- Head and Neck Physical Exam
Head
- Position
- Skull
- Size
- Shape
- Congenital deformity
- Deformity due to trauma
- Symmetry
- Tenderness
- Hair
- Quantity
- Distribution
- Texture
- Colour
- Alopecia
- Lice/Nits
- Hirsutism
- Skin
- Rashes
- Lesions
- Scars
- Trauma
- Jaundice
- Pallor
- Turgor
Face
- Asymmetry
- Masses
- Myxedema
- Congenital abnormalities
- Characteristic Facies
- Mask facies (Parkinson’s)
- Moon facies (Cushing's Syndrome)
- Flat affect (depression)
- Ticks
- Myxedema
Eyes
Note: The basic eye exam is considered here. For further details, see the Ophthalmology Physical Exam and the Nervous Physical Exam
- Position and Alignment
- In front of patient survey the eyes for position and alignment. If one or both eyes protrude assess for exopthalmos
- Structural
- Eyebrows
- Inspect hair and skin, noting quality, distribution, underlying skin quality
- Lids
- Ptosis
- Lid lag
- Having the pt. slowly move from upward to downward gaze, the examiner should observe if the eyelid lags behind the globe on downward gaze
- Cellulitis
- Myxedema
- Periorbital edema
- Nephritic edema
- Lacrimal swelling
- Excess tearing or dryness
- Upper lid retraction
- Most common sign of thyroid-associated orbitopathy
- Note presence of proptosis, optic nerve involvement or restriction of extraocular muscles
- Mechanisms for upper lid retraction include: proptosis, sympathetic hyperactivity of Muller muscle during hyperthyroidism; upgaze restriction; fibrosis of levator muscle and contralateral ptosis
- Entropion/ectropion
- Conjunctiva and sclera: injection, foreign body
- Have patient look upwards and downwards as you displace the opposing lid in the opposing direction. I.e. look up and physician displaces lower lid downwards
- Iris for coloboma
- Cornea for ulcers, abrasions
- Pupils
- Size and symmetry of pupils
- Decreases with age: 7 mm at 10 yrs, 6 mm at 30, and 4 mm at 80 yrs
- Simple/benign anisocoria:pupillary inequality of < 0.5 mm present in 20% of population
- Pupils reactive to light and accomodation
- Red reflex
- Symmetrical corneal light reflection (assessment of conjugate gaze)
- Lens for opacity, cataracts
- Visual Acuity: Use Snellen eye chart for each eye (see cranial nerve test in nervous system section)
- Visual field testing through confrontation (see cranial nerve test in nervous system section)
- Examiner’s head positioned directly in front of patient
- Patient covers one eye and gazes into examiner’s opposite eye with uncovered eye
- Examiner tests four quadrants by getting patient to state number of fingers held up halfway between patient and examiner
- Repeat for other eye
- Extraocular movements (see cranial nerve test in nervous system section)
- Positional nystagmus in predicting BPPV: sensitivity: 78%, specificity: 50%
- Ptosis
- Lid lag
- Fundoscopic examination with ophthalmoscope
- Optic disc
- Colour
- Contour and sharpness of disc edges
- Disc to cup ratio
- Papilledema (increased intracranial pressure)
- Vasculature
- Colour
- Size
- Light reflex
- Venous pulsations
- Arteriovenous malformations
- Fovea and surrounding macula (dry atrophic vs. wet exudative, drusen)
- Retina
- Colour
- Cotton wool spots
- Tears
- Microhemorrhages
Ears
- Inspection
- Pinnae
- Scars
- Trauma ("Cauliflower ear" from subchondral hematoma)
- Inflammation
- Lesions
- Herpes Zoster lesion accompanied by facial nerve neuropathy in Ramsay Hunt syndrome
- Skin tumors (squamous cell carcinoma, basal cell carcinoma)
- Otorrhea: color, consistency, clarity, odour
- Tenderness
- Congenital abnormalities: pre-auricular sinus, aural atresia
- Palpation
- "Tug Test": the auricle and tragus are tender on palpation and with movement in acute otitis externa
- Tenderness on palpation of the mastoid process may be present in acute otitis media
- Otoscopy
- Use of otoscope:
- Gently elevate pinna upwards and backwards for adults, downwards and backwards for children to straighten external auditory meatus
- Use largest speculum that can be easily inserted into canal
- Hold otoscope as you would a pen, bracing extended pinky finger on patient’s temple for stability
- Gently insert otoscope into meatus while looking through instrument
