Download Clinical Guidelines for Head and Neck Examination

Clinical Guidelines for Head and Neck Examination
PARTICIPANT________________________ Date Observed___________
CHECKLIST FOR Head and Neck EXAMINATION
STEP/TASK
CASES
GETTING READY
1. Greet the patient respectfully and with kindness.
2. Tell the patient you are going to examine his/ her head and neck.
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
3. Ask the patient to uncover his/her head. Ask the patient to sit on the
examining table with arms at sides.
4. Wash hands thoroughly and dry them. If necessary, put on new
examination or high-level disinfected surgical gloves on both hands.
A) Examination of the Head
1.
THE SCALP:



Elicit History
Examine the scalp for hair distribution, a swelling, or an ulcer.
Examine a swelling :
-Inspection for the number, site , size, shape, color , surface,
edge, pulsation
-Palpation for hotness, tenderness, size, shape, surface, edge or
margin, consistency and mobility or fixity
-Special characters e.g. fluctuation, translucency, pulsation and
anatomical plan
- Regional Examination for :
a) lymph nodes enlargement
b)Circulatory sufficiency (arterial pulse , venous drainage ,presence of
varicose veins or lymphdema)
c)Nerve lesion ( motor or sensory deficits)

Examine an ulcer for:
-Inspection for number, site, size, shape, floor, edge, discharge ,
surrounding area for associated abnormalities
-Palpation for tenderness, edge, base, mobility or fixity to underlying
tissue.
-Regional Examination( as before)
2. THE SKULL:



Elicit History
Examine for the size ,shape
Regional Examination
3. THE CRANIAL NERVES: (look at CGL no…..)
4.THE EYE:
-Look for Jaundice
-Examine for Exophthalmos
-Fundus examination (CGL no ...)
5. THE NOSE
Inspect for shape ,size , deformity
Skin changes over the nose (ulcer, nodule, etc..)
6.THE EAR
Look for deformities( shape ,size, accessory auricle)
Inspect for swelling or ulcer
Otoscope (CGL NO…)
7.THE MOUTH:







Examine the mouth wearing a glove
Use a good light and spatula
Retract the lip to see the buccal mucosa
Push the cheek outwards to see the buccal side of the gum
Push the tongue away from the inside of the gum and the floor of
mouth; then push it aside to see the lateral aspect of its posterior
third
Depress the tongue to look at fauces, tonsils and pharynx
Always remember to palpate the structures in the mouth
bimanually; one finger inside the mouth and one outside.
a)Examination of the lip:
-Inspect and palpate the lips for any pigmentation, excoriation, scars,
ulcers, swellings (localized or diffuse) or other anomalies.
-Evert the lip fully to examine the mucous surface of its inner aspect and
the gingivo-labial fold
-Regional Examination( as before)
b)Examination of the cheeks:
-The angle of the mouth is retracted, and the interior is illuminated with a
torch
-Examine the interior of the cheek for pigmentations, ulcers, swellings
-If a parotid disease is suspected examine the orifice of the parotid duct.
c)Examination of the teeth:
-Ask the patient to open his /her mouth
-Inspect the teeth for their shape, color, dental carries and presence of
rough or broken edges.
-Look for pulpless, impacted, non-erupted or missing teeth by counting
their number
-If patient wears denture ask for its removal before proceeding with the
examination, notice if it is smooth and well fitting.
d)Examination of the gum:
-Evert the lips fully to inspect the gums
-Look for their color ,the crenated edges ,the relation to the necks of the
teeth, pigmentation ,ulcers , swellings
e)Examination of the tongue:
-Examine the tongue for size, shape ,color, surface ,mobility
-Determine the general condition of the mucous membrane; dry or moist,
clean or furred
-Note if there is any swelling ( diffuse or localized)or ulcer or fissures
(describe it )
-To palpate the tongue it should be relaxed and at rest within the mouth.
-To palpate the posterior quarter of the tongue, ask the patient to open
his/her mouth widely. Holding all the fingers of the left hand stiff and
straight, press the fingers firmly into the cheek in such a way that they
intervene between the teeth. Should the patient bite, he/she will bite his/her
cheek and not your palpating finger.
-Regional Examination(before)
f)Examination of the floor of the mouth :
-Ask the patient to open the mouth and to put the tip of the tongue on the
roof of the mouth and to bend the head slightly backwards.
-Inspect the floor of the mouth and the undersurface of the tongue
-Do bimanual palpation for any visible swelling
g)Examination of the fauces and the palate
-Ask the patient to tilt his /her head slightly backwards and to open the
mouth to its fullest extent
-In good light ,observe ,ask the patient to say AH, notice the movement of
the palate
-Depress the tongue with a spatula and through a light on the throat
-Inspect the tonsils,pillarsof the fauces the posterior pharyngeal wall
-To palpate he pharynx, the patient is seated on a stool and the examiner
stands on his/her right side. The head is held firmly with the left hand, the
index finger of which is pushed in between the jaws to prevent the patient
from biting the examiner's finger. The right index finger is then passed
behind the soft palate to palpate the posterior nares, nasopharynx and back
of tongue.
-Look for palatal deformity, defect , perforation, swelling, ulcer
8. THE SALIVARY GLANDS

