📋 Key Information Summary
- Visual acuity is the single most important ophthalmological test — always assess with a Snellen chart (or pinhole if reduced) before any other eye examination.
- Pupil reactions — test for direct, consensual, and relative afferent pupillary defect (RAPD/Marcus Gunn pupil) using the swinging torch test; a RAPD indicates optic nerve pathology.
- Visual fields — use the confrontation method; map defects to specific anatomical lesions (e.g., bitemporal hemianopia = chiasmal compression).
- Extraocular movements — assess all six cardinal directions and convergence; a painful, restricted up-and-in gaze suggests a CN III palsy.
- Fundoscopy — systematically examine: red reflex → optic disc → vessels → macula → periphery; dilated fundoscopy is essential for screening diabetic retinopathy.
- Papilloedema vs papillitis — papilloedema is bilateral, painless, with preserved vision (raised intracranial pressure); papillitis is usually unilateral with painful vision loss (optic neuritis).
- Otoscopy — identify the tympanic membrane landmarks (umbo, light cone, malleus); pneumatic otoscopy assesses TM mobility and is essential for diagnosing otitis media with effusion.
- Rinne & Weber tests — Weber lateralises to the affected ear in conductive loss and to the normal ear in sensorineural loss; Rinne confirms by comparing air vs bone conduction.
- Throat examination — always assess CN IX, X, XII; ask the patient to say "aah" and observe uvular deviation (away from the side of a CN X lesion).
- Horner's syndrome triad of ptosis, miosis, and anhidrosis results from disruption of the oculosympathetic pathway; differentiate central, pre-ganglionic, and post-ganglionic causes.
- Caution: Never perform fundoscopy through a contact lens; always remove it first. In suspected raised ICP, do NOT perform pneumatic otoscopy.
- ATSI consideration: Aboriginal and Torres Strait Islander Australians have significantly higher rates of otitis media and trachoma; examination techniques should be culturally sensitive.
Introduction & Overview
Examination of the ears, eyes, nose, and throat (EENT) forms a core component of the comprehensive clinical examination in Australian medical practice. These structures are intimately connected via the cranial nerves (CN II–XII) and share embryological, vascular, and lymphatic pathways. A systematic EENT examination detects pathology ranging from benign conditions (e.g., serous otitis media, allergic rhinitis) to life-threatening emergencies (e.g., papilloedema from raised intracranial pressure, Horner's syndrome from carotid dissection or apical lung malignancy).
In Australia, eye and ear diseases carry a disproportionate burden among Aboriginal and Torres Strait Islander communities. Trachoma remains endemic in some remote Central Australian communities, and chronic suppurative otitis media affects Indigenous children at 5–10 times the rate of non-Indigenous children (AIHW, 2023). The RACGP's Guidelines for Preventive Activities in General Practice (Red Book) recommends routine EENT screening at all ages, with particular attention to those at risk.
This article provides a structured approach to the EENT examination, covering the techniques, normal findings, abnormal findings, and their clinical significance relevant to Australian practice. Mastery of these examination skills enables clinicians to detect serious intracranial, vascular, and neoplastic pathology through bedside assessment.
Essential equipment for EENT examination: Snellen chart (or pocket vision card), Ishihara plates, pen torch, ophthalmoscope, otoscope with pneumatic attachment, tongue depressor, tuning forks (512 Hz preferred), cotton wisp, neurotip, and measuring ruler.
Eye Examination
The eye examination is structured in a logical sequence: visual acuity → visual fields → pupil reactions → external inspection → extraocular movements → (then fundoscopy — covered in the next section). Always assess visual acuity first, as it is the most important single test in ophthalmology and provides a baseline for all subsequent findings.
Visual Acuity
Visual acuity measures the resolving power of the fovea and the integrity of the entire visual pathway. It must be tested in every eye examination.
1
Prepare
Ensure adequate room lighting. Use a standard Snellen chart at 6 metres (or a projected chart). Provide appropriate refractive correction if the patient wears glasses.
2
Test each eye separately
Cover the non-tested eye with an opaque occluder (not the patient's fingers — light leaks through). Ask the patient to read the smallest line possible.
3
Record correctly
Record as "distance acuity / chart distance." A patient reading the 6/6 line at 6 m is recorded as 6/6. If they can only read the 6/60 line, record 6/60. Count fingers (CF), hand movements (HM), perception of light (PL), and no perception of light (NPL) are used for sub-Snellen acuities.
4
Pinhole test
If acuity is reduced, repeat through a pinhole occluder. Improvement with pinhole indicates a refractive error; no improvement suggests pathology (cataract, retinal, or optic nerve disease).
5
Near acuity (if needed)
Use a near-reading card (Jaeger chart) at 30–40 cm to assess near vision, particularly for presbyopia assessment in patients over 40 years.
Common Snellen equivalents in Australia: 6/6 = normal; 6/9 = mild impairment; 6/12 = legal driving standard in most Australian states (corrected); 6/18 = moderate impairment; 6/36 = severe impairment; 6/60 = legally blind (if best corrected).
