Slide 1: E. Solis MD, MPH
HEENT
Slide 2: Learning Objectives
The student will be able to identify different components of the head, eyes, ears, nose, and throat The student will be able to identify anatomic landmarks of the head, eyes, ears, nose and throat
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The student will be able to identify and perform the proper techniques for a basic exam of the head, eyes, ear, nose and throat The student will be able to describe and record findings of the head, eyes, ears, nose and throat examination
Slide 4: Learning Objectives
The student will be able to identify different disorders of the head, eyes, ears, nose, and throat The student will be able to identify the signs and symptoms of HEENT disorders
Slide 5: Objective 1: Components of the HEENT Exam
HEAD inspection: skull- size ,shape, symmetry, deformity scalp- redness, scaling hair- quantity, distribution ,nits, lice face – symmetry, involuntary movements, skin lesions, color, shape
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Palpation: skull ( including temporal artery)- size contour, lumps, deformities, tenderness scalp- mobility, lesions hair – texture Temporomandibular joint – pain, decreased ROM
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Neck Lymph nodes- enlargement,mobility Trachea – deviation Thyroid gland- size, tenderness, mobility
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EYES Inspection: eyebrows- hair loss, scaling eyelids – redness, swelling, lesions
Slide 9: Conjunctiva – paleness, inflammation Sclera – icterus, inflammation Cornea (anterior chamber) – opacities Lens- opacities Pupils – size ,shape, equality, reaction
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Tests: -pupillary reactions direct and consensual -accommodation -Extraocular movement
Slide 11: Funduscopic Examination - red orange reflex - optic disc - blood vessels - Hemorrhages, exudates
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Visual acuity Near Vision Far Vision Peripheral vision
Slide 13: EARS Inspection: Auricle (anterior & posterior)deformities, lumps, lesions, position Palpation: Pulls on pinna – tenderness
Slide 14: Otoscope exam external canal- cerumen, discharge, foreign bodies, swelling Tympanic membrane- color, landmarks, bulging ,retraction, perforation light reflex
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Tests Auditory acuity – decreased hearing Weber test- lateralization Rinne test- AC vs BC
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Nose and sinuses Inspection: External nares – asymmetry, deformity Internal nares with otoscope – swelling, turbinates, septal deviation, perforation, discharge, blood crusting, ulcers, polyps
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Sinuses Palpation: Frontal – tenderness Maxillary- tenderness
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Mouth and pharynx (throat) Inspection: Lips- color, moisture, lumps, ulcers, cracking Buccal mucosa- color, moisture, lesions Teeth – loose, missing, dental caries Gums- inflammation, swelling, bleeding, discoloration
Slide 19: Tongue (dorsal, ventral, sides, floor) - asymmetry, lesions, salivary ducts Palate- lumps, lesions Tonsils – presence, size, color, pus symmetry Pharynx – inflammation, exudates Uvula- inflammation, deviation
Slide 20: Objective 2: Anatomic Landmark
To be able to identify common structures in this region which are routinely assessed during physical exam
Slide 21: HEAD
Describe anatomy and landmarks of the head
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The SKULL
Slide 25: Temporomandibular Joint
Slide 29: Objective 3: Physical Exam
To be able to identify and perform proper techniques for the basic examination of the head, neck, eyes, ears, nose and throat
Slide 30: Procedure
HEAD Stand beside or behind the seated patient
Observe head position midline, tilted to one side, rotated
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Skull Scalp Hair
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Inspect the skull for: - size – normocephalic, micro/macrocephalic - shape - deformity Palpate the skull for: - symmetry - mass-if present give the exact location, size , shape ,mobility and tenderness -deformity -tenderness- if present localize
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The SCALP
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Inspect the scalp for: - scales - scars - parasites, nits - mass - pay special attention to the areas behind the ears, at the hairline and at the crown of the head. Note for any hair loss pattern
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Palpate the scalp for: - tenderness -mass ( sebaceous cyst, lipoma, tumor) - or fluctuant scalp masses like hematoma, abscess, depressed fracture - scalp movement
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Hair : inspect and palpate - color - length - distribution- well distributed - pattern of hair loss- receding hair line - quantity –thin, thick or fairly abundant - texture- fine or coarse - moisture – dry or oily - look for lice and nits
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Palpation of Temporomandibular joint
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Locate the TMJ with your fingertips placed just anterior to the tragus of each ear. Allow your fingertips to slip into the joint space as the patient’s mouth open and gently palpate the joint space
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An audible or palpable snapping or clicking in the TMJ is not unusual, but pain, crepitus, locking or popping may indicate TMJ syndrome
Slide 43: Objective 4: Record Findings
To be able the describe and record findings of the head, neck, eyes, ears and throat
Slide 44: Record the Findings
Normocephalic, head held erect and in the midline, thick hair, well-distributed, no focal areas of hair loss, coarse and dry, scalp moves freely under examining fingers, no mass or tenderness, temporal arteries palpable but not thickened
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Describe anatomy and landmark of the FACE
Slide 47: Procedure
FACE Stand or sit in front of the patient at the same level Inspect the face for: - skin : color, pigmentation and lesions - shape – oval, round, prominent and protruding chin - facial expression and involuntary movements - edema - symmetry – if asymmetric present describe eg..shallow nasolabial fold.
