CLINICAL MEDICINE

HEENT: Head, Face, & Neck

Dr. Elena Solis | 10-19-2020 | 1st Semester

INTRODUCTION

- Many signs and symptoms of various systemic diseases

present within the head and neck area.

- Examination requires an adequate light source. In the

absence of a head mirror and a light source from a
gooseneck lamp, a penlight will suffice with a good
examination room lighting.

A must equipment:

Penlight
Tongue depressor
Tuning fork

BASIC CONCEPTS: ANATOMY & PHYSIOLOGY
Bones of the skull
Protection for sight, hearing and other senses
Regions of the head take their names from the underlying
bones of the skill, for example, the frontal area. Knowing this
anatomy helps locate and describe physical findings (Bates)
☺Two paired salivary glands lie near the mandible: the parotid
gland, superficial to and behind the mandible (both visible and
palpable when enlarged), and the submandibular gland, located
deep to the mandible. Feel for the latter as you bow and press
your tongue against your lower incisors. Its lobular surface can
often be felt against the tightened muscle. The openings of the
parotid and submandibular ducts are visible within the oral
cavity.
☺The superficial temporal artery passes upward just in front of
the ear, where it is readily palpable. In many normal people,
especially thin and elderly ones, the turtorous course of one of
its branches can be treated across the forehead.

Dr. Romainetic
 CLINICAL MEDICINE
HEENT: Head, Face, & Neck
Dr. Elena Solis | 10-19-2020 | 1st Semester

EXAMINATION PROPER
4. Inspect the SCALP systematically from the frontal to the occipital
area by parting the hair by region and note for:
o lesion, scars, scaliness, masses,lumps, nits, scabs
HEAD INSPECTION
1. Seat at the same level or slightly higher than the patient.
2. Observe the position of patient’s head, note any tilting, abnormal
head movement like nodding, jerking or bobbing motion. Normal
position: midline, upright and still

5. Inspect the HAIR

☺Look for redness and scaling that may indicate

seborrheic dermatitis or psoriasis; soft lumps that may
be pilar cysts (wens); pigmented nevi.

Note: quantity, distribution,color,texture, and any pattern

of loss.
You may see loose flakes of dandruff.

☺Fine hair is seen in hyperthyroidism; coarse hair in

hypothyrodism. Tiny white ovoid granules that adhere
to hairs may be nits (lice eggs).
3. Inspect the SKULL for size, shape ,symmetry.

☺An enlarged skull may signify hydrocephalus or

Paget’s disease of bone. Palpable tenderness or
step-offs may be present after head trauma.

☺Skin: Acne is found in many adolescents. Hirtuism

(excessive facial hair) occurs in some women with
PCOS.

HEAD PALPATION
1. If patient is seated higher than you, ask the patient to bow his/her
head, so that you may reach it adequately.
2. You may seat or stand in front or behind the patient.
3. Palpate the skull through the scalp by gentle rotary movement
starting from the frontal area towards the occipital area.
4. Note for tenderness, soft tissue swelling, or any bony prominence
or depression,

Dr. Romainetic
 CLINICAL MEDICINE
HEENT: Head, Face, & Neck
Dr. Elena Solis | 10-19-2020 | 1st Semester

5. deformities in areas where it is not expected.

6. Palpate the patient’s hair and note for its texture

Note whether: smooth, coarse, not brittle.

Palpate the temporal arteries, noting the ff:
- thickening
- hardness
- tenderness

Landmarks of the face

HEAD AUSCULTATION
For patients suspected for having vascular anomaly in the brain,
auscultate over the:
a. Temporal region
b. Over the eyes
c. Below the occiput

☺ Use the bell of the stethoscope to detect any bruit.

(Picture below) Facial Muscles and Cranial nerve V and

Record your Findings:
Head held erect and midline, normocephalic,
VII
symmetric, normal shape, no deformities, no
depression ,no lumps, no tenderness.
Scalp move freely under examining fingers. No
scaliness,scars,nits.
Hair is black, thick , well distributed, no focal areas
of hair loss, hair is coarse and dry
Temporal arteries not visible but palpable with
strong pulsation.

FACE

Facial bones
Protection for sight, hearing and other senses

Dr. Romainetic
 CLINICAL MEDICINE
HEENT: Head, Face, & Neck
Dr. Elena Solis | 10-19-2020 | 1st Semester

NECK

Important structures of the neck that need to be evaluated:

1. Trachea
2. Lymph nodes
3. Thyroid gland

PROCEDURES
1. Stand or sit in front of the patient at the same level.
2. Observe for skin color, pigmentation, lesions
3. Note the patient’s facial expression and contours.
4. Observe for asymmetry, involuntary movements, edema, masses
and facies.