Visual Fields — Confrontation Testing
Confrontation testing screens for visual field defects. It maps each eye's field to detect lesions along the visual pathway from retina to visual cortex.
1
Position
Sit approximately 1 metre from the patient. Each eye is tested separately. The examiner closes or covers their own eye corresponding to the patient's open eye (i.e., right eye to right eye).
2
Finger counting
Test each quadrant by presenting 1, 2, or 3 fingers randomly. The patient should count them. Test the four quadrants (superior-temporal, superior-nasal, inferior-temporal, inferior-nasal).
3
Red desaturation
Use a red hat pin or red target. Compare the intensity and colour of red between the two eyes and across quadrants. Desaturation (appears pink/grey) indicates optic nerve dysfunction.
4
Map the defect
Correlate the field defect with the anatomical lesion.
| Field Defect | Location of Lesion | Common Causes |
|---|---|---|
| Monocular vision loss | Optic nerve (ipsilateral) or retina | Optic neuritis, central retinal artery/vein occlusion |
| Bitemporal hemianopia | Optic chiasm | Pituitary macroadenoma, craniopharyngioma |
| Homonymous hemianopia | Contralateral optic tract or radiation | Stroke (MCA territory), tumour |
| Homonymous quadrantanopia | Temporal or parietal lobe radiation | Stroke, temporal lobe epilepsy (superior = Meyer's loop) |
| Homonymous hemianopia with macular sparing | Occipital cortex (visual cortex) | Posterior cerebral artery stroke |
| Centrocaecal scotoma | Optic nerve | Optic neuritis, nutritional deficiency (B12), toxic (methanol, tobacco–alcohol amblyopia) |
Pupil Reactions
Pupillary assessment evaluates the afferent (CN II) and efferent (CN III, sympathetic) pathways. Always assess in a dimly lit room.
1
Inspect resting pupils
Note size (in mm using a pupil gauge), shape (round, irregular, keyhole), symmetry, and any anisocoria (size difference >1 mm is abnormal).
2
Direct response
Shine a bright light into one eye. The illuminated pupil should constrict (direct response). Test the other eye.
3
Consensual response
When shining light into one eye, observe the opposite pupil — it should also constrict (consensual response via the Edinger–Westphal nucleus).
4
Swinging torch test (RAPD)
Swing a light rapidly between both eyes, dwelling for 2–3 seconds on each. In a relative afferent pupillary defect (RAPD), the affected pupil paradoxically dilates when light swings onto it. This is pathognomonic of significant optic nerve dysfunction.
5
Accommodation
Ask the patient to focus on a distant object, then shift gaze to a near target (your finger at 10 cm). Normal response = pupil constriction with convergence. Loss of accommodation with preserved light reflex = Argyll Robertson pupil (neurosyphilis).
Emergent pupil findings: A unilateral, fixed, dilated pupil in a comatose patient suggests CN III compression (posterior communicating artery aneurysm herniation) — this is a neurosurgical emergency. Bilateral fixed dilated pupils indicate severe brainstem injury or drug effects (e.g., atropine, mydriatics).
External Eye Inspection
Systematic external inspection detects anterior segment and adnexal pathology.
- Lids and lashes: Inspect for ptosis (margin–reflex distance), entropion, ectropion, blepharitis (crusting at lid margin), chalazion, hordeolum (stye), and lid lag (thyroid eye disease).
- Conjunctiva: Evert the lower lid to inspect the palpebral conjunctiva for papillae (allergic), follicles (viral/infectious), subconjunctival haemorrhage, and jaundice. Inspect the bulbar conjunctiva for injection (ciliary vs peripheral).
- Sclera: Look for blue sclerae (osteogenesis imperfecta), scleral icterus (jaundice), and scleritis (deep, violaceous injection).
- Cornea: Inspect clarity, surface regularity, and presence of foreign bodies. Use fluorescein staining with a blue light (cobalt blue filter) to detect corneal abrasions, ulcers, or dendritic lesions (herpes simplex keratitis).
- Anterior chamber: Assess depth (shallow in narrow-angle glaucoma risk), clarity (cells and flare in anterior uveitis), and hyphaema (layered blood — trauma).
- Iris: Note colour, irregularity (traumatic mydriasis, synechiae), and coloboma.
- Lens: Observe for cataracts (leukocoria — white reflex — may indicate cataract or retinoblastoma in children).
Extraocular Movements
Extraocular movement testing assesses CN III (oculomotor), CN IV (trochlear), and CN VI (abducens) and their integration in the brainstem gaze centres.
1
Test the six cardinal directions
Ask the patient to follow your finger without moving their head. Test all six directions of gaze — up-right, right, down-right, up-left, left, down-left — plus convergence.
2
Identify diplopia
If the patient reports double vision, cover one eye and ask which image disappears. The image that disappears corresponds to the affected eye. The diplopia is worst in the direction of action of the paralysed muscle.
