HEENT Part 1

Head+Neck Hx: Common/Concerning Symptoms

neck/thyroid mass/lump

neck pain

headache

Examination of the Head+Neck Process

1. examine hair/scalp/skull

2. inspect skin on head+face

3. palpate cervical lymph nodes

4. examine trachea

5. inspect thyroid gland

6. palpate thyroid gland

7. examine carotid arteries+jugular veins

Examination of Head+Neck: Hair

observe

• quantity

• distribution

• texture

• pattern of loss

inspect

• loose flakes→dandruff

Examination of Head+Neck: Scalp

1. part hair in several places

2. inspect

• scaliness

• lumps

• nevi

• lesions

Examination of Head+Neck: Skull

observe

• size

• contour

inspect

• deformities

• depressions

• lumps

palpate

• tenderness

Examination of Head+Neck: Face

inspect

• asymmetry

• involuntary movement

• edema

• masses

observe

• color

• pigmentation

• texture

• thickness

• hair distribution

• any lesions

Examination of Head+Neck: Palpate Cervical Lymph nodes

position pt

• relaxed

• neck→slightly flexed+turned towards side you are examining

palpate

• pads of fingers in a rotary motion

observe (see both sides→detect asymmetry)

• size

• shape

• delimitation

• mobility

• consistency

• tenderness

submental→palpate with 1 hand

supraclavicular nodes→must shrug shoulders

Examination of Head+Neck: Trachea

inspect

• midline position

palpation

• deviation

• should have symmetric space between trachea+SCM bilaterally

auscultation

• stridor

Examination of Head+Neck: Inspect Thyroid Gland

inspect

tangential lighting
directed downward from pt’s chin

• contours of the thyroid gland

• enlargment

observe
at rest+swallowing

• upward movement of thyroid

• contour

• symmetry

Goiter

thyroid enlargement

over 2x+ normal size

with/without nodules

Examination of Head+Neck: Thyroid Gland Palpation

palpate between thyroid isthmus→between cricoid cartilage+suprasternal notch

one hand gently retract SCM→other hand palpates gland

palpation (at rest+swallowing)

• size

• shape

• consistency

• nodules

• tenderness

thyroid enlargment present→listen to lateral lobes for bruit

Examination of Head+Neck: Carotid Arteries+Jugular Veins

part of CV exam→important to acknowledge structures in neck

External Ear (General)

auricle+ear canal

function: captures sound waves→transfers to inner ear

components

• auricle

• ear canal

Auricle

part of external ear

cartilage covered by skin

• helix

• antihelix

• lobule

• tragus

Ear Canal

part of external ear

24 mm long

s-shaped

end of external ear/start of middle ear→TM

outer 1/3

• encased in cartilage

• hair-covered skin

• wax-producing glands

inner 2/3

• thin skin→very sensitive

• hairless

Middle Ear Components

tympanic membrane

ossicles

Ossicles

parts of middle ear

malleus

• umbo→where the tip of malleus meets the TM

• handle

• short process

incus

stapes

Tympanic Membrane Components

TM→part of middle ear

pars flaccida

pars tensa

cone of light

Inner Ear Components

aka: labyrinth

cochlea

semicircular canals

otoliths

CN 8

Cochlea

part of inner ear

responsible for hearing

Semicircular Canals+Otoliths

parts of inner ear

function→balance

• SCC→rotational movement

• otolith→linear movement

Paranasal Sinuses

part of nose

• maxillary sinuses

• ethmoid sinuses

• frontal sinuses

• sphenoid sinuses

Ears+Nose Common/Concerning Symptoms

partial/complete hearing loss

earache

ear discharge

tinnitus→ringing in ears

dizziness

lightheadedness

rhinorrhea

nasal congestion

epistaxis

Examination of the Ear Process

1. examine external ear+palpate tragus+mastoid

2. examine ear canals/TM/malleus

3. test auditory acuity (gross hearing)

4. test conductive vs sensoneurial hearing loss
   -weber
   -rinne

Examination of the Ear: External Ear Otoscope Process

1. use otoscope→largest ear speculum that can be easily be inserted into the ear canal

2. R ear→use left hand→pull auricle up+back+slightly away from the head

3. hold otoscope with right hand→use bracing technique for safety (in event of unexpected movement)

4. insert speculum gently→down+forward motion

Examination of the Ear: Examine Ear Canals+TM+Malleus

I: canal

• discharge

• foreign body

• redness

• swelling

• cerumen

• color

• consistency

visualize: TM

• note bony landmarks

• TM mobility→pneumatic otoscope

Examination of the Ear: Auditory Acuity

if pt expresses hearing loss/difficulty breathing

whispered voice test

1. instruct pt to repeat letters/numbers whispered to them

2. stand arm’s length (2 ft) behind pt

3. occlude one ear+gently rub tragus in circular motion

4. exhale full breath

5. whisper combo of 3 letters/numbers
   -repeat correctly→normal
   -incorrect/no repear→repeat test with new letters/numbers

