Table 4: Head and Neck Exam
| Physical Sign / Manoeuvre | Rationale | Technique(s) | Interpretation | Evidence | Pre-Clerkship | Clerkship |
|---|---|---|---|---|---|---|
| Inspection (including swallowing) symmetry mass scar lesion pulsations | To detect any pathology | (swallowing) direct observation good lighting | Enlargement of glands, tumour | Siminoski, 1995. | 3 | 4 |
| Ear Exam | ||||||
| Inspection External ear Skin changes Discharge 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 disease | Orient, 2000, p233. | 3 | 4 |
| Palpation 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) 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 Rarely performed | 4 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 | 3 | 4 | |
| Palpation External nose, bony and cartilaginous part, septum | To detect inflammation, fracture | Tenderness due to fracture or inflammation | 3 | 4 | ||
| Percussion 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. | 2 | 4 |
| Mouth Exam | ||||||
| Inspection 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 |
| Palpation Salivary gland Oral cavity Tongue 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 | 3 | 4 | |
| Thyroid Exam | ||||||
| Inspection | Diagnosis Management | 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. | 3 | 4 |
| Palpation | Diagnosis Management | 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. | 3 | 4 |
| 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 |
References
- 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.