Examination of the Head and Neck

NOTE: Neurologic testing of the head and neck is covered by the neurologic exam checklist.

Equipment Needed

• An Otoscope
• An Ophthalmoscope
• Tongue Blades
• Cotton Tipped Applicators
• Latex Gloves

General Considerations

• The head and neck exam is not a single, fixed sequence. Different portions are included depending on the examiner and the situation.

Head

1. Look for scars, lumps, rashes, hair loss, or other lesions. [p168] [1]
2. Look for facial asymmetry, involuntary movements, or edema.
3. Palpate to identify any areas of tenderness or deformity.

Eyes

Visual Acuity

1. Position the patient 20 feet in front of the Snellen eye chart. [2]
2. Allow the patient to use their glasses or contact lens if present.
3. Have the patient cover one eye at a time with a card.
4. Ask the patient to read progressively smaller letters until they can go no further.
5. Record the smallest line the patient read successfully (20/20, 20/30, etc.) [3]
6. Repeat with the other eye.

Inspection

1. Ask the patient to look up and pull down both lower eyelids to inspect the conjuntiva and sclera.
2. Next spread each eye open with your thumb and index finger. Ask the patient to look to each side and downward to expose the entire bulbar surface.
3. Note any discoloration, redness, discharge, or lesions. Note any deformity of the iris or lesion cornea.

Extraocular Muscles

Corneal Reflections

1. Shine a light from directly in front of the patient. [p173] ++ [4]
2. The corneal reflections should be centered over the pupils.
3. Asymmetry suggests extraocular muscle pathology.

Extraocular Movement

1. Stand or sit 3 to 6 feet in front of the patient. [p174] ++
2. Ask the patient to follow your finger with their eyes without moving their head.
3. Check gaze in the six cardinal directions using a cross or "H" pattern.
   
4. Check convergence by moving your finger toward the bridge of the patient's nose.

Visual Fields

Covered elsewhere...

Pupillary Reactions to Light

Covered elsewhere...

Ophthalmoscopic Exam

1. Darken the room as much as possible. [p175] ++
2. 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. [5]
3. Use your left hand and left eye to examine the patient's left eye. Use your right hand and right eye to examine the patient's right eye. Place your free hand on the patient's shoulder for better control.
4. Ask the patient to stare at a point on the wall or corner of the room.
   
5. Look through the ophthalmoscope and shine the light into the patient'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 patient's eye.
6. Adjust the diopter dial to bring the retina into focus. Find a blood vessel and follow it to the optic disk. Use this as a point of reference.
7. Inspect outward from the optic disk in at least four quadrants and note any abnormalities. [pictures on p208]
8. Move nasally from the disk to observe the macula.
9. Repeat for the other eye.

Ears

1. Inspect the auricles and move them around gently. Ask the patient if this is painful. [p179]
2. Palpate the mastoid process for tenderness or deformity.
3. Hold the otoscope with your thumb and fingers so that the ulnar aspect of your hand makes contact with the patient.
4. Pull the ear upwards and backwards to straighten the canal.
5. Insert the otoscope to a point just beyond the protective hairs in the ear canal. Use the largest speculum that will fit comfortably. [6]
6. Inspect the ear canal and middle ear structures noting any redness, drainage, or deformity.
7. Insufflate the ear and watch for movement of the tympanic membrane. [p599] [7] ++
8. Repeat for the other ear.

Nose

It is often convenient to examine the nose immediately after the ears using the same speculum. [p183]

1. Tilt the patient's head back slightly.
2. Insert the otoscope into the nostril, avoiding contact with the septum.
3. Inspect the visible nasal structures and note any swelling, redness, drainage, or deformity.
4. Repeat for the other side.

Throat

It is often convenient to examine the throat using the otoscope with the speculum removed. [p184]

1. Ask the patient to open their mouth.
2. Using a wooden tongue blade and a good light source, inspect the inside of the patients mouth including the buccal folds and under the tougue. Note any ulcers, white patches (leucoplakia), or other lesions.
3. If abnormalities are discovered, use a gloved finger to palpate the anterior structures and floor of the mouth. ++
4. Inspect the posterior oropharynx by depressing the tongue and asking the patient to say "Ah." Note any tonsilar enlargement, redness, or discharge.

Neck

1. Inspect the neck for asymmetry, scars, or other lesions.
2. Palpate the neck to detect areas of tenderness, deformity, or masses.
3. The musculoskeletal exam of the neck is covered elsewhere...