The parotid gland:
-Inspection( of the gland, the duct , the face)
Inspection of the gland( generalized or localized swelling),ask the patient
to clinch the teeth( contraction of the masseter muscle)
Inspection of the duct, retract the cheek with spatula and look for the
orifice of the Stenson`s duct opposite the second upper molar tooth. Apply
gentle pressure over the gland and note any discharge or pus or blood
Inspection of the face for any asymmetry and examine for facial nerve
paralysis (look at CGL no….)
Test for the movements of the jaw
-Palpation
Palpate the main body of the gland .Assess the swelling for hotness,
tenderness, surface , edge, consistency
Palpation of the duct:
Its anterior part is best – palpated bidigitally, between the index finger
inside the mouth and the thumb over the cheek
The posterior part is palpated by rolling the finger across the duct while
the patient clinches the teeth to contract the muscle( the posterior part lies
over the masseter)
Relations: Examine the two jaws, the temporomandibular joints, the other
salivary glands and the cervical lymph nodes on both sides
Bimanual examination helps in determining if there is a deep lobe
enlargement.

The submandibular salivary gland:
Inspection: inspect the submandibular triangle, and note if there is a
swelling beneath and in front of the angle of the jaw.
Inspect the floor of the mouth( as before).Notice if the orifice of the
Wharton's ducts on either sides of the fraenum lingue are red or
swollen
Apply steady pressure over the gland and see if purulent saliva exudes
from the orifices
Insert a dry swab under the tongue and drop some lemon juice on the
dorsum. Remove the swab and look for the flow of saliva from the
two ducts
Palpation:
Bimanual palpation; the patient's head is flexed and inclined slightly
to the affected side. Insert the index finger into the mouth and
insinuate its tip between the alveolus and side of the tongue just
behind the last molar tooth. With the help of the fingers of the other
hand placed beneath the jaw, palpate the gland and the duct from
behind forwards
9.THE JAW and TEMPEROMANDIBULAR Joints

Elicit history (loss of teeth, unilateral nasal obstruction, epiphora,
or nasal discharge. Ask about trauma, irradiation, dental sepsis
,sinusitis , tooth extraction or generalized bone ache and joint
disease )

Examine the upper jaw ( the maxilla) systematically
-The anterolateral surface
-The upper surface
-The inferior surface
-The medial surface
-The posterior surface




Examine the cervical lymph nodes
Test the integrity of the second division of the fifth cranial nerve
Transillumination of the maxillary sinus
Examine the lower jaw
Inspect the mandible for the site and character of any swelling and
the condition of the overlying skin
Ask the patient to open the mouth and inspect the alveolar margin,
the gingivolabial folds and the floor of the mouth
Note if a swelling affects one aspect of the bone or expands to
include both surfaces of the bone
Palpation of the body, angle and lower part of the ramus of the
mandible from within and from outside the mouth.
Bimanual palpation for the upper portion of the ramus and its
codyloid and coronoid processes
Examine all aspects of the bone and note the characters of any
swelling

Temporomandibular joints :
Ask the patient to open and close the mouth and note any deformity ,
dental malocclusion ,or limitation of movement
Place the finger over the joint while the patient opens and closes
his/her mouth; notice if there any crepitus or clicking.
B) EXAMINATION OF THE NECK
X
X
X
X
X


X
X
X
X
X
Elicit History
Exposure :all clothing are removed as far as the nipple line

Inspection:
Observe the contour of the neck and report any anomaly
Follow routine examination for a swelling
Ask the patient to swallow and notice if there any movement
with deglutition( e.g. thyroid swelling )
Define the anatomical site of any swelling
Look for neck pulsations, dilated veins, any scare

Palpation :
In general swelling of the neck are examined from behind
The patient sits on a stool ; his/her head flexed passively with
one hand and palpate the swelling with the other hand
The head is also flexed passively towards the side of the
swelling
Always feel lumps in the neck with muscles relaxed and
contracted ( the sternomastoid and the trapezius)
The relation to the trachea : the movement with swallowing
The relation to the hyoid bone : the movement with the
protrusion of tongue
Palpation of the cervical lymph nodes: Can be done either
from the front or behind the patient
Examine all the groups systematically( superficial and deep,
upper and lower)
Thyroid swelling : Find the relation to
The skin
The sternomastoid
The larynx and trachea
The Carotid vessels: At the upper border of the thyroid
cartilage, examine one side at a time.
The suprasternal notch


Percussion : percuss over the manubrium sterni in order to
rule out retrosternal extension( dull on percussion)
Auscultation; in thyrotoxicosis a systolic or continuous
bruit may be heard over the thyroid gland ( mainly over
the superior thyroid artery)
PARTICIPANT IS ___ QUALIFIED ___ NOT QUALIFIED TO PERFORM
BREAST EXAMINATION BASED ON THE FOLLOWING CRITERIA: