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.
- 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 and .
- 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.
- 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.
- 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.
- 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 .
Tuning fork tests
- Performed in order to distinguish between and . See also
- Weber test: tests for lateralization (sound is heard louder in one ear than the other)
Rinne test: tests for air conduction vs bone conduction in the examined ear
- 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.
- Air conduction is normally greater than bone conduction, so the patient should still be able to hear the tuning fork next to the outer ear after they can no longer hear it when placed on the mastoid process.
- Unable to hear the tuning fork; → There is conductive hearing loss (bone conduction > air conduction) in the examined ear (Rinne test is negative)
- Still able to hear tuning fork over the outer ear; → There is no conductive hearing loss (Rinne test is positive); possible sensorineural hearing loss (air conduction > bone conduction) if there is diminished hearing in the examined ear
Overview of possible findings
|Rinne left||Rinne right||Weber||Possible finding|
|Positive||Positive||Normal||Normal hearing or bilateral|
|Positive||Positive||Lateralization to the left||in the right ear|
|Positive||Positive||Lateralization to the right||in the left ear|
|Negative||Positive||Lateralization to the left||in the left ear|
|Positive||Negative||Lateralization to the right||in the right ear|
|Negative||Positive||Lateralization to the right||Combination hearing loss in the left ear|
|Deafness in the left ear|
When screening for hearing loss, examine each ear individually in a quiet room.
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 (normal sclerae are white) 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.
- Pupil size
Indirect and direct
- Note whether both the illuminated and non-illuminated pupils constrict after light exposure.
- The patient from a predetermined distance from a Snellen chart (a chart used to evaluate visual acuity), 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.
Confrontation visual field testing
- 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 (the area in which objects can be seen while focusing the eyes on a central point), 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.
- If the finger is simultaneously seen by you and the patient, the visual field is intact/unremarkable.
- 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.
- This part of the examination assesses the cranial nerves involved in ocular motility.
- See .
- Note the presence of lid lag or (caused by spasm of the smooth muscle portion of the levator palpebrae superioris due to sympathetic overactivity; present if the sclera can be seen above the iris as the patient looks down)
- 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).
Inspection and palpation
- Inspect for any obvious deformities, asymmetry, masses, .
- Palpation of the parotid gland
- Assessment of range of motion of the cervical spine
- Ask the patient to tilt their chin so that it is resting against their chest or to flex their neck.
- See .
- Assessment of spinal accessory nerve function
- Ask the patient to move their head to the left and right, and to lift their shoulders against resistance.
- See .
- Evaluate for .
Examination of the thyroid
- 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
- 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 .
Signs and differential diagnosis
Red flag symptoms of the head and neck
|Location||Clinical features||Possible diagnoses|
|Head|| || |
|Face|| || |
|Eyes|| || |
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|Mouth|| || |
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|Ear|| || |
|Lymph nodes|| |
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