Physical Exam of the Head & Neck

INTRODUCTION It is usually the initial part of a general physical exam, after the vital signs. It is usually the initial part of a general physical exam, after the vital signs. It begins with inspection, and then proceeds to palpation. It requires the use of several special instruments in order to inspect the eyes and ears, and special techniques to assess their special sensory function. It begins with inspection, and then proceeds to palpation. It requires the use of several special instruments in order to inspect the eyes and ears, and special techniques to assess their special sensory function.

EXAMINATION of the HEAD Inspection Observe the patient's facial expression and appearance. Look for symmetry, size, shape, masses and involuntary movements Observe the patient's facial expression and appearance. Look for symmetry, size, shape, masses and involuntary movements Hair: Observe quantity, distribution, texture, pattern of any hair loss. Look for lice or nits (the eggs of lice) Hair: Observe quantity, distribution, texture, pattern of any hair loss. Look for lice or nits (the eggs of lice) Scalp: Part the hair in several places and look for scaliness, erythema, skin lesions and nodules Scalp: Part the hair in several places and look for scaliness, erythema, skin lesions and nodules

Palpation Palpate with finger pads Palpate with finger pads Generally, palpation is done only if patient symptomatic (head pain, trauma, etc.) Generally, palpation is done only if patient symptomatic (head pain, trauma, etc.) Skull: deformity from trauma, muscular tenderness from tension headaches Skull: deformity from trauma, muscular tenderness from tension headaches Temporal arteries: thickening, tenderness, or absent pulse in temporal arteritis Temporal arteries: thickening, tenderness, or absent pulse in temporal arteritis Hair: texture may change in thyroid disease, becoming more coarse Hair: texture may change in thyroid disease, becoming more coarse Palpation of the lymph nodes Palpation of the lymph nodes

Microcephaly a congenitally small skull resulting from failure of the brain Microcephaly a congenitally small skull resulting from failure of the brain Macrocephalus is an abnormally large head due to hydrocephalus, Paget’s disease (osteitis deformans), and acromegaly Macrocephalus is an abnormally large head due to hydrocephalus, Paget’s disease (osteitis deformans), and acromegaly Oxycephaly (steeple skull) characterized by a long anteroposterior axis, narrow in width, and pointed at the vertex. It is caused by premature union of the cranial sutures Oxycephaly (steeple skull) characterized by a long anteroposterior axis, narrow in width, and pointed at the vertex. It is caused by premature union of the cranial sutures Deformities of skull (cranium)

Microcephaly

hydrocephalus Macrocephalus setting sun phenomenon hydrocephalus

steeple skull

Apert syndrome a form of acrocephalosyndactyly steeple skull steeple skull + syndactyly

ANATOMY OF THE EAR ANATOMY OF THE EAR External ear External ear Auricle (or pinna) and external auditory canal are cartilage covered with thin, sensitive skin Auricle (or pinna) and external auditory canal are cartilage covered with thin, sensitive skin Cerumen secreted from distal 1/3 of canal- protects skin Cerumen secreted from distal 1/3 of canal- protects skin Middle ear: Middle ear: Tympanic membrane (TM) normally looks "pearly gray" Tympanic membrane (TM) normally looks "pearly gray" Pars tensa- inferior 2/3 Pars tensa- inferior 2/3 Pars flaccida- superior 1/3 (covers the chorda tympani) Pars flaccida- superior 1/3 (covers the chorda tympani) Umbo- where malleus attaches to TM, Umbo- where malleus attaches to TM, Malleus- manubrium (handle) and short process are visible Malleus- manubrium (handle) and short process are visible Eustachian tube- equalizes middle ear pressure Eustachian tube- equalizes middle ear pressure Inner ear: Inner ear: The cochlea and semicircular canals The cochlea and semicircular canals

