wilkins chpt 13 extra oral exam

inspection

systemic visual examination

as soon as you meet the patient/ as they walk in

palpation

using fingertips to move or compress structures against tissues, bone or between fingertips

subgroups of extraoral examinations

1. overall appraisal

2. lymph nodes

3. salivary glands, thyroid glands and larynx

4. TMJ

5. muscles

keys to effective examination

• consistent sequence to include all structures

• good palpation technique

• careful documentation of all findings

good palpation technique

compression against a firm structure like; finger, underlying bone or muscle

palpitations of the head, neck and oral cavity are done with the

index, middle and ring fingertips; as these are the most sensitive surfaces

some are also done with the thumb

bidigital palpation

using 2 (or more) fingers from one hand

manual palpation

fingers from one hand

bimanual palpation

fingers from both hands

bilateral palpation

both hands on either sides of the face

if something abnormal is found, the patient is the source of the information

• request info from the patient

• they may know how long it was persisted and the cause of the finding

overall appraisal of head and neck

• greet and sit patient

• while chatting, do a visual assessment of the face and neck

• divide face and neck into imaginary zones and note signs of; ex.
  - asymmetry
  - unequal pupils
  - skin color changes
  - lesions
  - if herpetic lesion — patient needs to be rescheduled

examples of notable findings

• lesions or color changes of the skin

• uneven pattern hair loss

• masses in neck

• wounds, bruises, scars

• swelling

• asymmetry

• moles and freckles (generalized)
  - mole
  - > 5 mm
  - irregular margins
  - halo around that is red or white
  - measure and document if ^ is present

imaginary sections for overall appraisal of head and neck examples

• forehead

• eyelids, pupils and sclera

• cheeks, nose

• philtrum, lip outline

• neck, larynx, thyroid

lymph nodes of the head and neck

• postauricular

• preauricular

• occipital

• deep cervical chain

• superficial cervical chain

• submandibular

• submental

• supraclavicular

lymphatic system

a network of lymph nodes connected by lymphatic vessels

• play a role in immune defense

lymph

clear fluid that carries nutrients/waste between body tissues and bloodstream

lymph nodes

bean shaped structures that filter and trap bacteria, fungi, viruses and waste

• enlarged when infected
  - presence of inflammation — painful
  - cancer — not painful

all substances carried by the lymphatic system passes through

at least one lymph node, where waste is filtered and destroyed, then it returns to bloodstream

how many lymph nodes are in the body

700

how many lymph nodes are in the face and neck area

170-200

lymph nodes vary in size from

head of pin to a baked bean

lymphadenopathy

enlarged lymph node

lymph nodes enlarged half inch to an inch

virus

lymph nodes enlarged over an inch

bacterial infection

metastasis

transporting cancer cells throughout body

when oral cancer metastasizes, it spreads commonly through

the lymphatic system to the cervical chain or lymph nodes in the neck

incorrect palpation technique

• walking or dancing the fingertips over a structure

• tickling patient

correct palpation technique for occipital lymph nodes

• visually inspect head and scalp of patient from behind

• have patient lift hair so neck is visible

• begin at midline of neck and palpate along hairline

• circular motion to compress tissues against underlying bone

occipital lymph nodes palpation technique

• fingers at base of the skull

• circular motions to compress tissues against skull

• cover area slightly above and below hairline — 1 inch

• palpate until the SCM muscle is reached

• BILATERAL

postauricular lymph nodes palpation technique

• visually inspect borders and behind each ear

• patients head/ upright position

• palpate using circular motions

• top of ear to bottom/palpating entire chain

• BILATERAL OR BIMANUAL

preauricular nodes palpation technique

• apply circular motions with fingertips against the underlying bone

• patients head is upright

• top to bottom ensuring entire chain is palpated

• using stead circular motions

to inspect the ear

• check ear by displacing cartilage forwatd

• look at back of ear

• look at skin behind ear

• check borders of ear

• do same to left ear

ears are common sites for

lesions and skin cancer

submental nodes palpation technique

• located under mandible on each side of midline

• patients head upright

• compress area behind and between the midline of mandible between thumb and index finger

