ASSESSING THE HEAD,FACE, AND NECKDr/Magda Bayoumi
The head, face, and neck form a large portion of what is often referred to as the head, eyes, ears, nose, and throat (HEENT) system. This is actually a complex set of varied organs, combined during assessment because of their proximity to one another and the integration among the components of the system.
INTERACTION WITH OTHER SYSTEMSENDOCRINEThyroid and parathyroid glands located in neck.RESPIRATORY Respiratory tract begins at nasal and oral cavities. Injuries to head and face can affect breathing. Respiratory infections often begin in upper airways of nose and throat.INTEGUMENTARY Skin-color changes on face (e.g., cyanosis, pallor, jaundice) may indicate systemic problems.DIGESTIVEMouth is beginning of digestive tract.
CARDIOVASCULAR Temporal and carotid arteries located in head and neck. Neck and jaw pain may indicate cardiovascular disease.MUSCULAR Facial muscles needed for expression, communication and nutrition.URINARYChanges in face (e.g., edema or uremic frost) may reflect renal problems.LYMPHATICCervical lymph nodes located in neck. Tonsils located in pharynx. Mast cells located in pharynxSKELETALSkull protects brain.REPRODUCTIVE Pregnancy can cause changes in facial color (chloasma). Lips and mouth are erogenous areas.
Two landmarks on the face that are useful in determining symmetry of facial features are the palpebral fissures and the nasolabial folds. The palpebral fissure is the distance between the upper and the lower eyelid. The nasolabial fold is the distance from the corner of the nose to the edge of the lip. This is the facial crease that is often seen when someone smiles. The anterior and posterior triangles are important landmarks of the neck. The sternocleidomastoid and trapezius muscles form the triangles. Both triangles are helpful in locating the underlying structures of the neck.
The tools that will be necessary to examine the head, face, nose, mouth, throat, and neck are a penlight or otoscope for focused light, tongue blades, gauze, stethoscope, transilluminator, cup of water, and gloves.If you are using an otoscope as a light source, you will want a wide-tipped speculum. A nasal speculum is another useful piece of equipment. Lighting is very important, and some examiners prefer also using a gooseneck lamp or headlamp when examining the mouth and throat.
Assessing the Head and FaceHead Size: ■ Inspect head size and shape and symmetry of facial features.■ Variation is wide, between and within gender and racial/ethnic group.Inspecting head size and shape and symmetry of facial features
A B N O R M A L F I N D I N G S / R AT IONALE■Abnormal increase in head size in young child: May indicate hydrocephalus.■ Inconsistently large head size in adolescent or adult: May indicate acromegaly.
2-Head Shape: Variation is wide, although shape should be symmetrical and contour rounded.3-Facial Appearance: Facial appearance varies by gender, age, and racial/ethnic group. However, there should be symmetry of features and movement.
A B N O R M A L F I N D I N G S / R AT I O N A L E ■Facial appearance inconsistent with gender, age, or racial/ethnic group: May indicate an inherited or chronic disorder with typical facies, such as Graves’ disease, hypothyroidism with myxedema, Cushing’s syndrome, or acromegaly. ■ Asymmetry of features: Previous trauma, surgical alterations, congenital deformity, paralysis, or edema. Asymmetry is also seen with Bell’s palsy and stroke. Asymmetry of movement: Suggests neuromuscular disorder or paralysis. Tics, or spastic muscular contractions, usually occur in the head and face.
Two good places to inspect for symmetry of facial features are the palpebral fissures and the nasolabial folds.
PALPATION OF THE HEAD AND FACEHead Contour/Facial Structures ■ Use light palpation to note head size, shape, symmetry, masses or areas of tenderness.■ Use light palpation to palpate the scalp for mobility and tenderness.■ No tenderness or lesions.■ Relatively smooth with no unexpected contours or bulges.
A B N O R M A L F I N D I N G S / R AT I O N A L E■ Contour abnormalities, including bulges or projections:Previous trauma, surgery, or congenital deformity.■ Tenderness: Trauma, TMJ syndrome, temporal arteritis, or inflammatory process.
TMJ (Temporo-mandibular Joint)Palpate the TMJ by placing fingers over the TMJ and palpating the joint as the patient opens and closes his or her mouth.■ Smooth, symmetrical motion, with no pain, crepitus, or clicking.A B N O R M A L F I N D I N G S / R AT I O N A L E■ Irregular or uneven movement, pain with motion, or crepitus/popping: TMJ syndrome.
ASSESSING THE SINUSESAssessment of the sinuses includes inspection (with transillumination), palpation,and percussion.Only the frontal and maxillary sinuses are readily accessible for assessment.Remember, the frontal sinuses are located above the eyebrows and the maxillary sinuses are located below the eyes.
