When
This clearly shows the front and middle sections of the lower nasal passage, the bottom of the nose. Fine
the lower nasal passage is free.
8) Examine the right half of the nose with the patient's head slightly thrown back and to the right.
In this case, the middle nasal passage is visible.
9) With IV and V fingers, move the right jaws so that the nose of the beak of the nasal dilator is not
closed completely (and did not pinch the hairs) and remove the nasal dilator from the nose.
10) Inspection of the left half of the nose is performed in the same way: the left hand holds the nasal dilator, and
the right hand lies on the crown of the head, while the right half of the beak of the nasal dilator is in
the upper inner corner of the vestibule of the nose on the left, and the left - in the lower outer.

1) There are a large number of methods for determining
respiratory function of the nose. The simplest method of V.I. Voyacheka,
at which the degree of air permeability through
nose. To determine breathing through the right side 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
fluff of cotton wool to the right vestibule of the nose and ask the patient
take a short breath in and out. The nasal
breathing through the left side of the nose. By deflection of fleece
the respiratory function of the nose is evaluated. Breathing through each
half of the nose may be normal, obstructed, or
absent.

2) The definition of the olfactory function is performed in turn by each
half of the nose with odorous substances from the olfactometric set
or using a device - an olfactometer. For determining
the olfactory function on the right is pressed with the index finger
right hand the left wing of the nose to the nasal septum, and the left hand
take a bottle of an odorous substance and bring it to the right vestibule
nose, ask the patient to inhale the right half of the nose and
determine the smell of a given substance. Most commonly used substances
with aromas of increasing concentration - wine alcohol, tincture
valerian, acetic acid solution, ammonia, etc.
The definition of smell through the left half of the nose is performed
similarly, only the right wing of the nose is pressed with the index
with the finger of the left hand, and with the right hand they bring the odorous substance to the left
half of the nose. Smell may be normal (normosmia),
low (hyposmia), absent (anosmia), perverted
(cocasmia).

Radiography. She is one of the most
common and informative methods
examinations of the nose and paranasal sinuses.
The following methods are most often used in the clinic.
With nasal projection (occipital-frontal) in
the patient's head is laid in such a
so that the forehead and the tip of the nose touch the cassette. On
the resulting image best shows the frontal and
less lattice and maxillary sinuses

For naso-chin projection (occipital-chin)
the patient lies on the cassette face down with open mouthtouching
to her nose and chin. Such a picture clearly shows
frontal as well as maxillary sinuses, ethmoid cells
labyrinth and sphenoid sinuses (Fig. 1.4 b). In order to
see the level of fluid in the sinuses on the x-ray,
apply the same styling, but in an upright position
sick (sitting).
With lateral (bitemporal), or profile, projection of the head
the examinee is placed on the cassette in such a way that
the sagittal plane of the head was parallel to the cassette,
the X-ray beam passes in the frontal direction slightly
in front (1.5 cm) of the auricle tragus.

The most common
X-ray styling,
used in
paranasal
sinuses:
a - nasolabial (occipital);
b - naso-chin
(occipital-chin)

c - lateral (bitemporal,
profile);
r - axial
(chin-vertical);
d - computer
paranasal tomogram
sinuses

With axial (chin-vertical) projection of the patient
lies on his back, throws his head back and the parietal part
fits on the cassette. In this position, the chin
the area is horizontal and the x-ray
the beam is directed strictly vertically to the thyroid notch
larynx. In this styling, wedge-shaped
the sinuses are separated from each other (Fig. 1.4 d). In practice, like
as a rule, two projections are used: naso-chin and
nasolabial, with indications other styling is prescribed.
In the last decade,
methods computed tomography (CT) and magnetic nuclear
resonance imaging (MRI) scans, which have much larger
permissive possibilities.

These methods are the most informative.
modern diagnostic methods with
the use of optical systems for visual
control, rigid and flexible endoscopes with
different viewing angles, microscopes.
The introduction of these high-tech and
expensive methods has significantly expanded
horizons of diagnostics and surgical
opportunities of an ENT specialist.

1. Examine the neck area, the mucous membrane of the lips.
2. Palpate the regional lymph nodes of the pharynx: submandibular, in
retromandibular fossae, deep cervical, posterior cervical, in the supra- and
subclavian fossa.
Stage II. Pharyngeal endoscopy. Oroscopy.
1. Take the spatula in the left hand so that the thumb supports the spatula
below, and the index and middle (possibly ring) fingers were on top. Right
the hand is placed on the crown of the patient.
2. They ask the patient to open his mouth, with a spatula flatten out alternately the left and
right corners of the mouth and examine the vestibule of the mouth: mucous membrane, excretory
the ducts of the parotid salivary glands, located on the buccal surface at the level
upper premolar.
3. Examine the oral cavity: teeth, gums, hard palate, tongue, excretory ducts
sublingual and submandibular salivary glands, bottom of the mouth. The bottom of the mouth can be
examine by asking the subject to raise the tip of the tongue or lifting it
with a spatula.

