1. The Head and Neck Lecture 1 Dr. Maysa Almomani Nur 206, Fall 2015 Chapter 7

2. Head, Eyes, Ears, Nose, Throat, (HEENT),& Neck Identify key anatomic structures important in examining H & N – Regions of the skull – Anatomic detail of the eye – Three bones of middle ear, auricle, & pinna – Nasal turbinates – Sinuses – Nine groups of cervical lymph nodes

3. Assessment Techniques for HEENT & Neck Visual acuity Extraocular movements Pupillary reaction Fundoscopic exam Auditory acuity Oral and pharyngeal mucosa Gums, Cervical lymph nodes, Cricoid cartilage, Thyroid isthmus and lobes

4. HEENT History Descriptors 1.Mode of onset a. describe events coincident with onset b. onset gradual or sudden? c. total duration of the symptom 2.Location of the symptom 3.Character of the symptom 4.Radiation of the symptom 5.Frequency of the symptom 6.Precipitating factors 7.Aggravating factors

5. HEENT History 8. Relieving factors 9.Associated symptoms 10.Course of symptoms (getting worse, better, etc) 11.Effect of symptoms on daily life 12.Past treatment or evaluation of the symptom a. when, where, by whom? b. what studies were done and what were the results? c. results of past treatment d. past diagnosis 13.Patients concerns

6. The Head

7. Health History (Head) Headaches Full description and 7 attributes of pain: 1.Location (One-sided, bilateral, radiates? ) 2.Quality (what is it like?) Steady or throbbing? 3.Quantity or severity (how bad? Pain Rating scale) 4.Timing (when does/did it occur? For how long? How often?) Continuous or comes and goes?

8. Headaches 5.Setting in which it occurs (environmental, activities, emotional reaction, circumstances) 6.Remitting or exacerbating (anything makes it better or worse?) e.g. coughing, sneezing, changing positions 7.Associated manifestations (anything else that accompanies pain?) e.g. nausea, vomiting, neurological, such as change in vision or motor sensory deficits Point to area of pain and discomfort Family History (migraine)

9. Types of Headache Tension headache (bilateral, generalized or localized to back of head: muscle tension, emotional) Migraine (dilatation of arteries outside or inside the skull, or generalized: tension, foods, PMS, noise, bright light) Cluster headache (face pain, unilateral stuffy, runny nose, reddening and tearing of the eye) Vascular headache (dilatation of arteries inside skull, generalized: due to caffeine withdrawal, fever) Headaches with eye disorders (face pain: due to farsightedness, astigmatism, acute glaucoma, increased IOP ) SEE Table 7-1(p. 249)

10. Head – Inspection and Palpation Inspect – Hair distribution, quantity – Scalp – scaling, nevi – Skull – size, contour – Face – expression, contours – Skin – color, pigmentation, hair distribution, lesions Palpate – Hair texture – Skull – lumps – Face – sinuses – Skin – texture, temperature

11. Examining the Head The hair – I: Quantity, distribution, pattern of loss, – P: texture, The scalp – Scaling, nevi, lesion The skull – General size and contour, deformities, – depressions, lumps, tenderness

12. Examining the Head The face – Facial expression, contour, symmetry, features, movement, edema, masses – sinuses The skin – Color, pigmentation, thickness, hair distribution, lesions – texture, temperature

13. Anatomy of the Eye Puncta Pupil Limbus Iris

15. Anatomy of the Eye Tear fluid protects the conjunctiva & cornea from : drying & inhibits microbial growth gives a smooth optical surface to the cornea The fluid comes from: -meibomian glands within the eyelids -conjunctival glands -lacrimal glands lies mostly within the bony orbit -

16. The Eye

17. Aqueous humor is a clear liquid fills the anterior and posterior champers of the eye. It is produced by the ciliary body, circulates from the posterior chamber the pupil anterior chamber drains out through the canal of Schlemm This circulation control the pressure inside the eye

18. Circulation of Aqueous Humor

19. Optic chiasm, at the base of the frontal lobe of the brain

20. The Eye Eye and vision problems Change in vision? Is the onset sudden or gradual sudden visual loss suggests: retinal detachment and occlusion of the central retinal artery.