INSPECTION OF THE SINUSESFrontal and Maxillary Sinuses Inspect frontal sinuses above the eyes and maxillary sinuses below the eyes.No periorbital edema or discoloration.A B N O R M A L F I N D I N G S / R AT I O N A L E■ Periorbital edema and dark undereye circles: Sinusitis.
Frontal and Maxillary Sinuses by Transillumination■ Transilluminate frontal sinuses by shining light upward under eyebrow.■ Transilluminate maxillary sinuses by shining light below eyes while looking for a red glow on the roof (palate) of the mouth.Frontal sinus: Normally, red glow noted above eyebrow.Maxillary sinus: Normally, red glow noted on roof of mouth.■ Expected variations include absence of transillumination because the ability to transilluminate is dependent on the thickness of the bones overlying the structure examined.
A B N O R M A L F I N D I N G S / R AT I O N A L EAbsence of transillumination over one sinus when opposite structure transilluminates: Mucosal thickening or sinus fullness with sinusitis.■ Absence of transillumination must be considered with other findings.
PALPATION OF THE SINUSES:Frontal and Maxillary SinusesPalpate frontal sinuses by pressing upward just below eyebrows; note tenderness.■ Palpate maxillary sinuses by pressing below eyes;note tenderness.■ No tenderness.
A B -NORMAL■ TENDERNESS: MAY INDICATE INFECTIOUS ORALLERGIC SINUSITISPERCUSSION OF THE SINUSESPercuss frontal sinuses with direct or immediate percussion above eyebrows.Percuss maxillary sinuses with direct or immediate percussion below eyes.No tenderness. Resonant tone.
■ABNORMALTENDERNESS: SUGGESTS SINUSITIS.DULL TONE: INDICATES THICKENING OR FULLNESS OF SINUS CAVITYOR CAVITIES, ASSOCIATED WITH CHRONIC OR ACUTE SINUSITIS.
INSPECTION OF THE NOSE:External Nose■ Note size, shape, and symmetry.■ Midline placement. Shape symmetrical and consistent with age, gender, and race/ethnic group.■ No nasal flaring.■ No drainage
A B N O R M A L F I N D I N G S / R AT I O N A L E■ Misalignment of nose or shape inconsistent with patient’s biographical information: Previous trauma, congenital deformity, surgical alteration, or mass. Abnormal shape also associated with typical facies, including acromegaly or Down syndrome.■ Nasal flaring: Suggests respiratory distress, especially in infants, who are obligatory nose breathers.■ Clear, bilateral drainage: Allergic rhinitis.■ Clear, unilateral drainage: May be spinal fluid as a result of head trauma or fracture.■ Clear, mucoid drainage: Viral rhinitis.■ Yellow or green drainage: Upper respiratory infection.■ Bloody drainage: Trauma, hypertension, or bleeding disorders
Internal Nasal Mucosa:Tilt head back and use nasoscope or penlight to inspect nasal mucosa.■ Pink, variations consistent with ethnic group/race and with oral mucosa.■ Moist, with only clear, scant mucus present.■ Intact, with no lesions or perforations.■ No crusting or polyps.■ Septum located midline.
A B N O R M A L F I N D I N G S / R AT I O N A L E ■Bright red mucosa: Inflammation from rhinitis or sinusitis; also suggests cocaine abuse.■ Pale or gray mucosa: Allergic rhinitis.■ Copious or colored discharge: Allergic or infectious disorder, epistaxis, head or nose trauma.■ Clustered vesicles: Herpes infection.■ Ulcers or perforations: Chronic infection, trauma, or cocaine use.■ Dried crusted blood: Previous epistaxis.■ Polyps (elongated, rounded projections): Allergies, irritation or chronic infections.■ Deviated septum: Normal variant or followingtrauma.
ALERTA DEVIATED SEPTUM IS CAUSE FOR CONCERN IFBREATHING IS OBSTRUCTEDTurbinatesInspect the turbinates. The middle turbinate is located more medially, the inferior turbinate is more lateral, and the superior is not visible.Medial and inferior turbinates visible, symmetrical and shape/size consistent with general features of patient. Overlying mucosa coloring consistent with other mucous membranes.
R AT I O N A L E / S I G N I F I C A N C E■ Enlarged, boggy turbinates: Allergic disorder.■ Pale or gray mucosa overlying turbinates: Allergic disorder.
PALPATION OF THE NOSEExternal NoseOcclude each nostril and note patency.■ Cartilaginous portion is slightly mobile. Nontender, no masses. Nares patentA B N O R M A L F I N D I N G S / R AT I O N A L E■ Deviations or masses: Previous trauma or infection.
Because the mucous membranes reproduce cells rapidly, mouth lesions tend to heal quickly with treatment. Therefore any persistent lesion requires medical attention. Be aware of the possibility of oral cancer.
