Ch. 9-11: Assessing the Head, Face, Mouth, Neck, Ears, and Eyes

What is the most common type of headache?

Tension headaches

feels like a tight band around the head; often stress-related

Tension headache

Vascular, sharp stabbing pain on one side, often behind one eye; occurs in cycles (15 min–3 hours)

Cluster headache

Throbbing pain and pressure in front of the face and sinus; nasal congestion.

Sinus headache

Unilateral, pulsating, intense pain lasting from a few hours to 3 days; cause nausea and vomiting.

Migraine

A sensation of spinning or movement, even when still

Vertigo

How do you assess the skull?

Inspect and palpate for contour, tenderness, symmetry, deformities, masses, and depressions.

Normal head shape and size, symmetrical and midline

Normocephalic

Pain, tenderness, macrocephaly, tics, involuntary movements, depressions

Abnormal findings assessing the head

What are tics and where are they commonly seen?

Spasmodic muscle contractions in the face, neck, and shoulders

Shape, symmetry, nasolabial folds, palpebral fissures, expressions, edema, skin condition

Inspect on the face

Symmetry, normal skin, no edema, equal nasolabial folds and palpebral fissures

Normal findings of the face

Asymmetry, flat affect, swelling, mask-like face (Parkinson’s), acromegaly, edema

Abnormal findings of the face

Excess growth hormone causing enlarged facial features

Acromegaly

What structures should be palpated on the face?

Earlobes, temporal arteries, zygomatic arches

Palpate the jaw as the patient opens/closes mouth; check for clicking or limited ROM

Assessing for TMJ

Breathing issues, smell, drainage (rhinorrhea), congestion, sinusitis, epistaxis, allergies.

Assessing the Nose (ROS)

How do you assess nasal patency?

Occlude one nostril at a time and ask the patient to breathe in through the other

Symmetry, straight septum, moist pink mucosa, no drainage or tenderness

Normal findings for Nose

Deviated septum, lesions, discharge, polyps, tenderness

Abnormal findings for Nose

Thin, watery nasal discharge

Rhinorrhea

How do you manage a nosebleed (epistaxis)?

Sit upright, tilt head forward, pinch nares for 5–10 mins

When is a nosebleed considered an emergency?

If bleeding >1 cup, >15–20 minutes, interferes with breathing, or follows trauma.

Dry mouth (xerostomia), jaw/tooth/mouth pain, TMJ, bruxism, bleeding, hygiene

Assessing the Mouth (ROS)

Dry mouth caused by reduced saliva; often medication-induced

Xerostomia

Teeth grinding, especially at night

Bruxism

Temporomandibular joint dysfunction causing clicking, pain, and jaw stiffness

TMJ Disorder

Difficulty swallowing (dysphagia), sore throat, hoarseness, pain

Assessing Throat (ROS)

Neck pain, swelling, lumps, thyroid issues, goiter

Neck ROS Screening

Color, moisture, lesions, swelling, symmetry

Inspecting the lips

Cracking, pallor, angular cheilitis, herpes, angioedema

Abnormal lip findings

White to ivory, 28–32 teeth, clean, smooth edges, no decay.

Normal findings for Tooth

Discoloration, broken/missing teeth, decay, malocclusion

Abnormal findings for Tooth

Color, lesions, swelling, tight margin at teeth, bleeding, and tenderness

Inspecting buccal mucosa

Abnormal findings in buccal mucosa

• Thrush (candidiasis)

• Gingivitis

• Aphthous stomatitis (canker sores)

• Gingival hyperplasia

a inflammatory disease or oral mucosa manifested by single or multiple painful erosion or ulcers

Aphthous stomatitis (canker sore)

Mild periodontal disease; red, swollen gums

Gingivitis

Enlargement/overgrowth of gum tissue; may be medication-related (Dilantin)

Gingival hyperplasia

Chronic infection of the gums

Periodontal disease

Candidiasis fungal infection that creates thick, white to yellow patches on the tongue or buccal mucosa

Thrush

What is torus palatinus?

A benign bony ridge on the midline of the hard palate

Color, moisture, movement, nodules, tremors, midline positioning

Assessing the Tongue

Glossitis, leukoplakia, squamous cell carcinoma, hairy tongue, ulcers

Abnormal findings of the tongue

• Deep red color, ulcerations, lesions or growths.

• Hard palate is a shade of yellow if jaundice is present.