21. The Health History (Eye) Common or concerning symptoms – Worse during close work or at distances? Hyperopia (farsightedness ) Presbyopia ( ( aging vision) inability to focus on near objects that often occurs in middle-aged persons) Myopia (nearsightedness) – Blurring? Macular degeneration, peripheral loss in advanced glaucoma, one-sided loss in hemianopsia

22. The Eye Scotomas (spots or specks in the vision / areas where the patient cannot see & suggesting – move around with eye movement (vitreous floaters) – fixed (lesions in the retinas or visual pathway) Flashing lights (detachment of vitreous from retina) Pain in or around the eyes, redness, excessive tearing or watering

23. The Eye Double vision (diplopia): due to lesion in brain stem or cerebellum, Extra ocular muscle weakness or paralysis – Horizontal (cranial nerve III, VI) – Vertical – Which eye? One eye cornea or lens

24. Examining the Eye Visual acuity Visual fields Conjunctiva & Sclera Cornea, lens, pupils Extraocular movements Fundi, including – Optic disk and cup – Retina – Retinal vessels

25. Visual Acuity Snellen Eye Chart (to test the acuity of central vision) – Position 20 feet from the chart – Put your glasses if you use them – Cover one eye with the card – Read smallest line possible – Position patient closer to chart, if can’t read largest letter – Note the distance

26. Snellen Eye Chart – The smallest row that can be read accurately indicates the patient's visual acuity in that eye – e.g. 20/30 *20 indicates the distance of the pt. *30 indicates the distance at which a normal person can read the line

27. Snellen Eye Chart “20/40 corrected” Patient could read the 40 line with glasses (a correction) In US, a person considered legally blind when the vision in the better eye, corrected by glasses, is 20/200 or less.

28. Snellen Eye Chart Estimates visual acuity In each eye separately

29. Visual Fields by Confrontation Normal: - Assuming the examiner has normal field of vision, patient should have the same extent of field of vision. - If you find a defect, test one eye at time - Use a small red object

30. Visual Fields by Confrontation Screening: temporal quadrants of each eye by confrontation Technique – Position self in front of patient. – nose is medial field of vision. – Patient's right eye to your left eye and vice versa. – Patient to look straight not move eyes. – Place your hands about 2 feet apart – Compare your field of vision with the patient. – Bring your finger from the right field of vision until it is recognized – Test all four quadrants. Both eyes at same time Abn.: one eye at a time http://www.youtube.com/watch?nomobile=1&edufilter=_RCxmPbsbl2nprwt8_MfhA&v=jdaq-Ecz7Co Normal: Assuming the examiner has normal field of vision, patient should have the same extent of field of vision.

31. Visual Fields Abnormality reflects lesion in visual pathways Localizing a lesion – Neurologic lesions – Optic nerve lesion Blind spots Scotomas Homonymous hemianopsia (optic tract). A loss of vision in the nasal half of the visual field of one eye and the temporal half of the visual field of the other eye. Bitemporal hemianopsia (optic chiasm). Hemianopia in the temporal halves of the visual fields of both eyes. Quadrantic defects (optic radiation partial ) See book page 254 Table 7-5

32. External Examination of the Eyes - Inspection Position and alignment of the eye – Assess inward or outward deviation, abnormal protrusion, such as ocular tumors Eyebrows - quantity and distribution – Scaliness/ scaling (seborrheic dermatitis) – lateral thinning in hypothyroidism

33. External Examination of the Eyes - Inspection Eyelids – Surrounding tissues – Width palpebral fissure – Edema of lids – Color of lids – Lesions – Condition & direction of eyelashes (ectropian: lower lid outward, entropian: inward) – Adequacy of eyelid closure (prominent eyes, facial paralysis)

34. External Examination of the Eyes - Inspection Lacrimal apparatus – Excess tearing or dryness – Lacrimal gland and lacrimal sac for swelling – Tear drainage from nasolacrimal duct (characteristics) Conjunctiva and sclera – Color (&translucency), vascular pattern, nodules, swelling ( yellow sclera indicates jaundice) * ask patients to look up as you depress both lower lids with your thumbs inspect for color and vascular patterns.

