Head and Neck Examination

The head and neck examination is the portion of the physical examination done to observe for signs of head and neck disease or illness. The head and neck examination consists of inspection, palpation, and auscultation. The information gathered from the physical examination of the head and neck, along with the information from the history, is used by the physician to generate a differential diagnosis and treatment plan for the patient.

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Introduction

The head and neck examination is often annotated as HEENT (head, eyes, ears, nose and throat) in clinical documentation shorthand.

Equipment needed:

  • Otoscope
  • Ophthalmoscope
  • Tongue depressor

Positioning: 

  • Individual sits upright with arms at side. 
  • Perform all exams on the undressed individual while preserving the individual’s modesty.
  • Classically, the exam is performed from the right side of the individual.

Environment:

  • Ensure good lighting, privacy, and hygiene. 
  • Drape individual with a sterile gown, towel, or sheet.

Initial steps:

  • Explain the exam steps to the individual and obtain consent. 
  • Obtain vital signs including pulse oximetry (oxygen saturation).
  • Ask the individual to indicate areas of tenderness to avoid exacerbating pain. 

Inspection

The 1st part of the head and neck exam begins with inspection of the individual. Note pertinent positive and negative findings. 

General appearance

  • Pertinent positives:
    • Well or no acute distress
    • Comfortable, normal affect
  • Pertinent negatives:
    • In distress (mild, moderate, or severe)
    • Disheveled
    • Evasive or oppositional
  • Level of consciousness: 
    • Alert: normal response
    • Confused: disoriented to surroundings
    • Lethargic: drowsy, needs stimulation to initiate response
    • Obtunded: slowly responding, needs repeated stimulation to maintain attention
    • Stuporous: minimal response to stimulation
    • Comatose/unresponsive: no response to stimulation
  • Respiratory rate (RR):
    • Normal: RR 12–20/min in adults (pediatric RR varies based on age)
    • Bradypnea: RR < 12/min
    • Tachypnea: RR > 20/min, shallow breathing
    • Hyperpnea: RR > 20/min, deep breathing
  • Work of breathing:
    • Note any observable breathing patterns.
    • Labored breathing: 
      • Abnormal respirations with ↑ effort to breathe
      • Use of accessory muscles (i.e. sternomastoid, scalene)
      • Stridor, grunting, or nasal flaring
      • Pursed lip breathing
      • Supraclavicular or intercostal retractions

Skull and scalp

  • Classically written as “normocephalic, atraumatic” for normal clinical exam documentation (NC/AT for shorthand)
  • Notice any:
    • Asymmetries
    • Deformities
    • Lacerations
    • Signs of trauma
  • Skull shapes:
    • Skull shape varies by:
      • Age
      • Gender
      • Race
    • Malformation causes:
      • Congenital disorders
      • Trauma
      • Brain tumors
      • Scalp swelling
      • Hematomas
      • Skin cancer of the scalp
      • Hydrocephalus
  • Close inspection of the scalp by moving the hair is pertinent to a good exam:
    • Start at an area and move the hair in small pieces to inspect the scalp.
    • Systemically go through the entire scalp.
    • Note: Skin cancers can be missed if the exam is not done properly!
Brachycephaly diagram

Variation in skull shape

Image by Lecturio. License: CC BY-NC-SA 4.0

Hair

  • Inspect the hair during the scalp inspection. 
  • Hair growth or lack of growth can indicate certain diseases or illnesses:
    • Alopecia
    • Fungal infection (ringworm)
    • Traumatic hair loss
    • Posterior hair loss in a baby not yet able to rollover

Eyes

Classically written as “pupils equal, round, and reactive to light and accommodation” for normal clinical exam documentation (PERRLA for shorthand)

General:

  • Inspect for:
    • Symmetry of the eyes and eyelids
    • Swelling of the eyes and eyelids
    • Redness of the eyes and eyelids
  • Visual acuity: Evaluate using the Snellen chart.
  • Visual fields: Evaluate using the confrontation test.

