Extraoral Examinations II

Head and Neck Exams Importance

Early detection significantly improves survival

Obtain baseline clinical status of the patient

Positioning the Patient

Upright position

• assess facial symmetry

• Better access to posterior neck

Tilt head for access

Lighting is essential

Coronal Plane

Cuts the frontal portion

Front and back

Sagittal Plane

Lateral section

Left and right

Axial Plane

Horizontal or transverse section

Up and down

Median Plane

Sagittal midline

Lymph Nodes

Filter lymph fluid via

Serves a vital role in development and maintenance of the immune response

Cervical Lymphadenopathy

Inflammation (painful)

Neoplastic (painless)

• Firm, rubbery, fixed

Palpitation Method

2 to 3 fingers and apply gently pressure in circular motion

Use the thumb and knuckle of index finger for pinching method

Always evaluate for symmetry

Adjust the position of the patient for better access

Lips

Structure that surrounds the oral aperture bounded by the upper and lower vermillion

Vermillion

Red part of the lips contiguous with oral mucosa and gingivolabial groove

Lips

Vermillion Border

Demarcated outer rim of the lips

Cupid’s Bow

Curves medially and superiorly from the commissures to the paramedian peaks at base of philtral pillars

Oral Commissure

Lateral aspect of vermillion of the upper and lower lips (cheilion)

Strabismus

Eye misalignment

Nystagmus

Uncontrolled eye movements

Pupillary Dilation and Constriction

Check for symmetry

Normal pupils (3-5 mm)

Mydriasis

Miosis

Mydriasis

8 mm pupil

Causes - brain injury, recreational drug use, arousal, adrenaline

Cocaine, MDMA, meth, psychedelic mushrooms

Antidepressants, antihistamines, atropine, Parkinsons

Migraines, head trauma, eye injury

Miosis

1.5 mm pupil

Causes: drugs, Horner syndrome, drug poisoning, uveitis, brainstem stroke

Opioids, benzo, neurosyphilis, cluster headaches

Pupillary Reflex

Testing CN III (Oculomotor)

Direct reflex - pupil of stimulated eye constricts

Indirect (consensual) reflex - pupil of contralateral eye constricts

Nail Abnormalities

Clubbing

Kiolonychia

Pitting

Splinter hemorrhages

Transverse grooves

Trachyonychia (rough, longitudinal ridges)

Longitudinal melanonychia

Palpating Muscles

Bilateral - do both sides

Gentle palpation

2 lbs of pressure to assess familiar pain

Masseter

Origin - zygomatic bone, zygomatic arch

Insertion - mandibular and ramus

Innervation - masseteric n. (anterior division of CN V3)

Bilateral Action - elevates mandible

Unilateral Action - lateral movement of mandible

Temporalis

Origin - temporal fascia, temporal fossa (infeiror temporal line)

Insertion - coronoid process of mandible

Innervation - deep temporal n. (anterior division of CN V3)

Bilatera action - anterior fibers elevate mandible, posterior fibers retrude mandible

Unilateral action - lateral movement of mandible

Medial Pterygoid

Origin - maxillary tuberosity and palatine bone, medial surface of lateral pterygoid plate and fossa

Insertion - pterygoid rugosity on medial surface of mandibular angle

Innervation - medial pteerygoid n. (trunk of CN V3)

Bilateral action - elevation of mandible

Unilateral action - ipsilateral lateral pterygoid to protrude mandible and produce medial movement toward the opposite side

Lateral Pterygoid

Origin - greater wing of sphenoid bone, lateral pterygoid plate

Insertion - mandible and TMJ articular disk, condylar process and neck of mandible

Innervation - lateral pterygoid n. (anterior division of V3)

Bilateral action - protrudes mandible and opens the mouth

Unilateral action - ipsilateral medial side to side movements

Temporomandibular Joint (TMJ)

Palpate the lateral pole anterior to external auditory meatus with 1 lbs of pressure

Assess pain/tenderness

Feel for joint noises, clicks crepitus, subluxation

Observe jaw deviation vs deflection on opening and closing

Thyroid Gland

Inferior to thyroid cartilage

Palpate the cricoid cartilage

Have the patients swallow and palpate gland

Evaluate for symmetry and consistency

Trachea at midline

Macule

Vitiligo

Flat skin lesion

Patch

Tinea corporis

Macule with some surface change

Either sluight scale or fine wrinkling

Papules

Flat warts

Small elevated skin lesions less than 0.5 cm

Plaque

Breast carcinoma

Elevated plateau-like lesion greater than 0.5 cm but without substantial depth

Pustule

Acne

Vesicles filled with cloudy or purulent fluid

Nodules

Scars

Elevated, marble-like lesions greater than 0.5 cm both in diameter and depth

Vesicles

Herpes simplex

Small, fluid filled

Wheal

Urticaria

Papule or plaque of dermal edema

Often have central pallor and irregular border

Scale

Psoriasis

Thickened stratum corneum

Scales are dry and usually whitish

Not to be confused with crusts, which are often more moist and usually yellow/brown/red

Telangiectasia

Sun damage/aging

Superficial blood vessels enlarged sufficiently to be clinically visible