Extra Oral Examination in Clinical Practice

• The aim is to understand the relevance of extra oral examinations in clinical practice.
• By the end of the session students will be able to:
  • Explain the relevance and importance of the extra oral examination of the patient.
  • Identify areas of particular significance related to extra oral examination.
  • Explore the techniques and observations to carry out a thorough and effective extra oral examination.
• An extra oral examination is part of the general initial assessment.
• Extra oral examinations identify undisclosed or undiagnosed conditions.
  • These conditions may malignancies, endocrine disorders, and indications of cardiovascular risk

Areas of the Face of Focus

• Upper Face: Forehead, eyes, cheeks/cheekbones, upper part of nose
• Lower Face: Lower part of nose, lips, chin, general symmetry

Neck Area Examination

• Palpate (feel) for swelling, tenderness, and lymph gland enlargement
• Look for any swelling / tenderness / abnormality
• Lymphadenopathy is a disease of the lymph glands, often recognized as swelling and tenderness.

Lymph Nodes

• Normal, healthy lymph nodes:
  • Small (pea-sized), not tender to the touch, and usually mobile.
• Abnormal lymph nodes:
  • Feel fixed and are often tender to the touch.
• If an abnormality is detected, make careful notes on size, location, consistency, etc with diagrams.
• Swollen and tender nodes are often due to recent infections, e.g., a cold.
• During a lymph node examination:
  • Stand behind the patient, ensure they are relaxed, and have their head slightly forward.
  • Use the pads of the fingertips in an on/off motion.

Temporomandibular Joint (TMJ)

• The TMJ is formed by the mandible and temporal bone, made up of capsules and ligaments.
• It's responsible for jaw movement for eating/talking etc and is a very used joint.
• Problems are common and can cause pain and difficulty opening.
• Teeth Grinding (Bruxism) is often caused by stress.
  • Bruxism creates pain and stiffness on opening, headaches, neck aches, as well as other intra-oral problems
• When examining the TMJ:
  • Palpate both sides and ask the patient to open and close to determine if:
    • There's any tenderness, pain, deviation to one side, and/or clicking
  • Stand behind the patient to carry out examination and examine both sides at the same time, using the tips of fingers, and gentle pressure

The Face

• Check for any deviation from "Normal"
• Significant asymmetries should be noted and discussed with the patient (as to the cause)
• This may be due to previous trauma/surgery, CVA's, infections, nerve paralysis, etc.
• Check if there's any unexplained swelling, bruising, pallor, or excessive sweating

Eyes

• Check the eyes

Lips

• Check if lips are moist or dry and chapped.
• Check for signs of cracking at the corners of the mouth (commissures).
• Angular Cheilitis is cracking at the corners (commissures of the mouth) maybe one or both .
  • Angular Cheilitis is Inflamed, often red and sore and maybe caused by Fungal infection
  • Ask patient about history of condition and any treatment they have had.
  • May be difficult and painful for patient to open for dental treatment

Herpes Labialis (Cold Sore)

• This is a Common condition where mild to severe outbreaks may occur.
• It's is caused by the Herpes Simplex Virus.
  • The Herpes Simplex Virus lies dormant in nerve cells but is activated by certain situations/conditions
  • This leads to to the outbreak of one or more lesions on or near the lips
• Treatment should be avoided if patient presents with a Cold Sore until it has completely healed due to being Contagious

Suspicious lesions

• Be aware of any lesions on or near the lips that look suspicious

Squamous Cell Carcinoma

• A malignant lesion may present as a sore, ulcer, blister, red or white patch on the lip that hasn't gone away/healed.
• There may be associated swelling of the lymph nodes or surrounding structures
• If SCC is suspected, an urgent referral is needed (details of duration, size, location, and consistency, with diagrams).

Summary of Examination

• Closely look at the face, lips, eyes, and general appearance of the patient. Note anything unusual or abnormal.
• Carefully examine all lymph nodes of the neck area, looking for signs of abnormalities.
• Examine the TMJ for signs of malfunction or abnormality.
• Ask the patient about anything, to get a full history and possible explanation of findings.