Physical Exam of thePhysical Exam of the Head & Neck Head & Neck

INTRODUCTIONINTRODUCTION

It is usually the initial part of a general It is usually the initial part of a general physical exam, after the vital signs. physical exam, after the vital signs.

It begins with inspection, and then It begins with inspection, and then proceeds to palpation. It requires the use proceeds to palpation. It requires the use of several special instruments in order to of several special instruments in order to inspect the eyes and ears, and special inspect the eyes and ears, and special techniques to assess their special sensory techniques to assess their special sensory function.function.

EXAMINATION of the HEADEXAMINATION of the HEAD

Inspection Inspection Observe the patient's facial expression and apObserve the patient's facial expression and ap

pearance. Look for symmetry, size, shape, maspearance. Look for symmetry, size, shape, masses and involuntary movements ses and involuntary movements

Hair: Observe quantity, distribution, texture, pHair: Observe quantity, distribution, texture, pattern of any hair loss. Look for lice or nits (the attern of any hair loss. Look for lice or nits (the eggs of lice) eggs of lice)

Scalp: Part the hair in several places and look fScalp: Part the hair in several places and look for scaliness, erythema, skin lesions and nodulor scaliness, erythema, skin lesions and nodules es

PalpationPalpation • • Palpate with finger pads Palpate with finger pads

• • Generally, palpation is done only if patient symptomatic (head pGenerally, palpation is done only if patient symptomatic (head pain, trauma, etc.) ain, trauma, etc.)

• • Skull: deformity from trauma, muscular tenderness from tensioSkull: deformity from trauma, muscular tenderness from tension headaches n headaches

• • Temporal arteries: thickening, tenderness, or absent pulse in teTemporal arteries: thickening, tenderness, or absent pulse in temporal arteritis mporal arteritis

• • Hair: texture may change in thyroid disease, becoming more coaHair: texture may change in thyroid disease, becoming more coarserse

• • Palpation of the lymph nodesPalpation of the lymph nodes

MicrocephalyMicrocephaly a congenitally small skull resulting fr a congenitally small skull resulting from failure of the brainom failure of the brain

MacrocephalusMacrocephalus is an abnormally large head due to h is an abnormally large head due to hydrocephalus, Paget’s disease (osteitis deformans), aydrocephalus, Paget’s disease (osteitis deformans), and acromegalynd acromegaly

Oxycephaly (Oxycephaly (steeple skull) characterized by a long steeple skull) characterized by a long anteroposterior axis, narrow in width, and pointed at tanteroposterior axis, narrow in width, and pointed at the vertex. It is caused by premature union of the cranial he vertex. It is caused by premature union of the cranial suturessutures

Deformities of skull (cranium)Deformities of skull (cranium)

MicrocephalyMicrocephaly

Macrocephalus setting sun phenomenon

hydrocephalushydrocephalus

steeple skullsteeple skull

Apert syndromeApert syndrome a form of acrocephalosyndacty a form of acrocephalosyndacty

lyly

steeple skullsteeple skull + syndactyly

ANATOMY OF THE EAR ANATOMY OF THE EAR      External ear External ear

• • Auricle (or pinna) and external auditory canal are Auricle (or pinna) and external auditory canal are cartilage covered with thin, sensitive skin cartilage covered with thin, sensitive skin

• • Cerumen secreted from distal 1/3 of canal- proteCerumen secreted from distal 1/3 of canal- protects skin cts skin

Middle ear: Middle ear: • • Tympanic membrane (TM) normally looks "pearlTympanic membrane (TM) normally looks "pearl

y gray" y gray" • • Pars tensa- inferior 2/3 Pars tensa- inferior 2/3 • • Pars flaccida- superior 1/3 (covers the chorda tyPars flaccida- superior 1/3 (covers the chorda ty

mpani)mpani)• • Umbo- where malleus attaches to TM, Umbo- where malleus attaches to TM, • • Malleus- manubrium (handle) and short process Malleus- manubrium (handle) and short process

are visibleare visible• • Eustachian tube- equalizes middle ear pressure Eustachian tube- equalizes middle ear pressure

Inner ear:Inner ear: • • The cochlea and semicircular canalsThe cochlea and semicircular canals

EXAMINATION of the EAREXAMINATION of the EAR

Inspection Inspection External ear - observe position and shape, inspect for symmetExternal ear - observe position and shape, inspect for symmet

ry, lesions, drainage from external auditory meatusry, lesions, drainage from external auditory meatus Position: Top of auricle should be above line drawn between Position: Top of auricle should be above line drawn between

outer canthus of eye and occipital protuberance. Low set auriouter canthus of eye and occipital protuberance. Low set auricle may signify chromosomal abnormality. cle may signify chromosomal abnormality.

