Friday, May 12, 2017

Return to: Medical Student Instruction

Introduction to the Head and Neck Exam

The order in which this is performed may vary, but establishing a routine where all aspects of the exam are included is important to avoid excluding components of the exam.

  • Inspect the face
    • Note any signs of syndromic facies, large tumors, skin lesions
  • Pupillary response (CN II, III)
  • Extraocular movements (CN III, IV, VI)
    • Malignancies as well as infections of the head and neck can affect extraocular movements
  • Sensation to light touch in all three distributions (CN V)
    • Sensation is often abnormal in patients with facial fractures but may also be affected if there is perineural spread of a tumor along CN V
  • Muscles of facial expression: raise eyebrows, close eyes, wrinkle nose, smile, pucker lips (CN VII)
    • Facial weakness can be described using the House-Brackmann scale with I being normal and VI being complete paralysis
    • Facial paralysis can be due to an abnormality anywhere along the course of the facial nerve intracranially to peripheral (facial nerve nuclear in the pons -> petrous temporal bone -> internal auditory meatus -> facial canal -> stylomastoid foramen --> parotid gland
  • Hearing with Rinne and Weber with at least 512 Hz (CN VIII)
    • Weber: Place the tuning fork in the midline and determine which ear its heard louder. Normal: heard equally loud in both ears (also equal in symmetric bilateral hearing loss). Unilateral conductive hearing loss: lateralize to affected ear. Unilateral sensorineural hearing loss: lateralize to contralateral ear.
    • Rinne: Place the tuning fork in front of the ear and over the mastoid and determine in which position it is heard louder. Normal: air conduction > bone conduction (positive Rinne). Conductive hearing loss: bone conduction > air conduction (negative Rinne). Sensorineural hearing loss: air conduction > bone conduction (positive Rinne).
    • A flipped 256 Hz fork corresponds to a 15 dB hearing loss. Whispered voice is about 20 dB and normal spoken voice is 50 to 60 dB.
  • Turn head against resistance, palpate SCM (CN XI)
  • Protrude tongue (CN XII)
    • Tongue will deviate toward the side of the lesion
  • Examine ears with otoscope (consider pneumatic otoscopy)
    • Evaluate size, shape, lesions on external ear (microtia, "cauliflower ear", skin cancers)
    • Evaluate external auditory canal (otorrhea, lesions, swelling with otitis externa)
    • Evaluate for signs of otitis media, serous effusion, TM perforation, cholesteatoma, myringosclerosis, hemotympanum. Unilateral serous effusion should raise concerns for nasopharyngeal mass.
    • Mobility on insufflation (hypermobile: thin, flaccid TM; hypomobile: fluid or thickened TM).
  • Examine nose with nasal speculum
  • Examine oral cavity/oropharynx including gums, teeth, tongue, floor of mouth, mucosa, hard palate, soft palate, tonsils, assess gag reflex (CN IX, X). Ensure that patients with dentures remove these prior to exam.
    • Oral cavity: lips, anterior 2/3 tongue, teeth, floor of mouth, hard palate, buccal and gingival mucosa
    • Oropharynx: posterior 1/3 tongue (base of tongue), tonsils, soft palate/uvula, lateral and posterior pharyngeal walls visualized through oral cavity see: Tonsillectomy and Adenoidectomy
    • Evaluate for leukoplakia, erythroplakia, ulcers, masses, tonsillar hypertrophy (symmetric vs asymmetric), poor dentition, swelling, purulent drainage, abscess
    • Bifid uvula may indicate submucous cleft
  • Palpate lymph nodes (level I-VI) as well as salivary glands
  • Assess thyroid for nodules or thyromegaly
  • Palpate intraorally including tonsils, tongue, floor of mouth, base of tongue
    • The first sign of a tongue or floor of mouth cancer may be a palpable mass rather than a visible lesion. Calculi in the submandibular gland or duct may be palpable along the floor of the mouth. Masses on the tonsil, particularly unilateral masses may be concerning for a tonsillar cancer.
  • Laryngeal exam