Head and Neck Examination

Examination of the Head and Neck

• Examination includes assessing the shape of the skull, eyes, ears, nose, mouth, thyroid gland, carotid pulse, jugular veins, and jugular venous pressure

Head Exam Methods

• Inspection is done by describing all pathology
• Percussion is a method
• Palpation is a method

Head Exam Regions

• Inspection includes assessing the shape of the head and facies
• Percussion of head
• Palpation of head
• Assess disturbance in motor innervation n. VII

Head Inspection

• Normocephalic head is a mesocephalic head
• Dolichocefalic is an elongated antero-posterior diameter
• Brachycefalic is a shortened antero-posterior diameter
• Turicephaly (oxycephaly) is a steeple skull, pointed vertex, premature closure of the sutures, and normal mental functions.
• Microcephaly is a congenitally small skull

Posture of the Head

• Torticollis is when the head is flexed sideways
• Tremor is a posture
• Musset's sign is synchronous nodding in aortic insufficiency

Facies

• Facies provide information about psychiatric state and specific diseases
• Facies febrilis
• Facies Hypocratica
• Facies mitralis
• Facies nephritica
• Facies pletorica
• Facies pallida
• Facies anemica
• Facies endocrinopathy
• Facies Acromegalica
• Facies thyreotoxica
• Facies myxoedematosa
• Facies Cushing
• Facies diabetica

Head Percussion

• Percussion of head is done to diagnose fractures, instability, and crepitation
• Palpate the hairy segment of the head x injuries and tumors invisible in the hair
• Pain in frontal sinuses can indicate sinusitis
• Lipoma are examined

Head Palpation

• Sensory innervation of the face is done through n. V = n. trigeminus

Disturbance in Motor Innervation n. VII

• Central disturbance can mean the patient had a stroke
• Peripheral disturbance can mean facial nerve or Bell's palsy
• Lagopthalmos is when the eye doesn't close fully, leaving a rabbit's eye

Temporal Arteritis

• Untreated or inadequately treated temporal arteritis may result in unilateral or bilateral blindness (up to 50%)
• Occulomotor disturbances are a symptom
• Vertigo and hearing impairment are symptoms
• Cervical myelopathy is a symptom
• Unilateral or bilateral limb bruits claudication
• Brainstem strokes and TIAs are a symptom

Examination of the Noise and Ears

• Nose include size, form, secretions
  • Epistaxis
  • Rhinitis
• Mucous
• Mucopurulent
• Purulent secretion
• Watery - allergy
• Ears
• Urate tophi in gout
• Sunburn or frostbite of the pinna
• Discharge - drainage from the meatus, inflammation, bleeding, mastoiditis

Examination of the Eyes

• Prominent supraorbital ridges can indicate acromegaly
• Thick eyebrows in females can indicate virilism

Eyes & Eyelids

• Swelling can be blepharitis, myxedema, or kidney disease
• Xanthelasma
• Pigmentation can occur with Addison disease or thyreotoxicosis

Location of Eyeballs

• Physiology - "mid position"
• Pathology
  • Exophthalmos – symmetric (thyreotoxicosis)
  • Asymmetric (retroorbital tumors)
• Thrombosis of cavernal sinus is unilateral exophthalmos + swelling of the conjunctiva (chemosis) + furuncle
• Horner's syndrome = enophthalmos + miosis + ptosis, compression of cervical sympaticus by tumors

Thyrotoxicosis

• Exophthalmos
• Graefe's sign – eyelid lag
• Moebius' sign – the eyes diverge by nearpoint focusing
• Stellwag's sign – infrequent blinking and stare in thyrotoxicosis

Movement of the Eyeballs

• The patient follows the index finger during examination
• Squinting indicates strabismus
  • Divergent
  • Convergent
• Nystagmus can show a vertical, horizontal, or rotational pattern

Ocular Conjunctiva

• Pale conjunctiva can indicate anemia
• Purple conjunctiva can indicate polycythemia
• Red conjunctiva can indicate inflammation
• Hematomas can indicate bleeding diseases
• Xerophthalmia is dry, may be due to Vitamin A deficiency or Sjoegren's syndrome

Ocular Sclera

• Icterus is jaundice
• Subconjunctival bleeding
• Blue sclera can indicate osteogenesis imperfecta
• Black melanin spots are normal in black races or can show a disturbance in tyrosine metabolism

Ocular Cornea

• Arcus senilis
• Copper deposit can indicate Wilson's disease

Ocular Pupils

• Assess Shape: circular x irregular
• Assess Size
• Myosis - constricted
• Mydriasis – dilated
• Uneven - anisocoria
• Reaction to light and accommodation

Examine the Mouth

• Lips
  • Cyanosis
  • Paleness
  • Cheilosis = angular stomatitis
  • Herpes simplex - labialis

Examine the Oral Cavity, Tongue

• Tongue Movements
  • Hypoglossal paralysis – glossoplegia
  • Macroglossia is myxedema
  • Xerostomia indicates dry mouth, Sjoegren syndrome
  • Brownish coat: dehydration, abdominal emergencies, uremia, lung infections
  • Pernicious anemia: Hunter's glossitis (B12, ATB)
  • Multiple bites can indicate epilepsy

Examine the Oral Cavity

• Thrush indicates candidosis
• Graphite spots can be Addison's disease
• Bleeding gums can indicate scurvy
• Gingivitis
• Abscesses
• Necrosis: leukemia
• Colored bands on the gums may indicate metal intoxication

