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Physical Exam of the Head & Neck INTRODUCTION It is usually the initial part of a general physical exam, after the vital signs. It begins with inspection, and then proceeds to palpation. It requires the use of several special instruments in order to inspect the eyes and ears, and special techniques to assess their special sensory function. EXAMINATION of the HEAD Inspection Observe the patient's facial expression and appearance. Look for symmetry, size, shape, masses and involuntary movements Hair: Observe quantity, distribution, texture, pattern of any hair loss. Look for lice or nits (the eggs of lice) Scalp: Part the hair in several places and look for scaliness, erythema, skin lesions and nodules Palpation • Palpate with finger pads • Generally, palpation is done only if patient symptomatic (head pain, trauma, etc.) • Skull: deformity from trauma, muscular tenderness from tension headaches • Temporal arteries: thickening, tenderness, or absent pulse in temporal arteritis • Hair: texture may change in thyroid disease, becoming more coarse • Palpation of the lymph nodes Deformities of skull (cranium) Microcephaly a congenitally small skull resulting from failure of the brain Macrocephalus is an abnormally large head due to hydrocephalus, Paget’s disease (osteitis deformans), and acromegaly Oxycephaly (steeple skull) characterized by a long anteroposterior axis, narrow in width, and pointed at the vertex. It is caused by premature union of the cranial sutures Microcephaly Macrocephalus hydrocephalus setting sun phenomenon steeple skull Apert syndrome a form of acrocephalosyndactyly steeple skull + syndactyly ANATOMY OF THE EAR External ear • Auricle (or pinna) and external auditory canal are cartilage covered with thin, sensitive skin • Cerumen secreted from distal 1/3 of canal- protects skin Middle ear: • Tympanic membrane (TM) normally looks "pearly gray" • Pars tensa- inferior 2/3 • Pars flaccida- superior 1/3 (covers the chorda tympani) • Umbo- where malleus attaches to TM, • Malleus- manubrium (handle) and short process are visible • Eustachian tube- equalizes middle ear pressure Inner ear: • The cochlea and semicircular canals EXAMINATION of the EAR Inspection External ear - observe position and shape, inspect for symmetry, lesions, drainage from external auditory meatus Position: Top of auricle should be above line drawn between outer canthus of eye and occipital protuberance. Low set auricle may signify chromosomal abnormality. Possible findings Tophi- deposits of uric acid crystals found in patients with gout Chondritis- infection of cartilage, often caused by piercing "Cauliflower"-repeated trauma causes cartilage necrosis Otitis externa- "swimmer's ear", pulling on lobe often painful Skin cancer - often nodular, with induration, scaling and superficial ulceration. External ear auricular tophus postauricular cyst Middle ear - otoscopic exam Insert otoscope slowly, avoiding bumping the canal Cerumen removal may be necessary Cerumen spoon- often causes EAC bleeding Irrigation - contraindicated if TM perforation Removal with direct visualization Pneumatic otoscopy • assesses mobility and compliance of TM • Effusion (fluid in middle ear) will hamper TM mobility • Retraction from eustachian tube dysfunction may allow movement only with negative pressure Findings Mobility • Bulging, no mobility • Retracted, no mobility Color • Red • Deep red or blue • White flecks, plaques Bubbles Pus in middle ear- otitis media (OM) Eustacian tube dysfunction +/- effusion Infection, crying Blood (from trauma) Healed inflammation Serous fluid The Ear-Hearing assessment Response to questions during history Response to a whispered voice Tuning fork air/bone conduction Rinne (left) Weber (right) ANATOMY OF THE EYE External eye: Eyelids, lacrimal gland and duct, palpebral fissures, medial and lateral angles. Internal eye: Light travels through cornea, anterior chamber, pupil, lens, and vitreous body on the way to the retina. Fundus: The posterior structures of the eye include the retina, retinal arteries and veins, the optic disc and the macula. These structures are viewed with the ophthalmoscope ANATOMY OF THE EYE External eye: Eyelids, lacrimal gland and duct, palpebral fissures, medial and lateral angles. Internal eye: light travels through cornea, anterior chamber, pupil, lens, and vitreous body on the way to the retina. Fundus: The posterior structures of the eye include the retina, retinal arteries and veins, the optic disc and the macula. These structures are viewed with the ophthalmoscope EXAMINATION of the EYE Vision testing • Should be done with any visit involving an eye complaint • Used to screen children for visual problems Acuity: • Far vision - test at 6 m with Snellen chart • Patient covers one eye, and is instructed to read the smallest line possible. Patient must correctly read half of symbols on line. Repeat for other eye. • Near vision - test at 35cm with pocket chart • Patient covers one eye, and is instructed to read smallest line possible. Repeat for other eye. Visual fields: • Confrontation