Lymph Nodes

1. Systematically palpate with the pads of your index and middle fingers for the various lymph node groups. [p187]
   1. Preauricular - In front of the ear
   2. Postauricular - Behind the ear
   3. Occipital - At the base of the skull
   4. Tonsillar - At the angle of the jaw
   5. Submandibular - Under the jaw on the side
   6. Submental - Under the jaw in the midline
   7. Superficial (Anterior) Cervical - Over the sternomastoid muscle
   8. Posterior Cervical - Behind the sternomastoid muscle
   9. Supraclavicular - In the angle of the sternomastoid and the sternum
2. The deep cervical chain of lymph nodes lies below the sternomastoid and cannot be palpated without getting underneath the muscle:
   1. Inform the patient that this procedure will cause some discomfort.
   2. Hook your fingers under the edge of the sternomastoid muscle.
   3. Ask the patient to bend their neck toward the side you are examining.
   4. Move the muscle backward and palpate for the deep nodes underneath.
3. Note the size and location of any palpable nodes and whether they were soft or hard, non-tender or tender, and mobile or fixed.

Thyroid Gland

1. Inspect the neck looking for the thyroid gland. Note whether it is visible and symmetrical. A visibly enlarged thyroid gland is called a goiter. [p188]
2. Move to a position behind the patient.
3. Identify the cricoid cartilage with the fingers of both hands.
4. Move downward two or three tracheal rings while palpating for the isthmus.
5. Move outward from the midline while palpating for the lobes of the thyroid.
6. Note the size, symmetry, and position of the lobes, as well as the presence of any nodules. The normal gland is often not palpable.

Special Tests

Upper Eyelid Eversion

This procedure is performed when a foreign body is suspected. [p191] ++

1. Ask the patient to look down.
2. Gently grasp the patient's upper eyelashes and pull them out and down.
3. Place the shaft of an applicator or tongue blade about 1 cm from the lid margin.
4. Pull the lid upward using the applicator as a fulcrum to turn the lid "inside out." Do not press down on the eye itself.
5. Pin the eyelid in this position by pressing the lashes against the eyebrow while you examine the palpebral conjuntiva.
6. Ask the patient to blink several times to return the lid to normal.

Facial Tenderness

1. Ask the patient to tell you if these maneuvers causes excessive discomfort or pain. [p184] ++
2. Press upward under both eyebrows with your thumbs.
3. Press upward under both maxilla with your thumbs.
4. Excessive discomfort on one side or significant pain suggests sinusitis.

Sinus Transillumination

1. Darken the room as much as possible. [p193] ++
2. Place a bright otoscope or other point light source on the maxilla.
3. Ask the patient to open their mouth and look for an orange glow on the hard palate.
4. A decreased or absent glow suggests that the sinus is filled with something other than air.

Temporomandibular Joint

1. Place the tips of your index fingers directly in front of the tragus of each ear. [p465] ++
2. Ask the patient to open and close their mouth.
3. Note any decreased range of motion, tenderness, or swelling.

Notes

1. Page numbers refer to Barbara Bates' A Guide to Physical Examination and History Taking, Sixth Edition , published by Lippincott in 1995.
2. A hand-held vision card may be substituted for the Snellen chart at the bedside. These cards are also used to test near vision.
3. Visual acuity is reported as a pair of numbers (20/20) where the first number is how far the patient 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 patient can only read letters a "normal" person can read from twice the distance.
4. Additional Testing - Tests marked with (++) may be skipped unless an abnormality is suspected.
5. Diopters are used to measure the power of a lens. The ophthalmoscope actually has a series of small lens of different strengths on a wheel (positive diopters are labeled in green, negative in red). When you focus on the retina you "dial-in" the correct number of diopters to compensate for both the patient's and your own vision. For example, if both you and your patient wear glasses with -2 diopter correction you should expect to set the dial to -2 with your glasses on or -4 with your glasses off.
6. The line of hairs in the external ear is a good approximation of where the bony canal begins. Inserting the speculum beyond this point can be very painful.
7. Insufflation means to change the pressure in the outer ear. The tympanic membrane normally moves easily in response to this pressure change. Lack of movement is a sign of negative pressure or fluid in the middle ear. Bates refers to this procedure as pneumatic otoscopy.