- Impaired view usually due to wrong size speculum or incorrect angulation
- Mobility of drum can be assessed via pneumatic otoscopy if available
- External auditory canal
- Cerumen: occlusion/impaction
- Otorrhea: mastoid cavity, otitis externa
- Cholesteatoma
- Keratosis obturans
- Foreign body
- Inflammation
- Exostoses (surfer’s ear)
- Tympanic membrane (TM)
- Landmarks
- Pars tensa posteroinferiorly
- Pars flaccida anterosuperiorly
- Cone of light anteroinferiorly
- Malleus: umbo (center), long process (extending superiorly), lateral process (anterosuperior)
- Incus: long process (extending posterosuperiorly)
- Light reflex in anteroinferior quadrant
- Bulging (97.1% probability of otitis media)
- Injected (if distinctly red, 84.8% probability of otitis media)
- Fluid-line, bubbles (serous otitis)
- Retraction (70% probability of otitis media)
- Hearing
- Auditory acuity (see cranial nerve test in nervous system section)
- Whispered voice test
- Normal test virtually excludes significant hearing loss
- Abnormal whispered voice test 90-99% sensitive and 80-87% specific for significant hearing loss
- Rinne Test
- Weber Test
Nose
- External
- Skin
- Trauma
- Inspect and palpate nasal bones and cartilages for asymmetry and abnormalities
- Nasal Cavity
- Tilt head back and apply light pressure to the tip of the nose to open the nostrils; use Thudichum nasal speculum if available; hold handle parallel to floor to open nasal vestibule anteroposteriorly
- Patency of choanae, Cottle’s Test of Nasal Patency
- Polyps or lesions
- Turbinate: colour, size and signs of inflammation (frequently asymmetrical on exam)
- Rhinorrhea
- Septum: deviation, perforation, trauma, Kiesselbach’s plexus (Little's area) for blood vessel engorgement or signs of recent epistaxis
- Sinuses
- Temperature (acute sinusitis: sensitivity: 16%; specificity: 83%)
- Tenderness to palpation (acute sinusitis: sensitivity: 48%; specificity: 65%)
- Transillumination (acute sinusitis: sensitivity: 73%; specificity: 54%)
- Sinusitis
- Symptoms most sensitive for detecting sinusitis: nasal discharge (72%), cough (70%), sneezing (70%). These symptoms are not highly specific
Oropharynx
- Assess for strep throat with the Strep Throat Score
Inspect
- Lips
- Observe color, noting any lumps, ulcers, cracks or changes
- Oral Mucosa
- Color
- Ulcers
- White patches
- Nodules
- Look specifically for herpetic lesions, apthous ulcers, angular stomatitis, thrush and oral lichen planus
- Gums and Teeth
- Examine gingival margins and interdental papillae for inflammation or retraction
- Inspect for missing, discolored, misshapen or abnormally positioned teeth
- Roof of Mouth
- Inspect for color and architecture of hard palate
- Torus palatinus: a benign midline bony protursion of the hard palate
- Tongue
- Symmetry and midline protrusion
- Atrophy and fasiculation (brainstem or hypoglossal nerve lesion)
- Erythroplakia or leukoplakia (Tongue cancer)
- Unilateral hypoglossal nerve weakness causes a deviation of the tongue in the ipsilateral direction
- Pharynx
- Inspect for equal palatal elevation
- Uvular position (deviation in peritonsillar abcess, CN X paralysis)
- Inspect soft palate, anterior and posterior pillars, tonsils and pharynx
- Look for inflammation, swelling, exudate, ulceration, or tonsillar enlargement
- Tonsils
- Hypertrophy
- Exudates or crypts
- Erythmea
- Abscesses
- Uvular position (deviated by peritonsillar abcess or CN X paralysis)
- Swelling
- Structural abnormalities
- Cleft palate
- Torus palatinus (benign)
Palpate
- Tongue and Floor of Mouth
- Ask patient to protrude tongue, inspecting for symmetry, deviation, fasiculations
- Inspect for glossitis seen in B12 deficiency
- Note: 30% of patients with oral carcinoma are asymptomatic. Carcinoma occurs most commonly on one side of the tongue or at its base
- Salivary glands
- Palpate the sublingual, submandibular and/or the parotid glands if signs of inflammation for heat, tenderness and/or swelling
- Temperomandibular joints
Motor Examination
- Gag Reflex (CN IV/V)
- Equal palatal elevation (CN V)
- Central tongue protursion (CN XII)
Vasculature
- Examine the jugular venous pressure.
