head and neck examination

Question 1

overview

Answer 1

• intro
• inspection
• palpation
• auscultation
• auriscope

Question 2

Inspection: head and face x9

Answer 2

• Expression
• Facial symmetry
• Features- cushings acromegaly
• Swellings (pulsations)
• Hair (distribution, loss)
• Shape of face and skull
• Scars
• Skin (e.g. rashes, acne, blisters,
  vitiligo)
• Movements (weakness)

Question 3

inspection: eyes x3

Answer 3

• Lid lag, proptosis, eye movements
• Check the sclera for jaundice or anaemia
• Features of thyroid eye disease

Question 4

inspection: nose x3

Answer 4

• Look at the nose from in front, the side and from above the patient,
  observe the nasal pyramid, notice any discharge
• Ask the patient to block one nostril and assess the air flow in the othernostril (reverse the nostril tested).
  thumb.
• Elevate the tip of the nose to inspect the nasal vestibule – use a light
  source eg otoscope/pen torch or head light

Question 5

inspection: mouth x5

Answer 5

• Lips (cyanosis, angular stomatitis, other lesions e.g. BCC)
• Open mouth – inspect inside, dentition, floor of mouth, hard and soft
  palate, inside of cheeks, parotid duct opening (2nd upper molar)
  (Ask the patient to say ‘Ah!’)
• Oropharynx, uvula, tonsillar folds and tonsils
  (Ask the patient to stick tongue out and move from side to side)
• Tongue - dorsal surface, both lateral borders (dryness/fasciculation/
  wasting)
• Ask the patient to touch roof of mouth with the tongue to inspect
  underside of the tongue and floor of the mouth, frenulum,
  submandibular duct and opening

Question 6

inspection: teeth x6

Answer 6

• Assess oral hygiene, being aware of halitosis (can be due to poor tooth
  brushing, post nasal drip or acid reflux)
• Note any loose teeth, broken teeth or worn down teeth (due to recent
  trauma, neoplastic causes such as maxillary sinus tumours, acid erosion
  from vomiting/diet/reflux, tooth grinding(bruxism)
• Presence of dentures and recent changes to fit (due to rubbing,
  breakage, bony changes eg Paget’s or soft tissue lesions/ulcers)
• Assess occlusion (or bite) and ask if it feels normal to the patient when
  they bite together
• Assess gums for inflammation or pallor (anaemia) hyperplasia (drug
  reactions)
• Assess gums for pigmentation (normal in Black and Ethnic minority
  groups- see photo below*). Can be an indication of metabolic disorders
  such as Addison’s disease, amalgam tattoos from fillings, heavy metal
  poisoning, heavy smoking, malignancy

Question 7

inspection: ears

Answer 7

• The pinna (outer ear): note any nodules or other lesions
• Note if the pinna is pushed forward (mastoiditis)
• External auditory meatus (note any discharges)
• Behind the pinna (for scars)
• Mastoid process (bruising or Battle’s sign)

Question 8

inspection: neck x3

Answer 8

• Scars, swelling
• Lump - observe site, size, skin changes
• Movement with tongue protrusion (‘please stick your tongue out’) and
  swallowing (‘take sip of water, hold in mouth, then swallow’)

Question 9

palpation of skull and face x5

Answer 9

• Palpate each mastoid process
• Run your fingers around each orbital margin (notice any irregularity and
  the orbital notch)
• Check for tenderness along the temporal artery on each side
• Feel the maxilla and the mandible
• Place your Index and middle fingers over the T-M joint (just in front of
  the tragus) and ask the patient to open and close their mouth and then
  move the jaw sideways – observe movement of the joint (be gentle as
  this might be uncomfortable

Question 10

palpation of nose x2

Answer 10

• Palpate the nasal cartilage and bones
• Feel for tenderness over the paranasal sinuses (maxillary, ethmoidal,
  frontal)

Question 11

palpation of mouth x4

Answer 11

1. Along the floor of the mouth (under the tongue)
2. Inside of cheeks
3. Salivary glands (of the three pairs of salivary glands only two are
   easily palpated*)
4. Substance of tongue (warn patient may trigger gag reflex)

• *Parotid gland – two parts - from zygoma to the angle of the jaw with
  the superficial part overlying the masseter muscle – palpate at the
  angle of the jaw and over the masseter and the “tail” of parotid below
  the earlobe just behind the angle of jaw
• *Submandibular gland – palpate with one hand under the mandible,
  feeling towards the midline and one finger under the tongue inside
  mouth.

Question 12

palpation of ears x2

Answer 12

• Press in front of meatus or pull gently on the pinna (if either cause
  discomfort consider that there may be infection in the canal and care
  required with auriscope)
• Palpate gently over each mastoid process – looking for tenderness

Question 13

palpation of neck x2

Answer 13

• From the front of the patient, check the position of the trachea
• Move behind the patient to examine the neck in greater detail – ensure
  the patient knows what will happen with this part of the examination.
• Palpate the lateral aspects and the whole of the front of the neck,
  looking for any swellings including lymph nodes by following a ‘Z’.

Question 14

ausculation

Answer 14

carotid brui:
diaphragm over carotid artery with held breath

thyroid brui:
use the diaphragm of the stethoscope and ask the
patient to hold his/her breath –

Question 15

things to remeber when using Auriscope

Answer 15

ask if in pain

right hand for righ ear and vice versa

hold like a pen and rest with pinky