Sclera and conjunctiva:

  • Pale conjunctiva: sign of anemia
  • Scleral icterus: sign of jaundice
  • Blue sclerae: sign of anemia or osteogenesis imperfecta 
  • Injection or redness (list not exhaustive): 
    • Sign of glaucoma
    • Sign of possible drug use if bilateral
    • Sign of foreign body if unilateral

Pupils:

  • Note pupil size in millimeters:
    • Normal size is 2–5 mm and equal bilaterally.
    • A difference > 2 mm is considered abnormal (anisocoria).
  • Test the pupillary light reflex:
    • Shine a light into each pupil in a dim room to detect pupillary response (constriction).
    • When the light is shined into 1 eye:
      • Ipsilateral pupil constriction (direct response)
      • Contralateral pupil constriction (consensual response)
    • Note the speed the pupils constrict.
    • An abnormal pupillary light reflex is slow and can be described as sluggish or nonreactive.
    • Causes of abnormal pupillary light reflex: 
      • Optic nerve injury
      • Oculomotor nerve damage
      • Brain stem lesions
      • Drug effect (e.g., opiates, barbiturates)
  • Test for accommodation reflex:
    • The individual is asked to look at a distant object (often a spot on the wall in the room) and then asked to look at a close object (often the examiner’s finger held 6–12 inches in front of the individual). 
    • Watch the individual’s eyes: 
      • Pupils should constrict when moving from the distant object to the close object.
      • Pupils should dilate when moving from the close object to the distant object.
    • Defects in light reaction, but not accommodation, raise concern for syphilis (Argyll Robertson pupils (also known as “prostitute’s pupils”) accommodate but do not react).

Extraocular eye movements:

  • Classically written as “extraocular movements intact” for normal clinical exam documentation (EOMI for shorthand)
  • Instruct the individual to follow the examiner’s finger with the eyes.
  • Watch the individual’s eyes.
  • Move the finger in a “+” and an “H” pattern to test all cranial nerves and the 6 cardinal directions of gaze.
  • Move the finger to the middle and inward, causing the individual to cross the eyes and also test accommodation.
  • Note any deficits:
    • Cranial nerve (CN) palsies
    • Strabismus
    • Nystagmus

Fundoscopic exam: 

  • Performed with an ophthalmoscope:
    • Choose correct settings.
    • Dim the lights in the room.
    • Have the individual focus on a fixed object straight ahead.
    • Hold the ophthalmoscope in the RIGHT hand and use the RIGHT eye to look through the instrument at the individual’s RIGHT eye.
    • With the left hand, brace the individual’s head.
    • Bring the scope closer to the individual to look for the red reflex.
    • Move closer and toward the individual’s nose to look for the optic nerve.
    • Focus the ophthalmoscope.
    • Observe the cup-to-disc ratio.
    • Scan around to look at the vessels.
    • Observe the macula and fovea.
    • Repeat for the other eye.
  • Fundoscopic examination:
    • Normal findings: 
      • A pink optic disc free of hemorrhages or exudates
      • Well-demarcated blood vessels
      • Cup-to-disc ratio: < 0.5
    • Abnormal findings:
      • Hemorrhages/exudates on optic disc
      • Arteriovenous (AV) nicking/vascular abnormalities
      • Cup-to-disc ratio: > 0.5
      • Optic disc cupping: glaucoma
      • Papilledema: elevated intracranial pressure
      • Optic neuritis: infections, multiple sclerosis 

Eye muscle, cranial nerve innervation, and muscle movement:

Table: Eye muscle, cranial nerve innervation, and muscle movement
Eye muscleCranial nerve innervationMuscle movement
Superior rectusOculomotor (III)
  • Intorsion
  • Elevation
Inferior rectusOculomotor (III)
  • Abduction
  • Depression
Medial rectusOculomotor (III)Adduction
Inferior obliqueOculomotor (III)
  • Extorsion
  • Abduction
  • Elevation
Superior obliqueTrochlear (IV)
  • Intorsion
  • Abduction
  • Depression
Lateral rectusAbducens (VI)Abduction
Muscles Involved in Eye Movement

Cranial nerves III, IV, and VI: the innervated muscle and eye movement specific to each muscle
SR: superior rectus
IR: inferior rectus
MR: medial rectus
LR: lateral rectus
IO: inferior oblique
SO: superior oblique

Image by Lecturio. License: CC BY-NC-SA 4.0

Mnemonic

  • LR6 (lateral rectus by CN6)
  • SO4 (superior oblique by CN4)

Nose

  • Examine the external nose looking for signs of bleeding or discharge.
  • Using an otoscope, examine the nasal mucosa, septum, and turbinates looking for boggy or erythematous mucosa.
Nasal inspection