Possible findings Possible findings Tophi- deposits of uric acid crystals found in patients with gouTophi- deposits of uric acid crystals found in patients with gou

t t Chondritis- infection of cartilage, often caused by piercing Chondritis- infection of cartilage, often caused by piercing "Cauliflower"-repeated trauma causes cartilage necrosis"Cauliflower"-repeated trauma causes cartilage necrosis Otitis externa- "swimmer's ear", pulling on lobe often painful Otitis externa- "swimmer's ear", pulling on lobe often painful Skin cancer - often nodular, with induration, scaling and supeSkin cancer - often nodular, with induration, scaling and supe

rficial ulceration. rficial ulceration.

    External earExternal ear

                                     

auricular tophusauricular tophus

                                             

postauricular cystpostauricular cyst

Middle ear - otoscopic examMiddle ear - otoscopic exam Insert otoscope slowly, avoiding bumping the canal Insert otoscope slowly, avoiding bumping the canal Cerumen removal may be necessary Cerumen removal may be necessary Cerumen spoon- often causes EAC bleeding Cerumen spoon- often causes EAC bleeding Irrigation - contraindicated if TM perforation Irrigation - contraindicated if TM perforation Removal with direct visualization Removal with direct visualization Pneumatic otoscopy Pneumatic otoscopy

• • assesses mobility and compliance of TMassesses mobility and compliance of TM• • Effusion (fluid in middle ear) will hamper TM mobility Effusion (fluid in middle ear) will hamper TM mobility • • Retraction from eustachian tube dysfunction may allow movement only with negative prRetraction from eustachian tube dysfunction may allow movement only with negative pr

essure essure Findings Findings Mobility Mobility

• • Bulging, no mobility Pus in middle ear- otitis media (OM) Bulging, no mobility Pus in middle ear- otitis media (OM) • • Retracted, no mobility Eustacian tube dysfunction +/- effusionRetracted, no mobility Eustacian tube dysfunction +/- effusion

ColorColor• • Red Infection, cryingRed Infection, crying• • Deep red or blue Blood (from trauma) Deep red or blue Blood (from trauma) • • White flecks, plaques Healed inflammation White flecks, plaques Healed inflammation

Bubbles Serous fluid Bubbles Serous fluid

The Ear-Hearing assessmentThe Ear-Hearing assessment

Response to questions during historyResponse to questions during history Response to a whispered voiceResponse to a whispered voice Tuning fork air/bone conductionTuning fork air/bone conduction

Rinne (left)Rinne (left) Weber (right)Weber (right)

ANATOMY OF THE EYEANATOMY OF THE EYE

External eye: Eyelids, lacrimal gland and duct, External eye: Eyelids, lacrimal gland and duct, palpebral fissures, medial and lateral angles. palpebral fissures, medial and lateral angles.

Internal eye: Light travels through cornea, anteInternal eye: Light travels through cornea, anterior chamber, pupil, lens, and vitreous body on rior chamber, pupil, lens, and vitreous body on the way to the retina. the way to the retina.

Fundus: The posterior structures of the eye incFundus: The posterior structures of the eye include the retina, retinal arteries and veins, the olude the retina, retinal arteries and veins, the optic disc and the macula. These structures are ptic disc and the macula. These structures are viewed with the ophthalmoscope viewed with the ophthalmoscope

ANATOMY OF THE EYEANATOMY OF THE EYE

Internal eye: light travels through cornea, anterior chamber, pupil, lens, and vitreous body on the way to the retina.

Fundus: The posterior structures of the eye include the retina, retinal arteries and veins, the optic disc and the macula. These structures are viewed with the ophthalmoscope

External eye: Eyelids, lacrimal gland and duct, palpebral fissures, medial and lateral angles.