INSPECTION OF THE MOUTH AND THROATLips:■Inspect color, condition, lesions, odor.■ Midline, symmetrical, skin intact, pink, and moist.■ Coloring consistent with ethnic group/race.■ No unusual odors
A B N O R M A L F I N D I N G S / R AT I O N A L E■ Asymmetry of placement: Congenital deformity,trauma, paralysis, or surgical alteration.■ Pallor: Anemia.■ Redness: Inflammatory or infectious disorder.■ Cyanosis: Vasoconstriction or hypoxia.■ Lesions: Infectious or inflammatory disorder.■ Cheilitis (inflammation of lips), drying, andcracking: Dehydration, allergy, lip licking.■ Cheilosis (fissures at corners of lips): Deficiency of B vitamins or maceration related to overclosure. Chancre: Single, painless ulcer of primary syphilis.■ Angioedema: Allergic response. ■ Herpes simplex (clustered area of fullness/nodularity that forms vesicles, then ulceration): Herpes viral infection.■ Halitosis: Infections or gastrointestinal problems.
■ Angioedema: Allergic response.■Herpes simplex (clustered area of fullness/nodularity that forms vesicles, then ulceration): Herpes viral infection.■ Halitosis: Infections or gastrointestinal problems.
Teeth and Bite:Have patient open and close mouth. Note occlusion andnumber, color, condition of teeth.■ Most adults have 28 teeth, or 32 if the four third molars, or wisdom teeth, are erupted. (However, they are usually impacted or extracted.)■ Teeth should be white, not loose, with good occlusion, and in good repair.
■ Various abnormalities include loose, poorly anchored teeth, malalignment, dental caries. Discoloration of teeth: Chemicals or medications (tetracycline may discolor teeth gray if administered before puberty).■ Mottled enamel: Fluorosis (excessive fluoride). Dental cariesMalocclusionFluorosisTetracycline staining
Oral Mucosa and Gums:ASSESSMENTTECHNIQUES/NORMAL VA R I AT I O N S■ Inspect color, condition, lesions of mucosa.■ Note condition of gingiva, bleeding, retraction, or hypertrophy.■ Pink, moist, intact mucosa. Color variants acceptable if consistent with patient’s ethnic group/race for instance, dark stippling in dark-skinned patients.■ Gums consistent in color with other mucosa and intact, with no bleeding.
Gum hyperplasia: Side effect of medications, such as dilantin or calcium channel blockers.Gum recession or inflammatory gum changes (gingivitis/ periodontal disease): Poor dental hygiene or vitamin deficiency.Gingival recession Chronic gingivitis Leukemia.
■ Pale or gray gingivae: Chronic Gingivitis■ Abrasions, erosion of underlying mucosa: In denture wearers, poorly fitted dentures. Inflamed, bleeding gingivae may also be seen with leukemia and human immunodeficiency virus (HIV).
Hard and Soft Palate:Inspect color and condition of hard and soft palate.Palate intact, smooth, pink.■ Bony, mucosa-covered projection on the hard palate or on floor of mouth are normal variations.
A B N O R M A L F I N D I N G S / R AT I O N A L E ■ Perforation: Congenital or from trauma or drug use. Cocaine use, HIV palatal candidiasis
Salivary Ducts:■ Stensen’s duct: Inspect inner aspect of cheek (buccal mucosa) opposite the second upper molar.■ Wharton’s duct: Have patient lift tongueand inspect the floor of mouth.Stensen’s duct intact at buccal mucosa at level of second molars.■ Wharton’s duct intact at either side of frenulum.■ Both ducts with moist and pink mucosa; no lesions, swelling, or nodules.
A B N O R M A L F I N D I N G S / R AT I O N A L E■ Fullness or inflammatory changes of glands: Blockage of duct by calculi, infection, malignancy. Parotitis is inflammation of parotid glands, (Parotitis;
Tongue: Inspect color, texture, moisture, and mobilityPink and moist.■ Coloring may vary consistent with ethnic group/race.■ Mucosa intact with no lesions or discolorations.■ Papillae intact. Tongue is freely and symmetrically mobile.■ Geographic tongue is a normal variation.
A B N O R M A L F I N D I N G S / R AT I O N A L EAbsence of papillae, reddened mucosa, ulcerations:Allergic, inflammatory, or infectious cause.■ Color changes: May indicate underlying problems; for example, red “beefy” tongue is seen with pernicious anemia. Black, hairy tongue: Fungal infections. Hypertrophy and discoloration of papillae:Antibiotic use.■ Reddened, smooth, painful tongue, with or without ulcerations (glossitis): Anemia, chemical irritants, medications.■ Cancers may form on the tongue and on other oral mucosa.
Red, beefy Black, hairy tongue tongue Cancer of the tongue Glossitis
Oropharynx:Inspect oropharynx for color, lesions, and drainage.Mucosa is pink, moist, intact. The lymphoid-richposterior wall may have a slightly irregular surface. No lesions, erythema, swellings, exudate, or discharge.