EXAMINATION of the EAR Inspection Inspection External ear - observe position and shape, inspect for symmetry, lesions, drainage from external auditory meatus External ear - observe position and shape, inspect for symmetry, lesions, drainage from external auditory meatus Position: Top of auricle should be above line drawn between outer canthus of eye and occipital protuberance. Low set auricle may signify chromosomal abnormality. Position: Top of auricle should be above line drawn between outer canthus of eye and occipital protuberance. Low set auricle may signify chromosomal abnormality. Possible findings Possible findings Tophi- deposits of uric acid crystals found in patients with gout Tophi- deposits of uric acid crystals found in patients with gout Chondritis- infection of cartilage, often caused by piercing Chondritis- infection of cartilage, often caused by piercing "Cauliflower"-repeated trauma causes cartilage necrosis "Cauliflower"-repeated trauma causes cartilage necrosis Otitis externa- "swimmer's ear", pulling on lobe often painful Otitis externa- "swimmer's ear", pulling on lobe often painful Skin cancer - often nodular, with induration, scaling and superficial ulceration. Skin cancer - often nodular, with induration, scaling and superficial ulceration.

External ear External ear

auricular tophus auricular tophus

postauricular cyst postauricular cyst

Middle ear - otoscopic exam Insert otoscope slowly, avoiding bumping the canal Insert otoscope slowly, avoiding bumping the canal Cerumen removal may be necessary Cerumen removal may be necessary Cerumen spoon- often causes EAC bleeding Cerumen spoon- often causes EAC bleeding Irrigation - contraindicated if TM perforation Irrigation - contraindicated if TM perforation Removal with direct visualization Removal with direct visualization Pneumatic otoscopy Pneumatic otoscopy assesses mobility and compliance of TM assesses mobility and compliance of TM Effusion (fluid in middle ear) will hamper TM mobility Effusion (fluid in middle ear) will hamper TM mobility Retraction from eustachian tube dysfunction may allow movement only with negative pressure Retraction from eustachian tube dysfunction may allow movement only with negative pressure Findings Findings Mobility Mobility Bulging, no mobility Pus in middle ear- otitis media (OM) Bulging, no mobility Pus in middle ear- otitis media (OM) Retracted, no mobility Eustacian tube dysfunction +/- effusion Retracted, no mobility Eustacian tube dysfunction +/- effusion Color Color Red Infection, crying Red Infection, crying Deep red or blue Blood (from trauma) Deep red or blue Blood (from trauma) White flecks, plaques Healed inflammation White flecks, plaques Healed inflammation Bubbles Serous fluid Bubbles Serous fluid

The Ear-Hearing assessment Response to questions during history Response to questions during history Response to a whispered voice Response to a whispered voice Tuning fork air/bone conduction Tuning fork air/bone conduction Rinne (left) Rinne (left) Weber (right) Weber (right)

ANATOMY OF THE EYE External eye: Eyelids, lacrimal gland and duct, palpebral fissures, medial and lateral angles. External eye: Eyelids, lacrimal gland and duct, palpebral fissures, medial and lateral angles. Internal eye: Light travels through cornea, anterior chamber, pupil, lens, and vitreous body on the way to the retina. Internal eye: Light travels through cornea, anterior chamber, pupil, lens, and vitreous body on the way to the retina. Fundus: The posterior structures of the eye include the retina, retinal arteries and veins, the optic disc and the macula. These structures are viewed with the ophthalmoscope Fundus: The posterior structures of the eye include the retina, retinal arteries and veins, the optic disc and the macula. These structures are viewed with the ophthalmoscope

ANATOMY OF THE EYE Internal eye: light travels through cornea, anterior chamber, pupil, lens, and vitreous body on the way to the retina. Fundus: The posterior structures of the eye include the retina, retinal arteries and veins, the optic disc and the macula. These structures are viewed with the ophthalmoscope External eye: Eyelids, lacrimal gland and duct, palpebral fissures, medial and lateral angles.

