• Clinical science

Head and neck examination

Abstract

Examination of the head and neck is a fundamental part of the standard physical examination. It is typically one of the first parts of the physical examination and is performed with the patient in a seated position. Because the complete head and neck examination is lengthy, it is usually tailored to the patient's history and presenting complaint. In adult patients, the parts of the examination dealing with the ears and nose are generally not required unless there is a pertinent complaint.

Examination of the head

  • Inspect the skull and face.
  • Inspect the skin and scalp.
  • Palpate skull (especially if patient complains of tenderness or recent trauma).
  • Assess facial sensation and motor function.
    • Trigeminal nerve function: Lightly touch the forehead of the patient on both sides and the upper and lower areas of the cheek with the index finger. Ask the patient whether this feels the same on both sides of the face.
    • Facial nerve function: Ask the patient to furrow their forehead, close their eyes, show their teeth, and inflate their cheeks.
    • See examination of cranial nerves and cranial nerve palsies.

[1][2]

Examination of the ears

  • Inspect the external ear and note any skin abnormalities or discharge.
  • For patients complaining of ear pain or discharge, gently move the auricle up and down, and apply pressure to the tragus and the mastoid process.

Otoscopy

  • The tympanic membrane is divided into four quadrants:
    • Anterior superior (I)
    • Anterior inferior (II) → location of the triangular light reflex
    • Posterior superior (III)
    • Posterior inferior (IV)
  • Structures that are also observed in otoscopy:
  • Procedure
    • Place the largest speculum that comfortably fits in the patient's ear on the head of the otoscope and turn on the light source.
    • Angle the otoscope handle either directly downward or towards the patient's forehead.
    • Stabilize your otoscope hand by placing the fourth and fifth digits on the patient's head.
    • With your free hand, pull the ear up and in a posterior direction to straighten the canal as you insert the otoscope at a slightly downward angle.
  • Interpretation:
  • A pneumatic bulb allows for assessment of tympanic membrane mobility.

Otoscopy is an integral part of all pediatric examinations. It is usually only performed in adults if they have mentioned ear discomfort.

Auditory acuity

Screening assessments

  • Whispered voice test: While standing behind the patient, whisper a phrase or numbers in each ear → Ask the patient to repeat what you whispered.
  • Finger rub test: Place your fingers several centimeters from either ear → Rub your fingertips together and ask the patient if they heard it.
  • Interpretation: If any asymmetry is detected, or the patient complains of impaired hearing, further evaluation is indicated → See hearing loss.

Tuning fork tests

  • Weber test: tests for lateralization (sound is heard louder in one ear than the other)
    • Place the base of a vibrating tuning fork on the middle of the forehead → Ask the patient from which ear the sound is loudest.
    • Interpretation
  • Rinne test: tests for air conduction and bone conduction
    • Place the base of a vibrating tuning fork on the mastoid process of the ear → Once the patient no longer hears a tone, immediately hold the “U” part of the fork over the outer ear and ask the patient if they can still hear it.
    • Interpretation: Air conduction is greater than bone conduction, so the patient should still be able to hear the tuning fork.

Overview of possible findings

Rinne left Rinne right Weber Possible finding
Positive Positive Normal Normal hearing or bilateral sensorineural hearing loss
Positive Positive Lateralization to the left Sensorineural hearing loss in the right ear
Positive Positive Lateralization to the right Sensorineural hearing loss in the left ear
Negative Positive Lateralization to the left Conductive hearing loss in the left ear
Positive Negative Lateralization to the right Conductive hearing loss in the right ear
Negative Positive Lateralization to the right Combination hearing loss in the left ear
Deafness in the left ear
Negative Negative Normal Bilateral, symmetrical conductive hearing loss

Gelle test

  • Short description: to evaluate the mobility of the ossicles, e.g., in the diagnosis of otosclerosis.
  • Procedure: The vibrating tuning fork is placed against the forehead and the auditory canal is sealed using a pneumatic speculum, which creates positive pressure in the external auditory canal.
    • Gelle positive: Positive pressure disturbs both bone and air conduction. The sound of the tuning fork is perceived by the patient to be considerably weaker with the pneumatic speculum applied than without the pneumatic speculum. → Hearing is normal in the middle ear or there might be a problem in the middle ear that restricts the mobility of the ossicles.
    • Gelle negative: Despite positive pressure, there is no change in hearing in the patient. → evidence of otosclerosis

Additional tests

  • Audiogram, speech audiometry, impedance audiometry
  • See hearing loss.

