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Physical Examination of the Head and Neck

last modified on: Mon, 04/29/2024 - 08:37

return to: Medical Student Instruction

Introduction to the Head and Neck Exam

Note: 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.
  • see: How to Read an Audiogram

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