3
Test convergence
Ask the patient to follow your finger towards their nose. Normal convergence allows the eyes to converge to approximately 5–8 cm from the nose. Failure indicates midbrain pathology or Parkinson's disease.
| Nerve | Muscle | Action | Palsy Finding | Common Causes |
|---|---|---|---|---|
| CN III (Oculomotor) | Superior rectus, inferior rectus, medial rectus, inferior oblique, levator palpebrae | Up, down, in; lid elevation; pupil constriction | "Down and out" eye, ptosis, fixed dilated pupil | PCOM aneurysm, diabetes (pupil-sparing), tumour |
| CN IV (Trochlear) | Superior oblique | Intorsion, depression in adduction | Difficulty looking down and in; head tilt away from affected side | Trauma (longest intracranial nerve), microvascular |
| CN VI (Abducens) | Lateral rectus | Abduction | Inability to abduct the eye; convergent squint at rest | Raised ICP (false localising sign), diabetes, cavernous sinus pathology |
Clinical pearl — CN III palsy pupil involvement: A CN III palsy with pupil involvement (dilated, poorly reactive pupil) is a compressive cause (e.g., posterior communicating artery aneurysm) until proven otherwise — urgent CT angiography is required. A CN III palsy without pupil involvement is more likely ischaemic (diabetes, hypertension) and can be managed conservatively.
Fundoscopy
Fundoscopy (ophthalmoscopy) allows direct visualisation of the retina, optic disc, retinal vasculature, and macula. It is the only clinical examination that permits non-invasive visualisation of the central nervous system vasculature in vivo. In Australian general practice, fundoscopy is a mandatory component of the diabetic annual cycle of care (MBS item 721 equivalent review) and is recommended for assessment of hypertension, headache, and neurological presentations.
Technique — Direct Ophthalmoscopy
1
Prepare
Dim the room lights. Select a large, round white light spot with no filter. Set the ophthalmoscope dioptre to 0 (or the patient's refractive correction if known). Ask the patient to remove spectacles (the examiner may keep theirs on if needed).
2
Check the red reflex
From arm's length (~50 cm), observe the red reflex through the pupil. An absent or abnormal red reflex may indicate cataract, vitreous haemorrhage, or retinoblastoma (in children).
3
Approach the eye
For the RIGHT eye, hold the ophthalmoscope in your RIGHT hand and use your RIGHT eye. For the LEFT eye, use the LEFT hand and LEFT eye. Stand slightly to the patient's side, approximately 15 degrees temporal to their line of sight, and advance to within 2–3 cm of the patient's eye.
4
Find the optic disc
Ask the patient to look straight ahead. The disc is typically found by following a retinal vessel centrally (nasal to the macula). Focus by rotating the dioptre wheel.
5
Systematic examination
Examine in order: optic disc → retinal vessels (arteries and veins in all four quadrants) → macula (ask patient to look at the light briefly) → peripheral retina (ask patient to look in each direction).
Optic Disc Assessment
| Feature | Normal | Abnormal |
|---|---|---|
| Colour | Pink-orange | Pale (optic atrophy, previous ischaemic optic neuropathy); hyperaemic (papillitis, optic disc drusen) |
| Margins | Well-defined (temporal side usually sharper) | Blurred/obscured — papilloedema (bilateral), papillitis (unilateral), myelinated nerve fibres |
| Cup-to-disc ratio | ≤0.5 (varies with disc size) | >0.5, vertically elongated cup, or asymmetric CDR >0.2 between eyes — suspect glaucoma |
| Disc elevation | Flush with retinal surface | Elevated — papilloedema, optic disc drusen, optic nerve head tumour |
| Spontaneous venous pulsations | Present in ~80% of normal individuals | Absent — suggestive of raised intracranial pressure |
Papilloedema vs Papillitis (Optic Neuritis)
Critical distinction: Papilloedema and papillitis both cause a swollen optic disc, but their causes, urgency, and management are entirely different. Always check for RAPD — present in papillitis, absent in papilloedema.
| Feature | Papilloedema | Papillitis (Optic Neuritis) |
|---|---|---|
| Laterality | Bilateral (usually) | Unilateral (usually) |
| Vision | Initially preserved (transient obscurations may occur) | Reduced — painful vision loss (days to weeks) |
| Pain | Painless (unless headache from raised ICP) | Pain on eye movement (hallmark sign) |
| RAPD | Absent (symmetrical) | Present (Marcus Gunn pupil) |
| Colour vision | Preserved | Desaturated (red desaturation) |
| Cause | Raised intracranial pressure (tumour, idiopathic intracranial hypertension, venous sinus thrombosis) | Multiple sclerosis (most common in young adults), autoimmune, post-infectious |
| Urgency | Emergency — urgent neuroimaging (CT/MRI ± MRV) | Urgent — ophthalmology referral; MRI brain/orbits; consider IV methylprednisolone |
Retinal Vessel Assessment
Systematically examine the retinal arteries and veins. Normal arterioles are approximately two-thirds the diameter of venules (AV ratio ~2:3).
- Hypertensive retinopathy — Keith–Wagener–Barker grading:
- Grade I: Mild arteriolar narrowing (silver wiring).
- Grade II: Arteriovenous (AV) nicking — where arteries cross veins, the vein appears compressed.
- Grade III: Flame-shaped haemorrhages, cotton-wool spots (retinal nerve fibre layer infarcts), hard exudates (lipid deposits in a macular star pattern).