EXAMINATION of the EYEEXAMINATION of the EYE Vision testingVision testing

• • Should be done with any visit involving an eye complaintShould be done with any visit involving an eye complaint • • Used to screen children for visual problems Used to screen children for visual problems

Acuity:Acuity: • • Far vision - test at 6 m with Snellen chartFar vision - test at 6 m with Snellen chart• • Patient covers one eye, and is instructed to read the smallest line poPatient covers one eye, and is instructed to read the smallest line po

ssible. Patient must correctly read half of symbols on line. Repeat for ssible. Patient must correctly read half of symbols on line. Repeat for other eye.other eye.

• • Near vision - test at 35cm with pocket chart Near vision - test at 35cm with pocket chart • • Patient covers one eye, and is instructed to read smallest line possibPatient covers one eye, and is instructed to read smallest line possib

le. Repeat for other eye. le. Repeat for other eye. Visual fields:Visual fields:

• • Confrontation test estimates peripheral vision (may be important in Confrontation test estimates peripheral vision (may be important in glaucoma, multiple sclerosis, stroke, or pituitary or other CNS tumoglaucoma, multiple sclerosis, stroke, or pituitary or other CNS tumor) r)

• • Use your own visual fields as a referenceUse your own visual fields as a reference TechniqueTechnique - face patient at eye level. Ask patient to cover one eye. - face patient at eye level. Ask patient to cover one eye.

Slowly move your fingers from outside the patient's peripheral vi Slowly move your fingers from outside the patient's peripheral visual field towards the center of the patient's vision. Ask the patiesual field towards the center of the patient's vision. Ask the patient to tell you when he sees your fingers. nt to tell you when he sees your fingers.

EXAMINATION of the EYEEXAMINATION of the EYE

Be systematic – inspect eyebrows, lids, and globe includiBe systematic – inspect eyebrows, lids, and globe including conjunctivae ng conjunctivae

FindingsFindingsEyebrows: Loss of lateral growth may suggest hypothyroiEyebrows: Loss of lateral growth may suggest hypothyroi

dism dism Xanthelasma -irregular, slightly raised yellow periorbital Xanthelasma -irregular, slightly raised yellow periorbital

lesions may suggest lipid disorder lesions may suggest lipid disorder Eyelids : Ptosis - if upper lid covers part of pupil (muscle Eyelids : Ptosis - if upper lid covers part of pupil (muscle

weakness or neurologic lesion) weakness or neurologic lesion) Ectropion (lid turned out) Ectropion (lid turned out) Entropion (lid turned in) Entropion (lid turned in) Hordeolum (stye)-inflammation of sebaceous glandHordeolum (stye)-inflammation of sebaceous glandForeign body - may need to evert lid for full inspectionForeign body - may need to evert lid for full inspectionConjunctiva: Hemorrhage- from trauma Conjunctiva: Hemorrhage- from trauma

Eyelid edemaEyelid edema

Entropion (lid turned in)Entropion (lid turned in)

Ectropion (lid turned out)Ectropion (lid turned out)

After treated with neostigmine

myasthenia gravismyasthenia gravisautoimmune neuromuscular diseaseautoimmune neuromuscular disease

PtosiPtosiss

PtosisPtosis

unilateralbilateral

subconjunctival hemorrhage

chemosis conjunctivachemosis conjunctiva

Pale palpebral conjunctivPale palpebral conjunctivaa

Facial schingles with conjunctivitisFacial schingles with conjunctivitis

EXAMINATION of the EYEEXAMINATION of the EYE

Conjunctivitis- inflammation from infection, allergy... Pterygium - growth of Conjunctivitis- inflammation from infection, allergy... Pterygium - growth of conjunctiva over corneaconjunctiva over cornea

Cornea: Sensation tests cranial nerve V (CN V) Cornea: Sensation tests cranial nerve V (CN V) Arcus senilis - lipid deposits, seen in many elderly Arcus senilis - lipid deposits, seen in many elderly Pupils Pupils