EXAMINATION of the EYE Vision testing Vision testing Should be done with any visit involving an eye complaint Should be done with any visit involving an eye complaint Used to screen children for visual problems Used to screen children for visual problems Acuity: Acuity: Far vision - test at 6 m with Snellen chart Far vision - test at 6 m with Snellen chart Patient covers one eye, and is instructed to read the smallest line possible. Patient must correctly read half of symbols on line. Repeat for other eye. Patient covers one eye, and is instructed to read the smallest line possible. Patient must correctly read half of symbols on line. Repeat for other eye. Near vision - test at 35cm with pocket chart Near vision - test at 35cm with pocket chart Patient covers one eye, and is instructed to read smallest line possible. Repeat for other eye. Patient covers one eye, and is instructed to read smallest line possible. Repeat for other eye. Visual fields: Visual fields: Confrontation test estimates peripheral vision (may be important in glaucoma, multiple sclerosis, stroke, or pituitary or other CNS tumor) Confrontation test estimates peripheral vision (may be important in glaucoma, multiple sclerosis, stroke, or pituitary or other CNS tumor) Use your own visual fields as a reference Use your own visual fields as a reference Technique - face patient at eye level. Ask patient to cover one eye. Slowly move your fingers from outside the patient's peripheral visual field towards the center of the patient's vision. Ask the patient to tell you when he sees your fingers. Technique - face patient at eye level. Ask patient to cover one eye. Slowly move your fingers from outside the patient's peripheral visual field towards the center of the patient's vision. Ask the patient to tell you when he sees your fingers.

EXAMINATION of the EYE Be systematic – inspect eyebrows, lids, and globe including conjunctivae Findings Eyebrows: Loss of lateral growth may suggest hypothyroidism Xanthelasma -irregular, slightly raised yellow periorbital lesions may suggest lipid disorder Eyelids : Ptosis - if upper lid covers part of pupil (muscle weakness or neurologic lesion) Ectropion (lid turned out) Entropion (lid turned in) Hordeolum (stye)-inflammation of sebaceous gland Foreign body - may need to evert lid for full inspection Conjunctiva: Hemorrhage- from trauma

Eyelid edema

Entropion (lid turned in)

Ectropion (lid turned out)

After treated with neostigmine myasthenia gravis autoimmune neuromuscular disease Ptosis

Ptosis unilateralbilateral

subconjunctival hemorrhage

chemosis conjunctiva chemosis conjunctiva

Pale palpebral conjunctiva

Facial schingles with conjunctivitis

EXAMINATION of the EYE Conjunctivitis- inflammation from infection, allergy... Pterygium - growth of conjunctiva over cornea Cornea: Sensation tests cranial nerve V (CN V) Cornea: Sensation tests cranial nerve V (CN V) Arcus senilis - lipid deposits, seen in many elderly Pupils Pupils Check direct and consensual response to light Shine light source briefly into pupil, observing for constriction. Shine again into pupil, and observe for constriction of contralateral eye. Check accommodation (papillary constriction with near focus) Ask patient to look at finger held several feet from face, then to look at finger brought just beyond the end of the patient's nose. Findings: Findings: Miosis if <2mm (narcotic use, elderly) Miosis if <2mm (narcotic use, elderly) Mydriasis if >6mm (head injury, drugs) Mydriasis if >6mm (head injury, drugs) Anisocoria - unequal pupil size, may be normal variation Anisocoria - unequal pupil size, may be normal variation

hepatolenticular degeneration Kayser-Fleischer ring Arcus senilis cataract

Pterygium --growth of conjunctiva over cornea

sclera

ptosis (drooping of the upper eyelid from loss of sympathetic ptosis (drooping of the upper eyelid from loss of sympathetic innervation to the superior tarsal muscle) innervation to the superior tarsal muscle) anhidrosis (decreased sweating on the affected side of the face) anhidrosis (decreased sweating on the affected side of the face) miosis (small pupils) miosis (small pupils) enophthalmos (the impression that the eye is sunk in) enophthalmos (the impression that the eye is sunk in) Horner's syndrome