35. External Examination of the Eyes - Inspection Cornea and lens – Oblique lighting (from 2 feets) – Check for opacities, Iris: markings clearly defined – Anterior chamber: Apply tangential light to cornea and assess whether you are able to see the entire Iris without a shadow – Normally flat, crescentic shadow indicates “narrow angle glaucoma blocked drainage of aqueous humor and increase IOP"

36. External Examination of the Eyes - Inspection Pupils (pt look at a distant object & Flash a light) – Assess pupillary size, shape, symmetry, reactions (cranial nerves II and III ) – Large> 5mm (mydriasis: dilation), small <3mm (miosis: constriction) – Direct reaction (pupillary constriction in same eye) – Consensual reaction (pupillary constriction in the opposite eye) – If the light reaction is absent, test the near reaction – Prevent near reaction by using both the distance and the oblique lighting. – Darken the room and use bright light.

37. External Examination of the Eye The Near Reaction Technique: – Patient head still – Watch examiner’s finger – Move slowly Accommodation and convergence – Ask the patient to follow your finger as you bring it toward the bridge of his nose. – Note the convergence of the eyes and pupillary constriction. Normal: Convergence should be sustainable to within 5-8 cm & both pupils constrict poor ……in hyperthyroidism

38. Normal Findings 20/20 vision Eye balls are symmetrical in size and position. The upper lid covers upper portion of cornea, when the patient is looking straight. Eye lashes span outwards Lacrimal apparatus: Small lacrimal gland is recognizable. Hair distribution in eyebrows is in its entire length The sclera is white in color The palpebral conjunctiva appears pink.

39. Normal Findings Cornea is translucent, smooth and a vascular. Anterior chamber is clear with aqueous humor Iris is flat and color varies No shadow is cast when Iris is visualized with a tangential light no evidence of glaucoma Pupil is centrally located in the Iris Lens is transparent and uniform in density

40. Normal Findings Pupils are subtle, mild 0.05mm anisocoria (unequal in size) by itself and not necessarily an abnormal findings. Pupil size is 3-5 mm in diameter. They react briskly to light. Both pupils constrict consensually.

41. View of the eye muscles EOM

42. View of the eye muscles

43. Extraocular muscles (EOMs) (movement of the eye) Extraocular muscles (movement of eyes, cranial nerves III, IV, VI, & the six Extraocular muscles they innervate) – Oculomotor nerve (III)- right inferior rectus (responsible for moving the eye: most muscles of the orbit) – Trochlear nerve (IV)- superior oblique muscle (moves eye downward) – Abducens nerve (VI): lateral rectus muscle (moves eye laterally)

44. Extraocular muscles (EOMs) (movement of the eye) Ask pt to follow your finger or pencil through the six directions of gaze -to the pt extreme right -to the right and upward -down on the right -to the extreme left -to the left and upward -down on the left

45. Extraocular Movement Trace “H” Left Eye Movement, Cranial Nerves, & Muscles involved

46. The superior rectus muscle is a muscle in the orbit that elevates, adducts, and rotates the eye medially.muscleorbit As with most of the muscles of the orbit, it is innervated by the oculomotor nerve (Cranial Nerve III).innervatedoculomotor nerve The inferior rectus muscle is a muscle in the orbit that depresses, adducts, and rotates the eye laterally.muscleorbit As with most of the muscles of the orbit, it is innervated by the oculomotor nerve (Cranial Nerve III).innervatedoculomotor nerve The lateral rectus muscle is a muscle in the orbit that abducts the eyeball (makes it move outwards).muscleorbit It is the only muscle of the orbit innervated by the abducent nerve (Cranial Nerve VI).innervatedabducent nerve

47. . The medial rectus muscle is a muscle in the orbit that adducts the eyeball (makes it move inwards).muscleorbit As with most of the muscles of the orbit, it is innervated by the inferior division of the oculomotor nerve (Cranial Nerve III).innervatedoculomotor nerve Its origin is the anular tendon. The superior oblique muscle is a muscle in the orbit that causes the eye to look downwards when it is already directed medially (looking towards the nose).muscleorbiteye It is the only muscle supplied by the trochlear nerve. The superior oblique loops through a pulley like structure (the trochlea) to get the desired movement.trochlear nerve The inferior oblique muscle is a muscle in the orbit that adducts (medially rotates) and elevates the eyeball (i.e. it makes the eye move inward and upward).muscleorbit As with most of the muscles of the orbit, it is innervated by the oculomotor nerve (Cranial Nerve III).innervatedoculomotor nerve Its origin is the inferior rim of the orbit, directly below the supraorbital notch. It inserts laterally onto the eyeball, deep to the lateral rectus, by a short flat tendon. It elevates the eye most when it is already adducted.