Check direct and consensual response to light Check direct and consensual response to light Shine light source briefly into pupil, observing for constriction. Shine again into Shine light source briefly into pupil, observing for constriction. Shine again into

pupil, and observe for constriction of contralateral eye. pupil, and observe for constriction of contralateral eye. Check accommodation (papillary constriction with near focus)Check accommodation (papillary constriction with near focus)Ask patient to look at finger held several feet from face, then to look at finger broAsk patient to look at finger held several feet from face, then to look at finger bro

ught just beyond the end of the patient's nose. ught just beyond the end of the patient's nose. Findings: Findings:

• • Miosis if <2mm (narcotic use, elderly)Miosis if <2mm (narcotic use, elderly)• • Mydriasis if >6mm (head injury, drugs) Mydriasis if >6mm (head injury, drugs) • • Anisocoria - unequal pupil size, may be normal variation Anisocoria - unequal pupil size, may be normal variation

hepatolenticular degenerhepatolenticular degenerationation

Kayser-Fleischer ringKayser-Fleischer ring

Arcus senilisArcus senilis cataracataractct

Pterygium --growth of conjunctiva over corneaPterygium --growth of conjunctiva over cornea

sclerasclera

ptosis (drooping of the upper eyelid from loss of sympathetic ptosis (drooping of the upper eyelid from loss of sympathetic innervation to the superior tarsal muscle)innervation to the superior tarsal muscle)anhidrosis (decreased sweating on the affected side of the face)anhidrosis (decreased sweating on the affected side of the face)miosis (small pupils)miosis (small pupils)enophthalmos (the impression that the eye is sunk in)enophthalmos (the impression that the eye is sunk in)

Horner's syndrome

direct and consensual response to lightdirect and consensual response to light

AccommodationAccommodation

Extraocular eye movementsExtraocular eye movementsTest CN III, IV, VI and 6 extraocular muscles (EOM). Test CN III, IV, VI and 6 extraocular muscles (EOM). Technique Technique Patient watches your finger move through 6 "cardinal poPatient watches your finger move through 6 "cardinal po

sitions" sitions" Observe for coordinated movement, nystagmus (or "jerkObserve for coordinated movement, nystagmus (or "jerk

iness" of motion. iness" of motion. Findings Findings

Lack of coordinated movement denotes problem with cranial neLack of coordinated movement denotes problem with cranial nerves or muscle strength/alignment. rves or muscle strength/alignment.

Nystagmus- involuntary rhythmic eye movements Nystagmus- involuntary rhythmic eye movements A few beats of horizontal nystagmus at extreme lateral gaze is noA few beats of horizontal nystagmus at extreme lateral gaze is no

rmal rmal Lid lag- exposure of sclera over iris as patient moves eyes inferioLid lag- exposure of sclera over iris as patient moves eyes inferio

rly (found in hyperthyroidism) rly (found in hyperthyroidism)

Extraocular eye movementsExtraocular eye movements

Lid lag Lid lag (found in hyperthyroidism)(found in hyperthyroidism)

ANATOMY OF THE NOSE and ANATOMY OF THE NOSE and SINUSESSINUSES

The nasal bridge is formed by The nasal bridge is formed by the frontal and maxillary bonethe frontal and maxillary bones. s.

The septum divides the nose iThe septum divides the nose into two anterior cavities. Kiesnto two anterior cavities. Kiesselbach's plexus is a grouping selbach's plexus is a grouping of small blood vessels on the of small blood vessels on the anterior septum. It is a frequeanterior septum. It is a frequent site of nosebleeds. nt site of nosebleeds.

There are three paired turbinaThere are three paired turbinates - inferior, middle and supetes - inferior, middle and superior. rior.

The sinuses are air-filled and The sinuses are air-filled and paired extensions of the nasal paired extensions of the nasal cavities within the bones of thcavities within the bones of the skull. e skull.

