Head and Neck Exam 1 Flashcards
General Appearance
Apparent state of health
Level of consciousness
Signs of distress
-cardiac or respiratory; pain; anxiety/depression
Skin color and obvious lesions
Dress, grooming, and personal hygiene
-appropriate to weather and temperature
-clean, properly buttoned/zipped
Facial expression
-eye contact, appropriate changes in expression
Odors of body and breath
Posture, gait, motor activityOverview: Head Exam
Examine hair, scalp, skull, and face
Overview: Eye Exam
Check visual acuity and screen visual fields
Not position and alignment of eyes
Observe eyelids and inspect sclera and conjunctiva of each
Inspect each cornea, iris, and lens with oblique lighting
Compare pupils ad test reactions to light
Assess extraocular movements
Inspect ocular fundi with ophthalmoscope
Overview: Ear Exam
Inspect auricles, canals, and drums
Check auditory acuity
-if diminished check lateralization: Weber test
-and compare air and bone conduction (Rinne test)
Overview: Nose and Sinus Exam
Examine external nose.
Inspect nasal mucosa, septum and turbinates using light and nasal speculum
Palpate for tenderness of frontal and maxillary sinuses
Overview: Throat (or mouth and pharynx) Exam
Inspect lips, oral mucosa, gums, teeth, tongue, palate, tonsils, and pharynx
May also assess cranial nerves during this portion of the examination
Overview: Neck Exam
Inspect and palpate cervical lymph nodes
Note any masses or unusual pulsations
Feel for any deviation of trachea
Observe sound and effort of patient’s breathing
Inspect and palpate thyroid gland
Examination of Eyes
Look for symmetry/asymmetry
Hypertelorism - abnormally large distance between the eyes
Pupils PERRLA
-Pupils Equal, Round, Reactive to Light and Accommodation
Convergence - “follow the pencil”
CN III, IV, VI
CN V - blink
CN VII
Visual acuity 20/20, correlation with normal sight
Nystagmus - fast, uncontrollable eye movement
Visual fields: confrontation - measure outer edge of visual field
Hemianopsia - loss of vision for 1/2 visual field
Presbyopia - loss of ability to focus on close objects (farsighted)
Myopia - far objects blurred (nearsighted)
Eye Conditions
Ptosis - eyelids droop a little
Miosis/Mydriasis - small pupil/large dialated pupil
Anisocoria - pupils are different sizes
Icterus - yellowing of sclera - from jaundice
redness
Blood
Dryness
Pallor - white instead of moist pink inside of socket
-indicates iron deficiency (anemia)
Chalazion - eye gland gets swollen
Conjunctivitis - pink eye
Pterygium - benign; “swimmer’s eye”, response to sun
-whites of eyes look like they’re growing into pupil
-confused with symblepharon (eyeball starts to scar and hold onto eyelid) — can cause blindness
Pupillary reactions:
- pinpoint = opioids - dilated = cocaine
Examination of Ears
Use otoscope to get view of tympanic membrane to see if there’s any fluid behind it Check patency Check for discharge (Q-tips) Weber test Rinne’s Test
Weber’s Test
detects conductive hearing loss (ex. Wax buildup) and sensorineural hearing loss (ex. Age, neurological problem)
- tuning fork placed on midline - “Where can you hear the buzzing noise?”
Rinne’s Test
testing loss of hearing in one ear; compares perception of sounds transmitted by air conduction to those tramitted by bone condition through the mastoid (behind ear)
- tuning fork pressed against mastoid and then 1 cm from ear - “Which is louder?”
Weber’s Test Interpretation
Normal: sound heard in midline
Conducive hearing loss: sound heard in bad ear
Sensorineural hearing loss: sound heard in good ear
Rinne’s Test Interpretation
Normal: air louder than bone (Rinne’s positive)
Conductive hearing loss: bone louder than air (Rinne’s negative)
Sensorineural hearing loss: air louder than bone (Rinne’s FALSE positive)
Examination of Nose
Look for nasal deviation
Check patency;can you move anterior portion up?
Any secretions?
Signs of congestion?
Epistaxis? - nose bleeding
Rhinorrhea? - runny nose (“nose diarrhea)
Scars
Lesions
Supraalar crease (side of nose) - can be lost if someone has infection in canine tooth
Examination of Para-Nasal Sinuses
Check all of them!
-multiple (bilateral)
-front and maxillary
Percussion
Trans illumination
-if heavy congestion, won’t see the light though the sinus
Relate to history
Relate to ROS
Maxillary sinusitis (cheek sinuses)
-discharge? If so, color?
-headaches?