MESOPHARYNGOSCOPY
4. Holding a spatula in the left hand, they 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 not pressed flat
a spatula, and its end. When you touch the root of the tongue, emetic immediately occurs
traffic. Determine the mobility and symmetry of the soft palate by asking
the patient pronounce the sound "a". Normally, the soft palate is well mobile, the left and
the right sides are symmetrical.
5. Examine the mucous membrane of the soft palate, its uvula, front and back
palatine arches. Normally, the mucous membrane is smooth, pink, the arches are contoured.
Examine the teeth and gums in order to identify pathological changes.
Determine the size of the palatine tonsils, for this mentally divided into three parts
the distance between the medial edge of the anterior palatine arch and the vertical
a line passing through the middle of the uvula and soft palate. The size of the amygdala
protruding up to 1/3 of this distance, refer to I degree, protruding up to 2/3 - to II
degree; 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, separated in
they are not.
7. Determine the content in the crypts of the tonsils. To do this, take two
a spatula in the right and left hands. Squeeze down with one spatula
tongue, others gently press through the anterior arch on the tonsil
in the area of \u200b\u200bits upper third. On examination of the right tonsil, the tongue
squeeze 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 crypts or it
scanty, non-purulent in the form of minor epithelial plugs.
8. Examine the mucous membrane of the posterior pharyngeal wall. She is normal
pink, moist, even, on its surface are visible rare, size
up to 1 mm, lymphoid granules.

Epipharyngoscopy (Posterior Rhinoscopy)
9. The nasopharyngeal speculum is reinforced in the handle, heated in hot water to 40-45 ° C,
wipe with a napkin.
10. With a spatula, taken in the left hand, press down the front 2/3 of the tongue. Asking the sick
breathe through the nose.
11. The nasopharyngeal speculum is taken in the right hand, like a pen for writing, inserted into the oral cavity,
the mirror surface should be directed upwards. Then they turn on a mirror for a soft
the palate without touching the root of the tongue and the back of the throat. Direct a beam of light from the frontal
reflector to the mirror. With slight turns of the mirror (by 1-2 mm), the nasopharynx is examined
(fig. 1.5).
12. With posterior rhinoscopy, you need to examine: the fornix of the nasopharynx, choanae, the posterior ends of all
conchas, pharyngeal openings of the auditory (Eustachian) tubes. Normal vault of the nasopharynx
in adults, free (there may be a thin layer of the pharyngeal tonsil), mucous
the shell is pink, the choanae are free, the opener of the middle line, the mucous membrane of the posterior
the ends of the turbinates are pink with a smooth surface, the ends of the turbinates are not
protrude from the choanas, the nasal passages are free.

Posterior rhinoscopy (epipharyngoscopy):
a - position of the nasopharyngeal mirror; b - picture of the nasopharynx with posterior rhinoscopy: 1 - opener;
2 - choanas; 3 - posterior ends of the lower, middle and upper nasal concha; 4 - pharyngeal opening
auditory tube; 5 - tongue; 6 - pipe roller

FINGER EXAMINATION
Nasopharyngeal
13. The patient sits, the doctor stands up
behind to the right of the subject.
Left index finger
hands gently press the left
the patient's cheek between the teeth when
open mouth. Indicative
with your right finger quickly
pass behind the soft palate in
nasopharynx and palpate the nasopharynx,
vault of the nasopharynx, side walls
(fig. 1.6). In this case, the pharyngeal
the amygdala feels like an end
back of the index
finger.
Digital examination of the nasopharynx:
a - the position of the doctor and the patient; b - finger position
doctor in the nasopharynx

Stage I. External examination and palpation.
1. Examine the neck, larynx configuration.
2. Palpate the larynx, its cartilage: cricoid, thyroid;
determine the crunch of the cartilage of the larynx: thumb and forefinger
right hand, take the thyroid cartilage and gently shift it into one, and
then to the other side. Normally, the larynx is painless, passive
mobile in the lateral direction.
3. Palpate regional lymph nodes of the larynx:
submandibular, deep cervical, posterior cervical, pre-lingual,
pretracheal, paratracheal, in the supra- and subclavian fossa. IN
normal lymph nodes are not palpable (not palpable).

Stage II. Indirect laryngoscopy (hypopharyngoscopy).
1. The laryngeal mirror is strengthened in the handle, heated in hot water or over an alcohol lamp in
for 3 s to 40-45 ° C, wipe with a napkin. The degree of heating is determined
by applying a mirror to the back of the hand.
2. Ask the patient to open his mouth, stick out his tongue and breathe through the mouth.
3. Wrap the tip of the tongue above and below with a gauze napkin, take it with your left fingers
hands so that the thumb is on the upper surface of the tongue, the middle finger on the lower surface of the tongue, and the index finger lifts the upper lip. Slightly
pull the tongue towards themselves and downward (Fig. 1.7 a, c).
4. The laryngeal mirror is taken in the right hand, like a pen for writing, inserted into the oral cavity
mirror plane parallel to the plane of the tongue, without touching the root of the tongue and the back wall
pharynx. Having reached the soft palate, raise the tongue with the back of the mirror and put
the plane of the mirror at an angle of 45 ° to the median axis of the pharynx, if necessary, you can slightly
raise the soft palate upward, the light beam from the reflector is directed exactly to the mirror
(Fig. 1.7 b). They ask the patient to make lingering sounds "e", "and" (while the epiglottis
will move anteriorly, opening the entrance to the larynx for inspection), then inhale. Thus,
you can see the larynx in two phases of physiological activity: phonation and inspiration.
Correction of the position of the mirror should be done until it reflects
picture of the larynx, however, this is done with great care, very thin small
movements.
5. Remove the mirror from the larynx, separate it from the handle and dipped into a disinfectant solution.