Nasal inspection

Image by Lecturio. License: CC BY-NC-SA 4.0

Mouth and throat

  • Ask individuals to remove dentures or partials.
  • Examine the lips for ulcerations or lesions.
  • Examine the tongue (top and bottom):
    • Check the color.
    • Examine papillae for hairy tongue.
    • Fissures or furrows are signs of dehydration or hypovolemia.
  • Check mucous membranes for lesions and for dryness or moisture.
  • Check the uvula is midline.
  • Inspect the tonsils, soft palate, and posterior pharynx.
  • Examine dentition looking for color and decay.
Pharyngeal inspection

Pharyngeal inspection

Image by Lecturio. License: CC BY-NC-SA 4.0

Ears

  • Inspect the external canal (note any discharge or abnormalities).
  • Perform an otoscope exam to evaluate the internal ear canal and tympanic membrane: 
    • Gently lift the outside of the ear.
    • Inspect for the presence of any abnormalities such as discharge, redness, cerumen, swelling, or foreign bodies.
    • Signs of normal tympanic membrane:
      • Pearly gray, shiny, translucent
      • No bulging or retraction
      • Smooth in consistency
      • Light reflex: Cone-shaped reflection of light from the otoscope is seen at 5 o’clock in the right ear and at 7 o’clock in the left ear.
    • Abnormal signs of tympanic membrane:
      • Absence of the light reflex
      • Visible redness/bulging (suggests otitis media)
      • Air-fluid level (suggests effusion of the middle ear)
  • Assess hearing:
    • Cranial nerve VIII
    • Rub the fingers together near the individual’s ear and ask the side the individual can hear the rubbing (test random sides and then both).
    • If abnormalities are found, perform the Rinne test and the Weber test.
    • Rinne test: 
      • Strike a tuning fork and place on the mastoid process to test bone conduction.
      • Strike a tuning fork and place near the ear canal to test air conduction.
      • Ask the individual to count in seconds until the sound disappears.
      • Normal: air conduction time > bone conduction time
      • Conductive hearing loss: air conduction time < bone conduction time
      • Sensory hearing loss: air conduction time > bone conduction time
    • Weber test:
      • Strike a tuning fork and place in the center of the forehead. 
      • Ask the individual if the sound is coming from the right or the left.
      • Normal: Sound is equal in both ears.
      • Unilateral conductive hearing loss: Vibration is louder in the affected ear.
      • Unilateral sensory hearing loss: Vibration is louder in the normal ear. 

Neck

  • Notice any obvious deformities, asymmetry, or masses.
  • Visible abnormalities:
    • Inspect for obvious trauma, skin lesions, or rashes.
    • The thyroid gland is not normally visible.
    • An enlarged thyroid gland (goiter) needs further evaluation.
    • Jugular venous distension:
      • Tension pneumothorax 
      • Possible right heart failure
      • Fluid-volume retention state
  • Assess the range of motion of the cervical spine by asking the individual to:
    • Look up as high as possible (normal: 70° of extension)
    • Touch chin to chest (normal: 80°–90° of flexion)
    • Turn head right/left as far as possible (normal: 90° of rotation)
    • Touch right/left ear to shoulder (normal: 20°–45° of lateral flexion)

Palpation

Skull and scalp

  • Note any tenderness or swelling.
  • Palpate to feel skull shape and deformity.
  • In individuals with trauma, note dimensions of:
    • Lacerations
    • Hematomas
    • Depressed skull fractures
  • Hair texture:
    • Brittle and coarse: hypothyroidism (also causes loss of the hair on the outer edges of the eyebrows)
    • Extra fine and soft: hyperthyroidism

Face

Palpate the sinuses:

  • Technique:
    • Gently tap the frontal and maxillary sinuses bilaterally.
    • Work systematically, top to bottom, comparing left with right.
  • Assess for:
    • Areas of tenderness (a sign of sinusitis)
    • Swelling
    • Subcutaneous emphysema
Palpation/percussion of the frontal sinuses

Palpation/percussion of the frontal sinuses

Image by Lecturio. License: CC BY-NC-SA 4.0

Ears

  • Palpate for tragal tenderness. 
  • Palpate preauricular and postauricular lymph nodes. 
  • Palpate the mastoid process and gently move the auricle up and down. 
  • Tenderness may indicate:
    • Otitis externa
    • Mastoiditis
Mastoiditis

