Assessment of the Head and Neck

1
Assessment of the Head and Neck

• Head, Sinuses, and Neck
• Eyes and Ears
• Oropharynx and Nasopharynx

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Review of Related History

• Head trauma and sequelae
• Sequelae consequences, after effects
• Brain tumor and sequelae
• Headache
• Full symptom analysis
• Stiff neck
• Injury, strain, swelling
• Fever, bacterial or viral illness

3
Review of Related History

• Dizziness
• Sensation of faintness
• Vertigo
• Sensation of spinning
• Self internal
• Room or objects external
• Weakness
• Falls

4
Review of Related History

• Epistaxis
• Nosebleed
• Nasal discharge
• Frequent URIs
• Colds
• Seasonal allergies
• Nasal discharge
• Color and amount

5
Review of Related History

• Facial pain
• Sinusitis
• Painful ulcers or sores (mouth, lips, nose)
• Bleeding gums
• Sore throat
• Strep throat

6
Review of Related History

• Abnormal taste
• Hypogeusia
• Decreased sensitivity to taste
• -geusia a suffix meaning taste
• Dysgeusia
• Unpleasant taste
• Hoarseness
• Dysphagia

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Review of Related History

• Changes in vision
• Diplopia
• Double vision
• Blurred vision
• Halos
• Excessive tearing
• Burning of the eyes
• Eye pain
• Use of assistive devices

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Review of Related History

• Changes in hearing
• Ear pain
• Use of assistive devices

9
Review of Related History

• Thyroid problem
• Swelling in the neck area
• Change in temperature preference texture of
  hair, skin, nails menstrual patterns energy
  levels
• Tachycardia, palpitations
• Palpitations beating of the heart so vigorously
  that the person is aware of it

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Equipment

• Light source
• Tongue blade
• Cotton balls
• Tape measure
• Stethoscope
• Otoscope
• Snellen Eye Chart or Pocket Vision Card
• Ophthalmoscope

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Techniques

• Inspection
• Palpation

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General Considerations

• The head and neck exam is not a single, fixed
  sequence
• Different portions are included depending on the
  examiner and the situation
• It is usually most efficient to examine the ears,
  nose and throat in one smooth sequence

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Head
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Lymph Nodes

• Preauricular
• Postauricular
• Occipital
• Tonsillar
• Submandibular
• Submental
• Anterior Cervical Chain
• Posterior Cervical Chain
• Supraclavicular

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Inspection Head

• Observe head position and movement
• Normal upright, midline and still
• Jerking may indicate tremor
• Nodding may indicate aortic stenosis
• Inspect skull and scalp
• Size
• Shape
• Symmetry
• Lesions

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Inspection Head

• Inspect facial features
• Shape and Symmetry
• Cranial Nerve V (Trigeminal)
• Motor
• Jaw opening and clenching
• Mastication (chewing)
• Sensory
• Sensation over the face

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Inspection Head

• Inspect facial features
• Shape and Symmetry (Cont.)
• Cranial Nerve VII (Facial)
• Motor
• Raise eyebrows
• Smile, frown, and show teeth
• Puff out cheeks
• Close eyes tightly
• Sensory
• Taste anterior 2/3 of tongue

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Inspection Head

• Inspect facial features
• Unusual features
• Edema tissue swelling
• Prominent eyes
• Hyperthyroidism
• Sunken eyes
• Dehydration, malnutrition
• Hirsutism excessive hair growth
• Alopecia hair loss

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Inspection Head

• Unusual Features (cont.)
• Tics Spasmodic muscular contractions
• Facies
• An expression or appearance of the head and neck
  that, when taken together, are characteristic of
  a clinical condition or syndrome

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CushingSyndrome
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Myxedema
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Exophthalmos
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Acromegaly
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Down Syndrome
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Down Syndrome
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Palpation Head

• Palpate using a gentle rotary motion
• Proceed from front to back
• Skull and Scalp
• Contour smooth
• Symmetry
• Tenderness
• Scalp movement

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Palpation Head

• Hair as previously discussed

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Palpation Head

• Palpate for lymph nodes

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Sinuses
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Examination of the Sinuses

• Inspect the area over the frontal and maxillary
  sinuses
• Transillumination may be done if a problem is
  suspected
• Palpate over the frontal and maxillary sinuses
• Percuss over the frontal and maxillary sinuses

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Palpation Sinuses

• Palpate over the frontal and maxillary sinuses

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Palpation Sinuses
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Neck
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Anatomy
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Anatomy
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Anatomy
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Inspection Neck

• Inspect in
• Usual anatomic position
• Slight hyperextension
• Extension movement that increases the angle of
  a joint to 180 straightening the joint
• Hyperextension exaggerated extension
• gt 180
• As the person swallows with neck hyperextended

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Inspection Neck

• Inspect for
• Symmetry
• Alignment of trachea
• Fullness
• Masses, webbing, skin folds
• Jugular vein distention
• Carotid artery prominence
• Cranial Nerve XI (Spinal Accessory)
• Ability to shrug shoulders with and without
  resistance and turn head