- Grade IV: Papilloedema — indicates malignant hypertension. This is a medical emergency.
- Diabetic retinopathy:
- Non-proliferative: Microaneurysms, dot haemorrhages, hard exudates, cotton-wool spots, venous beading.
- Proliferative: Neovascularisation (new vessels on disc or elsewhere), pre-retinal or vitreous haemorrhage, tractional retinal detachment.
- Diabetic macular oedema: May occur at any stage; detected by OCT (optical coherence tomography) in Australian ophthalmology services.
- Retinal vein occlusion: Fundal appearance of "stormy sunset" — widespread haemorrhages and swollen disc. Central retinal vein occlusion (CRVO) involves all four quadrants; branch retinal vein occlusion (BRVO) affects one quadrant.
- Retinal artery occlusion: "Cherry-red spot" at the macula (in central retinal artery occlusion — CRAO) with pale, ischaemic retina. This is an ophthalmological emergency — refer immediately.
Sudden painless vision loss — fundoscopy findings: Central retinal artery occlusion (cherry-red spot) requires emergent thrombolysis or ocular massage within ~4 hours. Central retinal vein occlusion (stormy sunset fundus) requires urgent ophthalmology referral. Retinal detachment presents with "curtain" of vision loss — immediate referral needed.
Dilated Fundoscopy in Australian Practice
Dilated fundoscopy provides a wider field of view and is recommended for diabetic retinal screening, assessment of peripheral retinal pathology, and in patients with headache or neurological symptoms.
Tropicamide 1%
Mydriacyl® · Minims® · Mydriatic agent
Adult dose
1–2 drops into each eye; onset 15–20 min; mydriasis lasts ~4–6 hours
Paediatric dose
1 drop; use lower concentration (0.5%) in neonates and infants
Caution
Do NOT use in narrow-angle glaucoma risk (shallow anterior chamber) without prior ophthalmology assessment; warn patient about blurred vision and photosensitivity
PBS status
✔ PBS General Benefit
MBS item note: In Australia, dilated fundoscopy is often performed as part of diabetic annual reviews. MBS items 721 and 723 (GP Management Plans and Team Care Arrangements) support the comprehensive review process. Patients with diabetes should receive dilated fundoscopy annually — either through their GP (with appropriate training) or via ophthalmologist/optometrist referral. Tele-ophthalmology (e.g., KeepSight program through Diabetes Australia) is increasingly used in remote and rural settings.
Ear Examination & Nose Examination
Otoscopy
Otoscopy is the primary tool for examining the external auditory canal and tympanic membrane (TM). It is the most commonly performed ear examination in Australian primary care and is essential for the diagnosis of otitis media — the most frequent reason for antibiotic prescribing in Australian children.
1
Select speculum
Choose the largest speculum that comfortably fits the ear canal. In adults, 4–5 mm is typical. Larger specula provide a better field of view.
2
Straighten the canal
In adults, pull the pinna posterosuperiorly. In children under 3 years, pull the pinna posterosuperiorly AND downward (the cartilaginous–bony junction is more distal in young children).
3
Insert and inspect
Insert the speculum gently 1–1.5 cm. Inspect the canal first (cerumen, foreign body, discharge, canal wall oedema), then the tympanic membrane.
4
Inspect the tympanic membrane
Identify all landmarks: handle of malleus, umbo, pars tensa, pars flaccida, light cone (anterior–inferior), and the attic region.
Normal vs Abnormal Tympanic Membrane
| Feature | Normal TM | Abnormal Findings |
|---|---|---|
| Colour | Pearlescent grey, translucent | Yellow/amber (effusion), red (inflammation/haemorrhage), white (tympanosclerosis/scarring), blue (glomus tumour) |
| Light reflex | Clear, triangular, anterior–inferior | Absent or distorted (bulging TM, effusion) |
| Mobility | Moves with positive and negative pressure | Decreased or absent — middle ear effusion, adhesive otitis, ossicular fixation |
| Integrity | Intact | Perforation (central: within pars tensa; marginal: near annulus; attic: pars flaccida — cholesteatoma risk) |
| Malleus | Visible handle, short process visible posterosuperiorly | Retracted (negative middle ear pressure) or buried (effusion) |
Pneumatic Otoscopy
Pneumatic otoscopy is the gold standard for assessing tympanic membrane mobility and is essential for diagnosing otitis media with effusion (OME) — the leading cause of conductive hearing loss in Australian children. The RACGP and the Australian Society of Otolaryngology, Head and Neck Surgery (ASOHNS) recommend pneumatic otoscopy as a routine component of ear examination in children.
1
Ensure a seal
Insert the pneumatic otoscope speculum to achieve an airtight seal in the ear canal. An incomplete seal is the most common reason for a false-negative result.
2
Apply gentle positive and negative pressure
Squeeze and release the pneumatic bulb gently. Observe the TM for movement. A normal TM moves briskly with positive pressure (inward) and negative pressure (outward).
3
Interpret
No movement suggests effusion (serous, mucoid, or purulent). Excessive hypermobility suggests TM atrophy or ossicular chain discontinuity.