Indirect laryngoscopy (hypopharyngoscopy): a - the position of the laryngeal mirror (front view); b position of the laryngeal mirror (side view); c - indirect laryngoscopy; d - picture of the larynx with indirect
laryngoscopy: 1 - epiglottis; 2 - false vocal folds; 3 - true vocal folds; 4 arytenoid cartilage; 5 - intercarpal space; 6 - pear-shaped pocket; 7 - fossa of the epiglottis; 8
- the root of the tongue; 9 - the scapular laryngeal fold; 10 - the sub-voice cavity (tracheal rings); d - glottis
with indirect laryngoscopy

PICTURE AT INDIRECT LARYNGOSCOPY
1. In the laryngeal mirror, an image is seen that differs from the true one in that
the anterior parts of the larynx in the mirror are at the top (they seem to be behind), the posterior ones are at the bottom
(seem to be in front). Right and left side the larynx in the mirror is true
(do not change).
2. In the laryngeal mirror, the root of the tongue with the lingual
tonsil, then the epiglottis in the form of an expanded petal. Mucous membrane
The epiglottis is usually pale pink or slightly yellowish in color. Between
the epiglottis and the root of the tongue are visible two small depressions - the fossa of the epiglottis
(vallecules), limited by the median and lateral lingual-supraglottic folds.
3. During phonation, vocal folds are visible, normally they are pearlescent white.
The anterior ends of the folds at the place of their departure from the thyroid cartilage form an angle of the anterior commissure.
4. Over vocal folds pink vestibular folds are visible, between
vocal and vestibular folds on each side there are depressions - laryngeal
ventricles, inside which there may be small accumulations of lymphoid tissue - laryngeal
tonsils.
5. Below in the mirror the posterior parts of the larynx are visible; arytenoid cartilage is represented by two
tubercles on the sides of the upper edge of the larynx, are pink with a smooth surface, to
the vocal processes of these cartilages are attached to the posterior ends of the vocal folds, between
the cartilage bodies are the intercranial space.

6. Simultaneously with indirect laryngoscopy, indirect
hypopharyngoscopy, while the following picture is visible in the mirror. From
arytenoid cartilage up to the lower lateral edges of the petal
of the epiglottis there are scaly and laryngeal folds, they are pink
with a smooth surface. Lateral to the scapular-laryngeal folds
pear-shaped pockets (sinuses) are located - the lower part of the pharynx,
the mucous membrane of which is pink, smooth. Tapering downwards
pear-shaped pockets fit into the esophageal pulp.
7. During inhalation and phonation, symmetrical mobility is determined
vocal folds and both halves of the larynx.
8. When inhaling, a triangular shape forms between the vocal folds.
the space called the glottis through it
examine the lower larynx - the podvocal cavity; often
it is possible to see the upper tracheal rings, covered with pink mucous
shell. The size of the glottis in adults is 15-18 mm.
9. Examining the larynx, you should make a general overview and evaluate
the condition of its individual parts.

Stage I. External examination and palpation. The examination begins with a healthy ear.
Inspection and palpation of the auricle, the external opening of the auditory
passage, behind the ear region, in front of the ear canal.
1. To examine the external opening of the right ear canal in adults
need to delay auricle backward and upward, taking a large and
with the index fingers of the left hand behind the curl of the auricle. For viewing on the left
the auricle should be pulled back in the same way with the right hand. In children, ear retraction
the shell is produced not upward, but downward and backward. When pulling back the auricle
in this way there is a displacement of the bone and membranous cartilaginous
parts of the ear canal, which makes it possible to insert the ear funnel to the bone
department. The funnel keeps the ear canal in an erect position, and this
allows you to perform otoscopy.
2. To inspect the behind-the-ear region with the right hand, turn the right auricle
investigated anteriorly. Pay attention to the fold behind the ear (place
attachment of the auricle to the mastoid process), normally it is good
contoured.
3. With the thumb of the right hand, gently press on the tragus. Normal palpation
the tragus is painless, in an adult, soreness with acute external
otitis media, in a young child, such soreness appears with an average.

4. Then with the thumb of the left hand palpate the right
mastoid process at three points: projection of the antrum,
sigmoid sinus, apex of the mastoid process.
On palpation of the left mastoid process, the auricle
pull back with your left hand, and palpate with your right finger
arms.
5. With the index finger of your left hand, palpate the regional
lymph nodes of the right ear anteriorly, downward, posteriorly
external auditory canal.
With the index finger of your right hand, palpate in the same way
lymph nodes of the left ear. Normal lymph nodes are not
palpable.

Otoscopy.
1. Select a funnel with a diameter corresponding to the transverse diameter
external auditory canal.
2. Pull the patient's right auricle backward and upward with the left hand.
With the thumb and forefinger of the right hand, insert the ear funnel into
the membranous cartilaginous part of the external auditory canal.
When examining the left ear, pull the auricle with your right hand, and
enter with the fingers of your left hand.
3. The ear funnel is inserted into the membranous-cartilaginous part of the ear canal
to keep it in a straightened position (after pulling the ear
shells upward and backward in adults), the funnel cannot be inserted into the bone
ear canal as it causes pain. The funnel is long
its axis must coincide with the axis of the ear canal, otherwise the funnel will rest against
its wall.
4. Make light movements of the outer end of the funnel in order to
inspect all departments sequentially tympanic membrane.
5. With the introduction of a funnel, there may be a cough, depending on irritation
ends of branches vagus nerve in the skin of the ear canal.

