Examination of The Head and Neck

Examination of the head and neck is a fundamental part of the standard physical examination. It is typically one of the first parts of the physical examination and is performed with the patient in a seated position. Because the complete head and neck examination is lengthy, it is usually tailored to the patient’s history and presenting complaint. In adult patients, the parts of the examination dealing with the ears and nose are generally not required unless there is a pertinent complaint.

• Inspect the skull and face.
• Inspect the skin and scalp.
• Palpate skull (especially if the patient complains of tenderness or recent trauma).
• Assess facial sensation and motor function.
  • Trigeminal nerve

     function: Lightly touch the forehead of the patient on both sides and the upper and lower areas of the cheek with the index finger. Ask the patient whether this feels the same on both sides of the face.

  • Facial nerve

     function: Ask the patient to furrow their forehead, close their eyes, show their teeth, and inflate their cheeks.

  • See 
    examination of cranial nerves

     and cranial nerve palsies.

• Inspect the external ear and note any skin abnormalities or discharge.
• For patients complaining of ear pain or discharge, gently move the auricle up and down, and apply pressure to the tragus and the
  mastoid process

Otoscopy

• Procedure
  • Place the largest speculum that comfortably fits in the patient’s ear on the head of the otoscope and turn on the light source.
  • Angle the otoscope handle either directly downward or towards the patient’s forehead.
  • Stabilize your otoscope hand by placing the fourth and fifth digits on the patient’s head.
  • With your free hand, pull the ear up and in a posterior direction to straighten the canal as you insert the otoscope at a slightly downward angle.
• Interpretation
  • Inspect for the presence of discharge, redness, cerumen, swelling, and foreign bodies. 
  • The tympanic membrane normally reflects the otoscope’s light, which is known as the light reflex (or “cone of light”).  See otitis externa, otitis media, and tympanosclerosis for additional findings.
• A pneumatic bulb allows for the assessment of tympanic membrane mobility.
• Otoscopy is an integral part of all pediatric examinations. It is usually only performed in adults if they have mentioned ear discomfort.

Auditory acuity

Screening assessments

• Whispered voice test: While standing behind the patient, whisper a phrase or numbers in each ear → Ask the patient to repeat what you whispered.
• Finger rub test: Place your fingers several centimeters from either ear → Rub your fingertips together and ask the patient if they heard it.
• Interpretation: If any asymmetry is detected, or the patient complains of impaired hearing, further evaluation is indicated → See hearing loss.

Tuning fork tests

• Performed in order to distinguish between conductive hearing loss and  sensorineural hearing loss
• Weber test: tests for lateralization (sound is heard louder in one ear than the other)
  • Place the base of a vibrating tuning fork on the middle of the forehead and ask the patient from which ear the sound is louder.
  • The sound is normally heard equally in both ears.
  • Interpretation Lateralization → asymmetric hearing loss No lateralization → normal hearing or bilateral hearing loss
• Rinne test: tests for air conduction vs bone conduction in the examined ear
  • Place the base of a vibrating tuning fork on the 
    mastoid process of the ear. Once the patient no longer hears a tone, immediately hold the “U” part of the fork over the outer ear and ask the patient if they can still hear it.
  • Air conduction is normally greater than bone conduction, so the patient should still be able to hear the tuning fork next to the outer ear after they can no longer hear it when placed on the  mastoid process
  • Interpretation
    • Unable to hear the tuning fork; → there is conductive hearing loss
       (bone conduction > air conduction) in the examined ear (Rinne test is negative)
    • Still able to hear tuning fork over the outer ear; → there is no conductive hearing loss (Rinne test is positive); possible sensorineural hearing loss (air conduction > bone conduction) if there is diminished hearing in the examined ear 

Overview of possible findings

Gelle test

• Description: to evaluate the mobility of the ossicles, e.g., in the diagnosis of
  otosclerosis
• Procedure: The vibrating tuning fork is placed against the forehead and the auditory canal is sealed using a pneumatic speculum, which creates positive pressure in the  external auditory canal
• Gelle positive: Positive pressure disturbs both bone and air conduction. The sound of the tuning fork is perceived by the patient to be considerably weaker with the pneumatic speculum applied than without the pneumatic speculum. → Hearing is normal in the middle ear or there might be a problem in the middle ear that restricts the mobility of the ossicles.

  Gelle negative: Despite positive pressure, there is no change in hearing in the patient. → evidence of otosclerosis

Additional tests

• Audiogram, speech audiometry, impedance audiometry
• See hearing loss.

When screening for hearing loss, examine each ear individually in a quiet room.

Inspection and palpation

• Inspect for symmetry of the eyes and eyelids.
• Note any swelling or redness around the eyelids, and assess whether the eyelids can fully close.  Inspection of the sclera (normal sclerae are white) and inspection of the conjunctivae. Ask the patient to look up while you hold the lower lids with your thumb.  Inspect for color, vascular pattern, and whether there is any swelling. 

• Assess the pupillary size, location, shape, and reactivity to light (indirect and direct pupillary light reflex)
• For further information, see “Pupillary examination” in “Examination of the eye.

• Determine the clarity or sharpness of central visionat various distances by using an ophthalmological chart (e.g., Snellen chart).
• For further information, see “Visual acuity” in “Examination of the eye.”

• Assess light sensitivity and identify patterns of vision loss using a finger or pen.
• For further information, see “Visual field examination” “Examination of the eye.”

• Assess the movement and alignment of the eyes using a finger or a pen. 
• For further information, see “Extraocular movements” and “Examination of extraocular muscles.”

Other special tests

• The fundoscopic examinations are typically only performed in certain situations (e.g., suspected intracranial hypertension or stroke ).
• For further information, “Examination of the eye.”

Inspection and palpation

• Inspect for any obvious deformities, asymmetry, masses, or tracheal deviation.
• Palpation of the lymph nodes of the head and neck
• Palpation of the parotid gland
• Assessment of range of motion of the cervical spine Asks the patient to tilt their chin so that it is resting against their chest or to flex their neck.
• Assessment of spinal accessory nerve function, Ask the patient to move their head to the left and right and to lift their shoulders against resistance. See cranial nerve palsies.
• Evaluate for  jugular venous distention
  

Examination of the thyroid

• Inspection
  • The thyroid gland is located below the thyroid cartilage and is normally not visible.
  • Enlargement should prompt further evaluation.
• Palpation
  • Stand behind the patient. Place your finger pads below the thyroid cartilage and assesses the size and consistency of the thyroid
  • Ask the patient to swallow. The thyroid should slide beneath the fingers. The normal thyroid is usually not palpable.
  • Note any asymmetry or enlargement.

Nose

• Examine the external nose and test the patient’s ability to breathe through either nostril by covering one at a time.
• Examine the nasal mucosa, septum, and turbinates using an otoscope. Use the largest available speculum that will comfortably fit inside the nostril. Direct the speculum posteriorly and superiorly as you inspect the nasal cavity.
• Palpate for tenderness over the maxillary and 
  frontal sinuses. Inspect the lips. Inspect the oral mucosa
• Inspect the gums for redness or ulceration

Throat

• Inspect the tonsils
• Inspect the soft palate
• Inspect the posterior pharynx by having the patient stick out their tongue.
• Inspect the tongue.
• Assess tongue motility: See cranial nerve palsies.

Red flag symptoms of the head and neck