Assessment of the Head and Neck

1. Assessment of the Head and Neck Head, Sinuses, and Neck Eyes and Ears Oropharynx and Nasopharynx

2. 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

7. 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

8. 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

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

11. Techniques Inspection Palpation

12. 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

13. Head

14. Preauricular Postauricular Occipital Tonsillar Submandibular Submental Anterior Cervical Chain Posterior Cervical Chain Supraclavicular Lymph Nodes

15. 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

16. Inspection: Head Inspect facial features Shape and Symmetry Cranial Nerve V (Trigeminal) Motor Jaw opening and clenching Mastication (chewing) Sensory Sensation over the face

17. 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

18. Inspection: Head Inspect facial features Unusual features Edema: tissue swelling Prominent eyes Hyperthyroidism Sunken eyes Dehydration, malnutrition Hirsutism: excessive hair growth Alopecia: hair loss

19. 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

20. CushingSyndrome

21. Myxedema

22. Exophthalmos

23. Acromegaly

24. Down Syndrome

25. Down Syndrome

26. Palpation: Head Palpate using a gentle rotary motion Proceed from front to back Skull and Scalp Contour: smooth Symmetry Tenderness Scalp movement

27. Palpation: Head Hair as previously discussed

28. Palpation: Head Palpate for lymph nodes

29. Sinuses

30. 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

31. Palpation: Sinuses Palpate over the frontal and maxillary sinuses

32. Palpation: Sinuses

33. Neck

34. Anatomy

35. Anatomy

36. Anatomy

37. 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 > 180� As the person swallows with neck hyperextended

38. 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

39. Palpation: Neck Trachea Position Tugging Lymph nodes

40. Cricoid Cartilage

41. Examination of the Eyes

42. 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)

43. 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

44. 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

45. 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

46. Inspection of Conjunctiva

47. 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

48. Visual Fields

49. 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

50. 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

51. 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

52. Eye Patterns

53. Testing EOMs

54. 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

55. Pupillary Reactions

56. 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

57. 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

58. 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

59. Fundus of the Eye

60. 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

61. 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

62. 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.

63. 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

64. Examination of the Ears

65. 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

66. 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 > BC

67. 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

68. 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

69. Otoscopic Exam Inspect the middle ear structures

70. Oropharynx and Nasopharynx

71. Oropharynx: Inspection Lips Color Moisture Ulcers Lesions Cracking Edema Buccal Mucosa Color Ulcers White patches Plaques Nodules

72. 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

73. 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

74. Nose: Inspection External structures Symmetry Size Septal deviation Cranial Nerve I (Olfactory) Sense of smell

75. Nose: Inspection Internal structures Tilt person�s 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

78. 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

79. Caput Succedaneum

80. Cephalhematoma

81. 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

82. 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

83. 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

84. 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

85. 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

86. 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.html