Head and Neck - Examination Flashcards
Perform the introduction and inspection stage of a general Head and Neck examination
Face/Neck: Expression, Symmetry, Swellings, Hair, Shape of face/skull, Scars, Skin, Movements.
Eyes: Lid Lag, Proptosis, Eye movements. Check sclera for jaundice/anaemia. Features of thyroid eye disease.
Skull/Face: Facial symmetry, features of cushings, acromegaly, bony changes (suggestive of underlying/genetic)
Nose: Look at nose in front, above and sides of patient. Observe nasal pyramid and note discharge. Block 1 nostril assess air flow. Elevate tip of nose to inspect vestibule.
Ears: Pinna, note any lesions. Note if pinna pushed forwards (mastoiditis) External auditory meatus (discharge). Behind pinna for scars, Mastoid Process (bruising/battles sign)
Describe an Auriscope Examination (Head & Neck)
R hand for R ear, L hand for L ear.
Check patient not in pain, largest appropriate speculum, hold auriscope 45°, ask patient to turn head slightly away.
Inspect outer ear and meatus then gently pull pinna up and back. Rest little finger on patients cheek for support. Inspect auditory canal and visualise tympanic membrane looking for surface landmarks. Remove auriscope and repeat on other ear, change speculum if discharge.
Perform the palpation section of a general Head & Neck examination.
Skull and Face: palpate mastoid processes, run fingers around orbital margin, check for tenderness on temporal artery, feel maxilla and mandible, place index and middle finger over TM JOINT and ask patient to open and close their mouth and then move their jaw sideways.
Nose: palpate nasal cartilage and bones, feel for tenderness over paransasal sinuses (maxillary, ethmoidal and frontal)
Ears: press infront of meatus or pull gently on pinna (discomfort may suggest infection in canal), palpate gently over each mastoid process.
What are the three different hearing tests you would perform in a general Head & Neck examination?
Whispered Voice Test
Rinne’s Tuning Fork Test
Webber’s Tuning Fork Test
How would you perform a Whispered Voice Test?
To estimate degree of hearing loss (mild/moderate/severe/profound)
Stand behind patient and speak normally at 60cm from ear while masking other ear by gently rubbing tragus
Say a series of sounds and ask patient to treat what they have heard
If heard repeat using a whispered voice and record is these are also heard. If not heard repeat at smaller distance of 15cm and if not heard escalate to louder voice
What tuning fork would you use for hearing tests?
512Hz, the smaller one.
How would you perform a Rinne’s hearing test?
- To compare Air Conduction (AC) to Bone Conduction (BC)
- Activate 512Hz tuning fork
- Hold 5cm from external auditory meatus (ask patient if they can hear
- Place tuning fork on mastoid process and check patient can hear
- Ask which was louder and repeat for other ear
Positive if AC>BC. Negative if BC>AC - a conductive deafness.
If unilateral neural deafness a false negative may occur but initial whispering test should have demonstrated this.
How would you perform a Weber’s hearing test?
Advise patient that you will be placing fork on middle of forehead to find out if
- They can hear it in their head
- If yes, is it louder at one side or equal.
Steps:
- Activate fork
- Place base in midline
- Ask patient if louder in one ear or other
If it can’t be heard at all repeat once and record result. In normality or if hearing loss is symmetrical the sound is heard equally. Conductive deafness on one side means the sound will be heard loudest in that ear. Sensori-neural loss means the sound will be referred to the good ear.
How would you perform an Inspection of the Mouth, Throat and Neck during a head and neck examination?
Patient in chair, glad of water and neck exposed to clavicles.
Mouth:
- Lips (cyanosis, angular stomatitis),
- mouth (dentition, floor of mouth, hard and soft palate, inside of cheeks, parotid duct opening. Ahh!), -oropharynx, uvula, tonsillar folds and tonsils (stick tongue out and move side to side)
- Tongue: dorsal surface, both lateral borders (dryness/fasciculation/wasting)
- touch roof of mouth with tongue to inspect underside of tongue and floor of mouth, frenulum, submandibular duct and opening.
Bite: Ask patient to bite gently
Neck: (Water in patients hand) Scars, Swelling, Lump (size, skin changes), Movement with tongue protrusion (stick tongue out) and swallowing.
How would you perform the palpation stage of a mouth, throat and neck examination?
Neck: check trachea, lateral neck and front, palpate lymph nodes with Z.
(For swellings, note if mobile, vascular, cystic or nodular. Note if midline or lateral. If lateral is it anterior or posterior triangle? If midline is it thyroid swelling for thyroglobulin cyst? (Ask patient to swallow). If a nice then describe clinical level)
Bimanual palpation of mouth.
- Wear gloves
- Palpate for cystic swellings, roughened areas or stones in parotid duct. Along: inside of floor of mouth, inside of cheeks, salivary glands and substance of tongue.
When would you perform percussion in an examination of the Mouth, a neck and Throat?
If there is a palpable thyroid swelling consider percussion for retrosternal thyroid
How would you perform auscultation in an examination of the Mouth, Throat and Neck?
- Listen over the carotid artery’s for a carotid artery bruit. Ask patient to hold breath - will be heard in carotid artery stenosis.
- Listen over enlarged thyroid. Both lobes. in Graves’ disease a soft bruit may be heard