direct and consensual response to light

Accommodation

Extraocular eye movements Test CN III, IV, VI and 6 extraocular muscles (EOM). Technique Technique Patient watches your finger move through 6 "cardinal positions" Observe for coordinated movement, nystagmus (or "jerkiness" of motion. Findings Findings Lack of coordinated movement denotes problem with cranial nerves or muscle strength/alignment. Nystagmus- involuntary rhythmic eye movements A few beats of horizontal nystagmus at extreme lateral gaze is normal Lid lag- exposure of sclera over iris as patient moves eyes inferiorly (found in hyperthyroidism)

Extraocular eye movements

Lid lag (found in hyperthyroidism)

ANATOMY OF THE NOSE and SINUSES The nasal bridge is formed by the frontal and maxillary bones. The nasal bridge is formed by the frontal and maxillary bones. The septum divides the nose into two anterior cavities. Kiesselbach's plexus is a grouping of small blood vessels on the anterior septum. It is a frequent site of nosebleeds. The septum divides the nose into two anterior cavities. Kiesselbach's plexus is a grouping of small blood vessels on the anterior septum. It is a frequent site of nosebleeds. There are three paired turbinates - inferior, middle and superior. There are three paired turbinates - inferior, middle and superior. The sinuses are air-filled and paired extensions of the nasal cavities within the bones of the skull. The sinuses are air-filled and paired extensions of the nasal cavities within the bones of the skull. Frontal,Sphenoid, Ethmoid, Ethmoid,Maxillary

EXAMINATION of the NOSE Check patency by asking patient to occlude one nostril, and then breath through opposite nostril. Repeat for opposite nostril. External nose- - possible findings Deformity trauma External nose- - possible findings Deformity trauma Discharge infection, trauma, foreign body Discharge infection, trauma, foreign body Flaring respiratory distress Nasal cavity Nasal cavity Use nasal speculum, or larger ear speculum on an otoscope Ask patient to tilt head back Gently introduce the speculum into the vestibule, while visualizing the mucosa, and gently advancing the speculum until you can visualize the lower nasal cavity. If using a nasal speculum, open it in anterior-posterior direction, NOT pressing on sensitive septum Findings: Findings: Bluish, swollen mucosa- allergies Bluish, swollen mucosa- allergies Generalized redness- infection Generalized redness- infection Bleeding- often from Kiesselbach plexus, on anterior septum Bleeding- often from Kiesselbach plexus, on anterior septum

rosacea

External nose- - Deformities

nasal speculum If using a nasal speculum, open it in anterior-posterior direction, NOT pressing on sensitive septum NOT pressing on sensitive septum

Nasal cavity

EXAMINATION of the SINUSES Frontal and maxillary sinuses are the most accessible to examination Frontal and maxillary sinuses are the most accessible to examination Palpation and percussion may or may not be helpful - (sinus palpation or percussion is not reliable). Palpation and percussion may or may not be helpful - (sinus palpation or percussion is not reliable). The following increase the likelihood that your patient has sinusitis: The following increase the likelihood that your patient has sinusitis: History of colored nasal discharge History of colored nasal discharge Poor response to decongestants Poor response to decongestants Maxillary tooth pain Maxillary tooth pain Physical exam showing purulent nasal discharge Physical exam showing purulent nasal discharge

