Table 4: Head and Neck Exam
|Physical Sign / Manoeuvre||Rationale||Technique(s)||Interpretation||Evidence||Pre-Clerkship||Clerkship|
|Inspection (including swallowing)|
|To detect any pathology||(swallowing) direct observation good lighting||Enlargement of glands, tumour||Siminoski, 1995.||3||4|
|to detect external and middle ear pathology|
coronary artery disease
|Inspect under good light|
Inspect under good light
Inspect both earlobes
|Earlobe creases are risk factor for coronary artery disease||Orient, 2000, p233.||3||4|
Tragus, pinna, mastoid
|to detect otitis externa, or mastoiditis||Inspect under good lighting||Mastoid tip tenderness favours otitis externa; pain and swelling higher up is more consistent with mastoiditis||Gliklich, 1996.||3||4|
|Otoscopy||To detect otitis media, changes in the tympanic membrane||Inspect by using oto-scospe||Rothman, 2003.||3||4|
Percussion (palpation) of mastoid process
|To detect mastoiditis (post-auricular edema & erythema; these occur in 76% and 65% respectively of children with mastoiditis)||Palpate the mastoid for swelling and erythema||Erythema and edema indicate mastoiditis||Orient, 2000, p235.||2|
|Inspection - External skin changes, shape, septum, deformities, masses|
Internal – inspection
|to detect local or systemic disease, trauma, deformities, in bone, cartilage, skin and septum|
to detect polyp, masses, mucosal changes, nasal septum fluid (rhinorrhea)
deviated nasal septum
|Inspect under good light|
Use of otoscope with nasal attachment or use of nasal speculum
|Malignant ulcers, nasal deviation, blockage|
Change in nasal mucosa, septum, turbinates CSF, rhinorrhea
External nose, bony and cartilaginous part, septum
|To detect inflammation, fracture||Tenderness due to fracture or inflammation||3||4|
Percussion ? (palpation) over maxillary and frontal sinuses
Transillumination of frontal and maxillary sinuses
|To detect tenderness over nasal sinuses|
To check the content of the sinus (fluid, mass etc.)
|Percuss frontal and maxillary sinus area|
Transillumination has to be done in a dark room using a very bright light. Supraorbital notches for frontal (compare both sides)
For maxillary, penlight midline in the mouth (closed) or externally at the inferior portion of each orbit
|Tenderness indicates inflammation|
Opaque, dull or normal. A unilaterally opaque maxillary sinus is always abnormal. False positive may occur with frontal sinuses because they may develop asymmetrically. It must be resolved with x-ray.
Orient, 2000, p173.
Lips, oral cavity, teeth, tongue, gums, tonsils
|to detect local or systemic diseases|
to detect any abnormalities or changes
|A flashlight or the otoscope may be used as a light source||Ulcers, masses, tumours, tonsilitis||Ebell, 2000.||3||4|
|To detect masses, cysts, calculi in sub-mandibular ducts|
To detect tenderness and instability, mechanical disease of the jaw
|Palpate all symptomatic or unusual-appearing areas in the mouth and pharynx using gloves|
TMJ can be palpated by placing your fingertip in the external ear canal and having the patient open and close his mouth
|Palpate masses, can be tumour, cysts, calculi in salivary ducts|
Limitation of movement of lower jaw and pain indicate TMJ pathology
|Patient's head in neutral or extended position, neck from the side looking for lateral prominence.|
Ask patient to swallow, observe for symmetry, obvious masses.
|Protrusion if present >2 mm rules in goitre.|
No visible protrusion, goitre not likely
Protrusion <(or equal to)2 mm +LR 3.4
Simel, 2009, Chapter 21.
|Palpation of isthmus, lobes anteriorly or posteriorly with the patient swallowing and sternocleidomastoid muscles relaxed.|
Palpation of the cervical lymph nodes should be included with exam of the thyroid gland.
|Estimate size of thyroid as normal, enlarged, degree of enlargment.|
Compare lobes to size of patient's distal thumb phalynx. Thyroid with both lobes larger than distal thumb is palpably enlarged or volume is estimated at > 20-25 mL.
If gland is visibly enlarged in neutral position and palpably enlarged +LR 26.3 of goitre.
Make note of texture, nodules, tenderness, tracheal deviation. Palpation fails to detect 50% nodules <2 cm and 90% <1 cm.
:Nodule and Vocal cord paralysis +LR 12.0
Fixation of nodule +LR 7.4
Cervical lumpadenopathy +LR 7.8
|Simel, 2009, Chapter 21, 4.|
World Health Organization, 2007, p35-7.
|Auscultation||Diagnosis||Auscultation with the diaphragm to the stethoscope to distinguish between bruit and aortic stenosis||Arteriovenous communication inside a highly vascular gland suggests hyperthyriodism is cause for goitre||none||3||4|
- Ebell MH, et al. The rational clinical examination. Does this patient have strep throat? JAMA 2000 Dec 13;284(22):2912-2918.
- Gliklich RE, et al. A contemporary analysis of acute mastoiditis. Arch.Otolaryngol.Head.Neck.Surg. 1996 Feb;122(2):135-139.
- McGee SR. Evidence-based physical diagnosis. 2nd ed. St. Louis, Mo.: Saunders Elsevier; 2007.
- Orient JM, Sapira JD. Sapira's art & science of bedside diagnosis. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2000.
- Rothman R, et al. Does this child have acute otitis media? JAMA 2003 Sep 24;290(12):1633-1640.
- Sauve JS, et al. The rational clinical examination. Does this patient have a clinically important carotid bruit? JAMA 1993 Dec 15;270(23):2843-2845.
- Simel DL, et al. The rational clinical examination : evidence-based clinical diagnosis. New York; Chicago, IL: McGraw-Hill Medical; JAMA & Archives Journals, American Medical Association; 2009.
- Siminoski K. The rational clinical examination. Does this patient have a goiter? JAMA 1995 Mar 8;273(10):813-817.
- Williams JW,Jr, Simel DL. Does this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination. JAMA 1993 Sep 8;270(10):1242-1246.
- World Health Organization. Assessment of iodine deficiency disorders and monitoring their elimination: a guide for programme managers. 3rd ed. Geneva, Switzerland: WHO Press; 2007.