The doctor’s office. A scary place, depending on your point of view and the reasons for your visit in the first place. An Ear, Nose and Throat (ENT) office is no less intimidating, especially since it’s quite unlike a typical doctor’s office. First of all, you don’t remove your clothes and drape yourself in a gown exposing your rear-end, but that’s a blessing. But then you’re seated in a chair quite similar to the one found in a dentist’s office, and if you’re like me, cold beads of sweat form on your scalp as your heart thumps madly in your chest, since your brain quickly flashes an equation to the very front of your mind: “dentist = very bad pain.”
O.K., I don’t want to frighten you away from an ENT doctor’s practice, as that would be bad for business. But let’s face it, there’s naturally a bit of fear whenever you visit the doctor. The doctor’s office is not Disneyland. In some respects, it’s similar to Las Vegas but without the thrill—what happens in the doc’s office stays in the office—you know, with HIPPA and confidentiality and all that jazz. But if you change your mindset, it can be intriguing, fascinating and even a bit of fun. My purpose is to demystify your first visit to an ENT doctor.
The ENT exam room is one strange setting. As mentioned before, you find yourself in a large chair with armrests and a headrest, and you wonder if they’re going to strap you tight for a rollercoaster ride of torture and screaming. Behind your head you notice a light attached to the back of the chair with a bendable metal conduit. Off to the side there’s a strange cabinet with a bunch of switches, a couple of hoses and an assortment of paraphernalia, some bottles with unknown chemicals whose purpose eludes even the most inquisitive minds. You wonder what’s lurking inside those drawers. You also notice a large microscope behind the chair, two eye pieces converging into a larger lens, staring you down like a famished cyclops. You’d swear that microscope was smiling though it has no mouth.
Adorning the walls are posters with anatomic drawings and diagrams. You might find a three-dimensional model or two of an ear or a larynx, perhaps even a skull or parts of one sitting on the counter by the sink. You absorb your strange surroundings when suddenly the door opens and something stranger occurs: you come face-to-face with your ENT doctor.
She/he cheerily enters the room (unless he/she was sleep deprived due to an emergency the night before) and perhaps strapped around the doc’s head you’ll see a nifty, round mirror with a hole smack dab in the middle. It looks oddly familiar, perhaps you’ve seen it in an old black-and-white movie or T.V. show where a doctor was portrayed. Some of the younger, more “modern” ENTs may wear an electric headlight instead. I personally am attached to the classic head mirror, the same one I’ve used since I was a resident back in the 1990s. Anyway, after a bit or conversation and taking a pertinent history of your current problem and –if you’re lucky—one or two bad jokes, the ENT doctor will examine you.
Your doctor will look into your ears with a contraption called an otoscope. The otoscope is a lighted device that will illuminate deep into your ear. Despite myth and old wives’ tales, the light will not go through your head to the other side, your doctor cannot see the opposite ear no matter how many times you’ve been told your head is empty as a vacuum. The doc might even blow a few puffs of air into your ears with a bulb attached to the otoscope. Don’t worry—he’s not getting fresh with you. He’s looking for movement of your eardrum which is another helpful examination technique.
Your doc might also recline the chair back and pull in that microscope you saw earlier. This really magnifies the ear and provides better visualization, especially when the otoscopic exam is unclear or uncertain.
Next comes the fun part. The doc will flip the head mirror over one eye, turn on the light suspended behind you on the exam chair and reflect that light onto face. He then checks your nose, mouth and throat using this device. Excitement mounts as you most certainly say to yourself, “Wow! That copay was worth it!”
I usually proceed with the exam in the following order: ears, nose and throat, just like the specialty name (well, the official name is otolaryngology, but that’s a mouthful so we’ll stick with ENT). At the end I’ll do a neck exam to complete the process.
So the next item is the nose. A nasal speculum is inserted into one nostril, which kinda-sorta looks like a gynecologic speculum, but is much smaller and far less uncomfortable (so I was told). The nostril is stretched a little and the head mirror shines the light way down the nose. The doc might spray a decongestant to shrink the tissue inside the nose to improve visualization. An anesthetic spray might be used in order to suction or probe the nose or place a variety of instruments to remove something funny or to cauterize blood vessels in patients with nosebleeds. The doc might later place a fiberoptic scope into the nose and perhaps from there down into the throat to better evaluate things (see nasopharyngoscopy).
The doctor then examines your mouth and throat not with one, but TWO wooden tongue depressors! Yes, no expense is spared, despite all the talk of cost-cutting in medicine. The doc will prod your lips, push your tongue here and there and then finally puts the sticks farther back trying to gag you as you say “Aahh.” Well, most docs have a certain finesse that avoids gagging altogether, but what fun is that? We live for this moment! Just kidding, of course.
Next, the ENT doc may light an alcohol lamp on the top of the cabinet next to your chair and pass a dental mirror through the flame. I explain this serves as a branding tool, used to permanently sear “Fong was here,” on the back of your throat. The kids think this if funny, though a few adults nearly fainted (called a vasovagal episodes in the medical world) as I hurriedly recovered with “I was only kidding!”
I explain the purpose of the flame is to prevent the mirror from fogging and I place the warmed mirror on the back of my hand, to reassure the stunned victim—uh, I mean patient--that I’m not a madman. Now hold onto your seats for the fun part: I then grab the tongue with gauze and pull the tongue out, forcing the poor patient to say “eeee” while the warmed mirror is placed into the back of the throat. This is to view the voice box and other structures behind and below the tongue. If done properly, the mirror often does not cause one to gag, though on a few occasions patients have vomited, and I could see the vomitus coming up with the mirror, allowing me to make a hasty retreat just as the poor soul projects a stream of acidic-smelling emesis, splattering the floor below. This job never gets boring.
Finally, a neck examination is done by probing and feeling the deep structures of your neck, sometimes your face and head as well. This is called palpation. I often approach the patient from behind and feel the front and sides of the neck with both hands. Some fear I might choke them to death and remind me they’ve already paid their copay or promise they’ll pay the bill promptly after.
After all is done, we'll discuss a diagnosis and plan of action for your particular ENT problem. Your nose and throat may feel a bit numb if that anesthetic spray was used, and you might feel soreness in spots depending on what was done. If so, I usually explain, “If you leave the doctor’s office without a bandage, without a bit of pain or a sense of being violated, well then you’d feel you’ve been ripped-off!” to which many patients chuckle and nod in agreement. All joking aside, the majority of times the ENT doctor’s visit is quite painless and benign. So leave your fear at home…but remember to bring your insurance and credit cards.
©Randall S. Fong, M.D.