Otoscopic picture.
1. When otoscopy shows that the skin of the membranous-cartilaginous region has hair, here
earwax is usually present. The length of the external auditory canal is 2.5 cm.
2. The eardrum is gray with a pearlescent tint.
3. Identification points are visible on the tympanic membrane: short (lateral)
process and handle of malleus, anterior and posterior malleus folds, light cone
(reflex), the navel of the tympanic membrane (Fig. 1.8).
4. Below the anterior and posterior malleus folds, the stretched part of the tympanic
membranes, above these folds - the loose part.
5. On the eardrum, 4 quadrants are distinguished, which are obtained from the mental
drawing two lines, mutually perpendicular. One line is drawn along the handle
hammer down, the other - perpendicular to it through the center (umbilical) of the tympanic membrane and
the lower end of the hammer handle. The resulting quadrants are called:
anteroposterior and posterior superior, anteroposterior and posterior inferior.

Tympanic membrane diagram:
I - anteroposterior quadrant;
II - anteroinferior quadrant;
III - posterior lower quadrant;
IV - posterior superior quadrant

Function study auditory tubes... Study of the ventilation function of the auditory
pipe is based on blowing a pipe and listening to the sounds passing through it
air. For this purpose, a special elastic (rubber) tube with ear
inserts at both ends (otoscope), a rubber bulb with an olive at the end (balloon
Politzer), a set of ear catheters of various sizes - from number 1 to number 6.
5 ways of blowing the auditory tube are performed in sequence. Opportunity
performing this or that method allows you to determine the I, II, III, IV or V degree
permeability of the pipe. When examining, one end of the otoscope is placed in
external auditory canal of the subject, the second - of the doctor. The doctor listens through the otoscope
the noise of air passing through the auditory tube.
The test with an empty throat allows you to determine the patency of the auditory tube when
swallowing. When opening the lumen of the auditory tube, the doctor
hears a characteristic slight noise or crackling through the otoscope.
Toynbee's way. This is also a swallowing movement, however, performed by the subject at
closed mouth and nose. When performing the study, if the pipe is passable, the patient
feels a push in the ears, and the doctor hears a characteristic sound of air passing.
Valsalva way. The examinee is asked to take a deep breath, and then
increased expiration (inflation) with a tightly closed mouth and nose. Under pressure
of exhaled air, the auditory tubes open and air enters with force
the tympanic cavity, which is accompanied by a slight crackling, which feels
the subject, and the doctor listens to the characteristic noise through the otoscope. In case of violation
the patency of the auditory tube, the Valsalva experiment fails.

Olive ear balloon is injected on the eve of the nasal cavity
on the right and hold it with II finger of the left hand, and I
press the left wing of the nose to the septum with a finger
nose. Insert one olive of the otoscope into the external auditory
passage of the patient, and the second - into the ear of the doctor and ask the patient
pronounce the words "steamer", "one, two, three." In the moment
pronouncing a vowel squeeze the balloon with four
fingers of the right hand, while the I finger serves as a support. IN
blowing moment when pronouncing a vowel sound
the soft palate deviates posteriorly and separates the nasopharynx.
Air enters the closed cavity of the nasopharynx and
evenly presses on all walls; part of the air with
force passes into the pharyngeal openings of the auditory tubes, which
determined by the characteristic sound heard
through the otoscope. Then in the same way, but only after
the left half of the nose, blowing is performed, along
To the politician, left auditory tube.
Blowing out the auditory tubes, according to Politzer

Stage III. Radiological diagnostic methods.
Radiography is widely used to diagnose ear diseases
temporal bones; the most common are three
special styling: according to Schüller, Mayer and Stenvers. Wherein
radiographs of both temporal bones are performed at once. The main
a condition for traditional radiography of the temporal bones is
symmetry of the image, the absence of which leads to
diagnostic errors.
Lateral plain radiography of the temporal bones, according to Schüller
, allows you to identify the structure of the mastoid process. On
radiographs clearly visible the cave and perianthral cells,
clearly defined roof tympanic cavity and front wall
sigmoid sinus. From these pictures you can judge the degree
pneumatization of the mastoid process, characteristic of
mastoiditis destruction of bone bridges between cells.