Acute otitis media (AOM) vs otitis media with effusion (OME): AOM presents with bulging, erythematous TM ± fever, ear pain, and reduced mobility. OME presents with a retracted or neutral TM with amber discolouration and absent mobility on pneumatic otoscopy. In Australia, the NACI (National Aboriginal Community Controlled Health Organisation) guidelines emphasise that chronic suppurative otitis media (CSOM) with persistent perforation and discharge for >2 weeks requires systemic antibiotics and audiology referral.
Rinne & Weber Tests — Tuning Fork Assessment
These bedside tuning fork tests differentiate conductive hearing loss from sensorineural hearing loss. Use a 512 Hz tuning fork (preferred for clinical testing — lower frequencies are felt rather than heard).
1
Weber test
Strike the tuning fork and place it on the vertex (or forehead) at the midline. Ask the patient: "Do you hear this more in one ear or equally in both?"
2
Rinne test
Strike the tuning fork. Place it on the mastoid process (bone conduction — BC) until the patient says they can no longer hear it. Then immediately hold it adjacent to the ear canal (air conduction — AC). Ask: "Which is louder — the one on the bone or the one in front of the ear?"
| Test | Normal | Conductive Hearing Loss | Sensorineural Hearing Loss |
|---|---|---|---|
| Weber | Midline / equal | Lateralises to the affected ear | Lateralises to the normal ear |
| Rinne | Positive (AC > BC) | Negative (BC > AC) — "Bone is better" | Positive (AC > BC) — but both diminished |
Mnemonic: "Conductive = Contralateral" — In conductive loss, Weber lateralises to the affected ear (bone conduction bypasses the middle ear block). In sensorineural loss, sound "goes to" the better cochlea.
Nose Examination
Nasal examination assesses the external nose, anterior nasal cavity, and the nasopharynx. It is commonly performed for nasal obstruction, epistaxis, allergic rhinitis, and sinusitis assessment.
1
External inspection
Inspect the external nose for deformity (saddle nose in granulomatosis with polyangiitis, nasal fracture), asymmetry, and skin changes. Palpate for tenderness over the frontal and maxillary sinuses.
2
Anterior rhinoscopy
Use an otoscope (without speculum or with a large speculum) or a nasal speculum with a pen torch. Examine the inferior turbinate (turbinates should be pink, not boggy or pale-blue), nasal septum (deviation, perforation), and nasal mucosa (erythema, pallor, polyps).
3
Assess nasal patency
Occlude each nostril alternately and ask the patient to inspire gently. This detects unilateral obstruction (deviated septum, polyp, foreign body).
4
Transillumination (sinuses)
In a darkened room, place a bright torch against the infraorbital rim (maxillary sinus) or supraorbital rim (frontal sinus). Normal sinuses transilluminate; opacity suggests sinusitis or mucosal thickening. This is a screening test only — CT sinuses is definitive.
| Finding | Significance |
|---|---|
| Pale, boggy turbinates | Allergic rhinitis |
| Erythematous, swollen turbinates | Acute rhinosinusitis / viral URI |
| Nasal polyps | Chronic rhinosinusitis (bilateral); consider CF in children; unilateral polyp in adults may be antral choanal polyp or inverted papilloma — requires ENT referral |
| Septal deviation | Congenital or post-traumatic; may cause unilateral obstruction |
| Septal perforation | Cocaine use (most common in young adults in Australia), granulomatosis with polyangiitis (Wegener's), post-surgical, septal haematoma (late) |
| Saddle nose deformity | Granulomatosis with polyangiitis, relapsing polychondritis, tertiary syphilis, cocaine-induced midline destructive lesion |
| Kiesselbach's plexus bleeding | Anterior epistaxis (90% of nosebleeds) — usually benign; managed with anterior compression |
Posterior epistaxis: Suspect posterior epistaxis if anterior compression fails, if there is brisk bleeding from both nostrils, or if the patient is on anticoagulants. Posterior epistaxis may require ENT packing (Rapid Rhino® or Merocel®) and hospital admission. These patients should be referred to the emergency department.
Throat Examination & Horner's Syndrome
Throat Examination
Examination of the oral cavity and oropharynx is an essential component of the EENT examination. It assesses the palate, tonsils, uvula, tongue, and floor of mouth, and indirectly evaluates cranial nerves IX (glossopharyngeal), X (vagus), and XII (hypoglossal).
1
Position and lighting
Position the patient seated upright with good lighting. Use a pen torch and a tongue depressor. Ask the patient to open their mouth wide.
2
Inspect the oral cavity
Examine the buccal mucosa (Koplik spots in measles, white plaques in oral candidiasis), gums (gingival hyperplasia in phenytoin use, bleeding in scurvy or leukaemia), teeth (dental caries, tonsillar fossa), and hard palate (torus palatinus, petechiae).
3
Tongue and floor of mouth
Ask the patient to protrude the tongue — it should be midline (deviation towards the side of a CN XII lesion). Inspect for fasciculations (MND), atrophy, and ulceration. Bimanually palpate the floor of mouth for submandibular stones or masses.
