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 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
te their cheeks.
See examination of cranial nerves and cranial nerve palsies
Examination of 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
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
Rinne and Weber tunig-fork tests
Overview of possible findings

Gelle test
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
Examination of 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 (normal sclerae are white) and inspection of the conjunctivae
 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.
Examination of the conjunctiva
Pupils
Assess the pupillary size, location, shape, and reactivity to light (indirect and direct pupillary light
reflex)
For further information, see “Pupillary examination” in “Examination of the eye.”
Miosis and mydriasis
Visual acuity
Determine the clarity or sharpness of central vision at various distances by using an ophthalmological
chart (e.g., Snellen chart).
For further information, see “Visual acuity” in “Examination of the eye.”
Visual field testing
Assess light sensitivity and identify patterns of vision loss using a finger or pen.
For further information, see “Visual field examination” “Examination of the eye.”
Examination of extraocular muscles
Assess the movement and alignment of the eyes using a finger or a pen.
For further information, see “Extraocular movements” and “Examination of extraocular muscles.”
Clinical testing of the extraocular muscles

Fundoscopic examination and other special tests

The fundoscopic examination is typically only performed in certain situations (e.g., suspected
intracranial hypertension or stroke).
For further information, “Examination of the eye.”
Examination of the neck

 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.
Examination of 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.