test estimates peripheral vision (may be important in glaucoma, multiple sclerosis, stroke, or pituitary or other CNS tumor) • Use your own visual fields as a reference Technique - face patient at eye level. Ask patient to cover one eye. Slowly move your fingers from outside the patient's peripheral visual field towards the center of the patient's vision. Ask the patient to tell you when he sees your fingers. EXAMINATION of the EYE Be systematic – inspect eyebrows, lids, and globe including conjunctivae Findings Eyebrows: Loss of lateral growth may suggest hypothyroidism Xanthelasma -irregular, slightly raised yellow periorbital lesions may suggest lipid disorder Eyelids : Ptosis - if upper lid covers part of pupil (muscle weakness or neurologic lesion) Ectropion (lid turned out) Entropion (lid turned in) Hordeolum (stye)-inflammation of sebaceous gland Foreign body - may need to evert lid for full inspection Conjunctiva: Hemorrhage- from trauma Eyelid edema Entropion (lid turned in) Ectropion (lid turned out) Ptosis After treated with neostigmine myasthenia gravis autoimmune neuromuscular disease Ptosis bilateral unilateral subconjunctival hemorrhage chemosis conjunctiva Pale palpebral conjunctiva Facial schingles with conjunctivitis EXAMINATION of the EYE Conjunctivitis- inflammation from infection, allergy... Pterygium - growth of conjunctiva over cornea Cornea: Sensation tests cranial nerve V (CN V) Arcus senilis - lipid deposits, seen in many elderly Pupils Check direct and consensual response to light Shine light source briefly into pupil, observing for constriction. Shine again into pupil, and observe for constriction of contralateral eye. Check accommodation (papillary constriction with near focus) Ask patient to look at finger held several feet from face, then to look at finger brought just beyond the end of the patient's nose. Findings: • Miosis if <2mm (narcotic use, elderly) • Mydriasis if >6mm (head injury, drugs) • Anisocoria - unequal pupil size, may be normal variation hepatolenticular degeneration Kayser-Fleischer ring Arcus senilis cataract Pterygium --growth of conjunctiva over cornea sclera Horner's syndrome ptosis (drooping of the upper eyelid from loss of sympathetic innervation to the superior tarsal muscle) anhidrosis (decreased sweating on the affected side of the face) miosis (small pupils) enophthalmos (the impression that the eye is sunk in) direct and consensual response to light Accommodation Extraocular eye movements Test CN III, IV, VI and 6 extraocular muscles (EOM). Technique Patient watches your finger move through 6 "cardinal positions" Observe for coordinated movement, nystagmus (or "jerkiness" of motion. Findings Lack of coordinated movement denotes problem with cranial nerves or muscle strength/alignment. Nystagmus- involuntary rhythmic eye movements A few beats of horizontal nystagmus at extreme lateral gaze is normal Lid lag- exposure of sclera over iris as patient moves eyes inferiorly (found in hyperthyroidism) Extraocular eye movements Lid lag (found in hyperthyroidism) ANATOMY OF THE NOSE and SINUSES The nasal bridge is formed by the frontal and maxillary bones. The septum divides the nose into two anterior cavities. Kiesselbach's plexus is a grouping of small blood vessels on the anterior septum. It is a frequent site of nosebleeds. There are three paired turbinates - inferior, middle and superior. The sinuses are air-filled and paired extensions of the nasal cavities within the bones of the skull. Frontal, Sphenoid, Ethmoid, Maxillary EXAMINATION of the NOSE Check patency by asking patient to occlude one nostril, and then breath through opposite nostril. Repeat for opposite nostril. External nose- - possible findings Deformity trauma Discharge infection, trauma, foreign body Flaring respiratory distress Nasal cavity Use nasal speculum, or larger ear speculum on an otoscope Ask patient to tilt head back Gently introduce the speculum into the vestibule, while visualizing the mucosa, and gently advancing the speculum until you can visualize the lower nasal cavity. If using a nasal speculum, open it in anterior-posterior direction, NOT pressing on sensitive septum Findings: Bluish, swollen mucosaallergies Generalized rednessinfection Bleedingoften from Kiesselbach plexus, on anterior septum rosacea External nose- Deformities nasal speculum If using a nasal speculum, open it in anterior-posterior direction, NOT pressing on sensitive septum Nasal cavity EXAMINATION of the SINUSES Frontal and maxillary sinuses are the most accessible to examination Palpation and percussion may or may not be helpful - (sinus palpation or percussion is not reliable) . The following increase the likelihood that your patient has sinusitis: History of colored nasal discharge Poor response to decongestants Maxillary tooth pain Physical exam showing purulent nasal discharge Sinuses Frontal Ethmoid Maxillary ANATOMY OF THE Mouth and OROPHARYNX The Oral Cavity is comprised of the vestibule and the mouth Vestibule - space between the buccal mucosa to the outer gingival Mouth - tongue, teeth and gums / Tongue anchored to floor of oral