4
Tonsils and pharynx
Depress the tongue gently. Assess tonsil size (graded I–IV), symmetry, presence of exudate (bacterial tonsillitis, infectious mononucleosis), peritonsillar swelling (quinsy), and posterior pharyngeal wall (cobblestoning in chronic post-nasal drip, erythema).
5
Uvula and soft palate
Ask the patient to say "aah." Observe symmetrical elevation of the soft palate and midline position of the uvula. Uvular deviation occurs towards the normal side in CN X palsy (the affected side is paralysed and pulled by the intact contralateral muscle). A bifid uvula suggests submucous cleft palate.
6
Gag reflex
The afferent limb is CN IX; the efferent limb is CN X. Touch the posterior pharyngeal wall on each side with a tongue depressor. An absent gag reflex may indicate CN IX/X pathology — but note: up to 20% of normal individuals have a diminished or absent gag reflex.
| Cranial Nerve | Test | Normal Finding | Abnormal Finding |
|---|---|---|---|
| CN IX (Glossopharyngeal) | Gag reflex (afferent); taste to posterior 1/3 of tongue | Symmetrical gag | Absent gag (afferent); may have dysphagia |
| CN X (Vagus) | "Aah" → soft palate elevation; gag reflex (efferent); voice quality (hoarseness) | Midline uvula; symmetrical palate elevation | Uvular deviation (away from affected side); nasal speech; hoarse voice |
| CN XII (Hypoglossal) | Protrude tongue; push tongue into cheeks against resistance | Midline protrusion; no fasciculations | Tongue deviates towards the affected side; fasciculations (MND); atrophy (LMN lesion) |
Laryngeal nerve assessment: Recurrent laryngeal nerve (branch of CN X) palsy causes hoarseness and an immobile vocal cord. The left recurrent laryngeal nerve has a longer course (loops under the aortic arch) and is more vulnerable to mediastinal pathology — bronchial carcinoma, aortic aneurysm, and lymphadenopathy. All patients with persistent hoarseness >3 weeks require ENT referral for laryngoscopy (RACGP Red Book).
Horner's Syndrome
Horner's syndrome results from disruption of the oculosympathetic pathway at any point from the hypothalamus to the orbit. The classic triad is ptosis, miosis, and anhidrosis. Recognising Horner's syndrome is clinically critical because it may indicate serious underlying pathology including carotid dissection, Pancoast tumour (apical lung carcinoma), or brainstem stroke.
Clinical Features
Ptosis
Partial Ptosis (2–3 mm)
Müller's muscle (sympathetically innervated smooth muscle) is paralysed, causing mild drooping of the upper lid. Distinguishes from CN III palsy (which causes complete ptosis). The lower lid may also elevate slightly (inverse ptosis).
Miosis
Pupillary Constriction
The dilator pupillae muscle (sympathetic) is paralysed, leaving the parasympathetic sphincter unopposed. The affected pupil is 1–2 mm smaller than the contralateral pupil. Anisocoria is more pronounced in dim light. Direct and consensual light reflexes are intact (CN III pathway is normal).
Anhidrosis
Absent Sweating
Loss of sweating occurs on the ipsilateral face. The pattern depends on the level of the lesion: central and pre-ganglionic lesions cause hemifacial anhidrosis; post-ganglionic lesions (above the bifurcation) cause anhidrosis over a small area around the eye (the sudomotor fibres join the external carotid artery at the superior cervical ganglion).
The Oculosympathetic Pathway — Three Neurone Levels
| Level | Pathway | Causes of Disruption | Anhidrosis Pattern |
|---|---|---|---|
| First order (Central) | Hypothalamus → ciliospinal centre (C8–T2) via brainstem | Stroke (lateral medullary — Wallenberg syndrome), demyelination, tumour, syringomyelia | Hemifacial (entire ipsilateral face) |
| Second order (Pre-ganglionic) | Ciliospinal centre → superior cervical ganglion (ascends along sympathetic chain and carotid sheath) | Pancoast tumour (apical lung carcinoma — most important cause to exclude), cervical rib, thoracic surgery trauma, lymphadenopathy, brachial plexus injury | Hemifacial (entire ipsilateral face) |
| Third order (Post-ganglionic) | Superior cervical ganglion → orbit (travels along internal carotid artery) | Carotid dissection (most dangerous — may cause stroke), carotid aneurysm, cavernous sinus pathology, middle ear surgery, cluster headache | Periocular only (if lesion is distal to the external carotid branch point) |
Pharmacological Confirmation — Cocaine Drop Test
The cocaine drop test is the gold standard for confirming Horner's syndrome. Cocaine blocks the reuptake of noradrenaline at the synaptic cleft; in a normal eye, this causes pupillary dilation. In Horner's syndrome, there is no noradrenaline release (due to disrupted sympathetic supply), so the pupil fails to dilate.
Carotid dissection — time-critical diagnosis: Horner's syndrome with ipsilateral neck pain or headache in a young or middle-aged adult is carotid dissection until proven otherwise. This requires urgent CT angiography of the neck. Anticoagulation or antiplatelet therapy should be initiated. Carotid dissection is a cause of ischaemic stroke in younger adults and requires immediate vascular and neurological assessment.