Frontal, Frontal, Sphenoid,Sphenoid, Ethmoid, Ethmoid, MaxillaryMaxillary

EXAMINATION of the NOSEEXAMINATION of the NOSECheck patency by asking patient to occlude one nostril, and then breatCheck patency by asking patient to occlude one nostril, and then breat

h through opposite nostril. Repeat for opposite nostril. h through opposite nostril. Repeat for opposite nostril. External nose- - possible findings Deformity trauma External nose- - possible findings Deformity trauma Discharge infection, trauma, foreign bodyDischarge infection, trauma, foreign body

Flaring respiratory distress Flaring respiratory distress Nasal cavity Nasal cavity

Use nasal speculum, or larger ear speculum on an otoscope Use nasal speculum, or larger ear speculum on an otoscope Ask patient to tilt head back Ask patient to tilt head back Gently introduce the speculum into the vestibule, while visualizing the Gently introduce the speculum into the vestibule, while visualizing the

mucosa, and gently advancing the speculum until you can visualize tmucosa, and gently advancing the speculum until you can visualize the lower nasal cavity. he lower nasal cavity.

If using a nasal speculum, open it in anterior-posterior direction, NOT pIf using a nasal speculum, open it in anterior-posterior direction, NOT pressing on sensitive septum ressing on sensitive septum

Findings: Findings: Bluish, swollen mucosa- allergies Bluish, swollen mucosa- allergies Generalized redness- infection Generalized redness- infection Bleeding- often from Kiesselbach plexus, on anterior septum Bleeding- often from Kiesselbach plexus, on anterior septum

rosacea

External nose- External nose- - Deformities- Deformities

nasal speculumnasal speculumIf using a nasal speculum, open it in anterior-posterior direction,If using a nasal speculum, open it in anterior-posterior direction,

NOT pressing on sensitive septumNOT pressing on sensitive septum

Nasal cavityNasal cavity

EXAMINATION of the EXAMINATION of the SINUSESSINUSES

Frontal and maxillary sinuses are the most Frontal and maxillary sinuses are the most accessible to examination accessible to examination

Palpation and percussion may or may not Palpation and percussion may or may not be helpful - (sinus palpation or percussion be helpful - (sinus palpation or percussion is not reliable) .                is not reliable) .               

The following increase the likelihood that The following increase the likelihood that your patient has sinusitis:        your patient has sinusitis:         History of colored nasal discharge         History of colored nasal discharge          Poor response to decongestants        Poor response to decongestants         Maxillary tooth pain          Maxillary tooth pain           Physical exam showing purulent nasal dischargePhysical exam showing purulent nasal discharge

SinusesSinuses

FrontalFrontal

Ethmoid Ethmoid

MaxillaryMaxillary

ANATOMY OF THE Mouth and ANATOMY OF THE Mouth and OROPHARYNXOROPHARYNX

The Oral Cavity is comprised of the vestiThe Oral Cavity is comprised of the vestibule and the mouth Vestibule - space bebule and the mouth Vestibule - space between the buccal mucosa to the outer gitween the buccal mucosa to the outer gingival ngival

Mouth - tongue, teeth and gums / TonguMouth - tongue, teeth and gums / Tongue anchored to floor of oral cavity posterie anchored to floor of oral cavity posteriorly, and by frenulum anteriorly orly, and by frenulum anteriorly

Teeth and gums 32 adult teeth: 4 incisorTeeth and gums 32 adult teeth: 4 incisors, 2 canines, 4 premolars, 6 molars in eas, 2 canines, 4 premolars, 6 molars in each jaw ch jaw

Two paired salivary ducts enter the oral Two paired salivary ducts enter the oral cavity cavity

Wharton's ducts, from the submandibulWharton's ducts, from the submandibular glands, open on each side of the tongar glands, open on each side of the tongue's frenulum ue's frenulum

Stensen's ducts, from the parotid glands,Stensen's ducts, from the parotid glands, open onto the buccal mucosa across fro open onto the buccal mucosa across from the second molar of the upper jaw. m the second molar of the upper jaw.

The oropharynx is separated from the The oropharynx is separated from the mouth by the anterior tonsillar pillars mouth by the anterior tonsillar pillars

Tonsils lie between the anterior and posTonsils lie between the anterior and posterior tonsillar pillars terior tonsillar pillars

EXAMINATION of MOUTH and OROPHARYNXEXAMINATION of MOUTH and OROPHARYNXInspect lips, buccal mucosa, gingival, teeth, tongue, floor and roof of mouth Inspect lips, buccal mucosa, gingival, teeth, tongue, floor and roof of mouth

and the oropharynx. and the oropharynx. Use a light source (otoscope or pen-light). Use a light source (otoscope or pen-light). Use a gloved hand, or tongue depressor (preferable - some patients, particuUse a gloved hand, or tongue depressor (preferable - some patients, particu

larly children or confused older adults may bite!), to gently retract structlarly children or confused older adults may bite!), to gently retract structures (buccal wall, tongue) as necessary. To visualize the posterior orophures (buccal wall, tongue) as necessary. To visualize the posterior oropharynx: ask the patient to say "AAAAAH." arynx: ask the patient to say "AAAAAH."

