AFMC National Clinical Skills Working Group Evidence-Based Clinical Skills Document

Table 4: Head and Neck Exam

Physical Sign / ManoeuvreRationaleTechnique(s)InterpretationEvidencePre-ClerkshipClerkship
Inspection (including swallowing)





To detect any pathology(swallowing) direct observation good lightingEnlargement of glands, tumourSiminoski, 1995.34
Ear Exam

External ear

Skin changes


Earlobe creases
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 diseaseOrient, 2000, p233.34

Tragus, pinna, mastoid
to detect otitis externa, or mastoiditisInspect under good lightingMastoid tip tenderness favours otitis externa; pain and swelling higher up is more consistent with mastoiditisGliklich, 1996.34
OtoscopyTo detect otitis media, changes in the tympanic membraneInspect by using oto-scospeRothman, 2003.

Percussion (Palpation)

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 erythemaErythema and edema indicate mastoiditisOrient, 2000, p235.2

Rarely performed

Rarely performed
Nose Exam
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, fractureTenderness due to fracture or inflammation34

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.
Williams, 1993.

Orient, 2000, p173.
Mouth Exam

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 sourceUlcers, masses, tumours, tonsilitisEbell, 2000.34

Salivary gland

Oral cavity


Temperomandibular joint
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
Thyroid Exam

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
+LR >.41
Protrusion <(or equal to)2 mm +LR 3.4
Siminoski, 1995.

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.

Thyroid carcinoma
: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.
AuscultationDiagnosisAuscultation with the diaphragm to the stethoscope to distinguish between bruit and aortic stenosisArteriovenous communication inside a highly vascular gland suggests hyperthyriodism is cause for goitrenone34