Head & Neck Examination

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Head Neck Examination

• Dr.AbdulWAHID M Salih
• M.D. Surgery

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• Posture, weight, body shape
• If pt. enters, examine
• Gait.
• Posture
• Biult(Wt)BMI kg/m2.Normallt25
• Height.
• Limb amputations, deformities

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• Built
• Causes of stunted growth are
• Malnutrition (commonest type).
• Malabsorption syndrome.
• Chronic diarrhea.
• Liver cirrhosis.
• Nephrotic syndrome.
• Cystic fibrosis.
• Chronic infections.
• Genetic disorders
• Turners syndrome.
• Dwarfism.
• Mongolism.
• Achondroplasia.
• Congenital cyanotic heart diseases
• Endocrinal Cretinism and pituitary infantilism.

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General Condition

• Alertness
• Consciousness
• Cooperation
• Orientation to time,place and persons
• Intelligence and memory

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The expression of the face

• Facies febrilis is characterised by shiny eyes,
  redness in the face, an uneasy expression
  (febrile diseases).
• Facies hippocratica is associated with
  the anxiety in face, cavernous cheeks, and sharp
  nose (sudden abdominal attack).
• Facies mitralis is associated with prominent
  livid colour of the cheeks and acral cyanosis in
  the face (mitral stenosis)
• Facies nefritica is represented by paleness,
  eyelid oedemas, and infiltration of the face
  (nephritis).  
• Facies pletorica is characterised by livid
  redness in face (polycythaemia).

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Facies in cases of endocrinopathy

• Acromegalymassive supraorbital arcs, enlargement
  of the nose, chin, and legs.  
• Thyrotoxicosis remarkable
• uneasy expression, shiny
• eyes, and exophthalmos.
• Myxoedemaa passive expression of a bloated face
  and thinned or missing eyebrows on the lateral
  side.
•  Cushing syndrome a moon face

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Hair cover

• different in men and in women.
• Alopecia (hairlessness) is the most common
  deviation.
• Diffuse alopecia
• Healthy men
• Febrile conditions
• After cytostatic treatment
• Hyperthyroidism.  
•  Local alopecia
• Often unknownoccurs
• Protracted stress
• Thyrotoxicosis

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Facial
hallmarks Tetanus a certain smile (risus
sardonicus). Myasthenia gravis weak smile and
bilateral ptosis. Toxic look Pulmonary
tuberculosis. Suppurative lung
diseases. Cachectic malignancy, malnutrition
chronic inflammatory diseases.
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Face

• Color of skin
• Symmetrical
• Edema of the face.
• Hair deficiency, excess.
• Hirsutism
• tumour of adrenal glands and ovaries
• Older women
• 5.Cranial nerves
• Normal vs. Abnormal
• Paralysis
• Stroke, trauma, bells palsy

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• Pigmentation in butterfly
• MS (malar flush)(red).
• SLE (red).
• Pellagra (brownish).
• Pregnancy (brownish).

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Eyebrows

• Symmetrical
•  Asymmetric
• Congenital facial disorders
• Defects of innervation of the upper branch of n.
  Vii
•  Loss of hair from Outer 1/3 Hypothyroidism.
• Artificial.

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Eyelids

• Swelling infiltration of the skin by a serous
  fluidBilaterally glomerulonephritis and
  hypothyroidism.   
• Unilaterally stye abscess of a sebaceous
  gland.   
• Eyeglass-like haematoma subcutaneous bleeding in
  skull base fracture.
• Epicanthus skin plica covering the inner corners
  of both eyes (mongolism Down syndrome).
• Ectropionan external (outward) rolling of
  the eyelid edge.
• Entropion is a rolling of the eyelid edge against
  the eyeball (inward).
• Xanthelasma on the upper eyelids, it can be
  single or multiple (hyperlipoproteinaemia).
• Hyperpigmentationin some cases of thyrotoxicosis.

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Eyes

• Exophthalmos
• Enophthalmos
• Strabismus
• Ptosis
• Puffy eyelids
• Sclera and Conjunctiva

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• 1-Exophthalmos
• Bilateral
• Thyrotoxicosis.
• Congenital.
• Unilateral
• Cavernous sinus thrombosis.
• Leukemic infiltrations behind the eyeball.
• Arteriovenous aneurysm
• between cavernous sinus
• and internal carotid artery.