The axial projection, according to Mayer, allows more clearly than in the projection according to
Schüller, remove the bony walls of the external auditory canal,
erythematosus and mastoid cells. Expansion
atticoantral cavity with clear boundaries indicates the presence
cholesteatoma.
Oblique projection, according to Stenvers, is used to display the top of the pyramid,
labyrinth and internal auditory canal. What matters most is
the ability to assess the state of the internal auditory canal. When
the diagnosis of neuroma of the vestibular cochlear (VIII) nerve is assessed
symmetry of the internal auditory canals, subject to identity
laying the right and left ear. Styling is informative also in diagnostics
transverse fractures of the pyramid, which is most often one of
manifestations of a longitudinal fracture of the base of the skull.
Clearer structure temporal bone and ear are visualized when
using CT and MRI.
Computed tomography (CT). It is performed in the axial and frontal
projections with a slice thickness of 1-2 mm. CT allows

Plain radiograph of the temporal bones
in Schüller styling:
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 - the front surface of the pyramid

Plain radiograph of the temporal
bones in packing, according to Mayer:
1 - cells of the mastoid process;
2 - antrum;
3 - the front wall of the ear canal;
4 - temporomandibular joint;
5 - internal auditory canal;
6 - the core of the labyrinth;
7 - sine border;
8 - apex of the mastoid process

Temporal radiograph
bones in packing, by
Stenvers:
1 - internal auditory
passage;
2 - auditory ossicles;
3 - mastoid cells

Computed tomogram
temporal bone is normal

Depending on the tasks facing the doctor, the volume
the studies performed may vary. Information
hearing is necessary not only for diagnosis
ear diseases and solving the question of the method of conservative and
surgical treatment, but also with professional selection,
selection hearing aid... It is very important
examination of hearing in children in order to identify early impairments
hearing.

Research of hearing with the help of speech. After identifying complaints and
collecting anamnesis, a speech hearing test is performed,
determine the perception of whispered and spoken speech.
The patient is placed at a distance of 6 m from the doctor; test ear
should be directed towards the doctor, and the opposite
the assistant closes by tightly pressing the tragus to the hole
the external auditory canal II finger, while the III finger is slightly
rubs II, which creates a rustling sound that drowns out this ear,
excluding rehearing

The examinee is explained that he should loudly repeat
heard words. To exclude lip reading, the patient should not
look towards the doctor. In a whisper, using the air left in
lungs after an unforced expiration, the doctor pronounces words with
low sounds (number, burrow, sea, tree, grass, window, etc.), then
words with high sounds are treble (thicket, already, cabbage soup, hare, etc.).
Patients with lesions of the sound-conducting apparatus (conductive
hearing loss) hear low sounds worse. On the contrary, in case of violation
sound perception (sensorineural hearing loss) hearing impairment
high sounds.
If the examinee cannot hear from a distance of 6 m, the doctor shortens
distance 1 m and re-examines hearing. This procedure is repeated until
until the subject hears all the spoken words.
Normally, when studying the perception of whispering speech, a person hears
low sounds from a distance of at least 6 m, and high sounds - 20 m.
The study of colloquial speech is carried out according to the same rules.
The results of the study are recorded in the auditory passport.

Tuning forks is the next step in hearing assessment.
Study of air conductivity. For this, tuning forks are used.
C128 and C2048. The study begins with a low-frequency tuning fork
Holding the tuning fork by the leg with two fingers,
a blow of the jaws on the tenor of the palm makes him hesitate. Tuning fork C2048
oscillate by abrupt squeezing of the jaws with two fingers
or by the flick of 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 make
oscillations in the plane of the axis of the ear canal. Starting the countdown from
the moment the tuning fork is struck, the time is measured with a stopwatch, during
which the patient hears its sound. After the subject stops
hear the sound, the tuning fork is moved away from the ear and again brought closer, without exciting
it again. As a rule, after such a distance from the tuning fork's ear, the patient
hears a sound for a few more seconds. The final time is marked on
the last answer. Similarly, the study is carried out with the C2048 tuning fork,
determine the duration of the perception of its sound through the air.

Bone conduction study. Bone conduction is examined
tuning fork С128. This is due to the fact that the vibration of tuning forks with more
low frequency is felt by the skin, and tuning forks with a higher
frequency is heard through the air by the ear.
The sounding tuning fork C128 is placed perpendicular to the leg on the platform
mastoid process. Perception duration is also measured
stopwatch, counting down the time from the moment of excitement
tuning fork.
If sound conduction is impaired (conductive hearing loss) worsens
air perception of a low-sounding tuning fork C128; at
the study of bone conduction, the sound is heard longer.
Violation of air perception of a high tuning fork C2048
accompanied mainly by the defeat of the sound-perceiving
apparatus (sensorineural hearing loss). Decreases proportionally
and the duration of C2048 sounding through air and bone, although the ratio
these indicators remain, as in the norm, 2: 1.

Quality tuning fork tests are performed with the aim of
differential express diagnosis of lesion
sound-conducting or sound-perceiving departments of the auditory
analyzer. For this, experiments are carried out by Rinne, Weber, Zhelle,
Federice, when performing them, use the C128 tuning fork.
Rinne's experience Compares the duration of the air and
bone conduction. The sounding tuning fork C128 is attached with a foot to
site of the mastoid process. After cessation of sound perception
on the bone, the tuning fork, without exciting, is brought to the external auditory
aisle. If the subject continues to hear the sound through the air
tuning fork, Rinne's experience is regarded as positive (R +). Therein
if the patient, after the sound of the tuning fork stops,
the mastoid process does not hear it and at the external auditory canal,
Rinne's experience is negative (R-).