Symmetry
symmetric or asymmetric face
assess facial features like:
eyelids
eyebrows
palpebral fissures
mouth
nasolabial fold

Record the findings

Face is:
oval in shape
Symmetrical ☺Divide each side of the neck into two triangles bounded by the
fair skinned sternomastoid muscle. Visualize the borders of the two triangles as
with occasional pigmented papules follows:
scattered over the face Anterior triangle: mandible (above), sternocleidomastoid
no masses, nor involuntary movements, (laterally), midline of the neck (medially)
temporal artery not visible but palpable Posterior triangle: sternocleidomastoid m., trapezius, and
with strong pulsation, walls not thickened. clavicle. Note that a portion of the omohyoid muscle crosses
the lower portion of this triangle and can be mistaken for a
lymph node or mass.

Dr. Romainetic
 CLINICAL MEDICINE
HEENT: Head, Face, & Neck
Dr. Elena Solis | 10-19-2020 | 1st Semester

Neck vessels LYMPH NODES

Deep to the sternomastoids run the great vessels of the neck:
carotid artery and internal jugular vein. The external jugular vein
passes diagonally over the surface of the sternomastoid and may
be helpful when trying to identify the jugular venous pressure.

☺ Classification of lymph nodes of the head and neck w/

☺ Midline structures and Thyroid Gland. Identify the midline
structures:
Mobile hyoid bone below the mandible
Thyroid cartilage, readily identified by the
notch on the superior edge
Cricoid cartilage
Tracheal rings
Thyroid gland
☺ Thyroid gland - located above the suprasternal notch.
☺ Thyroid isthmus - second, third, fourth tracheal rings just
below the cricoid cartilage.
☺ Lateral lobes of thyroid - curve posteriorly around the
sides of the trachea and the esophagus; each is about 4-5 cm
in length. Except in the midline, the thyroid gland is covered
by thin straplike muscles anchored to the hyoid bone and
more laterally, by the sternomastoids; only sternomastoids are
visible.
directions of lymphatic drainage shown above:
Deep cervical chain - largely obscured by the
overlying SCM, but at its two extremes, the tonsilar
node and supraclavicular nodes may be palpable.
The submandibular nodes - lie superficial to the
submandibular gland, and should be differentiated.
Nodes are normally round or ovoid, smooth, and
smaller than this gland.
The gland is larger and has a lobulated, slightly
irregular surface
Note: tonsillar, submandibular, and submental
nodes drain portions of the mouth and throat as
well as the face.
Knowledge of the lymphatic system is important! When you
detect a malignant or inflammatory lesion, look for
enlargement of the regional lymph nodes that drain it; when a
node is enlarged or tender, look for a source such as infection
in its nearby area.

Dr. Romainetic
 CLINICAL MEDICINE
HEENT: Head, Face, & Neck
Dr. Elena Solis | 10-19-2020 | 1st Semester

Submental lymph node

Procedure
midline behind the tip of the chin
1. Explain the procedure .
2. The examiner should stand behind the seated patient
3. Enlarged lymph nodes maybe visible by inspection esp. with
oblique light
4. Examination is primarily by palpation
5. 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
6. Palpate the lymph nodes for the ff:
a. Size
b. Shape
c. Consistency
d. Tenderness
e. Warmth Submandibular
f. Mobility
Midway between the angle of the lower jaw and chin
g. Delimitation ( discrete or matted)

A normal lymph node

Should not be palpable but can be seen in otherwise healthy
individual
Usually less than 1 cm
discrete
Round or ovoid in shape
Smooth
Movable
Non tender

Enlarged or tender nodes, if unexplained, call for:

1. re-examination of the regions they drain and
2. careful assessment of lymph nodes in other regions to identify Preauricular
regional from generalized lymphadenopathy
Infront of the tragus of the ear
Tender nodes suggest inflammation.
A scar of past thyroid surgery is often a clue to unsuspected
thyroid disease.
Generalized lymphadenopathy is seen in HIV or AIDS. Infectious
mononucleosis, lymphoma, leukemia, and sarcoidosis

Hard or fixed nodes (fixed to underlying structures and not movable

on palpation) suggest malignancy.

Posterior cervical chain

Along the trapezius (anterior edge)
Along the SCM (posterior edge)

Dr. Romainetic
 CLINICAL MEDICINE
HEENT: Head, Face, & Neck
Dr. Elena Solis | 10-19-2020 | 1st Semester

Post auricular
superficial to the mastoid process

Occipital
At the base of the skull posteriorly

Tonsillar
At the angle of the mandible

Superficial cervical
Deep cervical chain superficial to the sternocleidomastoid.
Deep to the SCM and often inaccessible to examination. Hook
your thumb and fingers around either side of the SCM to find
them. Posterior cervical
along the anterior edge of the trapezius

INSPECTION
a. In the usual anatomic position
b. In slight hyperextension
c. As the patient swallows

Inspect the neck for :

symmetry
size ( long or short)
deformity
masses, webbing
position of trachea
jugular vein distention
carotid artery prominence
Supraclavicular lymph node
Examine the supraclavicular nodes in the angle between the SCM and trapezius muscles should be
clavicle and the SCM symmetrical and without palpable
☺Enlargement of a supraclavicular node, especially on the left, suggests masses or spasms and tenderness
possible metastasis from a thoracic or an abdominal malignancy.

