HEENT Assessment

Obtaining History If head or neck trauma, gather CC and current status info. Postpone rest of history until x-rays obtained.

History: Head and Neck Head trauma, skull surgery, jaw/facial fractures? Headaches? Swelling of face, jaws, mastoid process? Sinus infections/tenderness? Nasal discharge or post-nasal drip? Nosebleeds?

History: Head and Neck Mouth lesions, ulcers, or cold sores? Any difficulty swallowing or chewing? Any changes in sound of voice? Any allergies causing breathing difficulty? Any neck injury or surgery?

Additional Questions: Peds Drinking water treated with fluoride? Use pacifier or thumb? When did teething begin? Tonsils present? If not, when removed?

Additional Questions: Elderly Do you wear dentures? If so, how well do they fit?

Health Promotion Questions Smoke a pipe? Chew tobacco or use snuff? Does relaxation, exercise, or massage help relieve headaches? Is H/A associated with lack of sleep, missed meals, or stress? Job: sitting at computer terminal?, risk of head injury? (hard hat?) Do you grind your teeth? Last exam? Floss? Use seat belts?

Examination of Head, Neck, and Lymph

Hair and Scalp: Inspection Quality and thickness Distribution, pattern of loss (if any) Texture Lesions Presence of nits

Skull: Inspection/Palpation General size and contour Deformities, lumps and tenderness Palpate sinus areas and mastoid areas for tenderness Palpate temporal artery Check TMJ

Face: Inspection Facial expression Symmetry Involuntary movements Edema Masses or lesions Color and texture of skin Exopthalmos Rash

Neck: Inspection Asymmetry Range of motion Abnormal pulsations, vein distension Enlargement of thyroid, lymph, salivary glands Deviation of trachea Skin lesions Neck muscles

Neck: Palpation Assess lymph nodes, noting: Thyroid gland Trachea exact location size and shape tender? freely movable, adherent or matted together? texture: hard, soft, firm Thyroid gland Trachea

Neck: Auscultation Check for bruits: carotid arteries temporal arteries thyroid, if enlarged

Lymph Nodes: When to Biopsy? Immediate biopsy is indicated for: painless rubbery node of recent onset especially if > 1-2 cm in diameter A smaller, rapidly enlarging node is also a biopsy candidate. Unilateral nodes should have a biopsy sooner than bilateral ones. More conservative with stable node.

Eyes

History: Eyes Corrective lenses? Glasses/contacts? When lenses last changed? Blurred vision? Spots, floaters, halos around lights? Frequent eye infections/inflammation? Eye surgery or injury? Styes?

History: Eyes History of high blood pressure or diabetes? Any prescription medications for your eyes? Family history: cataracts, glaucoma, blindness?

Eye History: Peds Infant: gaze at you or other objects; blink at bright lights or quick movements? Eyes ever crossed? Ever move in different directions? Does child bump into things? Does child sit near television at home? How is child’s progress in school?

Eye History: Elderly Do eyes feel dry? Difficulty seeing in front of you but not to the sides? Problems with glare? Problems discerning colors? Difficulty seeing at night?

Health Promotion Questions Last eye examination? Eye care insurance? Occupation: prolonged reading or use of video display terminal? Any eye problems from air at work/home? Use goggles when appropriate? (when using tools, sports, swimming?)

Examination of the Eye Visual acuity External Eye Exam (SIMPLE): Symmetry Inflammation Masses Puncta Lacrimal duct Eyelinds

Abnormalities: External Eye Exam Lid lag Lid ophthalmus (incomplete closure) Ptosis (drooping) Blepharospasm Xanthelasma Ectropion (rolling out) Entropion (rolling in) Infections: hordeolum (sty) chalazion blepharitis

Conjunctiva Palpebral conjunctiva: lines lid Bulbar conjunctiva: over sclera Conjunctivitis: viral, bacterial, allergic Pterygium: thickening of bulbar conjunctiva

Ocular Muscles

Strabismus: Deviation of Eye Tropia: Malalignment or deviation of eye Exotropia: outward turning Esotropia: inward turning Phoria: Mild weakness apparent only with cover test Exophoria: outward drift Esophoria: inward drift

Globe Cornea Sclera Clear, smooth Arcus senilis Corneal reflex CN V Trigeminal CN VII Facial Sclera

Globe Pupil Iris Lens Size (3-5 mm) Light reflex Convergence Anisocoria: unequal pupils Light reflex Convergence Accommodation Iris Lens

Testing Peripheral Vision 60o Nasal 90o Temporal 60o Superior 70o Inferior

With Any Eye Pain: Numb eye with Tetracaine Use fluorescein paper (wet with sterile saline or water) Use Wood’s light to check for abrasions, foreign body

Differential Diagnosis The “Red Eye” Differential Diagnosis

Conjunctivitis If blurring: intermittent, clears on blinking Discharge: usually, crusting of lashes Pain: none or minor and superficial Pupils: Normal size and response Conjunctival Injection: Diffuse IOP: Normal (don’t measure if discharge) Cornea: Clear