A B N O R M A L F I N D I N G S / R AT I O N A L E■ Yellowish or green streaks of drainage on the posterior wall: Postnasal drainage.■ Gray membrane/adherent material: Diphtheria.■ White or pale patches of exudates with erythemic mucosa: Infection, including streptococcal bacterial infection or mononucleosis viral infection. Gonorrhea and chlamydia are also associated with exudative pharyngitis.■ Erythema: Inflammatory response, typically associated with infectious pharyngitis; also common in smokers.■ Scattered vesicles/ulcerations: Herpangioma.
Tonsils:Locate tonsils posterior to arches on sides of throat.■ Note color, size, and exudate.■ Symmetrical, pink, clean crypts.
A B N O R M A L F I N D I N G S / R AT I O N A L E■ Bulges adjacent to the tonsilar pillars: Potentialperitonsillar abscess.■ Reddened, hypertrophic tonsil, with or withoutexudates: Acute infection or tonsillitis.
Uvula:■ Have patient say “AH!” and note symmetrical rise of the uvula.■ Midline, pink, moist, without lesions.■ Symmetrical rise of the uvulaAbnormal variation Erythema, exudate, lesions: Infectious process. ■ Asymmetrical rise of the uvula: Problem with CN IX and CN X
PALPATION OF THE MOUTH AND THROATLips:Lightly palpate lips for consistency and tenderness.■ Soft, nontender, no masses.■Areas of induration, thickening, nodularity, or masses: Neoplasm.■ Tender induration that soon develops vesicles: Herpes simplex.
Tongue:Lightly palpate tongue for consistency and tenderness.■ Tissue is soft, without masses, nodules, thickenings, or tenderness.■ Tissue is soft, supple, without nodules, thickenings, masses, or tenderness. Sublingual glands may be palpable under the tongue but should be nontender, soft, and suppleA B N O R M A L F I N D I N G S / R AT I O N A L E■ Areas of induration, thickening, nodularity: Potential malignancy.■ Areas of unexpected induration, thickening, nodularity or other mass: Malignancy
Glands (Parotid, Submandibular, and Sublingual):Parotid: Palpate in front of ears.Submandibular and sublingual: Palpate under the mandible.Parotid glands are nonpalpable and nontender. Submandibular and sublingual glands may be palpable but should be nontender, supple, and soft.
A B N O R M A L F I N D I N G S / R AT I O N A L E■ Enlarged, tender parotid glands: Parotitis, blocked ducts, infection, or malignancy.
INSPECTION OF THE NECKInspect neck in neutral and hyperextended positions and as patient swallows.Neck erect, midline, no lumps, bulges, or masses.■ Thyroid not visible. No masses, swelling, or hypertrophy in mid to lower half of anterior neck.a- Inspecting the neck from the neutral positionb- Inspecting the neck when hyperextendedc- Inspecting the neck when the client swallows water
A B N O R M A L F I N D I N G S / R AT I O N A L E■Enlargements: Lymphadenopathy, lymphoma, or other malignancy.Torticollis (deviation of neck to one side caused by spasmodic contraction of neck muscles): Scars, tonsillitis, adenitis, disease of cervical vertebrae, enlarged cervical glands, cerebellar tumor, rheumatism retropharyngeal abscess.■ Enlarged, visible thyroid: Goiter or malignant mass.
HELPFULHINTSLymphatic tissue is largest in childhood and decreases in size with age. Normal palpable nodes are more likely to be found in children than in adults.Patients who present with a sore throat often complain about “swollen glands.” They are actually feeling their submandibular salivary glands.To distinguish between salivary glands and lymph nodes, remember: A normal lymph node is either small (_1 cm), round, soft to rubbery, movable, and nontender or tender and enlarged with infection.Submandibular glands are larger, soft, glandular, and not freely movable.A palpable normal node is more likely to be a superficial node than a deep cervical one. Deep cervical nodes are normally nonpalpable.
PALPATION OF THE NECKNeck:■ Use light palpation and check for masses or areas of tenderness.■ Supple, nontender, no masses.A B N O R M A L F I N D I N G S / R AT I O N A L E■ Masses: Lymphadenopathy, maligna
ASSESSING THE EYE AND THE EAR The primary function of the eye is vision, including central and peripheral vision, near and distance vision, and differentiation of colors. To accomplish these tasks, the external and internal structures of the eye work together to receive and transmit images to the occipital lobe of the brain for interpretation. Visual difficulties can result from disease or injury to any of the structures involved in the visual pathway.
UNDERSTANDING SOUNDS AND SOUND WAVES Hearing occurs by air conduction and bone conduction of sound waves. Sound waves are characterized by differences in pitch and loudness Frequency, the number of sound waves per second, determines the pitch of the sound.