Head and Neck Exam. Charlie Goldberg, M.D. Professor of Medicine, UCSD SOM
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1 Head and Neck Exam Charlie Goldberg, M.D. Professor of Medicine, UCSD SOM
2 Observation and Palpation Note right sided neck/jaw area swelling and R v L asymmetry Inspection face & neck: Does anything appear out of ordinary in Head & Neck? Bumps/lumps, asymmetry, swelling, discoloration, bruising/trauma? anything hidden by hair? Inspection & palpation of scalp, hair
3 Lymph Nodes of Head & Neck - Physiology Major lymph node groups located symmetrically either side of head & neck. Each group drains specific region
4 Lymph Node Enlargement Major Causes Enlarged if inflammation (most commonly infection) or malignancy Infection: Acute, tender, warm Primary region drained also involved (e.g neck nodes w/strep throat) Sometimes get diffuse enlargement in response to generalized infection or systemic inflammatory process (.e.g TB, HIV, Mono) Malignancy: Slowly progressive, firm, multiple nodes involved, stuck together & to underlying structures. Primary site malignancy could be nodes (e.g. lymphoma) or adjacent region (e.g. intra-oral squamous cell ca)
5 Lymph Node Anatomy & Drainage Ant Cerv Throat, tonsils, post pharynx, thyroid Post Cerv Back of skull Tonsillar Tonsils, posterior pharynx Sub-Mandibular Floor of mouth Sub-Mental Teeth Supra-Clavicular Thorax Pre-Auricular Ear
6 Lymph Node Exam Gently walk fingers along general regions comparing R to L
7 Function CN 7 Facial Nerve Facial Symmetry & Expression - Precise Pattern of Inervation L UMN R UMN R LMN - Forehead L LMN - Forehead R LMN Face L LMN -Face
8 CN 7 Exam Observe facial symmetry Wrinkle Forehead Keep eyes closed against resistance Smile, puff out cheeks Cute.. and symmetric!
9 Pathology: Peripheral CN 7 (Bell s) Palsy Patient can t close L eye, wrinkle L forehead or raise L corner mouth L CN 7 Peripheral (i.e. LMN) Dysfunction Central (i.e. UMN) CN 7 dysfunction (e.g. stroke) - not shown: Can wrinkle forehead bilaterally; will demonstrate loss of lower facial movement on side opposite stroke.
10 Function CN 5 - Trigeminal Sensation: 3 regions of face: Ophthalmic, Maxillary & Mandibular Motor: Temporalis & Masseter muscles
11 Function CN 5 Trigeminal (cont) Motor Temporalis (clench teeth) Masseter (move jaw side-side) Sensory Ophthalmic(V1) Maxillary (V2) Mandibular (V3) Corneal Reflex: Blink when cornea touched - Sensory CN 5, Motor CN 7
12 Testing CN 5 - Trigeminal Sensory: Ask pt to close eyes Touch ea of 3 areas (ophthalmic, maxillary, & mandibular) lightly, noting whether patient detects stimulus. Motor: Palpate temporalis & mandibular areas as patient clenches & grinds teeth Anatomy of Masseter and Temporalis Muscles ( Corneal Reflex: Tease out bit of cotton from q-tip - Sensory CN 5, Motor CN 7 Blink when touch cornea with cotton wisp
13 The Ear Functional Anatomy and Testing (CN 8 Acoustic) Crude tests hearing rub fingers next to either ear; whisper & ask pt repeat words If sig hearing loss, determine Conductive (external canal up to but not including CN 8) v Sensorineural (CN 8) Inner Ear Anatomy ( Animated Ear Function:
14 Great Moments In The History of Hearing Horton Hears A Who! Uncle Bill Hears Aunt Ruth!
15 CN 8 - Defining Cause of Hearing Loss - Weber Test 512 Hz tuning fork - this (& not 128Hz) is well w/in range normal hearing & used for testing Get turning fork vibrate striking ends against heel of hand or Squeeze tips between thumb & 1 st finger Place vibrating fork mid line skull Sound should be heard =ly R & L bone conducts to both sides.
16 CN 8 - Weber Test (cont) If conductive hearing loss (e.g. obstructing wax in canal on L) louder on L as less competing noise. If sensorineural on L louder on R Finger in ear mimics conductive loss
17 CN 8 - Defining Cause of Hearing Loss - Rinne Test Place vibrating 512 hz tuning fork on mastoid bone (behind ear). Patient states when can t hear sound. Place tines of fork next to ear should hear it again as air conducts better then bone. If BC better then AC, suggests conductive hearing loss. If sensorineural loss, then AC still > BC Note: Weber & Rinne difficult to perform in Anatomy lab due to competing noise home in quiet room!