Iritis Vision: slightly blurred No discharge Pain: Moderately severe, aching, photophobia Pupil: constricted, minimal response Conjunctival injection: Circumcorneal IOP: Normal to low Cornea: clear or slightly hazy

Keratitis (Corneal inflammation or foreign body) Vision: slightly blurred Discharge: none to mild Pain: sharp, severe foreign body sensation Pupil: normal or constricted, normal response Conjunctival injection: circumcorneal IOP: Normal (Caution: do not measure) Cornea: Opacification present; altered light reflex; (+) fluorescein staining

Acute Glaucoma (REFER) Vision: marked blurring Discharge: none Pain: very severe, frequently N & V Pupil: dilated, minimal or no reaction Conjunctival injection: diffuse with prominent circumcorneal injection IOP: elevated Cornea: hazy; altered light reflex Anterior chamber depth: shallow

Fundoscopic Exam

When to do Fundoscopic Exam Suspected neuro problems headache dizziness Diabetes Hypertension Toxoplasmosis

Optic Disk Size: 1.5 mm Shape: round--> slightly oval Color: salmon pink, yellowish-white Margins: distinct, fuzzy nasally Disc-cup ratio: Physiologic cup/Optic disk should be < .5 Normal variations

Retinal Vessels Number: Branches to all four quadrants Color: arteries brighter than veins (veins slightly darker and larger than arteries) A-V ratio (diameters): A/V > 1/2 (1/2 or less may mean diabetes) A-V Crossing: should cross with no disruption of blood flow (if flow impaired = A-V nicking)

Macula (central vision) Location: 2 disc diameters temporally from disc Fovea = center of macula NOTE: Uncomfortable for patients to have light shined on macula; aim for disc instead Abnormalities

General Background of Fundus Color: bright orange/red; consistent OU Abnormalities: microaneurysms hemorrhage hard exudate: creamy or yellowish, well-defined borders cotton wood spots (soft exudate): white/gray ovoid lesions with irregular borders

Ears

History: Ears Any hearing differences in one/both ears? Ear pain? Trouble with earwax? What is done? Ear injury? Ear surgery? Ringing or cracking in your ears? Foreign body in ear? Frequent ear infections? Drainage? Problems with balance, dizziness, vertigo?

History: Ears Rx or OTC meds or home remedies for the ears or any other conditions? Family: anyone with hearing problems? Occupational history

Ear History: Peds Infant: respond to loud or unusual noises? If > 6 months, does infant babble? If > 15 months, does toddle rely on gestures and make no attempt at sound? Child tugging at either ear? Any coordination problems? Hx: meningitis, recurrent OM, mumps, encephalitis?

Ear History: Elderly Any recent change in hearing? Wear a hearing aid? If so, for how long? How do you care for it?

Health Promotion Questions Last ear exam/hearing test? Results of test? Any meds for ears? Any concerns about ears/hearing? Do you work around loud equipment or machinery? (or LOUD MUSIC!)

Ear Assessment: Concepts Lightheadedness: detachment Vertigo: surroundings swirling around Dizziness: disturbance in relationship to space

Hearing Loss Otosclerosis: Bones fuse; ages 40-50 have some degree of hearing loss Conductive hearing loss: sound not getting to hearing apparatus Sensory hearing loss: High pitched sounds are the first to NOT be heard. Mixed hearing loss

External Ear: Inspection Pinna (auricle) Size and shape Level on head Flat or protruding Tophi or nodules External Auditory Canal Cerumen, discharge, foreign bodies Signs of infection

External Ear: Palpation Tophi and nodules Assess for tenderness (with ear pain, discharge or inflammation) move auricle press on tragus press on mastoid

Otoscopic Exam Technique Pinna up, back and out in adults Pinna down and out in children Advance slowly; ANCHOR the otoscope Observe canal: blood, tumors, wax, foreign bodies

Otoscopic Exam: Tympanic membrane (drum) Note color and luster Oval thin, partially transparent grey Gently move speculum to inspect entire ear drum Landmarks NOTE: The more scarring on the TM from healed ruptures, the less mobile it becomes ---> conductive hearing loss.

Testing Hearing Crude Tests Tuning Fork Weber test Rinne’s test Watch test Whisper test Tuning Fork Weber test Rinne’s test

Types of Hearing Loss

Vestibular Testing Romberg’s sign Post pointing Nystagmus

Nose, Throat, Mouth and Sinus

Nose Inspect for deformity, asymmetry, and inflammation Test for patency of each nostril Using speculum, note: color of nasal mucosa spectum, bleeding, perforation, deviation turbinates: visible, color, swelling, exudate, polyps

Mouth and Throat Lips, Tongue, Gums and teeth Buccal mucosa Palata and uvula Tonsils and pharyngeal wall Ducts Frenulum Note: sore throat may be due to PND

Sinuses Able to assess: Others Palpate for sinus tenderness in adult frontal sinus maxillary sinuses Others ethmoid sinus sphenoid sinus Palpate for sinus tenderness in adult Transillumination