HEENT

Guide to HEENT (Head, Eyes, Ears, Nose, and Throat) Physical Examination

This step-by-step guide will help you perform a systematic and thorough HEENT examination, ensuring you capture all important clinical findings.

1. General Inspection

Before starting the detailed examination, take a moment to observe the patient’s general appearance and any visible abnormalities.

Patient Positioning & Preparation

• Ensure the patient is seated comfortably in a well-lit room.

• Explain the procedure to the patient.

• Wash your hands and gather necessary tools: penlight, otoscope, ophthalmoscope, tongue depressor, gloves.

• Observe the patient’s posture, facial symmetry, skin condition, and any obvious abnormalities.

2. Head Examination

Inspection:

• Look for scalp lesions, swelling, bruising, or deformities.

• Observe for asymmetry, involuntary movements, or signs of trauma.

• Inspect the hair for distribution, thinning (e.g., hypothyroidism), or lice infestations.

Palpation:

• Feel the skull for lumps, tenderness, or deformities.

• Palpate the temporomandibular joint (TMJ):

  • Ask the patient to open and close their mouth.

  • Check for crepitus, tenderness, or limited movement.

• Assess facial sensation:

  • Lightly touch the forehead, cheeks, and jawline (CN V - Trigeminal Nerve).

3. Eye Examination

Inspection:

• Observe for asymmetry, swelling, redness, discharge, or lesions.

• Look at the eyebrows and eyelashes for thinning or missing hair.

• Assess eyelid positioning (ptosis in CN III palsy).

• Check for conjunctival pallor (anemia) or icterus (jaundice).

Visual Acuity (CN II - Optic Nerve)

• Use a Snellen chart at 6 meters (20 feet).

• Test each eye separately (cover one eye at a time).

• Normal vision: 20/20 (6/6).

Pupillary Light Reflex (CN II & III - Optic & Oculomotor Nerves)

• Shine a light into one pupil at a time.

• Observe direct response (same eye constricts) and consensual response (other eye constricts).

Extraocular Movements (CN III, IV, VI - Oculomotor, Trochlear, Abducens Nerves)

• Ask the patient to follow your finger in an “H” pattern.

• Look for nystagmus, strabismus, or limited movement.

Visual Fields (Peripheral Vision - CN II)

• Ask the patient to cover one eye.

• Move your fingers from the periphery to center and ask them to indicate when they see them.

Fundoscopy (Ophthalmoscopy - CN II)

• Dim the lights and use an ophthalmoscope.

• Look for red reflex, optic disc clarity, retinal hemorrhages, or papilledema.

4. Ear Examination

Inspection:

• Observe ear symmetry, skin lesions, discharge, redness, or swelling.

• Check the pinna and mastoid process for tenderness (mastoiditis?).

Palpation:

• Press the tragus and mastoid → Tenderness suggests infection (otitis externa/media).

Otoscopic Examination

• Pull the auricle upward and backward (adults) or downward and backward (children).

• Insert the otoscope and inspect:

  • External canal (wax, foreign bodies, discharge).

  • Tympanic membrane (should be pearly gray and intact).

  • Bulging, redness, perforation? → Otitis media.

Hearing Tests (CN VIII - Vestibulocochlear Nerve)

Whisper Test

• Stand behind the patient and whisper a number.

• Ask them to repeat it.

Rinne Test (Air vs. Bone Conduction)

• Strike a tuning fork and place it on the mastoid bone.

• When they stop hearing it, move it near the ear canal.

• Normal: Air conduction > bone conduction.

• Conductive hearing loss: Bone > Air (e.g., otitis media, wax impaction).

Weber Test (Lateralization of Sound)

• Strike the tuning fork and place it on the forehead.

• Ask if the sound is louder in one ear.

• Conductive loss: Louder in affected ear.

• Sensorineural loss: Louder in normal ear.

5. Nose Examination

Inspection:

• Look for nasal symmetry, septal deviation, discharge, swelling.

• Check external nasal skin for lesions.

Palpation:

• Press over the frontal (forehead) and maxillary (cheeks) sinuses for tenderness.

• Tender sinuses? → Suggests sinusitis.

Nasal Patency Test

• Ask the patient to occlude one nostril and breathe in through the other.

• If airflow is reduced → Consider nasal polyps, septal deviation.

Rhinoscopy (Use Otoscope with Speculum)

• Look inside for mucosal swelling, discharge, septal deviation, or polyps.

• Red mucosa? → Infection.

• Pale, boggy mucosa? → Allergies.

6. Throat & Oral Cavity Examination

Inspection:

• Ask the patient to open their mouth and say “ahh”.

• Use a tongue depressor and penlight to inspect:

  • Tongue (ulcers, atrophy, coating, tremors).

  • Buccal mucosa (lesions, thrush, leukoplakia).

  • Teeth & gums (cavities, gingival inflammation, bleeding).

  • Tonsils (enlarged, red, exudates?).

  • Uvula (midline or deviated?).

Cranial Nerve Tests (CN IX, X, XII - Glossopharyngeal, Vagus, Hypoglossal Nerves)

• CN IX & X (Glossopharyngeal & Vagus)

  • Ask the patient to say “ahh”.

  • Uvula deviates to one side? → CN X lesion.

  • Check gag reflex (touch the back of the throat).

• CN XII (Hypoglossal Nerve - Tongue Movement)

  • Ask the patient to stick out their tongue.

  • Deviates to one side? → CN XII lesion.

7. Neck Examination (Lymph Nodes & Thyroid)

Lymph Node Palpation

• Use gentle, circular movements.

• Check the following nodes bilaterally:

  • Preauricular

  • Postauricular

  • Submandibular

  • Submental

  • Anterior cervical

  • Posterior cervical

  • Supraclavicular (Virchow’s node → Gastric cancer metastasis).

Thyroid Examination

• Inspect the neck for swelling or asymmetry.

• Palpate the thyroid gland while standing behind the patient.

• Ask the patient to swallow and feel for movement.

• Auscultate for bruits (suggests hyperthyroidism).

Final Step: Thank the Patient

• Ensure the patient is comfortable.

• Summarize findings if needed.

• Wash your hands.