- Palpate for carotid (rate, rhythm and amplitude)
- Auscultate carotid for bruits
Neck
- Inspection
- Symmetry of muscles
- Scarring
- Tracheal position
- Masses/Swelling
- Webbing and skin folds
- Identify landmarks for major vessels
- Distention of the jugular vein
- Range of motion of cervical spine (with c-spine cleared)
- Anterior and posterior flexion
- Rotation
- Lateral flexion
- Meningeal irritation
- Nuchal rigidity: neck stiffness (sensitivity 90%, specificity 80%)
- Brudzinski’s sign: flex patient’s neck; patient involuntarily flexes hips and knee (60% sensitivity)
- Kernig’s sign: flex patient’s hip and knee to 90°, painful with subsequent extension of knee (60% sensitivity)
- Thyroid
- Inspection (from front): use tangential lighting
- Have the patient tilt their head back
- Locate the thyroid just below the cricoid cartilage
- Ask patient to swallow and observe thyroid movement noting contour and symmetry
- Midline lump (goiter), scars, raised JVP indicating obstruction from mass effect
- Ask patient to speak and cough
- Hoarseness and weeak cough in vocal cold palsy due to infiltration of the recurrent laryngeal nerve
- Palpation (from behind)
- Palpate thyroid and cricoid cartilages and the cricothyroid membrane
- Swallow test: ask patient to sip and swallow water
- Palpate both lobes of the thyroid
- Normal thyroid is non-palpable
- Enlarged thyroid may rise under your fingers
- Size, tenderness, mobility, consistency of thyroid
- If palpable mass, ascertain if solitary or multiple nodules, localize to either lobe or isthmus
- Thyroglossal duct cyst: suspected if a palpable central mass rises with tongue protrusion
- Auscultation for systolic bruit
Lymph Nodes
- Ask patient to drop chin slightly to relax anterior neck muscles
- Use the pads of three fingers to palpate
- Note:
- Size
- Shape
- Delimitation
- Consistency
- Mobility
- Tenderness
- “Up-and-down” palpation technique
- Palpate along jaw from chin to ears
- Submental node
- Submandibular nodes
- Parotid gland
- Pre-auricular nodes
- Post-auricular nodes
- Palpate down anterior border of sternocleidomastoid muscles (SCM) beginning at mandibular angle
- Anterior triangular nodes
- Tonsillar nodes
- Palpate laterally above and beneath the clavicle
- Supraclavicular nodes
- Infraclavicular nodes
- Palpate the posterior border of SCMs
- Posterior triangular nodes
- Palpate base of the skull posteriorly
- Special Note:
- Consistency of palpated nodes
- Soft, insignificant
- Rubbery, may be indicative of lymphoma
- Hard, may be malignant and/or granulomatous infection
- Supraclavicular Nodal Abnormalities
- These nodes are localized close to where major lymphatics empty into the systemic venous circulation. Therefore, they're flow consists of lymph drained from many of the bodies significant organ systems
- Lymphadenopathy of the supraclavicular lymph nodes may be indicative of deeper more insidious illness
- Of patient's undergoing supraclavicular lymph node biopsies, 46-69% have malignant disease, largely metatstatic carcinomas
References
- Bickley LS. The head and neck. In: Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking, 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:153-239.
- Ramachandran M, Gladman MA. Clinical Cases and OSCEs in Surgery. 2nd ed. Edinburgh. Churchill Livingstone Elsevier.
- McGee S. Evidence based physical diagnosis, 3rd ed. Philadelphia, PA: Elsevier; 2012.
- Acute Otitis Media Suspected. Essential Evidence Plus. http://www.essentialevidenceplus.com. Updated August 1, 2006. Accessed March 6, 2011.
- Warner G, Thirlwall A, Patel S, Martinez-Devesa P, Corbridge R. Otolaryngology and head and neck surgery. Oxford: Oxford University Press; 2009. 354.
- Sutter AD, Hickner J. Sinusitis (adult, acute). Essential Evidence Plus. http://www.essentialevidenceplus.com. Updated November 13, 2010. Accessed February 24, 2011.
- Thomas, K. E., Hasbun, R., Jekel, J., & Quagliarello, V.J. The diagnostic accuracy of Kernig’s sign, Brudzinski’s sign, and nuchal rigidity in adults with suspected meningitis. Clinical Infectious Diseases, 2002 (35):46-52.
- Seidel HM, Ball JW, Dains JE, Flynn JA, Solomon BS, Stewart RW. Mosby’s Guide to Physical Examination, 7th ed. St. Louis, MO: Mosby Elsevier; 2011:238-262
- Hall J et al, ed. Essentials of Clinical Examination Handbook 7th ed. New York, NY: TMSP, Thieme; 2013.
- Standford 25: An initiative to revive the culture of bedside medicine. Standford School of Medicine.
- William J. & Simel D. Does this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination. JAMA. 1993; 270(10): 1242-1246.