Head and neck examination

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 examination of cranial nerves and cranial nerve palsies.

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• 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

• 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
  • Inspect for the presence of discharge, redness, cerumen, swelling, and foreign bodies.
  • The tympanic membrane normally reflects the otoscope's light, which is known as the light reflex (or “cone of light”).
  • See otitis externa, otitis media, and tympanosclerosis for additional findings.
• 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

• Performed in order to distinguish between conductive hearing loss and sensorineural hearing loss. See also hearing loss.
• 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 and ask the patient from which ear the sound is louder.
  • The sound is normally heard equally in both ears.
  • Interpretation
    • Lateralization → asymmetric hearing loss
    • No lateralization → normal hearing or bilateral hearing loss
• 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.
  • Interpretation
    • 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 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

Additional tests

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

When screening for hearing loss, examine each ear individually in a quiet room.

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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.

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 (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.
• 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 (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.
• 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
  • This part of the examination assesses the cranial nerves involved in ocular motility.
  • See cranial nerve palsies.
  • Note the presence of nystagmus or lid lag (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).

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Inspection and palpation

• Inspect for any obvious deformities, asymmetry, masses, tracheal deviation.
• Palpation of the lymph nodes of the head and neck
• 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 meningism.
• 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 cranial nerve palsies.
• Evaluate for jugular venous distention.

Examination of the thyroid

• Inspection
  • The thyroid gland is located below the thyroid cartilage and is normally not visible.
  • Enlargement should prompt further evaluation.
• 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.

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Red flag symptoms of the head and neck

Location	Clinical features	Possible diagnoses
Head	Nuchal rigidity/reduced range of motion	Meningism
Face	Loss of cranial nerve function	Cranial nerve palsies Ischemic stroke
Eyes	Ptosis Incomplete lid closure	Cranial nerve palsies Ischemic stroke
	Xanthelasma	Hyperlipidemia
	Exophthalmos	Graves disease
	Yellow sclera	Jaundice
	Conjunctival injection	Conjunctivitis
	Conjunctival pallor	Anemia
	Horner syndrome	Arterial dissection Tumor
Mouth	Angular cheilitis	Iron deficiency
	Tonsillar erythema	Acute tonsillitis
	Strawberry tongue (also called raspberry tongue)	Scarlet fever
	Vesicles, blisters	Herpes virus infection
	Tongue coating	Leukoplakia Oral candidiasis
Ear	Hearing impairment	Hearing loss
	Pain, exudate	Ear infection
Lymph nodes	Enlarged lymph nodes	Various. (See enlarged lymph nodes)
Neck	Jugular venous distention	Volume overload Heart failure
	Thyroid gland enlargement	Goiter Thyroid cancer

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