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Palpate the temporal arteries, noting the ff: - thickening - hardness - tenderness Auscultate temporal arteries for bruits
Slide 51: Record findings
Face is oval in shape, symmetrical, fair skinned, with occasional pigmented papules scattered over the face, no masses, nor involuntary movements, temporal artery not visible but palpable with strong pulsation, walls not thickened
Slide 52: NECK
Describe the anatomy and landmarks of the NECK
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Thyroid Gland Trachea Lymph Nodes Carotid pulsations
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Slide 60: Procedure
Inspect the neck for : - symmetry - size ( long or short) - deformity - masses, webbing - alignment of trachea - jugular vein distention - carotid artery prominence
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Evaluate range of motion of the neck - flex, extend ,rotate and lateral turn of the head and neck - movement should be smooth ,painless and should not cause dizziness
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Palpate the neck for: - tracheal position - carotid pulsations - lymph nodes - thyroid gland
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The LYMPH NODES group
Slide 66: Procedure
LYMPH NODES The examiner should stand behind the seated patient Use the pads of both index and middle fingers as you move the skin over the underlying tissues in each area rather than moving your fingers over the skin in a rotatory fashion
Slide 67: 1. 2. 3. 4. 5.
Feel in sequence for the following nodes Preauricular –in front of the ear Posterior auricular – superficial to the mastoid process Occipital – at the base of the skull Tonsillar – at the angle of the mandible Submandibular – midway between the angle and the tip of the mandible
Slide 68: 6. Submental – in the midline 7. Superficial cervical – superficial to the SCM 8. Posterior cervical chain –along the anterior edge of the trapezius 9. Deep cervical chain –deep into the SCM but often inaccessible to examination 10. Supraclavicular –deep in the angle formed by the clavicle and the SCM
Slide 69: Palpate the lymph nodes for: - size - shape - delimitation ( discrete or matted together) - mobility - consistency - tenderness Small, mobile, discrete, nontender nodes are frequently found in normal persons
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Carotid pulsation
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Locate for the carotid pulse, in the neck just medial to and below the angle of the jaw ( do not palpate simultaneously) Excessive carotid massage can cause slowing of the pulse or a drop in blood pressure
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If you have difficulty feeling the pulse, rotate the patient’s head to the side being examined to relax the SCM muscle Examine the arterial pulse with the distal part of the 2nd and 3rd fingers
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The TRACHEA
Slide 79: Procedure
Inspect the trachea for any deviation from its usual midline position Then feel for any deviation by placing your finger along one side of the trachea and note the space between it and the SCM.
