20 - HEENT

What are some common complaints that indicate a head exam?

- headache (primary (tension, cluster, migraine) or secondary (subarachnoid hemorrhage, meningitis))

- head injury

- URI

- dizziness

What is important information to obtain when someone c/o a headache?

- history (OPQRST, emphasis on onset and timing)

- any change from prior headaches?

- hx of migraines (confirmed diagnosis, prior imaging)

- ROS (nausea/vomiting, prodrome, dizziness, aura, fever, vision changes)

What are red flag warning signs for headaches?

- progressively severe, over 2-3 month period

- sudden onset "thunderclap" or "worst headache of life"

- new onset after age 50 years

- aggravated and relieved by change of position

- precipitated by valsalva maneuver or exertion

- presence of cancer, HIV infection or pregnancy

- recent head trauma

- change in pattern from past headaches

- lack of a similar headache in the past

What are red flag physical exam signs for headache?

- papilledema

- neck stiffness

- focal neurologic deficits

What is important information to obtain when someone c/o a head injury?

- (+/-) LOC

- MOI (speed, height of fall, airbags)

- helmet/protective gear

What is important information to obtain when someone c/o an URI?

- (+/-) fever

- altered mental status

What is important information to obtain when someone c/o dizziness?

- (+/-) lightheadedness

- (+/-) dizziness

- ataxia

Indications for head exam

- head trauma

- AMS or confusion

- rash

- headache

- car accident

- infections/infestations

- pediatric examinations

- strokes

- intoxicated patient

- seizures

- overdose

- sinus infections

How many bones is the skull composed of?

seven bones (two frontal, two parietal, two temporal, one occipital)

How are the cranial bones used in documentation?

used to describe regions

What are major landmarks on the face?

- palpebral fissures

- nasolabial folds

What CNs innervate the facial muscles?

- CN V

- CN VII

What are the additional anatomy and landmarks on the face?

- temporal artery

- parotid time

- danger triangle

What features do we inspect on the head?

- hair

- scalp

- skull

- face

- skin

What are we assessing for hair?

- quantity

- distribution (i.e., hirsutism)

- texture (i.e., coarse/thin)

- patterns of loss (i.e., male pattern balding, patches)

Alopecia Atriata

Hirsutism

What are we assessing for scalp?

- scaling

- nodules/masses

- nevi

- lesions

- temporal artery

What are we assessing for the skull?

- size

- contour

- deformities

- tenderness

- masses

- depressions

- sutures/fontanelles

- trauma

What are the signs of a basilar skull fracture?

- battle sign

- racoon sign

battle sign

racoon sign

What are we assessing for the face?

- facial expressions/contours

- asymmetry

- involuntary movements

- edema

- masses

- look for syndromic facies

What are we assessing for skin?

- pigmentation

- texture

- hair distribution

- lesions

What areas of the face should be palpated?

- temporal arteries

- TMJ space

- salivary glands

Temporal artery assessment

- assess for thickening, hardness, or tenderness

- scalp tenderness and necrosis/jaw claudication

TMJ space assessment

non-tender, normal ROM

salivary gland assessment

- Parotid glands are usually non-tender, non-palpable

- assess Stenson's duct in the mouth

What is the exception for percussing the face?

evaluating for hypocalcemia (Chvostek sign and Trousseau's sign)

Chvostrek sign

percussion on the masseter muscle may produce a hyperactive masseteric reflex

Trousseau's sign

carpospasm with inflation of BP cuff

What is a reason for auscultating the face, and what does it suggest?

Bruit, highly suggestive of a vascular abnormality associated with temporal arteritis

Facial palsy

Hippocratic Facies

Myxedema Facies

Nephrotic Syndrome Facies

Parkinson's Masked Facies

What information should be obtained in a neck exam?

- HPI (OPQRST)

- ROS (swollen masses, swollen lymph nodes, difficulty moving the neck, numbness/tingling to arms or legs)

What information should be obtained if someone c/o a stiff neck?