In some patients, oropharynx is better seen if patient does not extend tongIn some patients, oropharynx is better seen if patient does not extend tongue.ue.

If needed, may place a tongue depressor on tongue on the distal half and gIf needed, may place a tongue depressor on tongue on the distal half and gently depress it. ently depress it.

• • PercussionPercussion Done only as needed, in patients who have potential dental sources of oral pain. Done only as needed, in patients who have potential dental sources of oral pain. Gently tap or press on teeth that may be a source of pain using a tongue blade wiGently tap or press on teeth that may be a source of pain using a tongue blade wi

ll identify which teeth are affected. ll identify which teeth are affected. • • Palpation Palpation

Done only as needed, primarily in patients whom you suspect may have squamoDone only as needed, primarily in patients whom you suspect may have squamous cell cancer of the head and neck, or when assessing a lesion in the oropharus cell cancer of the head and neck, or when assessing a lesion in the oropharynx.ynx.

Use a gloved hand, and warn the patient that you may inadvertently gag him. Use a gloved hand, and warn the patient that you may inadvertently gag him. Gently palpate the surface of the lesion with one or two fingers to assess its size, Gently palpate the surface of the lesion with one or two fingers to assess its size,

consistency (soft, firm, hard), underlying induration and tenderness. consistency (soft, firm, hard), underlying induration and tenderness. Use bimanual palpation (examination fingers placed in mouth, other fingers beloUse bimanual palpation (examination fingers placed in mouth, other fingers belo

w the jaw, to palpate the soft tissues on the floor of the mouth and the tonguw the jaw, to palpate the soft tissues on the floor of the mouth and the tongue. e.

FindingsFindings Lips Lips • • Angular cheilitis - fissures at corners of mouth Angular cheilitis - fissures at corners of mouth • • Actinic cheilitis- scaly raised lesions - sun damage, may precede cancer Actinic cheilitis- scaly raised lesions - sun damage, may precede cancer • • Angioedema - allergic swelling Angioedema - allergic swelling • • Herpes labialis- "cold sore“Herpes labialis- "cold sore“• • Carcinoma Carcinoma

Colors:Colors: • • Pale- anemia • Blue- cyanosis • Red- CO poisoningPale- anemia • Blue- cyanosis • Red- CO poisoning

Buccal Mucosa:Buccal Mucosa: • • Thrush- adherent white patches\ Thrush- adherent white patches\

Tongue: Tongue: Geographic tongue - so-called because it resembles a map Geographic tongue - so-called because it resembles a map Smooth - may indicate vitamin deficiency Smooth - may indicate vitamin deficiency Glossitis - erythematous, sometime swollen Glossitis - erythematous, sometime swollen Black hairy tongue Black hairy tongue Varicosities Varicosities Nonhealing ulcer or nodule- consider cancerNonhealing ulcer or nodule- consider cancer

Oropharynx Oropharynx Bifid uvula- may indicate cleft palate Bifid uvula- may indicate cleft palate Asymmetric movement of soft palate- lesion of CN IX or X Asymmetric movement of soft palate- lesion of CN IX or X Erythema, exudate- tonsillitis Erythema, exudate- tonsillitis Asymmetric tonsillar swelling (often with deviation of uvula) - peritonsillar absceAsymmetric tonsillar swelling (often with deviation of uvula) - peritonsillar absce

ss ss "Cobble-stone" - swelling of lymphoid tissue, often secondary to allergies. "Cobble-stone" - swelling of lymphoid tissue, often secondary to allergies. Post-nasal drip Post-nasal drip

Pale

InfectionInfection

CheilitisCheilitis

AngioedemaAngioedema

cleft lip and palatecleft lip and palate

Geographic tongueGeographic tongue

Black hairy tongueBlack hairy tongue

Herpes labialisHerpes labialis

Thrush- adherent white patchesThrush- adherent white patches monilial infection

Enlargement of tonsilEnlargement of tonsil

Salivary GlandsSalivary Glands

Look at the site of swelling :any skin Look at the site of swelling :any skin changes/overlying scars? changes/overlying scars?

