Ppt07

Chapter 7
The Head and Neck
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Common or Concerning Symptoms
Head Headache, history of head injury
Eyes Visual disturbances, spots (scotomas), flashing
lights, use of corrective lenses, pain, redness,
excessive tearing, double vision (diplopia)
Ears Hearing loss, ringing (tinnitus), vertigo, pain,
discharge
Nose Drainage (rhinorrhea), congestion, sneezing,
nose bleeds (epistaxis)
Oropharynx Sore throat, gum bleeding, hoarseness,
Neck Swollen glands, goiter

Head – Inspection and Palpation
• Inspect
– Hair distribution,
quantity
– Scalp – scaling, nevi
– Skull – size, contour
– Face – expression,
contours
– Skin – color,
pigmentation, hair
distribution, lesions
• Palpate
– Hair texture
– Skull – lumps
– Face – sinuses
– Skin – texture,
temperature

Eyes - Inspection
• Position and alignment of
eyes
• Eyebrows - quantity,
distribution
• Eyelids
– Width of palpebral
fissures
– Edema, color, lesions
– Condition and direction
of eyelashes
– Adequacy of closed
eyelids
• Lacrimal apparatus
– Lacrimal gland and sac
for swelling
• Conjunctiva and sclera
– Color, vascular pattern
• Cornea and lens - opacities
• Iris – markings clearly
defined
• Pupils – size, shape,
symmetry, reaction to light
(direct and consensual)

Eyes – Techniques of Examination
• Visual acuity
– Central vision: Snellen eye chart; position patient
20 feet from the chart
o Patients should wear glasses if needed
o Test one eye at a time
– Near vision: hand-held card (can also use to test
visual acuity at the bedside); hold 14 inches from
patient’s eyes

Eyes – Techniques of Examination (cont.)
• Visual fields
– Screening
o Both eyes at same time; start in the temporal fields
– Further testing
o If a defect is found, test one eye at a time
• Extraocular movements/six cardinal directions of gaze
– Normal conjugate movements
– Nystagmus
– Lid lag
– Convergence

Tips for Using the Ophthalmoscope
• Darken the room and have the patient look off in the distance
• Switch the ophthalmoscope light and turn the lens disc to the
large round beam of white light
• Turn lens disc to the 0 diopter
• Hold the ophthalmoscope in your right hand to examine the
patient’s right eye with your right eye; hold it in your left hand
to examine the patient’s left eye with your left eye
• Stand directly in front of the patient, 15 inches away, and start
at an angle of 15 degrees lateral to the patient’s line of vision
• Shine the beam of light onto the pupil and look for an orange
glow; this is the red reflex
• Follow the red reflex and move inward towards the nasal aspect
of the visual field

Ears – Inspection and Palpation
• Inspection
– Auricle for redness, lesions
– Ear canal
o Discharge, foreign bodies, redness, swelling
– Tympanic membrane
o Color, contour
• Palpation
– Auricle for lumps, tenderness

Ears - Hearing
• Auditory acuity
– Test one ear at a time
– Whisper test, standing 1-2 feet behind patient,
softly say “nine-four,” “baseball”
• Air and bone conduction
– Weber
o Lateralization of sound to impaired ear; suspect
unilateral conductive hearing loss
– Rinne
o Compare time of air vs. bone conduction
o If bone conduction is equal or greater than air
conduction, then suspect conductive loss

Nose and Sinuses – Inspection/Palpation
• Inspection
– Anterior and inferior surface – asymmetry or
deformity
– Inside of nose
o Mucosa – color, swelling, bleeding, exudate,
ulcers, or polyps
o Septum – deviation, inflammation, or perforation
o Turbinates – use otoscope to view middle and
inferior turbinates
• Palpation of sinuses – frontal and maxillary

Question
When using the otoscope to inspect inside the
nose, which of the following structures is not
visible?
a. Inferior turbinate
b. Middle turbinate
c. Superior turbinate
d. All of the above

Answer
c. Superior turbinate
By directing the speculum posteriorly, you should
be able to see the inferior and middle turbinates.

Mouth and Pharynx - Inspection
• Lips
– Note color, moisture,
lumps, ulcers, cracking,
or scaliness
• Oral mucosa
– Note color, ulcers, and
nodules
• Gums and teeth
– Note color, presence,
and position of teeth
• Roof of mouth
– Note color
• Tongue and floor of mouth
– Note color and texture,
ulcers, nodules
• Pharynx: soft palate,
anterior and posterior
pillars, uvula, tonsils, and
pharynx
– Note color, symmetry,
presence of exudate,
swelling, ulceration, or
tonsillar enlargement

Neck – Inspection and Palpation
• Inspection
– Symmetry, masses, scars, enlarged glands or lymph
nodes
– Trachea – position, alignment
– Thyroid gland - symmetry
• Palpation
– Lymph nodes (size, shape, delimitation, mobility,
consistency, tenderness)
o Preauricular, posterior auricular, occipital, tonsillar,
submandibular, submental, superficial cervical,
posterior cervical, deep cervical chain,
supraclavicular

Neck – Thyroid Gland
• Flex neck slightly forward
• Place fingers of both hands with index fingers just below
the cricoid cartilage
• Ask patient to swallow; feel for the thyroid isthmus rising
up under your finger pads (not always palpable)
• Displace trachea to the right and palpate laterally for the
right lobe of the thyroid; repeat on the left side
• Note the size, shape, and consistency
• Identify any nodules or tenderness
• If enlarged, listen over lateral lobes to detect a bruit

Question
When palpating the thyroid, which of the following
is true?
a. Flex the neck slightly backward
b. Place the index fingers just above the cricoid
cartilage
c. The thyroid isthmus may not be palpable
d. A bruit auscultated over the lateral lobe is
expected

Answer
c. The thyroid isthmus may not be palpable
• Ask the patient to swallow and feel for the
thyroid isthmus rising up under your finger pads
(not always palpable)
– Flex the neck slightly forward
– Place fingers of both hands with index fingers
just below the cricoid cartilage
o If enlarged, listen over lateral lobes to
detect a bruit

Ppt07

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