18 Examining the External Structures of The Ear - Observation Helix Tragus Mastoid External Canal Anti-Helix Note: Picture on L normal external ear; picture on R swollen external canal, narrowed by inflammation Lobe
19 Internal Ear Anatomy Inner Ear Anatomy (
20 Images courtesy American Academy of Pediatrics Normal Tympanic Membrane NOSE Long Process Left Ear Malleus Incus Short Process Malleus Malleus points down and back Cone of Light Umbo
21 Selected Tympanic Membrane Pathology Normal University of Toronto - Otitis Media University of Toronto - Perforated Tympanic Membrane Normal Images courtesy American Academy of Pediatrics University of Toronto - Wax
22 Using Your Otoscope Make sure battery s charged! Gently twist Otoscopic Head (clockwise) onto handle Twist on disposable, medium sized speculum Hold in R hand R ear, L hand L ear
23 Otoscope W/Magnified Viewing Head Advantage magnified view, larger field Speculum twists on; viewing same as for conventional head Rotate wheel w/finger while viewing tympanic membrane to enhance focus (default setting is green line) Focus Wheel Speculum Viewing Window
24 Otosocopy Basics Make sure patient seated comfortably & ask them not to move Place tip speculum in external canal under direct vision Gently pull back on top of ear Advance scope slowly as look thru window extend pinky to brace hand Avoid fast, excessive movement Stop if painful!
25 Look Dad - Otoscopy Sure is Easy!
26 The Nose Observe external structure for symmetry Check air movement thru ea nostril separately. Smell (CN 1 Olfactory) not usually assessed screen w/alcohol pad smell test detect odor from pad when 10cm. Test ea nostril separately Look into each nostril using otoscope w/speculum note color, septum (medial), turbinates (lateral)
27 Sinuses Normally Air filled (cuts down weight of skull), lined w/upper respiratory epitheliumækeeps antigens/infection from lung Maxillary & frontal accessible to exam (others not) Exam only done if concern re sinus infection/pathology Location of Frontal and Maxillary Sinuses
28 Sinuses (cont) Palpate (or percuss) sinus elicits pain if inflamed/infected Transilluminate normally, light passes across sinus visible thru roof of mouth.. Infection swelling & fluid prevents transmission Room must be dark Placed otoscope on infra-orbital rim while look in mouth for light Note: Not possible to see transmitted light if room brightly lit (e.g. the anatomy lab) try home in dark room! Palpate or Percuss Sinuses In areas outlined above Transillumination
29 Oropharynx Inspect posterior pharynx (back of throat), tonsils, mucosa, teeth, gums, tongue use tongue depressor & light otoscope works as flashlight (on newer Welch Allyn, head twists off) Can grasp tongue w/a gauze pad & move it side to side for better visualization Palpate abnormalities (gloved hand)
30 Oropharynx: Anatomy & Function CNs 9 (glosopharyngeal), 10 (vagus) & 12 (hypoglossal) Uvula midline - CN 9 Stick out tongue, say Ahh use tongue depressor if can t see palate/uvula rise -CN 9, 10 Gag Reflex provoked w/tongue blade or q tip - CN 9, 10 Tongue midline when patient sticks it out CN 12 check strength by directing patient push tip into inside of either cheek while you push from outside
31 Selected Pathology of Oropharynx L CN 9 palsy uvula pulled to R L peri-tonsilar abscess uvula pushed to R L CN 12 palsy tongue deviates L
32 What about the Teeth? Dental health has big implications: Nutrition (ability to eat) Appearance Self esteem Employability Social acceptance Systemic disease endocarditis,? other Local problems: Pain, infection Profound lack of access to care MDs primary Rx
33 Anatomy & Exam 16 top, 16 bottom Examine all Observation teeth, gums Gloved hands, gauze, tongue depressor & lighting if abnormal Look for: General appearance? All present Broken, Caries, etc? Areas pain, swelling? infection Localize:? Tooth, gum, extent Dental Anatomy ( Anatomy of a Tooth ( medlineplus
34 Common Dental Pathology Dental Caries and Common Dental Emergencies Journal of American Family Practice Facial Swelling (left) Secondary to Tooth Abscess
35 Thyroid Anatomy Thyroid Anatomy - National Institutes of Health (
36 Thyroid Exam Observe (obvious abnormalities, trachea) From front or behind Identify landmarks (touch and vision) Palpate as patient swallows (drinking water helps)? Focal or symmetric enlargement, nodules.
37 Neck Movement (CN 11 Spinal Accessory) Turn head to L into R hand function of R Sternocleidomastoid (SCM) Turn head to R into L hand (L SCM) Shrug shoulders into your hands
38 Summary Of Skills Wash hands Observation head & scalp; palpation lymph nodes Facial symmetry, expression (CN 7) Facial sensation, muscles mastication (CN 5) Auditory acuity; Weber & Rinne Tests (CN 8) Ear: external and internal (otoscope) Nose: observation, nares/mucosa (otoscope), smell (CN 1) Sinuses: palpation, transillumination Oropharynx: Inspection w/light & tongue depressor uvula, tonsils, tongue (CNs 9, 10, 12); Ahh ; Gag reflex; Teeth Thyroid: Observation, palpation Neck/Shoulders: Observation, range motion, shrug (CN 11) Time Target: < 10 min
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