1
Instil 10% cocaine drops
Place 2 drops of 10% cocaine solution in both eyes. Wait 45–60 minutes.
2
Normal response
Both pupils dilate (≥1 mm dilation from baseline). Normal anisocoria should be ≤0.5 mm after cocaine.
3
Horner's syndrome response
The affected pupil fails to dilate. Anisocoria increases. This confirms the diagnosis.
4
Localisation with apraclonidine or hydroxyamphetamine
Apraclonidine 0.5% drops: in post-ganglionic Horner's, the affected pupil dilates (denervation supersensitivity). Hydroxyamphetamine 1% (Paredrine): if post-ganglionic, no dilation; if pre-ganglionic, the pupil dilates. This distinguishes second-order from third-order lesions and guides imaging.
Investigations for Horner's syndrome — guided by level:
Central (first order): MRI brain with DWI (stroke) ± MRI spine (syringomyelia).
Pre-ganglionic (second order): CT chest (Pancoast tumour — apical mass) ± MRI brachial plexus. In Australia, a new Horner's syndrome in a smoker is lung cancer until proven otherwise — request CT chest with contrast urgently.
Post-ganglionic (third order): CT angiography of the neck (carotid dissection) ± MRI/MRA head and neck. Cluster headache may cause transient post-ganglionic Horner's during episodes.
Central (first order): MRI brain with DWI (stroke) ± MRI spine (syringomyelia).
Pre-ganglionic (second order): CT chest (Pancoast tumour — apical mass) ± MRI brachial plexus. In Australia, a new Horner's syndrome in a smoker is lung cancer until proven otherwise — request CT chest with contrast urgently.
Post-ganglionic (third order): CT angiography of the neck (carotid dissection) ± MRI/MRA head and neck. Cluster headache may cause transient post-ganglionic Horner's during episodes.
Distinguishing Horner's from other causes of ptosis and small pupil:
Horner's syndrome — partial ptosis + miosis + anhidrosis; pupil dilates poorly with cocaine; pupil dilation lag (dilates slowly in the dark).
Physiological anisocoria — both pupils react normally to light and darkness; difference remains constant; cocaine test normal.
Adie's tonic pupil — large, poorly reactive pupil (usually unilateral, young women); constricts with dilute pilocarpine 0.1% (denervation supersensitivity).
CN III palsy — complete ptosis + "down and out" eye + dilated pupil; may be painful.
Horner's syndrome — partial ptosis + miosis + anhidrosis; pupil dilates poorly with cocaine; pupil dilation lag (dilates slowly in the dark).
Physiological anisocoria — both pupils react normally to light and darkness; difference remains constant; cocaine test normal.
Adie's tonic pupil — large, poorly reactive pupil (usually unilateral, young women); constricts with dilute pilocarpine 0.1% (denervation supersensitivity).
CN III palsy — complete ptosis + "down and out" eye + dilated pupil; may be painful.
Special Populations
Paediatrics
Visual acuity
Use age-appropriate charts: Cardiff acuity cards (6–12 months), Kay pictures (2–3 years), Lea symbols (3–5 years), Snellen (≥5 years). Fixation preference testing detects amblyopia in pre-verbal children.
Red reflex (Brückner test)
Perform in all neonates and infants. An absent or asymmetric white reflex (leukocoria) may indicate retinoblastoma, congenital cataract, or retinopathy of prematurity — refer urgently to ophthalmology.
Otoscopy
Pull pinna posterosuperiorly and downward (in children <3 years). Otitis media is the most common reason for antibiotic use in Australian children. Myringotomy and grommet insertion (MBS item 41595) is indicated for chronic OME with hearing loss >3 months.
Fundoscopy
Difficult in uncooperative children — consider sedation or referral. Newborn screening for retinopathy of prematurity (ROP) is mandatory for infants born <32 weeks or <1500 g in Australia.
Elderly
Cataracts
The most common cause of visual impairment in older Australians. Fundoscopy is often limited by lens opacity. Refer for cataract surgery assessment if visual impairment affects function — long public wait times in Australia; private options available with MBS item 42698.
Age-related macular degeneration (AMD)
Leading cause of irreversible blindness in Australia. Inspect the macula for drusen (dry AMD) or haemorrhage (wet AMD). An Amsler grid is a useful screening tool. Wet AMD requires urgent intravitreal anti-VEGF injection (ranibizumab, aflibercept — PBS authority required).
Presbycusis
Bilateral high-frequency sensorineural hearing loss. Rinne positive, Weber central. Refer for audiology assessment and hearing aid fitting. GP Management Plans (MBS 721) can support access.
Giant cell arteritis (GCA)
New headache in a patient >50 years + jaw claudication + visual symptoms (amaurosis fugac) + ESR >50 — treat empirically with prednisolone 1 mg/kg before temporal artery biopsy to prevent irreversible vision loss.
Immunocompromised
CMV retinitis
Affects patients with CD4 <50 cells/µL (advanced HIV). Fundoscopy shows "pizza pie" or "cottage cheese and ketchup" appearance (haemorrhages with white necrotic retinitis). Requires urgent ophthalmology referral and systemic antiviral therapy (ganciclovir, valganciclovir).