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Compare it with the other side. The spaces should be symmetrical. If asymmetrical there is deviation
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Describe the anatomy and landmarks of the THYROID GLAND
Slide 85: Procedure
THYROID GLAND Patient should be seated Inspect the lower half of the neck in the anterior triangles Have him swallow or sip a glass of water to note any ascending mass in the midline or behind the SCM
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If the patient is obese or has a short neck , tilt the head back to be supported by his hands clasped at the occiput. Ask him to swallow while in this posture The thyroid gland, thyroid cartilage, and cricoid cartilage all normally rise as the person swallows
Slide 87: Palpation -best done from behind the patient - cricoid cartilage is the basic landmark for examination 2 methods of palpation: a) Palpation from behind b) Frontal palpation of the thyroid gland
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Palpate the thyroid gland for : - size - shape - symmetry - consistency of the gland, tenderness - presence of nodules - movement
Slide 92: Record findings
NECK Neck is supple with full range of motion, trachea midline, no lymphadenopathy noted. A 1x2 cm nodule is palpated in the right lobe of the thyroid; smooth, soft, nontender, moves freely when patient swallows
Slide 93: Objective 5:Record abnormal Findings
To be able to identify and record different disorders of head ,neck, eyes, ears, nose and throat
Slide 94: Facies
Expression or appearance of the face and features of the head and neck that when considered together, are characteristics of a clinical condition or syndrome
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Acromegaly -large head - forward projection of jaw - protrusion of frontal bone
Slide 96: Cushing Syndrome
- thin erythematous skin - hirsutism - rounded or moon shaped face
Slide 97: Mxyedema
- dull, puffy, yellowed skin - coarse sparse hair - temporal loss of eyebrows - periorbital edema - prominent tongue
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Hyperthyroid Facies - fine moist skin - fine hair - prominent eyes - lid retraction - startled expression
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(R) Facial Palsy - assymmetry of one side of the face - eyelid not closing completely - loss of nasolabial fold - drooping lower eyelid and corner of the mouth
Slide 100: SIGNS
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Hydrocephalus
Scars
Head tumor
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Alopecia areata
Slide 108: SYMPTOMS
HEADACHE
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HEADACHE - refers to pain perceived more than momentarily in the cranial vault , orbits and the nape. Pain elsewhere in the face is not included
Slide 110: Mechanisms of Headache 1. infection – meningitis, encephalitis 2. arterial dilatation – Malignant Hypertension 3. hemorrhage – intracebral , subdural and SAH 4.Expanding mass lesion – brain tumor
Slide 111: 5. Trauma – head trauma , inc. ICP 6. Tissue Ischemia – hypoxia, hypoglycemia
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Muscle contraction headache
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Muscle Contraction Headache: Tension Headache - Mild or moderate discomfort, a heavy feeling, a sense of pressure, tight band, steady rather than throbbing - related to emotional tension - not intensified by coughing - improved by shaking the head, massage, mild analgesics, application of hot packs
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Migraine Headache
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Classic Migraine 4 phases 1. Prodrome- an attack is often triggered by period of anxiety, tension, bright light, loud noise, skipped meals, foods and beverages, strong odors and change in sleep patterns
Slide 116: 2. Aura – visual disturbances 3. Headache - frequently present on awakening -severe throbbing, boring, aching headache over 1 hr. - does not disrupt sleep - increased in the reclining position, shaking the head, coughing or straining at stool
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Associated symptoms are N/V, photophobia, annoyance for odors, maybe normal or cold limbs and pale skin
4. Recovery
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Cluster Headache
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Cluster headache : Histamine headache or Histamine Cephalgia - due to dilatation of branches of the internal carotid artery - 5-6x more common in men - onset is typically 3rd- 4th decade of life - commonly episodic and begins w/o aura
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Unilateral , severe ,boring,, and throbbing headache that recurs consistently on the same side lasting an average of 40 min Associated symptoms are flushing, rhinorrhea, conjunctivitis, lacrimation, temporal artery dilatation on the affected side, sweating of the skin
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Slide 121: Other causes of headache: Hypertensive headache Brain tumor Hemorrhage -intracereberal hemorrhage -subarachnoid hemorrhage Bacterial meningitis Lumbar puncture headache