Teeth and Tonsils

• Teeth
• Progenia
• Tonsils: presence, size, purulent specks – plugs, pseudomembranes, films, and inflammation
• Posterior wall of oropharynx

Changes of Voice and Disturbances of Speech

• Hoarseness points to laryngitis, or neck tumors
• Coarse voice points to hypothyroidism
• Nasal slur refers to soft palate in diphtheria, split palate
• Aphonia is no speech
• Aphasia is no formed words (mild dysphasia)
• Motor aphasia (Broca's) where there's understanding but not repeating words
• Anarthria (dysarthria) is a defect in articulation

Example of Head Examination

• Head is mesocephalic by percussion diffusely non-painful, without pathological changes
• Outputs of the trigeminal nerve palpably non-painful
• Innervation of the facial nerve is intact
• Sclerae are white, bulbs are in a central position, freely movable in all directions, no nystagmus, no strabismus, pupils are isocoric reacting to light and convergence, no arcus senilis of the cornea, conjunctivae pink, eyelids without swelling, no xanthelasma
• Ears and nose externally without pathological changes and without discharge
• Lips are symmetrical without cynosis, oral cavity

Examination of the Neck

• Inspection
• Palpation
• Auskultation
• The neck examination should include:
  • Shape and length
  • Mobility of the neck
  • Glandula thyreoidea
  • Nodi lymphatici
  • Arterie carotis
  • Neck veins

Neck Shape & Length

• The normal neck is slim and symmetrical
• Pathology include:
  • Skinny: cachectic or sunken supraclavicular pits
  • Strong or obese
  • Carotid pulsation: visible or asthenic hypertension, hyperthyreosis, or aortic insufficiency
  • Horizontal scar indicates strumectomy or issues with the jugular region
  • Post-irradiation changes indicate radiotherapy of malignant tumors

Neck Mobility

• Normal mobility is physiological with free range of motion in all directions including flexion, extension, and turning to the left and right
• Pathology includes:
  • Limited mobility which can point to vertebrogenic syndrome, meningeal irritation, Bechterew's disease, or torticollis spastica or tonic contracture of the sternocleidomastoid muscle
  • Musset's sign, showing abnormal movement of the head

Thyroid Examination

• A normal thyroid gland has no enlargement and is non-palpable
• Goiter = struma, is enlargement of any etiology, visible or palpable. -Simple = no other pathology -Euthyroid -Hyperthyroid -Hypothyroid

Palpation of the Thyroid Gland

• Assess for size, symmetry, surface (smooth, irregular, nodular), and consistency (soft, firm, stone-hard)
• Assess for mobility and tenderness
• Assess for pulsation, thrill, and bruit
• Check if the patient has Cave retrosternal/intrathoracic goiter
• Parenchymatous: puberty diffuse, symetrical increases vascular low indicates Graves-Basedow
• Colloid: adults, diffuse, symetrical, but firmer

Thyroid Gland Palpation & Goiter

• Pathology: -Uni- + multinodular is asymetrical with swallowing difficulties -Malignant is hard, asymetrical, and tender -Hashimoto's thyreoiditis is autoimmune, can be small or nontender -Subacute thyreoiditis is viral -Riedel's thyreoiditis is fibrosis

Lymph Node Examination

• Normal lymph nodes are oval or globlar shaped
• Normal size ranges from 1-15 mm according to localization
• The human body has ~600 lymph nodes that act as physiological filters of the lymph

Palpating Lymph Nodes

• Palpate for size, localization, and consistence (soft, elastic, hard)
• Acute inflammation are soft and painful
• Malignant lymphoma are elastic and thus medium soft
• Metastatic tumors and lymphogranuloma are hard
• Pathologic lymph nodes can be packets and grown together, with skin loss of looseness

Superficial Lymph Nodes

• Head: preauricular, retroauricular, mental, occipital, and submandibular
• Cervical
• Chest (axillar or underarm, and supraclavicular)
• Inguinal and femoral lymph nodes

Enlargement of Lymph Nodes

• Occipital node enlargement is Rubeola or pyodermia of the head
• Pre or Retroauricular node enlargement is inflammation of the auditory meatus
• Submandibular node enlargement is inflammation of gums, lower jaw, or pharynx tumors
• Neck node enlargement is inflammation or tumor of rhinopharynx or thyroid gland
• Supraclavicular node enlargement is inflammation or tumor of breast or lungs or Virchow's node indicates stomach carcinoma, left side
• Axillar node enlargement is inflammation or tumor of breast
• Inguinal and femoral node enlargement is inflammation of lower extremities or the urogenital tract or tumor of the rectum and uterus

Neck Arteries

• Carotic arteries pulsation should be well palpable symmetrically, without murmurs
• Pathologically
  • Weakened - is palpable
  • Non-palpable pulsation
  • Narrowing
  • Complete obstruction of the lumen of the vessel

Carotid Artriae

• Inspection include visible pulsation after exercising or in hypertension and ao insufficiency, thyrotoxicosis, or in elderly
• Inspect pulsation in jugular area elongated aorta
• Auscultation include murmurs from the heart and atheromatous plack

Examination of Neck Veins

• CVP = cm of jugular filling over the sternoclavicular junction, normal under 2 cm
• Increased jugular filling can indicate right heart failure, pericarditis, or tricuspid insufficiency

Neck Exam Example

• A normal neck is slim, symmetrical in all directions, is freely movable (limited mobility sideways), and carotids pulsate symmetrically without murmurs
• The thyroid gland is not enlarged on palpation and no murmurs are heard above it
• The filling of the jugular veins is adequate
• Cervical lymph nodes are not palpable