Range of motion of the neck

a. flexion - touch chin to chest

b. lateral bending - ear to shoulder
c. lateral rotation- turn head left to
right
d. extension - extend head
backwards

motion should be smooth and

controlled

Dr. Romainetic
 CLINICAL MEDICINE
HEENT: Head, Face, & Neck
Dr. Elena Solis | 10-19-2020 | 1st Semester

TRACHEA

Procedure
1. Explain the procedure.
2. Inspect the trachea for any deviation from its usual
midline position.
3. Palpate for any deviation by placing your finger along
one side of the trachea and note the space between it Abnormalities:
and the SCM.
Goiter - simple, w/o nodules, or multinodular, and
are usually euthyroid. With swallowing, the lower
border of the gland rises and looks less symmetric.

When the thyroid gland is retrosternal, below

4. Compare it with the other side. The spaces should be
symmetrical. If asymmetrical there is deviation
the suprasternal notch, it is often not palpable.
Retrosternal goiters - causes hoarseness, SOB,
stridor, or dysphagia from tracheal
compression.

Neck hyperextension and arm elevation - cause

Masses in the neck may push the trachea to one side.
Tracheal deviation may also signify important
problems in the thorax, such as a mediatinal mass,
atelectasis, or a large pneumothorax
flushing from dilitation of the external jugular
veins and obstruction of thoracic inlet. Usually
are present in the 5th decade; over 85% are
benign.
Assessment of thyroid function depends upon
signs, symptoms, elsewhere in the body, and
on lab tests.

Soft in Grave’s disease; firm in Hashimoto’s

THYROID GLAND thyroiditis; Benign and malignant nodules,
Examination of the thyroid gland involves inspection, palpation
tenderness in thyroiditis. A localized systolic or
and auscultation
continuous bruit may be heard in
INSPECTION hyperthyroidism. JVD (common in heart
begin by inspecting the seated patient from the front and side
looking for any surgical scars, mass and distended veins.
failure)
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

Dr. Romainetic
 CLINICAL MEDICINE
HEENT: Head, Face, & Neck
Dr. Elena Solis | 10-19-2020 | 1st Semester

Inspect for swelling of the neck In patient with goiter the line to the suprasternal notch bows
outward.

Observed for enlarged thyroid or goiter

Epidemiologic classification of cervical goiter:
(WHO)
Grade 0 - no palpable or visible goiter
Grade 1 - a goiter that is palpable but not visible
with the head in the normal position.
Grade 2 - a goiter that is clearly visible when the
neck is in the normal position

PALPATION
Palpation of the thyroid gland mandates a gentle touch
Cricoid cartilage is the basic landmark for examination

In patient with normal gland size, the line down to suprasternal

notch is straight.

Dr. Romainetic
 CLINICAL MEDICINE
HEENT: Head, Face, & Neck
Dr. Elena Solis | 10-19-2020 | 1st Semester

2 methods of palpation of the thyroid gland

a. Palpation from behind Procedure for thyroid gland examination
(Posterior approach)
1. Explain procedure
2. Ask the patient to flex the neck slightly forward
to relax the SCM muscle.
3. Place the fingers of both hands on the patient’s
neck so that the index fingers are just below the
cricoid cartilage
4. Ask the patient to sip and swallow water. Feel
for thyroid isthmus rising up under your finger
pads. It is often but not always palpable.
5. Displace the trachea to the right with the fingers
of the left hand
6. With the right hand fingers, palpate laterally for
b. Frontal palpation the right lobe of the thyroid in the space
between the displaced trachea and relax SCM
muscle.
7. In similar fashion, examine the left lobe
8. The lobes are somewhat harder to feel than the
isthmus, so practice is needed.
9. The anterior surface of a lateral lobe is
approximately the size of the distal phalanx of
the thumb and feels somewhat rubbery.

Note the size, shape and consistency of the

thyroid gland and identify any nodule or
tenderness.
Gland is smooth ,soft, not enlarged, non tender,
no nodules

Dr. Romainetic
 CLINICAL MEDICINE
HEENT: Head, Face, & Neck
Dr. Elena Solis | 10-19-2020 | 1st Semester

AUSCULTATION

If the thyroid gland is enlarged, listen over the lateral lobes with
the bell of the stethoscope to detect a bruit, a sound similar to a
cardiac murmur but of noncardiac origin

Record your findings

Neck has full range of motion (supple)

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.

REFERENCES:
PPT
Bates’ Guide to Physical Examination and History Taking 11th
ed (mas maganda reviewhin ito kasabay ng Bates )

Dr. Romainetic