Core Curriculum Syllabus: Examination of the Head and Neck
The head and neck exam involves observation of all surface features and careful palpation. In addition, many interior surfaces must be inspected, which makes adequate illumination essential. A hand-held light is commonly used by most physicians to examine the mouth, but head mirrors or head lights provide much brighter light and free both hands for the examination. The otoscope is the basic instrument used to evaluate the ear.
Several techniques are used by otolaryngologists to better assess the ears, nose, and throat. The operating microscope provides an enlarged three-dimensional view of the ear canal and tympanic membrane, which is vastly superior to the monocular image obtained with the hand-held otoscope. The microscope also permits the bimanual removal of wax and foreign bodies. Indirect mirror exam permits examination of the larynx, hypopharynx, and nasopharynx. Fiberoptic and telescopic instruments are also useful.
Many structures are not accessible to direct examination, such as the sinuses, portions of the pharynx, and the middle and inner ear. The condition of these can often be inferred from a combination of a careful history and the physical examination of adjacent, more visible areas. For example, acute sinusitis can be diagnosed on the basis of characteristic history, the observation of purulence draining into the nose, and often, tenderness over the affected spaces. The inflamed sinus mucosa cannot be viewed directly. X-rays may demonstrate opacification of the sinuses, but in the absence of the patient history, accurate diagnosis cannot be made.
External Auricle: Congenital deformity such as microtia and accessory tragus can be associated with middle and inner ear malformations. Assess patency of external auditory meatus. Look for preauricular pits which may indicate sinus tracts.
Otoscopy: The canal should be thoroughly cleaned, and the largest speculum which will comfortably fit should be used. The external ear canal is normally curved, which limits the visibility of the eardrum and medial canal. Gentle traction on the auricle will move the cartilaginous canal and afford a better view. In adults, the auricle should be pulled superiorly, laterally, and inferiorly. In infants, the bony canal has not yet developed, and the auricle should be pulled inferiorly.
The external canal may be swollen due to external otitis or filled with cerumen or debris. Subcutaneous bony masses (exostoses) may project into the lumen. Note the condition of the skin and any lesions. The anterior canal wall commonly obscures the anterior portion of the ear drum. The tympanic membrane is normally pearly gray, shiny, translucent and concave. Changes in the appearance of this structure may indicate pathology in the middle ear, mastoid, or eustachian tube. White patches, called tympanosclerosis, can frequently be seen and provide evidence of prior significant infection. A dull, blue ear drum indicates hemotympanum. A red bulging tympanic membrane indicates acute bacterial otitis media. A dull, retracted, amber drum is seen in serous otitis. If a perforation is present, then the middle ear mucosa may be viewed directly. Healed perforations are often more transparent than the surrounding drum and may be mistaken for actual holes.
Pneumatic otoscopy refers to examining the tympanic membrane via an airtight speculum and observing movements with the gentle insufflation of air. Mobility may be limited by scarring, middle ear effusion, or perforation.
Eustachian tube function may be assessed by watching the ear drum as the patient swallows with the nose pinched off (Toynbee maneuver) and then swallows with the nose unobstructed. The first step normally causes the ear drum to retract, while the second step releases it.
Tuning forks can be used to grossly assess hearing, but more importantly, to differentiate between conductive and sensorineural hearing loss. A tuning fork placed in the center of the skull will normally be perceived in the midline (Weber). With a conductive hearing loss, the sound will appear to be on the side of the bad ear. If there is a sensorineural loss, the sound will be perceived in the better ear. The Rinne's test compares air conduction hearing (tuning fork tines in the air just outside external auditory canal) to bone conduction hearing (base of tuning fork over mastoid process). In conductive hearing loss, bone conduction is more sensitive than air conduction.
A proper, complete assessment of hearing requires audiometry. This is indicated in any patient with chronic hearing loss, or with acute loss that cannot be explained by canal occlusion or middle ear infection. It is also an integral part of the evaluation of the patient with vertigo.
Unilateral hearing loss due to serous otitis in an adult may be the presenting symptom of cancer of the nasopharynx, due to occlusion of the eustachian tube. All such patients should have a thorough nasopharyngeal exam, and careful palpation of the neck to detect possible metastasis from an occult tumor.
Complete evaluation of the ear includes assessment of the facial nerve and vestibular function.
