Basic Clinical Skills |
Physical Exam Study Guides
Examination of the Head and Neck
NOTE: Neurologic testing of the head and neck is covered by the neurologic exam study guide. The eyes are covered by the eye exam study guide.
- An Otoscope
- Tongue Blades
- Cotton Tipped Applicators
- Latex Gloves
The head and neck exam is not a single, fixed sequence. Different portions are included depending on the examiner and the situation.
- Look for scars, lumps, rashes, hair loss, or other lesions. [1]
- Look for facial asymmetry, involuntary movements, or edema.
- Palpate to identify any areas of tenderness or deformity.
- Inspect the auricles and move them around gently. Ask the patient if this is painful.
- Palpate the mastoid process for tenderness or deformity.
- Hold the otoscope with your thumb and fingers so that the ulnar aspect of your hand makes contact with the patient.
- Pull the ear upwards and backwards to straighten the canal.
- Insert the otoscope to a point just beyond the protective hairs in the ear canal. Use the largest speculum that will fit comfortably. [2]
- Inspect the ear canal and middle ear structures noting any redness, drainage, or deformity.
- Insufflate the ear and watch for movement of the tympanic membrane. [3] ++ [4]
- Repeat for the other ear.
It is often convenient to examine the nose immediately after the ears using the same speculum.
- Tilt the patient's head back slightly. Ask them to hold their breath for the next few seconds.
- Insert the otoscope into the nostril, avoiding contact with the septum.
- Inspect the visible nasal structures and note any swelling, redness, drainage, or deformity.
- Repeat for the other side.
It is often convenient to examine the throat using the otoscope with the speculum removed.
- Ask the patient to open their mouth.
- 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.
- If abnormalities are discovered, use a gloved finger to palpate the anterior structures and floor of the mouth. ++
- Inspect the posterior oropharynx by depressing the tongue and asking the patient to say "Ah." Note any tonsilar enlargement, redness, or discharge.
- Inspect the neck for asymmetry, scars, or other lesions.
- Palpate the neck to detect areas of tenderness, deformity, or masses.
- The musculoskeletal exam of the neck is covered elsewhere...
- Systematically palpate with the pads of your index and middle fingers for the various lymph node groups.
- Preauricular - In front of the ear
- Postauricular - Behind the ear
- Occipital - At the base of the skull
- Tonsillar - At the angle of the jaw
- Submandibular - Under the jaw on the side
- Submental - Under the jaw in the midline
- Superficial (Anterior) Cervical - Over and in front of the sternomastoid muscle
- Supraclavicular - In the angle of the sternomastoid and the clavicle
- The deep cervical chain of lymph nodes lies below the sternomastoid and cannot be palpated without getting underneath the muscle:
- Inform the patient that this procedure will cause some discomfort.
- Hook your fingers under the anterior edge of the sternomastoid muscle.
- Ask the patient to bend their neck toward the side you are examining.
- Move the muscle backward and palpate for the deep nodes underneath.
- Note the size and location of any palpable nodes and whether they were soft or hard, non-tender or tender, and mobile or fixed.

- Inspect the neck looking for the thyroid gland. Note whether it is visible and symmetrical. A visibly enlarged thyroid gland is called a goiter.
- Move to a position behind the patient.
- Identify the cricoid cartilage with the fingers of both hands.
- Move downward two or three tracheal rings while palpating for the isthmus.
- Move laterally from the midline while palpating for the lobes of the thyroid.
- Note the size, symmetry, and position of the lobes, as well as the presence of any nodules. The normal gland is often not palpable.
- Ask the patient to tell you if these maneuvers causes excessive discomfort or pain. ++
- Press upward under both eyebrows with your thumbs.
- Press upward under both maxilla with your thumbs.
- Excessive discomfort on one side or significant pain suggests sinusitis.
- Darken the room as much as possible. ++
- Place a bright otoscope or other point light source on the maxilla.
- Ask the patient to open their mouth and look for an orange glow on the hard palate.
- A decreased or absent glow suggests that the sinus is filled with something other than air.
- Place the tips of your index fingers directly in front of the tragus of each ear. ++
- Ask the patient to open and close their mouth.
- Note any decreased range of motion, tenderness, or swelling.
- Page numbers refer to Barbara Bates' A Guide to Physical Examination and History Taking, Sixth Edition , published by Lippincott in 1995.
- 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.
- 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.
- Additional Testing - Tests marked with (++) may be skipped unless an abnormality is suspected.
Author: Richard Rathe, MD / rrathe@dean.med.ufl.edu
Copyright: 1996 by the University of Florida
Location: http://www.medinfo.ufl.edu/year1/bcs/clist/heent.html
Created: August 1, 1996
Modified: December 19, 2000
Basic Clinical Skills |
Physical Exam Study Guides