• be sure to do each side

• BIDIGITAL

submandibular nodes palpation technique

• located under mandible on each side

• patient is upright

• use left hand to move tissue upward, rolling tissue up and over border of the mandible

• use right hand to palpate

• continue to palpate entire area

• MANUAL

superficial cervical lymph nodes palpation technique

• support patients head with left hand

• right hand rotate fingertips back and forth over muscle, covering entire length of muscle, from behind ear to the clavicle

• BIDIGITAL

deep cervical lymph nodes palpation technique

• position fingertips of right hand under the muscle

• apply compression against underlying tissues along entire muscle from clavicle to ear

• BIDIGITAL

supraclavicular nodes palpation technique

• above clavicle

• tell or ask patient you are going to slightly move their shirt

• patient facing forward with chin down

• rolling shoulders inward

• apply circular compression above clavicle on right side

• from shoulder to the notch is the entire chain

• repeat to palpate the left side

• MANUAL

lymph nodes normal findings

• healthy lymph nodes usually are not detectible

• no tenderness to palpation

infected lymph nodes findings

• firm

• tender

• enlarged and warm

• bilateral swelling

• freely moveable from underlying structures

• swollen, feels like a grape

• following infection, nodes remain enlarged occasionally, small, nontender and rubbery consistency

malignant lymph nodes

• firm

• not tender

• matted (stuck to each other)

• fixed (stuck to underlying tissue)

• unilateral (enlarged on only one side of head or neck)

salivary glands

produce saliva and release it into the mouth through ducts

• parotid

• submandibular

• sublingual

parotid glands

located on the surface of the masseter muscle between ear and jaw

extraorally and intraorally palpated

submandibular glands

sit below the jaw toward the back of the mouth

extraorally and intraorally palpated

sublingual glands

located under the tongue, beneath the mucous membrane of the floor of the mouth

intraorally palpated

parotid glands palpation technique

• largest; 2 lobes

• palms of hand in front of ears, fingers extending full length of cheek, slightly downward

• circular compression to press tissue against cheekbones

• normal gland is hard to detect, enlarged gland or nodules in gland are easily detectable

• BILATERAL

submandibular glands locating

• index fingers near angle of mandible

• move fingertips forward along mandible to locate slight depression in the border

• this is antegonial notch

• move finger anterior to notch and under jaw

• ask patient to put tongue up to the roof of the mouth

• gland will be come detectable

submandibular glands palpation technique

compress glands upward against tensed muscles

BILATERAL OR MANUAL

thyroid gland

endocrine gland, secretes thyroid hormone that control the body’s metabolic rate

goiter

enlarged thyroid gland

disorders of the thyroid are

very common

thyroid gland location

• bowtie shape

• located middle of lower neck

• sits below the larynx

• sits over trachea and above the clavicles

thyroid palpation technique

• move gland to the right to palpate left lobe

• move gland to the left to palpate right lobe

• healthy gland is sometime difficult to feel

• MANUAL

• do this from the front of patietn

locating temporomandibular joint

• stand in front of patient (observing for deviation)

• place fingers in front of tragus of ear

• as patient to open and close

• as mouth opens, fingertips with drop into the joint spaces

tmj palpation technique

• once located place fingertips over joints

• palpate as patient opens and closes slowly several times

• note any deviations during opening

• BILATERAL

lateral excursions of the jaw

side to side movements

palpating lateral excursions of the jaw

• ask patient to slightly move jaw to right

• repeat to the left

• ask patient to protrude jaw

• listen for abnormal sounds such as popping or clicking

tmj notable findings

• abnormal sounds

• grating sensations as jaw opens and closes

• asymmetrical movements

• tenderness or pain reported by patient