PAT module 13 and Wilkin's ch 13- extraoral examination and palpations

2 primary examination techniques

-inspection

-palpation

subgroup of inspection

overall appraisal

subgroups of palpations

-lymph nodes

-salivary and thyroid glands plus larynx

-TMJ

-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 surface like your finger or the patients muscle of underlying bone

fingertips

used to palpate structures of the head, neck, and oral cavity

patient as source of info

-remember to request info from patient

-he or she may have info about duration and may know the cause of notable finding

overall appraisal of head and neck

-greet and seat patient

-while chatting, do a visual assessment of face and neck

-divide face and neck into imaginary zones, noting signs of:

• asymmetry

• unequal pupils

• skin color changes

• lesions

• herpetic lesion needs to be rescheduled

notable findings

-lesions or color changes of skin

-uneven pattern of hair loss

-masses in the neck

-wounds, bruises, scars

-swelling of face or neck

-asymmetry of face or neck

-moles and freckles (generalized)

mole

-> 5mm

-irregular margins

-halo red/white

-measure and document

be discreet

-patients may be embarrassed or sensitive about their acne, acne scars, or moles; write them down on EOIO sheet and turn to show instructor

lymphatic system

a network or lymph nodes connected by lymphatic vessels and play a role in defense against infections

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 lymph nodes when infected may be…

-presence of inflammation (painful)

-cancer (not painful)

lymph node characteristics

-about 700 in the body

-170 to 200 in the head and neck area

-vary in size from the head of a pin to a baked bean

lymphadenopathy

enlarged lymph node

virus lymph node size

enlarge to half-inch to 1 inch across

bacterial infection lymph node size

enlarge over 1 inch

metastasis

lymphatic system can transport cancer cells throughout the body

oral cancer

metastasizes and most commonly spreads through the lymphatic system to the cervical chain of lymph nodes in the neck

incorrect palpation technique

-involves lightly walking or dancing the fingertips

-makes it unsuccessful in detecting nodules, tumors, swelling, or enlarged lymph nodes

-not trying to tickle the patient

5 types of palpations used

-digital

-bidigital

-manual

-bimanual

-bilateral

digital

use of a single finger

bidigital

finger and thumb of same hand

manual

all fingers from one hand to simultaneously compress tissue

bimanual

finger or fingers and thumb of each hand in opposition

bilateral

two hands are used at the same time to examine corresponding structures on opposite sides of the body

location of occipital lymph nodes

back of neck and base of the skull

palpation of occipital lymph nodes

-ask patient to tip head slightly forward and pull hair off of neck

-position finger at base of skull

-begin at midline working along hairline and 1in above and below

-use circular motion with fingertips to compress the tissue against the underlying bone

-palpate until SCM is reached

type of palpation used for occipital lymph nodes 

bilateral palpation o

location of postauricular lymph nodes

behind the ear

palpation of postauricular lymph nodes

-patients head upright

-palpate by using steady and gentle circular motion with fingertips to compress the tissue against underlying bone

-palpate from top to bottom on back of ear; ensure you palpate the entire chain

type of palpation used for the postauricular lymph nodes

bilateral or manual palpation p.a.

location of pre-auricular lymph nodes

in front of ear

palpation of pre-auricular lymph nodes

-palpate with steady and gentle circular motions

-palpate from top to the bottom on front side of ear ensuring you palpate the entire chain

type of palpation for pre-auricular lymph nodes

bilateral or manual palpation pr.a.

inspect the ear

-check the right ear by displacing cartilage forward

-look at back of ear

-look at the skin behind the ear

-check the borders of the ear

-do the same on left ear

-ears are common sites for lesions and skin cancer

location of submental lymph nodes

under the jaw on each side of the midline of the mandible

palpation of submental lymph nodes

-patient head upright

-use your thumb and index finger to compress the area behind and beneath the midline

-make sure to check each side of the midline

type of palpation for submental lymph nodes

bidigittal palpation sm

location of submandibular lymph nodes

under the jaw along the side of the mandible

palpation of submandibular lymph nodes

-patient head upright

-move tissue under mandible upward, pulling skin tight

-cup your fingers under the mandible and palpate from the angle forward

type of palpation for submandibular lymph nodes

manual palpation sman

location of SCM muscle

on side of neck

palpation of SCM muscle

-have patient turn head to one side

-palpate entire length of muscle from mastoid to clavicle

location of superficial cervical lymph nodes

in front of SCM muscle

palpation of superficial cervical lymph nodes

-patient will tip chin down slightly and turn head

-support patients chin

-palpate the lymph nodes by grasping the body of muscle between you fingertips and thumb