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• 2-Enophthalmos
• Horners syndrome.
• Dehydration.
• Shock.
• Severe wasting.

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3-Strabismus

• Convergent strabismus (convergent squint) axes
  of the eyeballs converge
• Divergent strabismus (divergent squint)
• axes of the eyeballs diverge

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• 4-Ptosis
• Unilateral
• Horners syndrome (Pancoasts tumor).
• 3rd nerve palsy.
• Local eye disease.
• Congenital.
• Bilateral
• Myasthenia gravis.
• Congenital heart diseases.

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• 5-Puffy eyelids
• Chronic cough (commonest cause).
• Renal diseases.
• SVC thrombosis.
• Myxedema.
• Mediastinal syndrome
• Angioneurotic edema.
• Nutritional edema (hypoproteinemia).
• Advanced right-sided heart failure.

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6-Conjunctiva Anemia (to be seen in lower
lid). Jaundice. Inflammation Hyperaemia Subconjun
ctival hemorrhage severe
hypertension, chronic coughs
and blood diseases. Bitots spots ? vitamin A
deficiency.
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6-Conjunctiva Bluish discoloration Hypoproteinemi
a congenital osteogenesis imperfecta gradually
occurring anemias Yellow colour Icterus In
Hypercarotinemia. Xerophthalmia
keratoconjunctivitis (Sjögrens syndrome).
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Nose

• Adequate size and shape, symmetric, without
  secretion.
• Big nose acromegaly.
• Rhinophyma is an enlarged nose, with rough
  surface (potato nose).
• Saddle nose congenital syphilis.
• Asymmetric nose after injuries.
• Epistaxis (profuse nose bleeding)
• injuries,
• uncontrolled hypertension
• haemorrhagic diathesis or rhinitis.  

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Nose Redness in tip alcoholism, mitral
stenosis and cold weather. Working ala nasi
pneumonia, toxemia,nervousness, bronchial
asthma and respiratory failure. Nasolabial fold
vitamin B2 deficiency ? sulphur granules. Any
discharge from the nostrils. InflammationFuruncle
close to the nostrils.
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Lips

• symmetric, pink, smooth, and moist.
• Asymmetric lips paresis of the  facial nerve
• defective
  teeth.
• Pallor anemia.
• Cyanotic lips
• Dry lips Dehydration
• Inflamed lips Cheilitis thiamine deficiency.
• Herpes
  labialis.
• Anguli infectiosi vitamin B2 deficiency
• insufficient
  hygiene
• 
  immunodeficiency. 

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Equipment

• Assure that you have all the supplies necessary
  to complete an oral examination
• Mirror
• Tissue retractor (tongue blade)
• Dry gauze

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Exam Tongue

• Wrap the tongue in a dry gauze and gently pull it
  from side to side to observe the lateral borders
• Retract the tongue to view the inferior tissues

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Oral cavity

• Mucous membrane of oral cavity is pink, shiny,
  without pathological changes.
• Pale anaemia.
• Erythematous stomatitis.
• Black spots of melanin pigmentation Addison's
  diseas.
• Petechial hg haemorrhagic diathesis.  
• Erosion, ulcers agranulocytosis or acute
  leukaemia.
• Soor (thrush) whitish fur on mucous membrane
• antibiotic therapy
• elderly people
• immunodeficiency.

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Tongue

• sticks out in medial line, it is pink and wet.
• Deviation cerebral apoplexy
• Dry tongue dehydration
• breathing through the mouth
• saliva is decreased.
• uremia,
• intestinal obstruction
• Coated tongue
• diseases of the oral cavity
• systemic diseases.
• Leucoplakia blue-white
• (pre-cancer state).

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Tongue

• Atrophy of papillae
• (Hunter's glossitis)
• pernicious anemia
• iron deficiency anemia
• pellagra.
• Bitten tongue
• big epileptic seizure.
• Macroglosia
• acromegaly, myxoedema, angioneurotic oedema,
• and glossitis.