Aspergillus endophthalmitis
Post-surgical or haematogenous dissemination in immunocompromised patients. Fundoscopy shows vitritis with chorioretinal infiltrates. Requires systemic and intravitreal antifungal therapy.
Mucormycosis (rhino-orbital-cerebral)
Rapidly progressive fungal sinusitis in poorly controlled diabetes (DKA) and immunocompromised patients. Presents with black necrotic nasal turbinates, proptosis, and orbital apex syndrome. Emergency — requires surgical debridement and IV amphotericin B.
Renal Impairment
Uraemic retinopathy
In chronic kidney disease (CKD Stage 4–5): cotton-wool spots, haemorrhages, hard exudates, and serous retinal detachment. Fundoscopy is an important component of CKD assessment in Australian nephrology practice.
Calcium–phosphate deposits
In severe hyperphosphataemia, calcification may occur in the conjunctiva (conjunctivitis) and cornea (band keratopathy). Dialysis patients are at increased risk.
Hepatic Impairment
Scleral icterus
Jaundice is first visible in the sclera (bilirubin >35 µmol/L). Examine in natural light. Distinguish from subconjunctival fat deposits (pinguecula) which are yellow and located nasally/temporally.
Hepatic encephalopathy
Assess for asterixis and fluctuating pupillary reactivity. Kayser–Fleischer rings (copper deposits in Descemet's membrane at the corneal limbus) — seen in Wilson's disease — should be looked for with slit-lamp examination in any young patient with unexplained liver disease.
Pregnancy
Pre-eclampsia
Fundoscopy may show hypertensive retinopathy (Grade I–IV). Papilloedema in pre-eclampsia/eclampsia indicates severe disease. Retinal detachment may occur in HELLP syndrome.
Pituitary tumour
Pituitary adenomas may enlarge during pregnancy (increased vascularity). Visual field assessment (bitemporal hemianopia) and fundoscopy (optic atrophy from chiasmal compression) are important monitoring tools.
Idiopathic intracranial hypertension
More common in obese women of childbearing age. Presents with headache, transient visual obscurations, and papilloedema. Monitor with serial fundoscopy and visual field testing. Acetazolamide is generally avoided in pregnancy (FDA category C) — discuss with neurology/ophthalmology.
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander Health — EENT Examination
Eye and ear disease represent significant contributors to the health gap experienced by Aboriginal and Torres Strait Islander Australians. Trachoma remains the only developed country in the world where blinding trachoma is still endemic, and chronic suppurative otitis media (CSOM) rates in Indigenous children are among the highest globally. A culturally safe and sensitive approach to EENT examination is essential.
📚 References
- 1. Royal Australian College of General Practitioners (RACGP). Guidelines for Preventive Activities in General Practice (Red Book). 9th edn. East Melbourne: RACGP; 2018 (updated 2023).
- 2. Australian Institute of Health and Welfare (AIHW). Eye health in Aboriginal and Torres Strait Islander people. Cat. no. IHW 226. Canberra: AIHW; 2023.
- 3. National Aboriginal Community Controlled Health Organisation (NACCHO). Otitis Media Guidelines for Aboriginal and Torres Strait Islander Children. Canberra: NACCHO/Department of Health; 2020.
- 4. Centre for Eye Health (CENEH) and Vision 2020 Australia. Diabetic Retinopathy Screening Guidelines for Optometrists in Australia. Sydney: University of New South Wales; 2019.
- 5. Lyons CJ, Lambert SR. Taylor and Hoyt's Pediatric Ophthalmology and Strabismus. 5th edn. Edinburgh: Elsevier; 2017.
- 6. Burton MJ, Ramke J, Marques AP, et al. The Lancet Global Health Commission on Global Eye Health: vision beyond 2020. Lancet Glob Health. 2021;9(4):e489–e551.
- 7. Harvey RJ, Lund VJ. Scott-Brown's Otorhinolaryngology, Head and Neck Surgery. 8th edn. Boca Raton: CRC Press; 2018.
- 8. Healthdirect Australia. Horner's syndrome — symptoms, diagnosis and management. Canberra: Healthdirect; 2023. Available at: https://www.healthdirect.gov.au/horners-syndrome.
- 9. MacLaren RE, Groppe M, Downes SM. Oxford Handbook of Ophthalmology. 4th edn. Oxford: Oxford University Press; 2018.
- 10. Therapeutic Guidelines Limited. Trachoma management in primary care. Aust Prescr. 2020;43(3):94–97.
- 11. National Health and Medical Research Council (NHMRC). NHMRC Statement on Trachoma Control in Remote Aboriginal and Torres Strait Islander Communities. Canberra: NHMRC; 2020.
- 12. Tusa RJ, Safran AB. Neuro-ophthalmological examination. In: Walsh and Hoyt's Clinical Neuro-Ophthalmology. 6th edn. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 1–25.
- 13. Lions Outback Vision. Annual Report 2023: Delivering eye care to rural and remote Western Australia. Perth: Lions Outback Vision; 2023.