Sinuses

Frontal

Ethmoid

Maxillary

ANATOMY OF THE Mouth and OROPHARYNX The Oral Cavity is comprised of the vestibule and the mouth Vestibule - space between the buccal mucosa to the outer gingival The Oral Cavity is comprised of the vestibule and the mouth Vestibule - space between the buccal mucosa to the outer gingival Mouth - tongue, teeth and gums / Tongue anchored to floor of oral cavity posteriorly, and by frenulum anteriorly Mouth - tongue, teeth and gums / Tongue anchored to floor of oral cavity posteriorly, and by frenulum anteriorly Teeth and gums 32 adult teeth: 4 incisors, 2 canines, 4 premolars, 6 molars in each jaw Teeth and gums 32 adult teeth: 4 incisors, 2 canines, 4 premolars, 6 molars in each jaw Two paired salivary ducts enter the oral cavity Two paired salivary ducts enter the oral cavity Wharton's ducts, from the submandibular glands, open on each side of the tongue's frenulum Wharton's ducts, from the submandibular glands, open on each side of the tongue's frenulum Stensen's ducts, from the parotid glands, open onto the buccal mucosa across from the second molar of the upper jaw. Stensen's ducts, from the parotid glands, open onto the buccal mucosa across from the second molar of the upper jaw. The oropharynx is separated from the mouth by the anterior tonsillar pillars The oropharynx is separated from the mouth by the anterior tonsillar pillars Tonsils lie between the anterior and posterior tonsillar pillars Tonsils lie between the anterior and posterior tonsillar pillars

EXAMINATION of MOUTH and OROPHARYNX Inspect lips, buccal mucosa, gingival, teeth, tongue, floor and roof of mouth and the oropharynx. Use a light source (otoscope or pen-light). Use a gloved hand, or tongue depressor (preferable - some patients, particularly children or confused older adults may bite!), to gently retract structures (buccal wall, tongue) as necessary. To visualize the posterior oropharynx: ask the patient to say "AAAAAH." In some patients, oropharynx is better seen if patient does not extend tongue. In some patients, oropharynx is better seen if patient does not extend tongue. If needed, may place a tongue depressor on tongue on the distal half and gently depress it. If needed, may place a tongue depressor on tongue on the distal half and gently depress it. Percussion Percussion Done only as needed, in patients who have potential dental sources of oral pain. Done only as needed, in patients who have potential dental sources of oral pain. Gently tap or press on teeth that may be a source of pain using a tongue blade will identify which teeth are affected. Palpation Palpation Done only as needed, primarily in patients whom you suspect may have squamous cell cancer of the head and neck, or when assessing a lesion in the oropharynx. Use a gloved hand, and warn the patient that you may inadvertently gag him. Use a gloved hand, and warn the patient that you may inadvertently gag him. Gently palpate the surface of the lesion with one or two fingers to assess its size, consistency (soft, firm, hard), underlying induration and tenderness. Use bimanual palpation (examination fingers placed in mouth, other fingers below the jaw, to palpate the soft tissues on the floor of the mouth and the tongue.

Findings Lips Lips Angular cheilitis - fissures at corners of mouth Angular cheilitis - fissures at corners of mouth Actinic cheilitis- scaly raised lesions - sun damage, may precede cancer Actinic cheilitis- scaly raised lesions - sun damage, may precede cancer Angioedema - allergic swelling Angioedema - allergic swelling Herpes labialis- "cold sore “ Herpes labialis- "cold sore “ Carcinoma Carcinoma Colors: Colors: Pale- anemia Blue- cyanosis Red- CO poisoning Pale- anemia Blue- cyanosis Red- CO poisoning Buccal Mucosa: Buccal Mucosa: Thrush- adherent white patches\ Thrush- adherent white patches\ Tongue: Tongue: Geographic tongue - so-called because it resembles a map Smooth - may indicate vitamin deficiency Glossitis - erythematous, sometime swollen Black hairy tongue Varicosities Nonhealing ulcer or nodule- consider cancer Oropharynx Oropharynx Bifid uvula- may indicate cleft palate Bifid uvula- may indicate cleft palate Asymmetric movement of soft palate- lesion of CN IX or X Erythema, exudate- tonsillitis Asymmetric tonsillar swelling (often with deviation of uvula) - peritonsillar abscess "Cobble-stone" - swelling of lymphoid tissue, often secondary to allergies. Post-nasal drip

