The head and neck examination is often annotated as HEENT (head, eyes, ears, nose and throat) in clinical documentation shorthand.
- Tongue depressor
- 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.
- Ensure good lighting, privacy, and hygiene.
- Drape individual with a sterile gown, towel, or sheet.
- 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.
The 1st part of the head and neck exam begins with inspection of the individual. Note pertinent positive and negative findings.
- Pertinent positives:
- Well or no acute distress
- Comfortable, normal affect
- Pertinent negatives:
- In distress (mild, moderate, or severe)
- 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:
- Signs of trauma
- Skull shapes:
- Skull shape varies by:
- Malformation causes:
- Congenital disorders
- Brain tumors
- Scalp swelling
- Skin cancer of the scalp
- Skull shape varies by:
- 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!
- Inspect the hair during the scalp inspection.
- Hair growth or lack of growth can indicate certain diseases or illnesses:
- Fungal infection (ringworm)
- Traumatic hair loss
- Posterior hair loss in a baby not yet able to rollover
Classically written as “pupils equal, round, and reactive to light and accommodation” for normal clinical exam documentation (PERRLA for shorthand)
- 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
- 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
- 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
- Normal findings:
Eye muscle, cranial nerve innervation, and muscle movement:
|Eye muscle||Cranial nerve innervation||Muscle movement|
|Superior rectus||Oculomotor (III)|
|Inferior rectus||Oculomotor (III)|
|Medial rectus||Oculomotor (III)||Adduction|
|Inferior oblique||Oculomotor (III)|
|Superior oblique||Trochlear (IV)|
|Lateral rectus||Abducens (VI)||Abduction|
- LR6 (lateral rectus by CN6)
- SO4 (superior oblique by CN4)
- 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.
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.
- 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.
- 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)
Skull and scalp
- Note any tenderness or swelling.
- Palpate to feel skull shape and deformity.
- In individuals with trauma, note dimensions of:
- 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
Palpate the sinuses:
- 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)
- Subcutaneous emphysema
- 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
Mouth and throat
- Palpate under the tongue for:
- Hypertrophy of the salivary gland
- Tap the tooth with a tongue depressor to check for dental tenderness.
Palpate tracheal position:
- 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
- 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.
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)
- Infectious mononucleosis
- Human immunodeficiency virus (HIV)
- Malignancy: Specific lymph groups drain specific regions.
|Level and nodal groups||Cancer sites of lymphatic spread|
|Submental and submandibular nodes|
|Upper jugulodigastric group|
|Middle jugular nodes|
|Inferior jugular nodes|
|Posterior triangle group||Back of skull|
|Anterior compartment group|
- 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
|CN I: olfactory nerve|
|CN II: optic nerve|
|CN III, IV, VI: oculomotor nerve, trochlear nerve, and abducens nerve|
|CN V: trigeminal nerve|
|CN VII: facial nerve|
|CN VIII: vestibulocochlear nerve|
|CN IX, X: glossopharyngeal nerve and vagus nerve|
|CN XI: accessory nerve|
|CN XII: hypoglossal nerve|
- 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.
- Bickley, L. (2012). Bates’ Guide to Physical Examination and History-Taking. Philadelphia, PA: Lippincott Williams & Wilkins.
- Walker, H.K., et al. (1990). Clinical Methods: The History, Physical, and Laboratory Examinations. Boston: Butterworths. https://pubmed.ncbi.nlm.nih.gov/21250045/
- 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/