Palpate the lump relationship to skin? Palpate the lump relationship to skin? Fixed to underlying structures? Fixed to underlying structures?

Look inside the mouth Look inside the mouth Inspect the gland and duct orifice Inspect the gland and duct orifice Bimanual palpation Bimanual palpation Cervical nodes Cervical nodes Any other pathology in the mouth? Any other pathology in the mouth?

epidemic parotitisepidemic parotitis

Acute purulent parotitis

Salivary Glands TumorSalivary Glands Tumor

ANATOMY OF THE NECKANATOMY OF THE NECK Triangles of the neck Triangles of the neck

Anterior: Bordered by mandibles and sternocleidomastoids (SAnterior: Bordered by mandibles and sternocleidomastoids (SCM) CM)

Posterior: Bordered by anterior margin of trapezius, posterior Posterior: Bordered by anterior margin of trapezius, posterior margin of the SCM, and superior margin of the clavicle.margin of the SCM, and superior margin of the clavicle.

EXAMINATION of the NECKEXAMINATION of the NECK Inspect the neck Inspect the neck Observe how the patient holds their head Observe how the patient holds their head Inspect the neck for symmetry, masses, goiter or scars, Inspect the neck for symmetry, masses, goiter or scars,

jugular vein distributionjugular vein distribution Evaluation range of motion of neckEvaluation range of motion of neck Palpate the neckPalpate the neck

• • Palpate the trachea with the index and ring finger oPalpate the trachea with the index and ring finger on the sternoclavicular joint and middle finger on the n the sternoclavicular joint and middle finger on the tracheatrachea

• • Trachea: should be midline, palpate superior to supTrachea: should be midline, palpate superior to suprasternal notch rasternal notch

• • Deviation may be sign of a mass or a tension pneuDeviation may be sign of a mass or a tension pneumothorax mothorax

• • Downward "tugging" may suggest aortic aneurysm Downward "tugging" may suggest aortic aneurysm

Congenital torticollis

EXAMINATION of the ThyroidEXAMINATION of the Thyroid

••InspectionInspection•• Inspect the thyroid with the neck slightly extended, Inspect the thyroid with the neck slightly extended,

using tangential lighting. Goiter is essentially ruled using tangential lighting. Goiter is essentially ruled outout

••Palpation:Palpation:

• • palpate for size, nodules, and tendernesspalpate for size, nodules, and tenderness• • Anterior or posterior approach Anterior or posterior approach • • Relax neck by using neutral position, also may furthRelax neck by using neutral position, also may furth

er relax muscles on one side by tilting toward that ser relax muscles on one side by tilting toward that side ide

• • Identify the appropriate level of the thyroid isthmuIdentify the appropriate level of the thyroid isthmus (below the cricoid cartilage). s (below the cricoid cartilage).

• • Gently retract the trachea to the opposite side of thGently retract the trachea to the opposite side of the lobe you are palpating. e lobe you are palpating.

• • Have the patient swallow a sip of water while you pHave the patient swallow a sip of water while you palpate alpate

AnatomyAnatomy

InspectionInspection

InspectionInspection

Graves disease

Thyroid adenoma

thyroidectomy

Anterior PosteriorAnterior Posterior

PalpationPalpation

BruitBruit

Put the stethoscope over the Put the stethoscope over the

thyroid thyroid

gland, and listen carefully. If a gland, and listen carefully. If a

systolic systolic

bruit heard over the thyroid is bruit heard over the thyroid is

almost almost

diagnostic of diffuse toxic goiter (↑ diagnostic of diffuse toxic goiter (↑

blood flow to the thyroid). blood flow to the thyroid).

AuscultationAuscultation

TracheaTrachea

Masses in the neck may push the trachea to one side.tracheal deviation may also signify important problems in the thorax, such as a mediastinal mass,atelectasis, or a large pneumothorax