Pale

Infection

Cheilitis

Angioedema

cleft lip and palate

Geographic tongue

Black hairy tongue

Herpes labialis

Thrush- adherent white patches monilial infection

Enlargement of tonsil

Salivary Glands Look at the site of swelling :any skin changes/overlying scars? Look at the site of swelling :any skin changes/overlying scars? Palpate the lump relationship to skin? Fixed to underlying structures? Palpate the lump relationship to skin? Fixed to underlying structures? Look inside the mouth Look inside the mouth Inspect the gland and duct orifice Inspect the gland and duct orifice Bimanual palpation Bimanual palpation Cervical nodes Cervical nodes Any other pathology in the mouth? Any other pathology in the mouth?

epidemic parotitis

Acute purulent parotitis

Salivary Glands Tumor

ANATOMY OF THE NECK Triangles of the neck Triangles of the neck Anterior: Bordered by mandibles and sternocleidomastoids (SCM) Anterior: Bordered by mandibles and sternocleidomastoids (SCM) Posterior: Bordered by anterior margin of trapezius, posterior margin of the SCM, and superior margin of the clavicle. Posterior: Bordered by anterior margin of trapezius, posterior margin of the SCM, and superior margin of the clavicle.

EXAMINATION of the NECK Inspect the neck Inspect the neck Observe how the patient holds their head Observe how the patient holds their head Inspect the neck for symmetry, masses, goiter or scars, jugular vein distribution Inspect the neck for symmetry, masses, goiter or scars, jugular vein distribution Evaluation range of motion of neck Evaluation range of motion of neck Palpate the neck Palpate the neck Palpate the trachea with the index and ring finger on the sternoclavicular joint and middle finger on the trachea Palpate the trachea with the index and ring finger on the sternoclavicular joint and middle finger on the trachea Trachea: should be midline, palpate superior to suprasternal notch Trachea: should be midline, palpate superior to suprasternal notch Deviation may be sign of a mass or a tension pneumothorax Deviation may be sign of a mass or a tension pneumothorax Downward "tugging" may suggest aortic aneurysm Downward "tugging" may suggest aortic aneurysm

Congenital torticollis

EXAMINATION of the Thyroid Inspection Inspection Inspect the thyroid with the neck slightly extended, using tangential lighting. Goiter is essentially ruled out Inspect the thyroid with the neck slightly extended, using tangential lighting. Goiter is essentially ruled out Palpation: Palpation: palpate for size, nodules, and tenderness palpate for size, nodules, and tenderness Anterior or posterior approach Anterior or posterior approach Relax neck by using neutral position, also may further relax muscles on one side by tilting toward that side Relax neck by using neutral position, also may further relax muscles on one side by tilting toward that side Identify the appropriate level of the thyroid isthmus (below the cricoid cartilage). Identify the appropriate level of the thyroid isthmus (below the cricoid cartilage). Gently retract the trachea to the opposite side of the lobe you are palpating. Gently retract the trachea to the opposite side of the lobe you are palpating. Have the patient swallow a sip of water while you palpate Have the patient swallow a sip of water while you palpate

Anatomy

Inspection

Inspection Graves disease Thyroid adenoma thyroidectomy

Anterior Posterior Palpation

Bruit Put the stethoscope over the thyroid Put the stethoscope over the thyroid gland, and listen carefully. If a systolic gland, and listen carefully. If a systolic bruit heard over the thyroid is almost bruit heard over the thyroid is almost diagnostic of diffuse toxic goiter ( ↑ diagnostic of diffuse toxic goiter ( ↑ blood flow to the thyroid). blood flow to the thyroid). Auscultation

Trachea Masses in the neck may push the trachea to one side.tracheal deviation may also signify important problems in the thorax, such as a mediastinal mass,atelectasis, or a large pneumothorax