48. In summary, the SIX cardinal directions of GAZE are as follows: (OD = right eye; OS = left eye) RIGHT & UP: OD = superior rectus, OS = inferior oblique RIGHT: OD = lateral rectus, OS = medial rectus RIGHT & DOWN: OD = inferior rectus; OS = superior oblique LEFT & UP: OD = inferior oblique, OS = superior rectus LEFT: OD = medial rectus, OS = lateral rectus LEFT & DOWN: OD = superior oblique, OS = inferior rectus

49. Normal Findings Full conjugate eye movements. No nystagmus in any direction No nystagmus : Jerky, oscillatory eye movements No Lid lag ( when eye move from above to downward)

50. The Eyes Examination :Inspection Lid lag / hyperthyrodism

51. Ophthalmoscopic Examination Perform direct opthalmoscopy, assess: – red reflex ( absence of red reflex suggests an opacity of the lens, cataract) – optic cup & disc – retinal blood vessels – retinal background – macula

52. The Eye

53. Opthalmoscopic Exam Patient focus on distant object (dark room) Both you and the patient should remove glasses if worn but contact lenses don’t need to be removed Switch on the scope light and turn the lens disc until you see the large round beam of white light. Adjust the size of the incident light beam to the size of the pupil. Ophthalmoscope should be close to your eyes. Your head and the scope should move together Set the lens opening at 0 diopters. With the ophthalmoscope 12-15 inches from the patient's eye. &angle of 15 degrees lateral to the patient’s line of vision Check for red reflex and opacities in lens or aqueous.

54. Opthalmoscopic Exam While adjusting the diopter setting, approach the patient more closely and systematically inspect the disc, noting the color, shape, margins and cup-to-disc ratio. Rt to Rt…Lt to Lt eyes Inspect vessels, noting obstruction, arterial/venous ratio. Note the presence of arterial/venous nicking and arterial light reflex. Check background by inspecting for pigmentation, hemorrhages, exudates. Next, try to identify the macula.

55. Normal Eye Fundus Disc – margins are sharp – color: yellowish orange to creamy pink – shape: round or oval – Cup to disc ratio: less than half – Central Cup :yellowish white Vessels – AV ratio 3:4 – No AV crossing – arterial light reflex Fundus background – No exudates (Yellow spot) or hemorrhages (red spot) – color : red to purplish Macula ( ( fovea is the center) -macula is located 2.5 disc distance temporal to dis -Tiny bright reflection (fovea): center -no vessels noted around Macula -it may be slightly pigmented

56. Features of the Arteries and Veins in the Retina Artery: bright light red, smaller than vein, Vein dark red, larger, inconspicuous or absent --------------------------------------------------------- Detecting papilledema: swelling of the optic disk and anterior pulging of the physiological cup. Can suggest serious disorder like meningitis, trauma, subarchenoid hemorrhage, mass/lesion

57. Diabetic Retinopathy

58. Abnormal results may include myopia, or nearsightedness, which is the ability to see near objects better than far objects hyperopia, or farsightedness, which is the ability to see far objects better than near objects presbyopia or an inability to focus on near objects that often occurs in middle-aged persons blurred vision (astigmatism) Color blindness which is an inability to see certain colors blocked tear duct, or a blockage in the tube that carries tears away from the eye cataract or a clouding of the lens in the eye that can cause vision problems eye trauma or injury strabismus an eye movement disorder, also called lazy eye glaucoma damage to the optic nerve, blood vessels, or fundus scratches or defects on the cornea

59. Abnormal findings/ Eye Ptosis: – Dropping of the upper lid

60. Abnormal findings/ Eye Sty: – A painful, tender red infection in a gland at the margin of the eyelid.

61. Abnormal findings/ Eye Chalazion: – Painless nodule, inside the led

62. Abnormal findings/ Eye Entropion ; an inward turning of the led margin. Ectropion ; the margin of the lower lid is turned outward exposing the palpebral conjunctiva See page 255