When screening for hearing loss, examine each ear individually (ask the patient to cover the other ear) in a quiet room.

[1][2]

Focused examination of the eyes

Inspection and palpation

  • Inspect for symmetry of the eyes and eyelids.
  • Note any swelling or redness around the eyelids, and assess whether the eyelids can fully close.
  • Inspection of the sclera and conjunctiva: Ask the patient to look up while you hold lower lids with your thumb.
    • Inspect for color, vascular pattern, and whether there is any swelling.

Pupils

  • Pupil size
    • The pupils are generally between 3–5 mm.
    • Note whether there is a difference in size between the two pupils (anisocoria).
  • Indirect and direct pupillary light reflex
    • Note whether both the illuminated and non-illuminated pupils constrict after light exposure.

Visual acuity

  • Procedure
    • The patient from a predetermined distance from a Snellen chart, covers one eye and reads rows of letters out loud.
    • Each row corresponds to a specific level of visual acuity.
    • The patient's visual acuity is determined by the smallest row for which the patient can correctly read more than half the letters.
  • Interpretation
    • Visual acuity is expressed with two numbers.
    • Normal visual acuity is 20/20.

Confrontation visual field testing

  • Procedure
    • Sit directly opposite the patient and ask the patient to cover one eye with their hand while you cover your own contralateral eye (i.e., you left eye if the patient covers their right eye).
    • Look at the nose of the patient and ask him/her to do the same.
    • Move your finger inwards from outside the edges of your visual field, ensuring that the finger is located at the same distance from the patient and yourself.
    • Ask the patient to notify you when he/she can see your finger.
  • Interpretation
    • If the finger is simultaneously seen by you and the patient, the visual field is intact/unremarkable.

Extraocular movements

  • Procedure
    • Ask the patient to follow the tip of a pen (or a similar object) with their eyes.
    • Test all directions: The patient should look upwards/below/to the left/to the right/diagonally.
  • Interpretation
  • Test the convergence reaction by asking the patient to follow the pen as you move it towards the bridge of their nose.
    • The eyes should converge while following the object to within 5–8 cm.

Fundoscopic examination and other special tests

  • The fundoscopic examination is typically only performed in certain situations (e.g., suspected intracranial hypertension or stroke).

[1][2]

Examination of the neck

Inspection and palpation

Examination of the thyroid

  • Inspection
  • Palpation
    • Stand behind the patient.
    • Place your finger pads below the thyroid cartilage and assesses the size and consistency of the thyroid.
    • Ask the patient to swallow.
      • The thyroid should slide beneath the fingers.
      • The normal thyroid is usually not palpable.
    • Note any asymmetry or enlargement.

[1][2]

Examination of the nose and throat

Nose

  • Examine the external nose and test the patient's ability to breathe through either nostril by covering one at a time.
  • Examine the nasal mucosa, septum, and turbinates using an otoscope.
    • Use the largest available speculum that will comfortably fit inside the nostril.
    • Direct the speculum posteriorly and superiorly as you inspect the nasal cavity.
  • Palpate for tenderness over the maxillary and frontal sinuses.
  • Inspect the lips.
  • Inspect the oral mucosa.
  • Inspect the gums for redness or ulceration

Throat

  • Inspect the tonsils
  • Inspect the soft palate
  • Inspect the posterior pharynx by having the patient stick out their tongue.
  • Inspect the tongue.
  • Assess tongue motility: See cranial nerve palsies.

[1][2]

Signs and Differential Diagnosis

Red flag symptoms of the head and neck

Location Clinical Features Possible diagnoses
Head
Face
Eyes
  • Ptosis
  • Incomplete lid closure
  • Conjunctival injection
  • Conjunctival pallor
  • Arterial dissection
  • Tumor
Mouth
  • Angular cheilitis
  • Tongue coating
Ear
  • Hearing impairment
Lymph nodes
Neck

[1][2]

  • 1. Bickley L. Bates' Guide to Physical Examination and History-Taking. Lippincott Williams & Wilkins; 2012.
  • 2. Goldberg C. A Practical Guide to Clinical Medicine. https://meded.ucsd.edu/clinicalmed/. Updated September 1, 2004. Accessed January 10, 2018.
last updated 07/08/2018
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