- history (neck injury/strain/head injury - numbness, paresthesia, weakness)

- associated swelling

- fever

- character

- predisposing factors

- efforts to treat

What are some thyroid complaints? (history)

- changed temperature preference

- swelling of the neck

- change in texture or hair, skin, or nails

- emotional instability

- increased prominence of eyes (exophthalmos)

- tachycardia/palpitations

- menstrual changes

- change in bowel habits

- medications: thyroid preparations

What are some thyroid complaints? (family history)

- thyroid dysfunction

- thyroid cancer

What history questions should you ask about enlarged lymph nodes?

- character

- associated local and systemic symptoms

What PMHx questions should you ask about enlarged lymph nodes?

- TB

- Blood transfusions

- Autoimmune conditions

- Malignancy

What family history questions should you ask about enlarged lymph nodes?

- malignancy

What social questions should you ask about enlarged lymph nodes?

- IVDA

- sexual history

- travel

Indications for a neck exam

- sore throat

- neck pain

- car accident

- trauma

- fatigue

- weight loss/gain

- prep for central lines

- hx of active cancer

- hx of HIV

- neck masses

- voice changes

Anterior triangle (location and contents)

location: medial border of SCM, mandible and midline of neck

contents: airway, major vasculature, nerves, and gastrointestinal structures

Posterior triangle (location and contents)

location: trapezius muscle, SCM, and clavicle

contents: spine and musculature

Great vessels in the neck (and their relation to the SCM)

deep to SCM: carotid artery and internal jugular vein

superficial to SCM: external jugular vein

What other structures are in the neck?

- trachea

- thyroid gland

What MSK components are present in the neck?

- cervical vertebrae

- ligaments

- sternocleidomastoid muscles

- trapezius muscles

What is the function of salivary glands?

produce saliva

What are the salivary glands?

three paired glands

- parotid gland (anterior to ear, above mandible)

- submandibular gland (medial to mandible at angle of jaw)

- sublingual (anterior in floor of mouth)

What do the salivary glands drain into?

Stenson's duct and Warton's duct

Lymph nodes

discrete structures surrounded by a capsule composed of connective tissue

How are lymph nodes examined

regionally (neck, axillary, groin), superficial and deep

Functions of the lymph system

- conserves fluid and plasma leakage from capillaries

- defends body against infection

- removes damaged cells from circulation

Thyroid function

- ductless gland that secretes hormones

- regulates growth and development through rate of metabolism

Thyroid (location and structure)

location: above suprasternal notch

structure: two lobed and isthmus

What does an examination of the neck include?

- external inspection

- lymph nodes

- thyroid

What does an external inspection of the neck include?

- symmetry

- alignment of trachea

- movement of hyoid bone and cartilage with swallowing

- fullness at base of neck (thyroid)

- fullness at posterior neck (buffalo hump)

- masses, webbing, and skinfolds

What does palpation of the neck include?

- tracheal position/alignment (space between trachea and SCM similar bilaterally)

- traceal tug (suggests presence of aortic aneurysm (with pulse), can be seen with respiratory distress (with breaths))

- crepitus (trauma)

What lymph nodes are palpated?

- preauricular

- posterior auricuar

- occipital

- tonsillar

- submandibular

- submental

- anterior cervical

- posterior cervical

- supraclavicular

What is being assessed during the lymph exam?