-pressure?Examination of Throat/Oral/Oropharynx
Inspection Palpation/percussion Normal anatomy Start from outside - work to inside Dentition
Peri-Oral and Intra-Oral Examination
Systematic assessment of lips; labial mucosa and sulcus (the gutter); commissures; buccal mucosa and sulcus; gingiva and alveolar ridge; tongue; floor of mouth; hard and soft palate; pharynx; tonsillar bed
Begin by observing lips and commissures (open AND closed)
-could be problem hiding in commissures
Note color, texture, surface abnormalities of vermillion borders (which are where lip becomes skin)
***loss of vermillion border is indicative of lip cancer
Inspection of Lips and Peri-Oral Region
Salivary gland hypofunction (dry mouth)
Dry/chapped lips/mucosa
Mouth opening restricted (bc of pain)
Angular cheilitis - inflammation and small cracks in corners of mouth
Tongue papillary atrophy - loss of lingual papillae (taste buds)
Examination of Labial Mucosa
With patient’s mouth partially open, visually examine and palpate labial mucosa and sulcus of maxillary vestibule, frenum (skin piece at midline), and mandibular vestibule
- labial mucosa = inner lips - palpate bc there are minor salivary glands in this mucosa; if hard portions, good chance it’s cancer
Observe color, texture, and any swelling or other abnormalities in the vestibular mucosa and gingiva
Examination of Buccal Mucosa
Retract buccal mucosa (cheeks)
Examine right and left buccal mucosa extending from labial commissure posterior to anterior tonsillar pillar
Note any change in pigmentation, color texture, mobility, and other mucosal abnormalities
Carefully examine commissures - do NOT retract with instruments
-not palpating and could even be blocking vision
Parotid gland located between first and second molar on each side high on buccal mucosa - “Stenson’s duct”
Examination of Gingiva
Examine buccal and labial aspects of gingival tissue and alveolar processes
-proceed from 1 to 32 (maxillary right posterior to maxillary left posterior, then drop the mandibular left posterior to mandibular right posterior)
Examine palatial and lingual aspects of gingival tissue and alveolar process (same direction)
Note any changes in color texture, pigmentation, mobility, and other gingival abnormalities
Mallampati Score
Used in anesthesia
An assessment of airway architecture as it applies to endotracheal intubation
-really just a description of how closed off back of the throat is
May be associated with obstructive sleep apnea or even snoring
Class 1: good
Class 2: slightly less open
Class 3: can barely see uvula
Class 4: can’t really see back of the throat at all (very bad)
***patient must stick out their tongue in order to get accurate reading
Palatine Tonsils - Oro/Pharyngeal Airway
HPV cancers almost always (75-80% of the time) effect tonsils
-THIS CANCER IS ON THE RISE
Should assess tonsils for asymmetry FOR EVERY SINGLE PATIENT
Examination of Tongue
With tongue at rest, partially open mouth, inspect dorsum for swelling, ulceration, coating, variation in size, color, or texture
Examine papillae (taste buds) and tip
Patient should extend tongue - not motion, direction, and abnormalities
-grasp tongue with 2x2 and palpate all surfaces (looking for granular cell tumor or squamous cell cancer)
Inspect lateral borders to tonsillar pillars, ventral surface
- “ventrum of tongue” = belly of the tongue
- precancerous lesions
- IF THERE’S CANCER IT’S MOST LIKELY GOING TO BE ON LATERAL PORTION (especially in posterior area)
Examination of Floor of Mouth
With tongue elevated, inspect for changes in color, texture, swellings, or other surface abnormalities
Mandibular tori
-bony projections on floor of mouth
- **important to see entire floor of mouth posteriorly
- another hotspot for oral cancer
Also look at teeth here…
- caries - oral candidiasis: “yeast infection” (can be white or red)
Look for salivary stones or salivary pooling
Examination of Hard Palate
Mouth wide open and patient’s head tilted back (depress base of tongue with index finger/mirror)
Minor salivary glands line hard palate
-hard “node thing” - high likelihood that it’s salivary gland cancer
First inspect hard palate, then inspect the soft palate behind it
-“say ah”: should we soft palate vibrate and move up
Also look at teeth here…
- can see caries - or oral candidiasis: “yeast infection” (can be white or red)
Linea Alba
“White line” where upper and lower teeth meet on the buccal mucosa
-be careful, white patches/sections are not the same as white LINES
Palatine Torus
Growth of bone in midsection of palate
Different than a tumor
-bony hard (tumors would be woody hard - have a little give to it)
On roof of mouth it is not uncommon for tori to be not symmetric
Only removed if affecting mouth in serious way
Oral Cancer Risk Assessment: Low
No tobacco, alcohol use, minimal sun exposure
Oral Cancer Risk Assessment: Elevated
Minimal tobacco use, minimal alcohol use, moderate sun exposure, gender, poor nutrition and habit, fair skin, drug use
excessive smokeless tobacco use, excessive alcohol consumption, excessive sun exposure, family history, HPV exposure, previous history of oral cancer, immunocompromised, gender, severely poor nutrition and habit, fair skin
Note: where its a little or a lot of something bad - still elevated somehow (just different levels of elevated)
Oral Cancer Relative 5 Year Survival
Oro-pharyngeal: 67%
Anterior oral cavity = 60%
As of Aug. 2016
70% of Leukoplakia Occurs…
Lip vermillion, buccal mucosa, gingiva
90%. Of Dysplasia Occurs…
Tongue, lip vermillion, and FOM
Oral Cavity Squamous Cell Cancer (OCSCC) Incidence Rates (IR)
For most sites, including lip, gingiva, and FOM have decreased in US
-consistent with declines of drug and alcohol use
Oro/Pharyngeal Squamous Cell Cancers (OPSCC) Incidence Rates (IR)
Base of tongue, tonsil, soft palate, and pharyngeal wall
Have SIGNIFICANTLY INCREASED, particularly in white men
-increase due to HPV (human papilloma virus)
-sexual habit issue - men have much more difficulty clearing HPV
***subtypes 16 and 18 are associate with these types of cancers
Incidence Rates (IR) for Oral Tongue Squamous Cell Cancer (OTSCC)
Anterior 2/3 of the tongue
Increasing in white men and women
On lateral border of tongue
Cause of this is unknown
- patients have zero risk factors - much more difficult to treat (usually just have to cut out a good portion of the tongue)
Consequences of Oral Cancer
Radiation therapy and complications
Surgical resection
Morbidity and Debility
Diminished quality of life
Intraoral Examination Components
Dental examination
Oral mucosal examination
Extraoral Examination Components
Facial inspection
Head and neck evaluation
-lymph node exam
-salivary gland exam
-thyroid exam
Temporomandibular exam
Cranial nerve exam