cavity posteriorly, and by frenulum anteriorly Teeth and gums 32 adult teeth: 4 incisors, 2 canines, 4 premolars, 6 molars in each jaw Two paired salivary ducts enter the oral cavity Wharton's ducts, from the submandibular glands, open on each side of the tongue's frenulum Stensen's ducts, from the parotid glands, open onto the buccal mucosa across from the second molar of the upper jaw. The oropharynx is separated from the mouth by the anterior tonsillar pillars Tonsils lie between the anterior and posterior tonsillar pillars EXAMINATION of MOUTH and OROPHARYNX Inspect lips, buccal mucosa, gingival, teeth, tongue, floor and roof of mouth and the oropharynx. Use a light source (otoscope or pen-light). Use a gloved hand, or tongue depressor (preferable - some patients, particularly children or confused older adults may bite!), to gently retract structures (buccal wall, tongue) as necessary. To visualize the posterior oropharynx: ask the patient to say "AAAAAH." In some patients, oropharynx is better seen if patient does not extend tongue. If needed, may place a tongue depressor on tongue on the distal half and gently depress it. • Percussion Done only as needed, in patients who have potential dental sources of oral pain. Gently tap or press on teeth that may be a source of pain using a tongue blade will identify which teeth are affected. • Palpation Done only as needed, primarily in patients whom you suspect may have squamous cell cancer of the head and neck, or when assessing a lesion in the oropharynx. Use a gloved hand, and warn the patient that you may inadvertently gag him. Gently palpate the surface of the lesion with one or two fingers to assess its size, consistency (soft, firm, hard), underlying induration and tenderness. Use bimanual palpation (examination fingers placed in mouth, other fingers below the jaw, to palpate the soft tissues on the floor of the mouth and the tongue. • • • • • Angular cheilitis - fissures at corners of mouth Actinic cheilitis- scaly raised lesions - sun damage, may precede cancer Angioedema - allergic swelling Herpes labialis- "cold sore“ Carcinoma Colors: • Pale- Findings Lips anemia • Blue- cyanosis • Red- CO poisoning Buccal Mucosa: • Thrush- adherent white patches\ Tongue: Geographic tongue - so-called because it resembles a map Smooth - may indicate vitamin deficiency Glossitis - erythematous, sometime swollen Black hairy tongue Varicosities Nonhealing ulcer or nodule- consider cancer Oropharynx Bifid uvula- may indicate cleft palate Asymmetric movement of soft palate- lesion of CN IX or X Erythema, exudate- tonsillitis Asymmetric tonsillar swelling (often with deviation of uvula) - peritonsillar abscess "Cobble-stone" - swelling of lymphoid tissue, often secondary to allergies. Post-nasal drip Pale Infection Cheilitis Angioedema cleft lip and palate Geographic tongue Black hairy tongue Herpes labialis Thrush- adherent white patches monilial infection Enlargement of tonsil Salivary Glands Look at the site of swelling :any skin changes/overlying scars? Palpate the lump relationship to skin? Fixed to underlying structures? Look inside the mouth Inspect the gland and duct orifice Bimanual palpation Cervical nodes Any other pathology in the mouth? epidemic parotitis Acute purulent parotitis Salivary Glands Tumor ANATOMY OF THE NECK Triangles of the neck Anterior: Bordered by mandibles and sternocleidomastoids (SCM) Posterior: Bordered by anterior margin of trapezius, posterior margin of the SCM, and superior margin of the clavicle. EXAMINATION of the NECK Inspect the neck Observe how the patient holds their head Inspect the neck for symmetry, masses, goiter or scars, jugular vein distribution Evaluation range of motion of neck Palpate the neck • Palpate the trachea with the index and ring finger on the sternoclavicular joint and middle finger on the trachea • Trachea: should be midline, palpate superior to suprasternal notch • Deviation may be sign of a mass or a tension pneumothorax • Downward "tugging" may suggest aortic aneurysm Congenital torticollis EXAMINATION of the Thyroid •Inspection • Inspect the thyroid with the neck slightly extended, using tangential lighting. Goiter is essentially ruled out •Palpation: • palpate for size, nodules, and tenderness • Anterior or posterior approach • Relax neck by using neutral position, also may further relax muscles on one side by tilting toward that side • Identify the appropriate level of the thyroid isthmus (below the cricoid cartilage). • Gently retract the trachea to the opposite side of the lobe you are palpating. • Have the patient swallow a sip of water while you palpate Anatomy Inspection Inspection Graves disease thyroidectomy Thyroid adenoma Palpation Anterior Posterior Auscultation Bruit Put the stethoscope over the thyroid gland, and listen carefully. If a systolic bruit heard over the thyroid is almost diagnostic of diffuse toxic goiter (↑ blood flow to the thyroid). Trachea Masses in the neck may push the trachea to one side.tracheal deviation may also signify important problems in the thorax, such as a mediastinal mass,atelectasis, or a large pneumothorax
