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.

Equipment Needed

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. [1]
  2. Look for facial asymmetry, involuntary movements, or edema.
  3. Palpate to identify any areas of tenderness or deformity.

Ears

  1. Inspect the auricles and move them around gently. Ask the patient if this is painful.
  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. [2]
  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. [3] ++ [4]
  8. Repeat for the other ear.

Nose

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

  1. Tilt the patient's head back slightly. Ask them to hold their breath for the next few seconds.
  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.

  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.
    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 and in front of the sternomastoid muscle
    8. Supraclavicular - In the angle of the sternomastoid and the clavicle
  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 anterior 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.
  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 laterally 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

Facial Tenderness

  1. Ask the patient to tell you if these maneuvers causes excessive discomfort or pain. ++
  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. ++
  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. ++
  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. 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.
  3. 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.
  4. 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