6. repeat on other ear

pass→3/6 correct

fail→under 3→conduct further audiometry testing

Examination of the Ear: Conductive vs Sensoneurial Hearing Loss

conductive

• EE→ME

• air conduction

sensorineural

• cochlea+CN8

• bone conduction

normal→AC>BC

Examination of the Ear: Weber+Rinne

weber→lateralization

1. instruct pt

2. stroke prongs of tuning fork→place on top of pt’s head

3. determine if sound is louder in 1 ear or equal in both

lateralizes to affected ear→conductive hearing loss
lateralizes to normal ear→sensorinueral hearing loss

rinne→air vs bone conduction

1. instruct pt

2. stroke prongs of tuning fork→place on mastoid bone level with ear canal

3. when pt can no longer hear sound→move to lateral ear→determine if they feel vibration
   -prongs→face forward

continued vibration/sound→AC>BC (normal)
BC>AC→conductive hearing loss
AC=BC→sensorinueral hearing loss

Examination of the Nose Process

1. inspect anterior+inferior surfaces of nose

2. test for nasal obstruction

3. inspect nasal cavity+mucosa

4. inspect nasal spectum

5. inspect nasa turbinates+meatuses

6. palpate nasal sinuses

Examination of the Nose: Inspect the Anterior Surfaces of the Nose

1. position pt upright+head tilted slightly backward

2. gently apple pressure to tip of the nose
   -use thumb to widen nostrils

3. use otoscope to examine each nasal vestibule

inspection

• deformities

• asymmetry

Examination of the Nose: Test for Nasal Obstruction

1. press on each ala nasi/nasal ala

2. ask pt to breathe in

Examination of the Nose: Inspection

1. ask pt to tilt head back slightly

2. insert speculum gently into vestibule of each nostril
   -avoid septum

3. direct speculum posterioly+upward to visualize each turbinate

I: nasal mucosa

• color

• swelling

• bleeding

• exudate

I: septum

• deviation

• inflammation

• perfoarmtion

• ulcers

• polyps

• epistaxis (bleeding)

I: turbinates+meatuses

• swelling

• polyps

• growths

• discharge

• foreign bodies

Examination of the Nose: Palpate Paranasal Sinuses

frontal sinuses→apply upward pressure under bony brows

maxillary sinuses→apply upward pressure beneath zygomatic bones

Mouth+Pharynx Common/Concering Symptoms

sore throat

bleeding/swollen gums

hoarseness

malodorous breath (halitosis)

Examination of the Mouth and Pharynx Process

1. inspect lips+oral mucosa

2. palpate oral mucosa

3. inspect gingiva+teeth

4. inspect roof+floor of mouth

5. inspect tongue

6. test hypoglossal nerve

7. palpate tongue

8. inspect soft palate/anterior+posterior pillars/uvular/tonsils/pharynx

9. test vagus nerve

Examination of the Mouth and Pharynx: Inspect Lips+Oral Mucosa

I: lips

• color
  -cyanosis
  -pallor

• moisture

• lumps

• ulcers

• cracking

• scaliness

I: oral mucosa (use light source+longue blade)

• discoloration

• white patches

• ulcers

• nodules

Examination of the Mouth and Pharynx: Palpate Oral Mucosa

P: oral mucosa (using gloves)

• sores

• bumps in mouth

Examination of the Mouth and Pharynx: Inspect Gingiva+Teeth

I: gingiva

• color

• swelling

• ulceration

• bleeding

I: teeth

• abnormal positioning

• discoloration

• quantity

• misshapen

P: teeth

• looseness

P: gums

• tenderness

Examination of the Mouth and Pharynx: Inspect Roof+Floor of Mouth

I: roof of mouth

• erythema

• discoloration

• nodules

• ulcerations

• deformities

1. grasp tongue with gauze→displace

2. I: floor of mouth

• erythema/reddened areas

• nodules

• ulcerations

Examination of the Mouth and Pharynx: Inspect the Tongue

I: tongue (including sides+undersurface)

• ulceration

Examination of the Mouth and Pharynx: Test the Hypoglossal Nerve

CN 12

controls motor function of tongue

1. ask pt to skick out their tongue+move side to side

2. I: tongue (during movement)

• symmetry

Examination of the Mouth and Pharynx: Palpate Tongue

1. use gauze→grasp tip of tongue→pull gently to one side

I+P tongue

• lumps

• bumps

2. repeat on other side

Examination of the Mouth and Pharynx: Inspect Soft Palate/Anterior+Posterior Pillars/Uvula/Tonsils/Pharynx

I: soft palate
anterior+posterior pillars
uvula
tonils

• color

• symmetry

• exudate

• swelling

• ulceration

• tonsilar enlargement

visualization: posterior pharynx

1. ask pt to say “ahh”→elevates soft palate+uvula→better view of posterior pharynx

I: posterior pharynx

• redness

• swelling

• exudate

• lesions

• asymmetry

• growths

• discoloration

Examination of the Mouth and Pharynx: Test the Vagus Nerve

1. ask pt to say “ahh”

2. assess

• symmetric rise of soft palate+uvula