Mastoiditis

Image by Lecturio. License: CC BY-NC-SA 4.0

Mouth and throat

  • Palpate under the tongue for:
    • Bogginess
    • Swelling
    • Tenderness
    • Lymphadenopathy
    • Hypertrophy of the salivary gland
  • Tap the tooth with a tongue depressor to check for dental tenderness.
Examination of the floor of the mouth

Examination of the floor of the mouth

Image by Lecturio. License: CC BY-NC-SA 4.0

Neck

Palpate tracheal position: 

  • Technique:
    • Use the pads of the fingers to gently feel the area of the thyroid.
    • Use both hands to feel both sides simultaneously and compare.
  • Assess for:
    • Tracheal deviation
    • Crepitus
    • Swelling/masses

Thyroid:

  • The normal thyroid is usually not palpable. 
  • Palpation is done with a posterior approach. 
  • Stand behind the individual and attempt to locate the thyroid isthmus by palpating below the thyroid cartilage.
  • Assess the size and consistency of the thyroid.
  • Ask the individual to swallow a sip of water as you palpate.
  • Feel for the upward movement of the thyroid gland.
Patient from South Sudan with a goiter

Goiter: Note the massive enlargement of the thyroid.

Image: “Iodine deficiency among goiter patients in rural South Sudan” by Chuot CC, Galukande M, Ibingira C, Kisa N, Fualal JO. License: CC BY 2.0

Lymph nodes of the head and neck:

Enlarged and/or tender lymph nodes (lymphadenopathy) may indicate:

  • Acute infectious process:
    • Streptococcal pharyngitis (anterior chain)
    • Otitis media (posterior chain)
    • Tuberculosis
    • Infectious mononucleosis
    • Human immunodeficiency virus (HIV) 
  • Malignancy: Specific lymph groups drain specific regions.
Head and Neck lymp nodes

Head and neck lymph nodes

Image by Lecturio. License: CC BY-NC-SA 4.0
Table: Malignancy
Level and nodal groupsCancer sites of lymphatic spread
Submental and submandibular nodes
  • Lip, anterior tongue, floor of mouth
  • Gingiva, buccal mucosa
Upper jugulodigastric group
  • Oral cavity
  • Pharynx
  • Larynx
Middle jugular nodes
  • Nasopharynx, oropharynx
  • Oral cavity
  • Larynx
Inferior jugular nodes
  • Hypopharynx
  • Subglottic larynx
  • Esophagus
Posterior triangle groupBack of skull
Anterior compartment group
  • Throat, tonsils, thyroid
  • Posterior pharynx

Auscultation

  • Auscultation is done with the diaphragm or bell of a stethoscope on unclothed skin.
  • Auscultate the carotid arteries with the bell of the stethoscope listening for a bruit (swooshing sound):
    • Carotid bruits indicate the presence of significant carotid artery stenosis.
    • A bruit results from turbulent, nonlaminar flow through a stenotic lesion.

