1. Head & Neck Physical Examination (Chapter 4) PHCL 326 NORA A. KALAGI MARCH 2016 1

2. Introduction HEENT  The HEENT, or Head, Eye, Ear, Nose & Throat Exam is usually the initial part of a general physical exam, after the vital signs  Like other parts of the physical exam, it begins with inspection, & then proceeds to palpation  It requires the use of several special instruments in order to inspect the eyes & ears, & special techniques to assess their special sensory function 2 Head & Neck

3. Structure of the Head 3 Head & Neck

4. Examination of The Head  Skull  Hair  Scalp & Face  Eyes  Nose  Neck  Ears  Mouth & Pharynx 4 Head & Neck

5. Skull Inspection ◦ for size, contour, shape & evidence of trauma Palpation ◦ for lumps, bumps & evidence of trauma 5 Head & Neck

6. Hair & Scalp Inspection ◦ for quantity, texture & distribution of the hair ◦ Inspect scalp for lesions & scales Palpation ◦ for texture (fine, dry, oily) 6 Head & Neck

7. Face Inspect the face for expression, symmetry, movement, lesions & edema 7 Head & Neck

8. Eyes 8 Head & Neck

9. Eyes.. Inspection Inspect the external & internal structures of the eyes Inspect the pupil size, shape & symmetric Assess iris for abnormal pigments or deposits Sclera should be white Conjunctiva clear 9

10. Eyes Inspection Test pupil reaction to light ◦ Dark condition ->> dilate ◦ Bright ->> constrict ◦ Normal response recorded as PERRLA?? ◦Pupils equal, round and reactive to light and accommodation 10 Head & Neck

11. Eye.. Mydriasis ◦Prolonged abnormal dilation of the pupil of the eyes induced by a drug or caused by disease.  Drugs with anticholinergic properties (e.g. Atropine) Miosis ◦An excessive constriction of the pupil of the eye. Either a normal response to an increase light or caused by drug or pathological condition or drugs  Opioid narcotics (e.g. Morphine) Periorbital edema ◦Edema of the eyelids in association with local injury, allergic reactions, hypoproteinemia Exophthalmos ◦Abnormal protrusion of the eye ball 11

12. Eye.. External structure 12

13. Eye.. Visual Acuity assessment Inspection General acuity can be obtained by reading a general sentence from any printed material (e.g., book, magazine, newspaper) The Snellen eye chart provides more accurate assessment 13 Head & Neck

14. Snellen Chart 14 The chart with the large E on the top line followed by a series of lines with increasingly smaller print

15. Eyes.. Checking Visual Fields Inspection Test peripheral visual fields with the confrontation technique ◦ It does not provide an accurate mapping of visual fields ◦ The test is useful for general screening and monitoring tool 15 Head & Neck

16. Eyes.. Assess extraocular muscles movement  Assess the extraocular muscles by having the patient follow the movements of your finger with his/her eyes (keeping the head stationary) as the finger is moved in all the six cardinal directions  These directions corresponds to the coordinated actions of the 6 muscles involved in eye movement, innervated by the cranial nerve (II, IV, VI)  The eyes normally follow the finger smoothly and in parallel with the movements; however, lateral nystagmus may occur normally.  Abnormalities indicate either problems with the cranial nerves that supply the eye muscles or problems with the eye muscles themselves. 16

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18. Eye.. Internal structures Inspection Inspect the retinal blood vessels & optic disc, 18 Head & Neck

19. Inspect the retinal blood vessels and optic disc using the ophthalmoscope for any lesions The retinal blood vessels are usually the first structures seen. Retinal arteries are thinner and brighter red than retinal veins. Note the size, color, and status of the arteriovenous crossings in all regions of the eyes. 19 DescriptionCause Red, linear, or flame shapedBleeding in nerve fiber retinal layer Red, roundBleeding in deeper retinal layers White cotton-wool appearanceHypertension, diabetes Eyes.. Internal structures

20. Eye.. Internal structures  Inspect the optic disc for size, shape, and sharpness of the borders and estimate the cup/disc ratio.  The optic disc, the head of the optic nerve (also known as the blind spot) is a yellowish ovoid.  Glaucoma is characterized by an increased cup/disc ratio 20

21. Nose 21 Head & Neck

22. Nose Inspection Inspect external nose and nasal cavity for symmetry, inflammation & lesions Palpation Palpate the frontal, ethmoid & maxillary sinuses for tenderness 22 Head & Neck

23. Nose 23 Sinuses inspection

24. Ears 24 Head & Neck

25. Ears Inspection  Inspect external ear for lesions, trauma, & size  Inspect ear canal & tympanic membrane with Otoscope  Inspect the canal for foreign bodies, discharge, color & edema  Inspect the tympanic membrane for color & perforation Palpation Palpate the external ear for nodules 25 Head & Neck

26. Ears 26

27. Hearing Simple  A commonly used but relatively inaccurate assessment of hearing is to test, one ear at a time  Assess the ability of the patient to hear a sequence of equally accented words/numbers (3-5-2-4) whispered from a distance of a couple of feet 27 Head & Neck

28. Auditory Acuity assessment  If the patient does not complain of hearing loss, this part of the exam is omitted.  Detecting Conductive v. Sensorineural Deficits: As with acuity, these tests would only be performed if the patient complained of hearing loss.  Transmission of sound can be broken into two components:  Conduction: The passage of sound from outside to the level of the 8th cranial nerve. This includes transmission of sound through the external canal and middle ears.  Sensorineural: The transmission of sound through the 8th nerve to the brain. 28

29. Hearing Other test: A.Rinne Test  The Rinne test compares sensitivity with bone and air conduction  By Placing the tip of a vibrating tuning fork (128 or 512 Hz) on the mastoid process behind the ear 29 Head & Neck

30. Hearing 30 B. Weber Test  The Weber’s test, place the tip of a vibrating tuning fork on the center of the patient’s forehead

31. Mouth & Pharynx 31 Head & Neck

32. Mouth & Pharynx 32

33. Mouth & Pharynx Inspection  Inspect the lips & mucosa for color, ulcerations, hydration & lesions  Inspect the teeth & gums for color, bleeding, inflammation, caries, missing teeth, ulcerations & lesions 33 Head & Neck

34. Mouth & Pharynx Inspection  Inspect the tonsils for color, exudates, lesions & ulcerations  Inspect the sides of the tongue for color, symmetry, ulceration & lesions  Note the odor of breath (examples?) ◦(e.g., alcohol odor in alcoholic intoxication, urinous odor in uremia, sweetish fruity odor in diabetes mellitus with ketoacidosis, a musty odor [fetor hepaticus] in severe parenchymal liver disease). 34 Head & Neck

35. Mouth & Pharynx Oral lesion: 35

36. Mouth & Pharynx 36

37. Neck Inspection Inspect the neck for symmetry, masses, and enlargement of gland and lymph node. 37 Head & Neck

38. Neck Palpation Palpate the trachea with the thumb on one side & the index & middle finger on other side of trachea, it should be midline Palpate the lymph nodes for size, shape, mobility, and tenderness. 38 Head & Neck

39. Neck Palpate the thyroid gland for size, shape, symmetry, tenderness, and nodules. 39

40. Neck 40

41. Neck 41  Assess Jugular Venus Pressure (JVP)

42. Thank you 42