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Tongue Tumor Pallor severe
anemia. Cyanosis congenital heart diseases,
cor pulmonale, heart failur and arteriovenous
fistula. Tremors nervousness, thyrotoxicosis
and parkinsonism. Absence of fur heavy smokers
and fungus infection. lingual varicosities
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Exam

• Gums
• Hard palate
• Soft palate
• tonsilar pillars,
• tonsils,
• oropharynx

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Gums

• pink, strong, without bleeding signs.
• Erythematous gingivitis.
• Bleeding (scurvy).
• Coloured edge of greyish
• chronic intoxication by heavy metals (lead,
  bismuth).   

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Oral Cavity

• Teeth are fully developed, healthy.
• Teeth nicotine stains.
• Decayed teeth
• Defective teeth
• Dentures (prosthesis)

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Buccal Mucosa

• Observe color,
• Lesions
• Amalgam tattoo
• Palpate tissue
• Observe Stensons duct opening for inflammation
  or signs of blockage

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Floor Of The Mouth
Must dry to observe Visualize Whartons duct
Palpate bimanually
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Squamous cell carcinoma

Floor of mouth
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Tonsils

• Missing
• tonsillectomy.
• Hypertrophied with furrows
• chronic tonsillitis
• Enlarged, erythematous
• acute tonsillitis.
• Asymmetric, bulging
• retrotonsillar abscess or tumour.

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Pharynx Soft palate 

• Pharynx
• symmetrical, mucous membrane is pink,
• Soft palate 
• Yellowish or yellow palate
•  Erythematous - in respiratory infections.   

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• Breath
• Diabetic ketoacidosis ?
• acetone smell.
• Uremia ?
• ammonia smell.
• Hepatic failure ?
• fetor hepaticus (mossy smell).
• Suppurative lung diseases ?
• putrid smell.

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• Parotids
• Mumps.
• Parotid tumors.
• Parotid stones.
• Liver cirrhosis.
• Endemic parotiditis

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Ears

• Shape
• external auditory canal
• pressure on tragus are painless
• palpation on processus mastoideus are painless.
• Gouty tophi on auricle are yellowish
  subcutaneous deposits of urates.
• Secretion in the auditory meatus meatus
  inflammation or otitis media.
• Bleeding from the auditory meatus  trauma.
• Pain when pulling the auricle, pressing on
  the tragus, and percussion onto processus
  mastoideus occur in case of otitis media or
  mastoiditis.

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Examination of the neck

• inspection, palpation, and auscultation  
• Inspection The shape and length of neck are
  proportional to the body.
• Slim neck cachexia the supraclavicular areas
  are notably sunken.
• Strong neck obese people.
• Pulsations of carotid visible in skinny people
  ,exertion, hypertension, hyperthyrodism, aortic
  insufficiency.
• Horizontal scar state after thyroidectomy,

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• Neck
• Describe the enlargement if present.
• Goitre
• enlarged lymphatic nodes
• filling of neck veins
• Post-radiation changes on the skin of the neck
  after radiotherapy 
• Movement is free in all directions.
• Change of posture
• Deviation to the side result of bleeding into
  the neck muscles
• muscle rupturefibrositis, or reflex spasm
  of muscles.
• 2.Opisthotonus inversion to the back in case of
  tetanus. 

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Palpation

• Carotid artery Weakened or not palpable
  pulsation
• contraction
• complete obstruction of the vessel lumen.
• Thyroid gland
• normally neither visible nor palpable.
• Goitre diffuse or nodal.

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Auscultation

• Carotids
• systolic murmur
• Aortic stenosis(bilateral audibility)
• carotid artery stenosis (asymmetric audibile). 
• Goitre
• The murmur can also be audible above.

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• TracheaShifted to site of lesion
• Lung or pleural fibrosis
• lung collapse.Shifted to opposite side
• Pleural effusion,
• Pneumothorax,
• Lung tumors
• Thyroid swelling.