Slide 122: Hypertensive headache - due to segmental dilatation of branches of external carotid artery - headache occurs in half of patients with accelerated HPN without encepalopathy - Headache often occipital, no aura - Diastolic pressure must exceed 120 mm hg to cause headache
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Brain tumor Benign and malignant intracranial neoplasms compress and place traction on surrounding structures Headache maybe the first symptom, the onset is recent, a recent change in the customary headache pattern has occured
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An apparent migraine aura persists after the headache subsides Headache starts by abrupt change in position, exertion and inc. in recumbent position May interfere with sleep
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Subarachnoid hemorrhage Results fr. rupture of a saccular anuerysm of the circle of willis, preceeded often by a leakage Excruciating generalized headache, followed by nuchal rigidity, then coma, often death
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Meningitis Headache , fever and signs of meningeal irritation ( nuchal rigidity) Headache intensified by sudden movement of the head
Slide 127: NECK
Stiff neck: 1) Torticollis ( wryneck) - the congenital type is due to hematoma or partial rupture of the muscle at birth resulting in unilateral muscle shortening
Slide 128: 2) Idiopathic – fibromyalgia 3) inflammatory/immune – osteomyelitis 4) Infectious – pharyngitis, meningitis 5) Metabolic - Tetanus
Slide 129: 6) Mechanical /trauma- fracture, dislocation 7) Neoplastic – thyroid cancer, lymphoma 8) Neurologic – parkinson’s disease 9) Psychosocial – malingering
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Nongoitrous cervical masses Midline cervical mass Thyroglossal cysts Suprahyoid cysts Subhyoid cysts Pyramidal lobe of thyroid Thyroid cartilage cysts Cricoid cartilage cysts
Slide 131: Lateral cervical cyst - Branchial cyst - Hygroma - Carotid body tumor - Cavernous hemangioma - Branchial fistula - Zenker’s diverticulum ( pharyngeal pouch)
Slide 132: Thyroid
Thyroid enlargement ( GOITER) - results from: a) hyperplasia of the thyroid tissue b) infection c) neoplastic growth ( primary thyroid cancer, metastatic growth, lymphoma) d) infiltration with foreign substances ( amyloid)
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Slide 133: - patient complains of fullness of mass in the neck , pressure symptoms - Determine the size of the component of the gland, extension the gland within the neck or into the retrosternal space, fixation to surrounding structures
Slide 134: -characterize the enlarge thyroid as diffuse, focal, nodular, or smooth - tenderness
Slide 135: -make an assessment of the state of thyroid function: Hypothyroid, Hyperthyroid, euthyroid - Clinical classification is based whether thyroid is diffuse or nodular - Level of functional thyroid state: a) toxic goiter b) nontoxic goiter ( euthyroid or hypothyroid)
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Retrosternal Goiter ( substernal, intrathoracic , or submerged goiter) - when the lower border of a goiter can’t be palpated - Goiter may rise only with inc. intrathoracic pressure like coughing. This is also called plunging goiter.
Slide 137: 1) 2)
2 physical signs of retrosternal goiter Tracheal displacement Venous engorgement in the neck
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Diffuse toxic goiter ( Grave’s Disease) -autoimmune disease char. by goiter, exophthalmos, pretibial edema, hyperthyroidism
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Thyroid syndromes - excess or deficit of thyroid hormones alter the physical structure of the body to produce physical signs - examine your patient to determine the size of the TG, to assess thyroid function, to judge the likehood of cancer
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Thyroid syndromes a) Hyperthyroidism - overproduction of the thyroid hormone or excessive thyroid medication - often with generalized muscle weakness, energetic, irritable, tachycardic, tremor frequent defecation, wt. loss , inc appetite
Slide 141: b) Hypothyroidism -due to iodine deficiency, deficit of TH, excessive dose of thiouracil drugs, lithium, thiocyanates, paraaminosalicylic acid, phenylbutazone - slow metabolism, fatigue, loss of energy, wt gain, constipation, coldness
Slide 142: Lymph Nodes
Determine if the lymph node is localized to the neck or generalized in other parts of the body Acute cervical lymphadenopathy 1) Localized lymphadenitis - common infections of the scalp, face, mouth, teeth, pharynx or ear
Slide 143: Submental lymph nodes - primary lesions from the lower lip, anterior tongue, floor of the mouth Posterior cervical lymph nodes and occipital - primary lesions from the posterior 2/3 of the scalp and nasopharynx
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Anterior cervical lymph nodes - primary lesions from anterior 2/3 of the scalp, face including maxillary sinus, oral cavity ( tongue, tonsils, larynx)
Slide 145: 2) Generalized lymphadenitis - syphilis - rubella - IM - HIV - Generalized Furunculosis
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Chronic localized cervical lymphadenopathy a) TB b) Hodgkin disease c) actinomycosis
Slide 147: d) Virchow node ( sentinel node) -enlargement of a single lymph node usually in the left supraclavicular group - it may be the result of either abdominal or thoracic malignancy
Slide 148: Thank You