-rotate your fingertips back and forth over muscle covering the entire length from behind ear to clavicle bone

type of palpation for superficial cervical lymph nodes

bidigital palpation sc

location of deep cervical lymph nodes

behind the SCM muscle

palpation of the deep cervical lymph nodes

-after you have completed the superficial cervical nodes, keep your hand in place and turn your patient’s head the opposite direction supporting the chin and slightly tipped downward

-your fingertip will “fall” into a shallow space with thumb positioned behind fingertips 

-palpate the nodes by applying gentle but firm compressions against underlying tissue

-must palpate entire length of muscle from clavicle to ear

type of palpation for deep cervical lymph nodes

bidigital palpation dc

location of supraclavicular lymph nodes

above the clavicle

palpation of supraclavicular lymph nodes

-ask and inform patient to move shirt to perform palpations

-patient position= forward with chin slightly downward

-have patient do hulk role

-palpate with your index finger and middle finger above clavicle bone using circular compressions from shoulder to notch

type of palpation for supraclavicular lymph nodes

manual palpation s

normal lymph node

-not detectible

-no tenderness

infected lymph node

-firm

-tender

-enlarged and warm

-bilateral swelling (on both sides)

-freely movable 

-swollen, feel a bit like a grape

infected lymph node following infection

occasionally remains enlarged; small (<1cm), nontender, with rubbery consistency

malignant lymph nodes

-firm 

-not tender

-matted (stuck to each other)

-fixed (stuck to underlying tissue)

-unilateral (only on one side)

salivary glands

produce saliva and release it into the mouth through ducts

location of parotid gland

on surface of masseter muscle between the ear and jaw 

parotid gland

largest of the salivary glands; has 2 lobes 

palpation of parotid gland

-place the fingertips along cheeks and slightly downward

-use circular compression to compress tissue against cheekbones

-normal gland is hard to detect; enlarged gland or nodules in gland are easily detectable

type of palpation for parotid gland

bilateral palpation pg

location of submandibular gland

below the jaw toward the back of the mouth

palpation of submandibular gland

-place finger near angle of mandible moving forward until you locate the antegonial notch

-just anterior to the notch move your fingers under the jaw to locate gland

-ask your patient to press the tip of tongue to roof of mouth

-this makes it easier to palpate the gland

-compress gland upward against the mylohyoid and tongue muscles

type of palpation for submandibular gland

bilateral or manual palpation smg

thyroid gland

-endocrine gland that secretes thyroid hormone that controls the body’s metabolic rate 

-AKA master gland

-disorders are very common with it 

goiter

enlarged thyroid gland

location of thyroid gland

in middle of lower neck covered by skin and muscles, situated below the larynx and sits over the trachea and just above the clavicles 

palpation of thyroid gland

-normal gland is not visible

-right lobe is 25% bigger in females

-sensitive area so be gentle and inform patient of process

-have the patient swallow or give them a drink of water and watch their neck

-once located, move to the right side to palpate left lobe and move to left side to palpate right lobe with your fingertips

type of palpation of thyroid gland

manual palpation tg

location of larynx

just above the thyroid 

palpation of larynx

-should move side to side with some click

-can be sensitive so be gentle and forewarn patient

location of TMJ

in front of ear depression

palpation of TMJ

-place fingers in front of the tragus of each ear

-ask patient to open and close mouth, move jaw right and left, and protrude jaw in and out

-as mouth is opened your fingertips should drop into joint spaces 

-note any deviations during opening and visually, pain or sensitivity from patient

-listen for abnormal sounds such as popping, clicking, or crepitus (gritty feeling)

type of palpation for TMJ

bilateral palpation tmj

location of masseter muscle

below the TMJ to the border of the mandible

palpation of masseter muscle

-place hand over the muscle and ask patient to clench

-check for tenderness

-palpate full length of muscle

type of palpation for masseter muscle

bilateral palpation mm

location of temporalis muscle 

on temporal region

palpation of temporalis muscle

-place hands over muscle

-ask patient to clench

-check for tenderness

type of palpation for temporalis muscle

bilateral palpation t

things to remember when documenting EO examination

-reappoint for any herpetic lesion

-use WNL= within normal limits

-if you make mistake, just draw one line through it

-do not write unless you have done it

-inform before you perform

-do not abbreviate except WNL

-you are evaluating/assessing the lymph nodes for any swelling or tender

-always tell patient what you find and document

3 main pairs of major salivary glands

-parotid

-submandibular

-sublingual

location of sublingual gland

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