• Torus palatinus

Abnormal findings for hard and soft palates

What is torus palatinus?

A benign bony ridge on the midline of the hard palate

How are the tonsils graded?

• +1 tonsils are visible and slightly protruding

• +2 tonsils are halfway between the tonsillar pillars and uvula

• +3 tonsils are almost touching the uvula

• +4 tonsils are touching each other

+1 tonsils size

are visible and slightly protruding

+2 tonsils size

are halfway between the tonsillar pillars and uvula

+3 tonsils size

are almost touching the uvula

+4 tonsils size

are touching each other

Pink, symmetric uvula rise, gag reflex present, no exudate

Normal tonsil/pharynx findings

What’s torticollis?

Neck muscle contraction causing head to tilt to one side

How do you assess trachea alignment?

Place finger at sternal notch and slide side to side to assess symmetry

What causes tracheal deviation?

Pneumothorax, atelectasis, tumors, pleural adhesions

Pulmonary fibrosis

tumor or aneurysm

Pleural adhesions

thyroid lobe enlargement

Large pulmonary atelectasis

pneumothorax (collapsed lung)

How is the thyroid inspected and palpated?

Visual inspection during swallow; palpate using anterior or posterior approach

Smooth, firm, non-tender; moves with swallowing; lobes may or may not be palpable

Normal findings for thyroid

Nodules, tenderness, goiter, asymmetry, fixed mass

Abnormal findings for thyroid

Key equipment for ENT assessment includes?

Gloves, gauze, penlight, tongue blade, water (for swallow), PPE

What do you inspect in the ears?

Size, shape, symmetry, color, lesions, angle (<10°), drainage.

Tophi (gout), cauliflower ear, microtia/macrotia, drainage, nodules

Abnormal findings for ears

Small bump on the upper ear helix—congenital variation

Darwin’s tubercle

How is hearing screened at bedside?

Whisper test: stand behind, whisper 6 letters/numbers, patient repeats.

What CN is tested during the whisper test?

Cranial Nerve VIII (Vestibulocochlear)

What are signs of hearing loss during a conversation?

Leaning in, watching your lips, asking to repeat questions.

What is presbycusis?

Age-related sensorineural hearing loss—associated with falls, depression, and cognitive decline

What is ototoxicity and what can cause it?

Ear/hearing damage from meds; tinnitus may be the first sign

Ringing or buzzing in the ears without external stimulus

Tinnitus

No pain or tenderness over auricle, tragus, or mastoid process

Normal findings when palpating the ears

Uric acid deposits in the ear, often seen in gout

Tophi

What is the purpose of inspecting the lacrimal duct?

Check for swelling or excessive tearing

Inspecting Pupil Size and Consensual Response Normal findings:

• Pupils constrict in response to light.

• Both eyes have a consensual response to direct light.

• Pupil is round and black.

• Both pupils are equal size.

• Diameter is 2 to 8 mm

bacterial infection causing erythema of the sclera and yellow-green drainage

Conjunctivitis

Drooping eyelid, may indicate CN III dysfunction or aging

Ptosis

What is entropion vs. ectropion?

• Entropion: eyelid turns inward (invert)

• Ectropion: eyelid turns outward (evert)

Entropion

eyelids turn inverted

Ectropion

eyelid turn everted

Pupil Size and Consensual Response abnormal findings

• Pupils are unequal in size or both dilated, constricted, or fixed.

• Anisocoria

• Mydriasis

• Miosis

• Horner's Syndrome

Gray-white ring around the cornea, common in aging adults

Arcus senilis

How do you assess pupil reaction (PERRLA)?

Pupils are Equal, Round, Reactive to Light and Accommodation

What CNs are involved in pupillary reflex?

CN II (optic) and CN III (oculomotor)

Anisocoria

Unequal pupil sizes; maybe harmless or a medical emergency causes may be related to genetic, medications, or a neurological disorder or injury

Mydrasis

Bilateral dilated and fixed pupils; maybe because by eye drops, stimulation of nerves, anesthesia, or central nervous system injury

Miosis

Abnormal constricted pupils; cause by strokes, medication, or brain damage

Horner’s syndrome

sign of a medical condition that affect one side of the face; drooping eyelid

Symmetry, no drainage, sclera white, conjunctiva pink, PERRLA, cornea clear

Normal findings for eye inspection

What tools are used to test visual acuity?

Snellen chart (distance), Rosenbaum chart (near)

What is the normal Snellen result?

20/20 vision