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Palpation Neck

• Trachea
• Position
• Tugging
• Lymph nodes

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Cricoid Cartilage
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Examination of the Eyes
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Visual Acuity

• Cranial Nerve II (Optic)
• Allow the person to use glasses or contact lenses
• You are interested in the person's best corrected
  vision
• Position the person 20 feet in front of the
  Snellen eye chart (or hold a Rosenbaum pocket
  card at a 14-inch "reading" distance)

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Visual Acuity

• Have the person cover one eye at a time with a
  card
• Ask the person to read progressively smaller
  letters until they can go no further
• Record the smallest line the person read
  successfully
• Repeat with the other eye
• Repeat with both eyes

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Visual Acuity

• Visual acuity is reported as a pair of numbers
  (e.g., 20/20) where the first number is how far
  the person is from the chart and the second
  number is the distance from which the "normal
  eye can read a line of letters
• For example, 20/40 means that at 20 feet the
  person can only read letters a "normal" person
  can read from twice that distance

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Inspection Eyes

• Observe the person for ptosis, exophthalmos,
  lesions, deformities, or asymmetry
• Ask the person to look up and pull down both
  lower eyelids to inspect the conjunctiva and
  sclera
• Next spread each eye open with your thumb and
  index finger
• Ask the person to look to each side, upward and
  downward to expose the entire bulbar surface.
• Note any discoloration, redness, discharge, or
  lesions
• Note any deformity of the iris or lesion cornea

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Inspection of Conjunctiva
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Visual Fields

• Cranial Nerve II
• Stand two feet in front of the person and have
  them look into your eyes
• Hold your hands to the side half way between you
  and the person
• Wiggle the fingers on one hand
• Ask the person to indicate which side they see
  your fingers move
• Repeat two or three times to test both temporal
  fields

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Visual Fields
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Visual Fields

• To test for neglect, on some trials wiggle your
  right and left fingers simultaneously
• The person should see movement in both hands
• If an abnormality is suspected, test the four
  quadrants of each eye while asking the person to
  cover the opposite eye with a card

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Corneal Reflections

• Shine a light from directly in front of the
  person
• The corneal reflections should be near the center
  of the pupils
• Asymmetry suggests extraocular muscle pathology

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Extraocular Movements (EOM)

• Cranial Nerves III (Oculomotor), IV (Trochlear),
  and VI (Abducens)
• Stand or sit 3 to 6 feet in front of the person
• Ask the person to follow your finger with their
  eyes without moving their head
• Check gaze in the six cardinal directions using a
  six-sided cross or "H" pattern
• Hold in the 4 corners momentarily to check for
  nystagmus
• Check convergence by moving your finger toward
  the bridge of the person's nose

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Eye Patterns
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Testing EOMs
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Pupillary Reactions

• Cranial Nerve II
• Dim the room lights as necessary
• Ask the person to look into the distance
• Shine a bright light obliquely into each pupil in
  turn
• Once in each eye, observing response in that eye
  (direct)
• A second time in each eye, observing response in
  opposite eye (consensual)
• Record pupil size in mm and any asymmetry or
  irregularity

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Pupillary Reactions
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Pupillary Reactions

• Check the reaction to accommodation (near
  reaction)
• Hold your finger about 10cm from the person's
  nose
• Bring your finger in toward the nose and watch
  for pupillary constriction as you near the nose

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Pupillary Reactions

• PERRLA is a common abbreviation
• Stands for "Pupils Equal Round Reactive to Light
  and Accommodation."
• The use of this term is so routine that it is
  often used incorrectly
• If you did not specifically check the
  accommodation reaction use the term PERRL

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Using the Ophthalmoscope

• The fundus of the eye includes the retina,
  macula, fovea, optic disc and retinal vessels
• This is only visible through the use of the
  ophthalmoscope

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Fundus of the Eye
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Using the Ophthalmoscope

• Darken the room as much as possible
• Adjust the ophthalmoscope so that the light is no
  brighter than necessary
• Adjust the aperture to a plain white circle
• Set the diopter dial to zero unless you
  have determined a better setting for your
  eyes

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Using the Ophthalmoscope

• .Position your hand so that your index finger is
  free to manipulate the diopter dial
• Alternatively, you may hold it to use your thumb
  for adjusting diopters

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Using the Ophthalmoscope

• Use your left hand and left eye to examine the
  person's left eye
• Use your right hand and right eye to examine the
  person's right eye
• Place your free hand on the person's
  shoulder for better control.
• Ask the person to stare at a point on the wall or
  corner of the room.