- size (length and width, typically small <2cm, >1cm supraclavicular is concerning for metastasis)

- consistency (soft/rubbery = normal, rubbery can be a sign of lymphoma, hard is concerning for malignancy)

- tenderness

- delimination (discrete or matted together)

- mobility (fixed nodes are typically malignant)

- skin changes (erythema, induration, drainage, skin breakdown)

Lymph exam technique

- use pads of index and middle fingers

- gentle rotary motion to move the skin over the underlying tissue

- pt should be relaxed with neck flexed slightly forward

- ask patient to rotate toward the side you are examining to relax the SCM to feel the nodes deep to it

- hook fingers around the SCM to feel nodes in the deep cervical chain

- follow a logical sequence to not miss a group

- roll test

Roll test (lymph nodes)

lymph nodes will be able to roll in 2 directions (muscles and arteries cannot do that)

How does a normal lymph node feel?

small, mobile, discrete, and non tender

Indications of tenderness on lymph exam

tender = classically infectious or inflammatory

non-tender + enlarges = clasically malignant

What should you do if you find an enlarged or tender lymph node?

- re-examine the areas that drain into the nodes

- Examine all other regions for generalized lymphadenopathy

How do you tell the difference between a submandibular gland and a lymph node?

The node is round, smooth, and smaller than a gland. The gland is larger, lobulated, and has an irregular surface)

Virchow's node

enlarged supraclavicular node on the left (concern for underlying abdominal or thoracic malignancy)

What should we inspect the thyroid gland for?

- enlargement

- surgical incisions

- rise and fall with swallowing

What lighting is helpful for a thyroid inspection?

tangential lighting

How do you palpate the thyroid?

- place fingers of both hands - posterior approach

- index fingers just at or just below the cricoid cartilage

- ask the patient to slightly flex their neck forward to relax the SCM

- ask the patient to sip and swallow water

- feel for the thyroid isthmus rising under fingertips

- displace the trachea to the right with fingers of the left hand

- with the right hand, palpate laterally for the right lobe of the thyroid in the space between the displaced trachea and SCM

- repeat to examine the left lobe

What components should we assess for during palpation of the thyroid?

- size (goiter = twice normal size)

- shape

- consistency (soft, firm, hard)

- tenderness

- nodules

What are the indications for auscultation of the neck?

- thyroid enlargement (auscultate over thyroid for bruits)

- stridor (auscultate over trachea)

- carotid stenosis (auscultate over carotids for brutis)

Goiter

enlargement of the thyroid gland

Causes of goiter

- lack of dietary iodine

- high levels of TSH

- Graves' disease

- Hashimoto's thyroiditis

- multinodular or solitary thyroid nodule

- thyroid cancer

- pregnancy

Graves disease

autoimmune antibodies to thyroid-stimulating hormone receptor, leading to overactive thyroid

Hashimoto disease

autoimmune antibodies against thyroid gland, often causing hypothyroidism

Hyperthyroid

Hypothyroid

Parotid enlargement

Lymphadenopathy

enlarged lymphs nodes

Lymphedema

edematous swelling due to excess accumulation of lymph fluid in tissues caused by inadequate lymph drainage

Lymphangitis

inflammation of the walls of lymphatic vessels, red streaks in skin

Thyroglossal duct cyst

Neck cysts

Torticollis (wry neck) causes

- birth trauma

- tumors

- trauma

- cranial nerve palsy

- muscle spasms

- infection

- drug ingestion

Webbed neck

When is a webbed neck classically seen?

Turner Syndrome (45, X)

What is found on a physical exam in someone with Turner Syndrome?

- short stature

- webbed neck

- developmental delay

- wide space nipples

What does a head circumference reflect (infant)?

rate of growth of the brain and skull

How does the head compare to the body length and weight of a newborn?

1/4 of body length, 1/3 of body weight

What do sutures feel like in an infant?

ridges

What do fontanelles feel like in an infant?

soft concavities

When does the anterior fontanelle close?

between 2 and 24 months (90% between 7 and 19 months)

When does the posterior fontanelle close?

by 2 months

Facial characteristics of Down Syndrome

- small, rounded head

- flattened nasal bridge

- oblique, upward slanted palpebral fissures

- prominent epicanthal folds

- low-set ears

- prominent tongue

- brushfield spots on the iris

Fetal alcohol syndrome