With a positive Rinne experience, the air conductivity of sound in
1.5-2 times higher than bone, with negative - on the contrary.
Rinne's positive experience is normal, negative
- in case of damage to the sound-conducting apparatus, i.e. at
conductive hearing loss.
If the sound-receiving apparatus is damaged (i.e.
sensorineural hearing loss) conducting sounds through the air, as in
normal, prevails over bone conduction. However, at the same time
the duration of the perception of a sounding tuning fork as if it were airborne,
and bone conduction is less than normal, therefore
Rinne's experience remains positive.

Weber's experience (W). It can be used to assess the lateralization of sound.
The sounding tuning fork C128 is attached to the crown of the subject's head to
the leg was in the middle of the head (see Fig. 1.15 a). Branches
tuning forks must oscillate in the frontal plane. IN
normally, the examinee hears the sound of a tuning fork in the middle of the head or
equally in both ears (normal<- W ->). With one-sided
damage to the sound-conducting apparatus, the sound is lateralized in
affected ear (for example, to the left W -\u003e), with unilateral lesion
sound receiving apparatus (for example, on the left) sound
lateralized into the healthy ear (in this case - to the right<При двусторонней кондуктивной тугоухости звук будет латерализоваться
towards the worse hearing ear, with bilateral sensorineural - in
side of the better hearing ear.

Jelle's experiment (G). The method allows you to detect a violation of sound conduction associated with
the immobility of the stirrup in the window of the vestibule. This type of pathology is observed in
in particular, with otosclerosis.
The sounding tuning fork is attached to the crown and at the same time pneumatic
funnel thicken the air in the external auditory canal (see Fig. 1.15 b). In the moment
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
pressing the stapes into the niche of the vestibule window - Zelle's experience is positive (G +).
With the immobility of the stapes, no change in perception at the moment of thickening
air in the external auditory canal will not occur - Zhelle's experience is negative
(G-).
Federici's experience (F). It consists in comparing the duration of the perception of the sound
tuning fork C128 from the mastoid process and tragus with obturation of the external
ear canal. After the cessation of sounding on the mastoid process, the tuning fork
placed with a leg on a tragus.
In norm and in case 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 - negative (F-).
Thus, Federici's experience, along with other tests, allows
differentiate conductive and sensorineural hearing loss.

The use of electro-acoustic equipment allows you to dose
the strength of the sound stimulus in generally accepted units - decibels
(dB), conduct a hearing test in patients with severe
hearing loss, use diagnostic tests.
The audiometer is an electrical sound generator that allows
deliver relatively clean sounds (tones) both through the air and through
bone. A clinical audiometer examines the hearing thresholds in the range
from 125 to 8000 Hz. Nowadays there are audiometers,
allowing to examine hearing in an extended frequency range - up to 18
000-20,000 Hz. With their help, audiometry is performed in extended
frequency range up to 20,000 Hz over the air. Through transformation
attenuator, the supplied sound signal can be amplified up to 100-120
dB when examining air and up to 60 dB when examining bone
conductivity. The volume is usually adjusted in steps of 5 dB, in
some audiometers - in more fractional steps, starting from 1 dB.

From a psychophysiological point of view, various
audiometric methods are divided into subjective and objective.
Subjective audiometric techniques find the widest
application in clinical practice. They are based on
subjective feelings of the patient and on the conscious, depending on his
will, response. Objective, or reflex, audiometry
based on reflex unconditioned and conditioned response
reactions of the subject, arising in the body with sound
influence and not dependent on his will.
Taking into account what stimulus is used in the study
sound analyzer, distinguish between such subjective methods as
tonal threshold and suprathreshold audiometry, research method
auditory sensitivity to ultrasound, speech audiometry.

Tonal audiometry is threshold and suprathreshold.
Tonal threshold audiometry is performed to determine thresholds
perception of sounds of various frequencies during air and bone conduction.
By means of air and bone telephones, the threshold is determined
the sensitivity of the hearing organ to the perception of sounds of different frequencies. results
studies are entered on a special grid form, called
"audiogram".
The audiogram is a graphical representation of the threshold hearing. Audiometer
is designed to show hearing loss in decibels compared to
the norm. Normal hearing thresholds for sounds of all frequencies, both airborne and
bone conduction lines are marked with a zero line. Thus, the tonal
threshold audiogram primarily makes it possible to determine the acuity of hearing.
By the nature of the threshold curves of air and bone conduction and their
the relationship can be obtained and a qualitative characteristic of the patient's hearing, i.e.
establish whether there is a violation of sound conduction, sound perception or
mixed (combined) defeat.

If sound conduction is disturbed, an increase is noted on the audiogram.
hearing thresholds for air conduction mainly in the range
low and medium frequencies and to a lesser extent - high. Hearing thresholds by
bone conduction remains close to normal, between the threshold
curves of bone and air conduction there is a significant
called a bone-air gap (cochlear reserve).
In case of impaired sound perception, air and bone conduction
suffer equally, bone-air gap is almost
absent. In the initial stages, predominantly perception suffers
high tones, and later this is a violation
manifests itself at all frequencies; the breaks of the threshold curves are noted, i.e.
lack of perception at certain frequencies
Mixed, or combined, hearing loss is characterized by the presence of
audiogram of signs of impaired sound conduction and sound perception, but
there is a bone-air gap between them.

