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Physical Examination of the Head and Neck

last modified on: Mon, 02/12/2024 - 13:04

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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.

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

  • Evaluate nasal mucosa, bony spurs, perforation, polyps, masses, crusting. Any unilateral nasal mass should not be biopsied prior to imaging to ensure that there is no intracranial component.

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
  • 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

  • Make note of level of any lymph nodes, size, mobility. If salivary gland swelling can massage the gland and determine if there is any drainage (and type) from the salivary duct (stenson's duct drains lateral to second molar, wharton's duct drains under the tongue)

Assess thyroid for nodules or thyromegaly

  • Thyroid nodules should move with swallowing while lymph nodes will stay in place

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.

see also: Flexible Fiberoptic Exam Transnasal Fiberoptic Laryngoscopy Instruction Video