Head and Neck Evaluation
Techniques of Examination
Head: Hair = fine — hyperthyroidism, coarse — hypothyroidism
Scalp = Redness + scaling — seborrheic dermatitis, psoriasis
Skull = Enlarged — hydrocephalus, Paget’s disease of bone
Tenderness — trauma
Face = read up on this topic
Skin = Hirsutism (excessive facial hair) in women
Eyes: Visual Acuity:
20/200 — patient can read print at 20 ft. Normal person reads at 200 ft.
“20/40 corrected” — can read at 40 line w/ glasses
Myopia = impaired far vision
Presbyopia = impaired near vision, in old people — sees better when far
Legal blindness = vision is better eye w/ glasses — 20/200
Also due to constricted field of vision (20 degrees or less in better eye)
Visual Fields by Confrontation
Screening starts in temporal fields b/c most defects here — homonymous
heminanopsia, bitemporal hemianopsia, quadrantic defects
“Fish bowl test” – wiggle fingers — patient normally sees both fingers
same time
Left temporal hemianopsia = patient’s left eye doesn’t see fingers until
crossed line of gaze
Temporal defect in visual field of one eye suggests nasal defect in other eye –
left homonymous hemianopsia
Enlarged blind spot — glaucoma, optic neuritis, papilledema (these affect optic
nerve)
Position and Alignment of Eyes
Abnormal protrusion — Graves’ disease, ocular tumors
Eyebrows
Scaliness — seborrheic dermatitis
Lateral sparseness — hypothyroidism
Eyelids
Blepharitis = inflammation of eyelids along lid margins — crusting/scales
If eyelids don’t close — damage corneas
Lacrimal Apparatus
Excessive tearing — increased production: conjuctival inflammation, corneal irritation
– impaired drainage: ectropion (lower lid turned outward so
doesn’t drain right), nasal duct obstruction
Conjunctiva and Sclera
Yellow — Jaundice
Local redness — nodular episcleritis Cornea and Lens-Opacities
Iris: Iris abnormally far forward — narrow angle w/ cornea — cast crescent shadow
Narrow angle — risk for acute narrow-angle glaucoma = sudden increase in
intraocular
pressure when block aqueous humor drainage
Pupils: Miosis = pupil constriction
Mydriasis = pupil dilation
Pupillary abnormalities: benign anisocoria, Horner’s syndrome. . .
Anisocoria = pupillary inequality < 0.5 mm — if pupillary reactions normal, then
anisocoria benign
Direction reaction (pupillary constriction in same eye)
Consensual reaction (constriction in opposite eye)
If reaction to light impaired — test near reaction in normal light
Ask patient to look alternately at finger and into distance behind it — watch for
constriction with near effort — diagnose Argyll Robertson , tonic (Adie’s)
pupils
Extraocular Muscles
Asymmetry of corneal reflections — deviation from normal ocular alignment
Temporal light reflection on one cornea — nasal deviation of that
Nystagmus = rhythmic oscillation of eyes
Sustained nystagmus w/in binocular field of gaze — neurologic problem
Lid lag — hyperthyroidism– can see rim of sclera between upper lid and iris
Lid seems lag behind eyeball
Left CN VI paralysis — eyes conjugate in right lateral gaze, not in left lateral gaze
(when looking left, left eye doesn’t follow)
Poor convergence — hyperthyroidism
Opthalmoscopic Exam
Contraindications for mydriatic drops (for pupil dilation) — head injury/coma-
need to observe pupillary reactions OR — suspicion of narrow-angle
glaucoma
Macular degeneration — poor central vision in old people – can be hemorrhages,
Exudates, cysts, “holes”
Vitreous floaters = dark specks/ strands between fundus and lens
Cateracts = densities in lens
Ear: Auricle
Otitis externa = move auricle — pain
Otitis media = move auricle — no pain (but can have tenderness behind ear)
Ear Canal and Drum
Exostoses = nontender, nodular swellings covered by normal skin in ear canal
Nonmalignant overgrowths
Acute otitis externa — canal swollen, narrowed, moist, pale, tender, red
Chronic otitis external — skin of canal thicken, red, itchy
Acute purulent otitis media — red, bulging drum
Serous effusion — amber drum
Auditory Acuity — test hearing by whispering into one ear
Air and Bone Conduction
Distinguish conductive and sensorial hearing loss
Weber Test = test for lateralization
Unilateral conductive hearing loss — sound lateralized to impaired ear – due to
acute otitis media, perforated ear drum, obstruction of canal
Unilateral sensorial hearing loss — sound lateralized to good ear
Conductive hearing loss — sound heard through bone as long/longer than in air
Sensorial hearing loss — sound heard longer through air
Nose and Paranasal Sinuses:
Tenderness of nasal tip — infection (furuncle)
Deviation of lower septum seldom obstructs air flow (pretty common)
Lower anterior part of septum — source of epistaxis = nosebleed
Septal perforation — trauma, surgery, cocaine, amphetamines
Viral rhinitis — mucosa red, swollen
Allergic rhinitis — mucosa pale, bluish, red
Polyps = pale, semitranslucent masses from middle meatus
Ulcers — nasal use of cocaine
Acute sinusitis — local tenderness, pain, fever, nasal discharge – Dx by transillumination
Mouth and Pharynx:
Denture Sore Mouth — bright red edematous mucosa beneath denture
Lips: Cyanosis, pallor
Oral Mucosa: read up on this topic if necessary
Gums and Teeth:
Gingivitis — redness, swollen interdental papillae
Lead poisoning — black line
Roof of Mouth:
Torus palatinus = midline lump
Tongue and Floor of Mouth:
Lesion of CN XII — asymmetric protrusion of tongue
Cancer of tongue – second leading cause of cancer in mouth (1st is lip)
Suspect persistent nodule/nodule that’s red/white
Induration — increase malignancy
Most often on side of tongue, can also be at base
Paralysis of CN X — soft palate fails to rise, uvula deviates to opposite side
Lymph Nodes:
Feel in sequence – Preauricular — Posterior auricular — Occipital — Tonsillar — Submandibular
– Submental — Superficial cervical — Posterior cervical — Deep cervical chain –
Supraclavicular
“Tonsillar node” — pulsates = carotid artery
Small, hard, tender “tonsillar node” high in mandible and SCM = styloid process
Enlargement of supraclavicular node — metastasis form thoracic or abdominal malignancy
Trachea and Thyroid Gland:
Tracheal Deviation — masses in neck, mediastinal mass, atelectasis, large
pneumothorax
Goiter = enlarged thyroid gland
Tenderness — thyroiditis
Hyperthyroidism — localized systolic or continuous bruit
Special techniques:
Exopthalmos = abnormal protrusion of eye
Nasal Lacrimal Duct Obstruction– regurgitation of mucopurulent fluid from puncta
Swinging Flashlight Test = determine if reduced vision due to ocular disease or optic
nerve
Damage optic nerve — afferent stimulus to midbrain decreased so pupil dilates from
constricted state — Afferent pupillary defect (Marcus Gunn pupil)
Transillumination of Sinuses – absence of glow — thick mucosa in frontal or maxillary
sinus, can also be due to absence of sinus.
Tags: bitemporal hemianopsia, Fish bowl test, Gingivitis, glaucoma, heminanopsia, Hirsutism, hyperthyroidism, hypothyroidism, Miosis, Nystagmus, optic neuritis, papilledema, pneumothorax, psoriasis, quadrantic defects, scalp, seborrheic dermatitis, Viral rhinitis