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Lymph Nodes

• Head and Neck
• preauricular
• postauricular
• occipital
• tonsillar
• submandibular
• submental

• superficial anterior cervical
• deep cervical
• posterior cervical
• supraclavicular
• infraclavicular

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Cervical LN location

• Preauricular - In front of the ear
• Postauricular - Behind the ear
• Occipital - At the base of the skull
• Tonsillar - At the angle of the jaw
• Submandibular - Under the jaw on the side
• Submental - Under the jaw in the midline
• Superficial (Anterior) Cervical - Over and in
  front of the sternomastoid muscle
• Supraclavicular - In the angle of the
  sternomastoid and the clavicle

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Regional lymphatic nodes

• Enlargement of inflamed node
• Single node
• chronic tonsillitis, nasopharyngitis, gingivitis,
  and dental affections.
• Multiple nodes
• tuberculosis, sarcoidosis, toxoplasmosis,
  infectious mononucleosis, and others.
• Enlargement of tumorous node
• Single node rigid solitary metastasis, e.g.
  Virchow's node in stomach carcinoma.
• Multiple nodes multiple metastases (thyroid
  gland carcinoma), haematological diseases
  (chronic lymphatic leukaemia, lymphomas).

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Lymph Nodes

• Submental
• Drains Lower 2 incisors Tip of tongue
  Center of lower lip Center of mandible

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Submandibular Drains Submental glands Ant.
2/3 of tongue, except tip Remainder of lower
lip not drained by submental Dentition
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Upper, lower deep cervical Location top and
bottom of SCM. Upper and lower groups. Both
drains Ant. neck inf. to hyoid. Tongue
Dentition Paratracheal nodes Superior
drains Upper hard palate 
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deep cervical

• The deep cervical chain of lymph nodes lies below
  the sternomastoid and cannot be palpated without
  getting underneath the muscle
• Inform the patient that this procedure will cause
  some discomfort.
• Hook your fingers under the anterior edge of the
  sternomastoid muscle.
• Ask the patient to bend their neck toward the
  side you are examining.
• Move the muscle backward and palpate for the deep
  nodes underneath.

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Preauricular Drains Ant. of meatus 2 finger
widths ant. of ear Postauricular Drains
Pinna Nearby scalp Occipital
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Supraclavicular Dx is Virchow's node, usually Lt
one Classically, stomach CA GI CA Pelvic
CA Other CAs  Infraclavicular Location
inferior to clavicle, in groove between pec
major and deltoid.
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Paratracheal Locationlateral to trachea
Drains Neck deep tissues associated with
recurrent laryngeal
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Lymph nodes of the head and neck, and the regions
that they drain
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Pallor

• detected in mucus membranes of lips, lower lids
  (not upper lids because of trachoma) and palms
• Anemia.
• Malignancy.
• Blood diseases.
• Infective endocarditis.
• Parasitic infestations.
• Malnutrition.
• Chronic infections.
• Rheumatic fever.

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• Jaundice
• yellow discoloration of the sclera and mucus
  membranes,
• apparent clinically when serum bilirubin exceeds
  2-3 mg/dl
• Cardiac (due to liver congestion)
• Right sided heart failure.
• Constrictive pericarditis.
• TS and TI.
• 2.Chest causes
• Pulmonary infarction (hemolysis of blood).
• Liver affection secondary to antituberculous
  drugs.
• Cor pulmonale.
• N.B Rifampicin changes color of body secretion
  to orange.
• 3Liver causes.
• 4.Blood causes
• as hemolytic anemia

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Cyanosis It is bluish
discoloration of the lips and mucus membranes
due to raised level of reduced HB in capillaries
more than 5 gm/dl (normally 1-2 gm/dl), so dont
say cyanosis with pallor. Normally O2 saturation
of arterial blood ? 95-99. O2 saturation of
venous blood ? 70. Cyanosis is apparent
clinically when O2 saturation is below
80. Types of cyanosis Central cyanosis
Peripheral cyanosis
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• Hydration
• Sunken orbits.
• Mucus membrane dryness.
• Skin turgor pinch skin normal returns
  immediately.
• Postural hypotension less BP when sit, stand.
• Peripheral perfusion press nose, time capillary
  return.
• Examine weight loss over hours.

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• Lower limbs
• Edema
• Unilateral or bilateral.
• Pitting or non-pitting.
• Tender calf muscles
• DVT
• peripheral neuritis.
• Rashes.
• Clubbing, spooning and cyanosis(nails).
• Pulsations.
• Hairs loss of hairs ? chronic ischemia.

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Differential Idiopathic Vascular Infectious
Neoplastic Degenerative Inflammatory
Congenital Autoimmune Trauma Endocrine and
metabolic Allergic Iatrogenic Drugs