Violation audiogram
sound conduction:
a - conductive form of hearing loss;
b - sensorineural form of hearing loss;
c - mixed form of hearing loss

Tonal suprathreshold audiometry. Designed to identify
the phenomenon of accelerated increase in loudness (FUNG - in the 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 intraulitic (cochlear) lesion
auditory analyzer.
A patient with hearing loss develops increased
sensitivity to loud (above-threshold) sounds. He notes unpleasant
sensations in a sore ear if they speak loudly or sharply
enhance the voice. FUNG can be suspected in clinical
examination. It is evidenced by the patient's complaints of intolerance
loud sounds, especially with a sore ear, the presence of dissociation between
perception of whispered and colloquial speech. The patient's whispering speech completely
does not perceive or perceives at the sink, whereas spoken
hears at a distance of more than 2 m.
change or sudden disappearance of the lateralization of sound, with
a tuning fork suddenly stops hearing
tuning fork while slowly moving it away from the diseased ear.

Methods of suprathreshold audiometry (there are more than 30 of them) allow direct or
indirectly detect FUNG. The most common among them
are the classic methods: Luscher - definition
differential threshold of perception of sound intensity,
volume equalization according to Fowler (with unilateral hearing loss),
index of small increases in intensity (IMPI, often denoted
as SISI test). Normal differential threshold of sound intensity
is 0.8-1 dB, the presence of FUNG is evidenced by its decrease below
0.7 dB.
Study of auditory sensitivity to ultrasound. Fine
a person perceives ultrasound during bone conduction in the range
frequencies up to 20 kHz and more. If the hearing loss is not associated with a lesion
snails (neurinoma of the VIII cranial nerve, brain tumors, etc.),
the perception of ultrasound remains the same as normal. When
damage to the cochlea increases the threshold of ultrasound perception.

Speech audiometry, in contrast to tone, allows you to determine
social suitability of hearing in a given patient. Method is
especially valuable in the diagnosis of central hearing lesions.
Speech audiometry is based on the definition of intelligibility thresholds
speech. Legibility is understood as a quantity defined as
the ratio of the number of correctly understood words to the total number
listened to, express it as a percentage. So, if out of 10
the patient heard the words presented for listening correctly
all 10, it will be 100% intelligibility if correctly parsed 8, 5 or
2 words, this will be respectively 80, 50 or 20% intelligibility.
The study is carried out in a soundproof room. results
studies are recorded on special forms in the form of curves
intelligibility of speech, while on the abscissa the intensity
speech, and on the ordinate - the percentage of correct answers. Curves
intelligibility are excellent for various forms of hearing loss, which has
differential diagnostic value.

Objective audiometry. Objective methods of hearing research
based on unconditioned and conditioned reflexes. Such research has
value for assessing the state of hearing with damage to the central departments
sound analyzer, when conducting labor and forensic
expertise. With a strong sudden sound, unconditioned reflexes
are reactions in the form of dilated pupils (cochlear-pupillary reflex,
or auropupillary), closing the eyelids (auropalpebral, blinking
reflex).
Most often, galvanic skin is used for objective audiometry.
and vascular reactions. The galvanic skin reflex is expressed in
change in the potential difference between two areas of the skin under
the influence, in particular, of sound irritation. Vascular reaction
consists in a change in vascular tone in response to sound stimulation, which
recorded, for example, using plethysmography.
In young children, the reaction is most often recorded when playing
audiometry, combining sound stimulation with the appearance of a picture in
the moment the child presses the button. Initially loud sounds
are replaced by quieter ones and the auditory thresholds are determined.

The most modern method of objective hearing research is
audiometry with registration of auditory evoked potentials (SVP). Method based
on registration of sound signals evoked in the cerebral cortex
potentials on the electroencephalogram (EEG). It can be used in children
infants and young people, mentally disabled persons and persons with normal
psyche. Since the EEG responses to sound signals (usually short - up to 1 ms,
called sound clicks) are very small - less than 1 μV, for their registration
use averaging using a computer.
More widely used the registration of short-latency auditory evoked
potentials (KSVP), giving an idea of \u200b\u200bthe state of individual formations
subcortical pathway of the auditory analyzer (vestibular cochlear nerve, cochlear
nuclei, olives, lateral loop, hillocks). But ABRs do not give any complete idea of \u200b\u200bthe response to a stimulus of a certain frequency, since
the stimulus itself should be short. In this regard, more informative
long-latency auditory evoked potentials (LEP). They register
responses of the cerebral cortex to relatively long-term, i.e. having a certain
frequency of sound signals and they can be used to induce auditory
sensitivity at different frequencies. This is especially important in children's practice when
conventional audiometry based on the patient's informed responses is not applicable.

Impedance audiometry is one of the methods of objective assessment
hearing based on acoustic impedance measurement
sound-conducting apparatus. In clinical practice, use
two types of acoustic impedance measurement - tympanometry and
acoustic reflexometry.
Tympanometry consists in recording acoustic
resistance that a sound wave meets at
propagation through the speaker system of outdoor, middle and
inner ear, when the air pressure in the outer
the ear canal (usually from +200 to -400 mm water column). Curve,
reflecting the dependence of the resistance of the tympanic membrane
from pressure, received the name tympanogram. different types
tympanometric curves reflect normal or
pathological condition of the middle ear.