Special Exams and Red Flags

Special exams

Table: Special exams
Cranial nerveExamination
CN I: olfactory nerve
  • Test the olfaction of the individual using nonirritating substances and familiar scents.
  • Common to use an alcohol swab
CN II: optic nerve
  • Visual acuity: Evaluate using the Snellen chart.
  • Visual fields: Evaluate using the confrontation test.
  • Pupillary light reflex: Shine a light in the individual’s eye to test bilateral pupillary constriction.
  • Fundoscopic examination
CN III, IV, VI: oculomotor nerve, trochlear nerve, and abducens nerve
  • Responsible for eye movement and accommodation
  • Eye movement: tested by asking the individual to follow the examiner’s finger
  • Accommodation:
    • Ask the individual to look at an object from distant to near, and then back to distant.
    • Normal response is constriction of the pupil when looking from distant-to-near objects and dilation of the pupil when looking from near-to-distant objects.
CN V: trigeminal nerve
  • Responsible for facial sensation: tested by lightly touching the different facial areas (forehead (V1), cheek (V2), jaw (V3)) and comparing both sides
  • Innervates the anterior ⅔ of the tongue with general sensations (e.g., pain and temperature)
  • Innervates the muscles of mastication: testing strength and symmetry by asking the individual to clench the jaw
  • Reflexes:
    • Masseter reflex:
      • With a reflex hammer, tap on the individual’s chin while the individual’s mouth remains slightly open.
      • Normal finding is jaw closure.
    • Corneal reflex:
      • Lightly touch the cornea with a cotton swab.
      • Normal finding is closing of the eyelid (blinking).
  • In trigeminal nerve injuries, the jaw deviates towards the affected side.
CN VII: facial nerve
  • Innervates facial expression muscles
  • Tested by asking the individual to perform certain movements (e.g., forehead wrinkling, closing the eyes tightly, inflating the cheeks, smiling, and whistling)
  • Innervates the anterior ⅔ of the tongue with special sensation (sweet, salty, and sour)
CN VIII: vestibulocochlear nerve
  • Tested by rubbing the fingers together near the ear
  • Weber and Rinne test (differentiates sensory or conductive hearing loss)
CN IX, X: glossopharyngeal nerve and vagus nerve
  • Tested by evaluating the uvula:
    • Normally: centrally located
    • Abnormally: deviates towards the normal side
  • Responsible for the gag reflex: tested by lightly touching the uvula with a tongue depressor
  • CN IX innervates the posterior ⅓ of the tongue with general and special sensation.
  • Hoarseness or impaired cough reflex indicates damage to CN X.
CN XI: accessory nerve
  • Innervates the trapezius muscle: Ask the individual to elevate the shoulders against resistance.
  • Innervates the sternocleidomastoid muscle: Ask the individual to rotate the head against resistance.
CN XII: hypoglossal nerve
  • Innervates the tongue muscles: tested by asking the individual to press against the cheek from the inside, while the examiner evaluates the strength from the outside
  • In CN XII injury, the tongue deviates toward the site of injury.

Red flags

Table: Important red flags found during head and neck examination
RegionFindingsPossible cause
Face
  • Facial asymmetry
  • Loss of facial sensation
  • Cranial nerve palsies
  • Stroke
Neck
  • Nuchal rigidity
  • ↓ Range of motion
  • Meningitis
  • Cervical spine injury
Eyes
  • Ptosis, myosis, anhidrosis: Horner syndrome
  • Xanthelasma: primary biliary cholangitis
  • Exophthalmos: Graves disease
Mouth
  • Strawberry tongue: scarlet fever, Kawasaki disease
  • Angular cheilitis: iron deficiency anemia

Clinical Relevance

  • Seborrheic dermatitis: a common, chronic, relapsing skin disorder presenting as erythematous plaques with greasy, yellow scales in susceptible areas (e.g., scalp, face, trunk). Management includes antifungal agents, steroids, calcineurin inhibitors, and keratolytic agents. 
  • Sinusitis: an acute inflammation of the mucosa of the paranasal sinuses or nasal passages with a duration < 4 weeks. The inflammatory condition can be caused by viral infections, bacteria, or fungi. Noninfectious etiologies of acute sinusitis can be allergens or irritants. Diagnosis is usually clinical. Management is supportive but might require antibiotics.
  • Otitis externa: an infection of the external auditory canal most often caused by an acute bacterial infection. Otitis externa is frequently associated with hot, humid weather and water exposure. Patients commonly present with ear pain, pruritus, discharge, and hearing loss. The diagnosis is clinical. Most types of otitis externa are treated with topical antibiotic therapy. 
  • Otitis media: an infection in the middle ear characterized by mucosal inflammation and fluid retention. The most common pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Otitis media can present with fever, otalgia, and diminished hearing. Diagnosis is made by history and otoscopic exam, which shows a bulging tympanic membrane with reduced mobility. Management includes observation or antibiotics.
  • Infectious mononucleosis: a highly contagious viral infection caused by the Epstein-Barr virus. The main method of transmission is the spread of infected saliva. Clinical manifestations of the condition include fever, tonsillar pharyngitis, and lymphadenopathy. Diagnosis is clinical and confirmed by antibody testing. No specific antiviral therapy is currently available.

References

  1. Bickley, L. (2012). Bates’ Guide to Physical Examination and History-Taking. Philadelphia, PA: Lippincott Williams & Wilkins.
  2. Walker, H.K., et al. (1990). Clinical Methods: The History, Physical, and Laboratory Examinations. Boston: Butterworths. https://pubmed.ncbi.nlm.nih.gov/21250045/
  3. Lewis, M.L. (2014). A comprehensive newborn exam: part I. General, head and neck, cardiopulmonary. Am Fam Physician. 90(5), 289–96. https://pubmed.ncbi.nlm.nih.gov/25251088/

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