The nose is a very narrow space, and it is impossible to completely examine the inner surface in the intact patient. Anterior rhinoscopy with a bivalve speculum usually discloses the anterior ends of the inferior turbinates and the septum. Topical vasoconstriction permits a somewhat more thorough examination. Nasal patency may be compromised by swollen turbinates, septal deviation, or intranasal masses, such as tumors, or nasal polyps. A perforation of the nasal septum can cause symptoms such as a whistling noise during breathing, epistaxis, and excessive crusting of the nose.
The sense of smell is rarely tested due to the difficulty in objectively quantifying responses, but by presenting common odors (lemon, coffee, vanilla) one can assess the patient's ability to detect an odor or identify it. Ammonia fumes will stimulate trigeminal endings, and thus produce a response in the absence of any olfaction; thus it is useful for distinguishing true anosmics from malingerers.
An adequate light and tongue blade are necessary for examining the mouth. The blade should be used to systematically expose all teeth and mucosal surfaces, including those recesses inferior and posterior to the tongue, and the gingivobuccal sulci. Dentures should always be removed to permit a complete examination. The parotid duct orifice can be seen on the buccal mucosa opposite the upper second molar, and massage of the gland should express clear fluid. The submandibular and sublingual glands empty into the floor of the mouth. Complete examination of the mouth includes bimanual palpation of the tongue and the floor of the mouth to detect possible tumors or salivary stones.
The posterior wall of the oropharynx can be visualized easily via the mouth, by depressing the tongue. Inspection of the hypopharynx, larynx, and nasopharynx requires use of indirect mirror exam. Mirrors should be prewarmed to minimize fogging. To examine the nasopharynx, use a small mirror. The patient should be instructed to open his mouth as widely as possible, RELAX his tongue, and try to breathe via the nose. The posterior tongue blade is depressed as much as possible to provide a space for the mirror above the tongue and posterior to the soft palate. Concentrating on nasal breathing causes the soft palate to relax and drop, providing a view of the nasopharynx. Only a small portion of the nasopharynx can be visualized in the mirror at once; therefore, it must be moved about to show the posterior choanae of the nose, the posterior nasopharyngeal wall, and the eustachian tube orifices.
The hypopharynx is examined with a large mirror. The patient is asked to lean forward slightly from the hips, with back straight and neck slightly extended (sniff position). The tongue is protruded as far as possible, and the examiner grasps the tip with a gauze sponge. Gentle anterior traction is applied. The patient must voluntarily relax and protrude his tongue, or else excessive traction (which may be painful!) may be required. The mirror is placed against the soft palate and used to push it posteriorly. The mirror is rotated as necessary for visualization of the base of the tongue valleculae, posterior and lateral pharyngeal walls, pyriform sinus openings, and larynx. At rest, the epiglottis normally overhangs and obscures the glottis. If the patient tries to produce a high pitched "Eeeee", the epiglottis usually lifts sufficiently to expose the cords. Vocal fold mobility should be assessed by asking the patient to alternately phonate, and inspire deeply. The glottis opens with inspiration and closes for phonation.
In patients with a hyperactive gag reflex or extremely overhanging epiglottis, mirror exam may not be feasible and a fiberoptic nasopharyngoscope may be inserted via the nose. A right-angle telescope is useful for close-up inspection and for photography.
The Paranasal Sinuses
Since direct visualization is difficult, one must rely on indirect physical assessment and radiology. Purulent drainage from the sinuses may be noted in the nose. Tenderness may be elicited by tapping over the frontal or maxillary sinuses or applying pressure under the supraorbital rim or near the medial canthi. The frontal and maxillary sinuses can be transilluminated by placing a bright light under the supraorbital rim and inside the mouth in a dark room. This method is not commonly used due to the availability and greater reliability of sinus x-rays. In addition, the availability of fiberoptically illuminated endoscopes now allow better direct visual assessment of the middle meatus and maxillary sinuses.
The Salivary Gland
The parotid and submandibular glands should be inspected and palpated to detect enlargement, masses, and/or tenderness.
The normal neck is supple, with the hyoid, larynx and trachea easily palpable in the midline. A complete examination should include external observation for symmetry and possible masses by thorough palpation of all tissue and auscultation. The exact position and size of any mass should be carefully noted, along with any relationship to the thyroid, carotid, or airway. A neck mass may be an inflammatory lymph node, an aneurysm, a thyroid mass, a dermoid, or a thyroglossal duct cyst. It may also be a metastasis from cancer in the head, neck or lung. With the exception of supraclavicular nodes, the neck is an uncommon site of metastasis from below the diaphragm.