Acoustic reflexometry is based on registration of changes
compliance of the sound-conducting system occurring when
contraction of the stapes muscle. Induced by sound stimulus
nerve impulses along the auditory pathways reach the upper olive
nuclei, where they switch to the motor nucleus of the facial nerve and go to
stapes muscle. Muscle contraction occurs on both sides. IN
external auditory canal, a sensor is inserted that reacts to
change in pressure (volume). In response to sound stimulation
an impulse is generated that passes through the above-described reflex
arc, as a result of which the stapes muscle contracts and comes in
movement of the eardrum, pressure (volume) changes in
external auditory canal, which is recorded by the sensor. Normal threshold
acoustic reflex of the stirrup is about 80 dB above
individual threshold of sensitivity. With neurosensory
hearing loss accompanied by FUNG, reflex thresholds are significantly
decline. With conductive hearing loss, pathology of the nuclei or trunk
of the facial nerve, the acoustic reflex of the stirrup is absent on the side
defeat. For differential diagnosis of retrolabyrinth
damage to the auditory tract, decay test is of great importance
acoustic reflex.

Types of tympanometric curves (according to Serger):
a - normal;
b - with exudative otitis media;
c - when the chain of the auditory ossicles is broken

The examination of the patient always begins with clarification of complaints and
anamnesis of life and disease. The most common complaints
dizziness, balance disorder, manifested
violation of gait and coordination, nausea, vomiting,
fainting, sweating, discoloration of the skin
covers, etc. These complaints may be persistent or
manifest itself periodically, have a fleeting nature or
last for hours or days. They can occur
spontaneously, for no apparent reason, or under the influence
specific factors of the environment and the body: in transport,
surrounded by moving objects, with overwork,
motor load, a certain position of the head, etc.

Vestibulometry includes the identification of spontaneous symptoms,
conducting and evaluating vestibular tests, analysis and generalization
received data. Spontaneous vestibular symptoms
include spontaneous nystagmus, changes in muscle tone of the limbs,
violation of gait.
Spontaneous nystagmus. The patient is examined in a sitting position or in
supine position, with the subject watching the finger
a doctor at a distance of 60 cm from the eyes; finger moves
sequentially in horizontal, vertical and diagonal
planes. Eye abduction should not exceed 40-45 °, since
overexertion of the eye muscles may be accompanied by twitching
eyeballs. When observing nystagmus, it is advisable to use
high magnification glasses (+20 diopters) to eliminate the influence
fixation of gaze. Otorhinolaryngologists use for this purpose
special glasses of Frenzel or Bartels; even more clearly
spontaneous nystagmus is detected with electronystagmography.

When examining the patient in the supine position, the head and
the body is given a different position, while in some
patients observe the appearance of nystagmus, designated as
positional nystagmus (position nystagmus). Positional nystagmus
may have a central genesis, in some cases it is associated with
dysfunction of otolith receptors, from which they break off
the smallest particles and get into the ampullae of the semicircular canals with
pathological impulses from cervical receptors.
In the clinic, nystagmus is characterized along the plane (horizontal,
sagittal, rotatory), in the direction (right, left, up,
down), by strength (I, II or III degree), by the speed of oscillatory cycles
(lively, sluggish), in amplitude (small, medium or large-spreading),
by rhythm (rhythmic or dysrhythmic), by duration (in seconds).

According to the strength, nystagmus is considered grade I if it occurs only with
looking towards the fast component; II degree - when looking not
only towards the fast component, but also straight ahead; finally,
nystagmus III degree is observed not only in the first two
positions of the eyes, but also when looking towards the slow
component. Vestibular nystagmus usually does not change.
directions, i.e. in any position of the eyes its fast component
directed in the same direction. About extra-labyrinth
(central) origin of nystagmus is evidenced by its
undulating character, when fast and
slow phase. Vertical, diagonal,
multidirectional (changing direction when looking in
different sides), converging, monocular,
asymmetrical (unequal for both eyes) nystagmus
characteristic of disorders of central genesis.

Tonic reactions of hand deviation. They are investigated at
performing index tests (finger, finger), Fischer-Vodak test.
Indicative tests. When performing a finger test
the subject spreads his arms to the sides and first with open, and
then, with his eyes closed, tries to touch the index
fingers of one and then the other hand to the tip of your nose. When
the normal state of the vestibular analyzer is without
difficulty completes the task. Irritation of one of
labyrinths leads to a miss with both hands in
the opposite side (towards the slow component
nystagmus). When the lesion is localized in the posterior cranial fossa
(for example, with pathology of the cerebellum) the patient misses
with one hand (on the side of the disease) to the "sick" side.

With a finger-finger test, the patient alternates with the right and left hand
should get your index finger into the doctor's index finger,
located in front of him at arm's length. Try
performed first with open, then closed eyes. Fine
the test subject confidently hits the doctor's finger with both hands, as with
open or closed eyes.
Fischer-Vodak test. Performed by the test subject sitting with closed
eyes and with arms outstretched. The index fingers are extended
the rest are clenched into a fist. The doctor positions his index fingers
opposite the patient's index fingers and in the immediate
proximity to them and observes the deviation of the test subject's hands. Have
a healthy person does not observe deviations of the hands;
maze, both arms are deflected towards the slow component
nystagmus (i.e. towards that labyrinth, the impulses from which
reduced).

Study of stability in the Romberg position. The subject is standing
bringing the feet closer so that their toes and heels touch, hands
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