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Using the Ophthalmoscope

• Look through the ophthalmoscope and shine the
  light into the person's eye from about two feet
  away
• You should see the retina as a "red reflex."
  Follow the red color to move within a few inches
  of the person's eye

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Examination of the Ears
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Auditory Acuity

• Cranial Nerve VIII (Acoustic)
• Whisper Test
• Stand 1-2 feet away and whisper monosyllabic and
  bisyllabic words
• Weber Test
• Strike tuning fork an place on top of the head
• Sound should be heard equally well in both ears

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Auditory Acuity

• Rinne Test
• Strike tuning fork an place on mastoid (bone
  conduction)
• When sound no longer heard move tuning fork in
  front of the ear (air conduction)
• AC 2x gt BC

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External Ears

• Inspect the auricles (should be aligned) and move
  them around gently
• Ask the person if this is painful
• Palpate the mastoid process for tenderness or
  deformity

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Otoscopic Exam

• Hold the otoscope with your thumb and fingers so
  that the ulnar aspect of your hand makes contact
  with the person
• Straighten the canal
• Adults Pull the ear upwards and backwards
• Children Pull the ear downwards and backwards
• Insert the otoscope to a point just beyond the
  protective hairs in the ear canal
• Use the largest speculum that will fit
  comfortably
• Inspect the ear canal noting redness, drainage,
  or foreign body

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Otoscopic Exam

• Inspect the middle ear structures

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Oropharynx and Nasopharynx
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Oropharynx Inspection

• Lips
• Color
• Moisture
• Ulcers
• Lesions
• Cracking
• Edema

• Buccal Mucosa
• Color
• Ulcers
• White patches
• Plaques
• Nodules

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Oropharynx Inspection

• Cranial Nerve XII (Hypoglossal)
• Tongue movement for speech and articulation (l,
  t, n)
• swallowing
• Teeth
• Occlusion
• Condition and number

• Gums
• Color
• Edema
• Bleeding
• Hard and soft Palates
• Color
• Configuration

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Oropharynx Inspection

• Tonsillar area
• Presence
• Color
• Uvula position
• Swelling
• Exudate

• Cranial Nerve X (Vagus)
• Hard and soft palate rise with phonation
• Cranial Nerve IX (Glossopharyngeal)
• Gag reflex
• Taste posterior 1/3 of tongue
• Swallowing and phonation

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Nose Inspection

• External structures
• Symmetry
• Size
• Septal deviation
• Cranial Nerve I (Olfactory)
• Sense of smell

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Nose Inspection

• Internal structures
• Tilt persons head backward
• Use a nasal speculum to examine the interior of
  the nares
• Examine for
• Color
• Exudate
• Polyps
• Sites of recent bleeding
• Septal deviation
• In the absence of a nasal speculum, you will only
  be able to observe the lower turbinates

76
Developmental Variations

• Neonates and Infants
• Skull bones are soft and separated
• Sutures Ossification begins at around 6 years of
  age
• Sagittal
• Coronal
• Lambdoidal
• Fontanels
• Anterior
• Ossify by around 18-24 months of age
• Posterior
• Ossify by around 2-3 months of age

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Neonatal Skull
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Developmental Variations

• Neonates and Infants
• Neonatal Variations at Birth
• Molding
• Overlapping cranial bones
• Caput Succedaneum
• Soft tissue swelling
• Crosses the suture lines
• Cephalhematoma
• Bleeding into the periosteum
• Does not cross the suture lines

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Caput Succedaneum
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Cephalhematoma
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Developmental Variations

• Neonates and Infants
• Head circumference very important up to two years
  of age
• Transillumination of the skull
• Not done as much as in the past
• Drooling is common up to on year of age
• Check for cleft lip and palate
• Neonates are obligatory nose breathers
• Maxillary and ethmoid sinuses very small

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Developmental Variations

• Neonates and Infants
• Eustachian tube is wide, short, and more
  horizontal
• Prone to otitis media
• Ear infection
• Deciduous teeth appear between 6 and 24 months

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Developmental Variations

• Children
• Subtle changes in facial appearance throughout
• Achieves visual acuity of 20/20 by 6 years of age
• Bruits are common in children up to age 5 or in
  children with anemia
• The thyroid of a young child may be palpable
• Should not be tender
• Watch for allergic salute
• Crease at the juncture between the cartilage and
  bone of the nose
• Maxillary sinuses may be palpated

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Developmental Variations

• Adolescents
• Males
• The nose and cricoid cartilage enlarge
• Facial hair develops
• First on the upper lip, then on cheeks, lower
  lip, and chin

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Developmental Variations

• Pregnancy
• Thyroid often enlarges
• May hear a thyroid bruit
• Chloasma (melasma)
• Edema and erythema of the nose and pharynx are
  common
• Epistaxis
• Nasal stuffiness
• Hypertrophy of the gums
• May bleed with brushing

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Developmental Variations

• Older Adults
• Thyroid may feel more nodular or irregular on
  palpation
• Be careful with range of motion
• Skin changes on the face and neck
• Buccal and nasal mucosa dryer
• Increased coarse nasal hairs (especially in men)
• Presbyopia (change in accommodation)
• Lens is more rigid, ciliary muscles of iris
  weaker

87
Videos of Examination of the Head and Neck

• Copy and paste these URLs into your Web browser.
• http//www.webster.edu/davittdc/index.html
• OR
• http//www.conntutorials.com/chapter8.html
• OR
• http//medinfo.ufl.edu/other/opeta/heent/HE_main.h
  tml