Head & Neck Examination:

Dr.AbdulWAHID M Salih
M.D. Surgery
 Posture, weight, body shape
If pt. enters, examine
Gait.
Posture
Biult(Wt);[BMI = kg/m^2.Normal<25]
Height.
Limb amputations, deformities
 Built:
Causes of stunted growth are:
1. Malnutrition (commonest type).
2. Malabsorption syndrome.
3. Chronic diarrhea.
4. Liver cirrhosis.
5. Nephrotic syndrome.
6. Cystic fibrosis.
7. Chronic infections.
8. Genetic disorders:
1. Turners syndrome.
2. Dwarfism.
3. Mongolism.
4. Achondroplasia.
9. Congenital cyanotic heart diseases
10.Endocrinal: Cretinism and pituitary infantilism.
 General Condition
Alertness
Consciousness
Cooperation
Orientation to time,place and persons
Intelligence and memory
 The expression of the face
Facies febrilis is characterised by shiny eyes, redness in
the face, an uneasy expression (febrile diseases).
Facies hippocratica is associated with the anxiety in
face, cavernous cheeks, and sharp nose (sudden
abdominal attack).
Facies mitralis is associated with prominent livid colour
of the cheeks and acral cyanosis in the face (mitral
stenosis)
Facies nefritica is represented by paleness, eyelid
oedemas, and infiltration of the face (nephritis).
Facies pletorica is characterised by livid redness in face
(polycythaemia).
 Facies in cases of endocrinopathy
Acromegaly;massive supraorbital
arcs, enlargement of the nose,
chin, and legs.
Thyrotoxicosis remarkable
uneasy expression, shiny
eyes, and exophthalmos.
Myxoedema;a passive expression
of a bloated face and thinned or
missing eyebrows on the lateral
side.
Cushing syndrome ;a moon face
 Hair cover
different in men and in women.
Alopecia (hairlessness) is the most common deviation.
Diffuse alopecia
Healthy men
Febrile conditions
After cytostatic treatment
Hyperthyroidism.
Local alopecia
Often unknownoccurs
Protracted stress
Thyrotoxicosis
 Facial hallmarks
Tetanus:
a certain smile (risus sardonicus).
Myasthenia gravis:
weak smile and
bilateral ptosis.
Toxic look:
Pulmonary tuberculosis.
Suppurative lung diseases.
Cachectic: malignancy,
malnutrition & chronic
inflammatory diseases.
 Face
1. Color of skin
2. Symmetrical

3. Edema of the face.

4. Hair: deficiency, excess.

Hirsutism
tumour of adrenal glands and ovaries
Older women
5.Cranial nerves
Normal vs. Abnormal
Paralysis
Stroke, trauma, bells palsy
Pigmentation in butterfly
MS (malar flush)(red).
SLE (red).
Pellagra (brownish).
Pregnancy (brownish).
 Eyebrows
Symmetrical
Asymmetric
Congenital facial disorders
Defects of innervation of the upper
branch of n. Vii
Loss of hair from Outer 1/3
Hypothyroidism.
Artificial.
 Eyelids
Swelling ;infiltration of the skin by a serous fluid;
Bilaterally ; glomerulonephritis and hypothyroidism.
Unilaterally; stye abscess of a sebaceous gland.
Eyeglass-like haematoma subcutaneous bleeding in
skull base fracture.
Epicanthus; skin plica covering the inner corners of
both eyes (mongolism Down syndrome).
Ectropion;an external (outward) rolling of the eyelid
edge.
Entropion is a rolling of the eyelid edge against
the eyeball (inward).
Xanthelasma ;on the upper eyelids, it can be single or
multiple (hyperlipoproteinaemia).
Hyperpigmentation;in some cases of thyrotoxicosis.
 Eyes
1. Exophthalmos
2. Enophthalmos
3. Strabismus
4. Ptosis:
5. Puffy eyelids:
6. Sclera and Conjunctiva
 1-Exophthalmos:
Bilateral:
1.Thyrotoxicosis.
2.Congenital.
Unilateral:
1.Cavernous sinus thrombosis.
2.Leukemic infiltrations behind the eyeball.
3.Arteriovenous aneurysm
between cavernous sinus
and internal carotid artery.
 2-Enophthalmos:

1.Horners syndrome.
2.Dehydration.
3.Shock.
4.Severe wasting.
 3-Strabismus
Convergent strabismus (convergent squint);
axes of the eyeballs converge

Divergent strabismus (divergent squint);

axes of the eyeballs diverge
 4-Ptosis:
Unilateral:
1.Horners syndrome (Pancoasts tumor).
2.3rd nerve palsy.
3.Local eye disease.
4.Congenital.

Bilateral:
1.Myasthenia gravis.
2.Congenital heart diseases.
 5-Puffy eyelids:
1.Chronic cough (commonest cause).
2.Renal diseases.
3.SVC thrombosis.
4.Myxedema.
5.Mediastinal syndrome
6.Angioneurotic edema.
7.Nutritional edema (hypoproteinemia).
8.Advanced right-sided heart failure.
 6-Conjunctiva:

Anemia (to be seen in lower lid).

Jaundice.
Inflammation; Hyperaemia
Subconjunctival hemorrhage;
severe hypertension,
chronic coughs
and blood diseases.

Bitots spots vitamin A deficiency.

 6-Conjunctiva:
Bluish discoloration
Hypoproteinemia
congenital osteogenesis imperfecta
gradually occurring anemias

Yellow colour ;
Icterus In Hypercarotinemia.

Xerophthalmia ;keratoconjunctivitis
(Sjgrens syndrome).
 Nose
Adequate size and shape, symmetric, without
secretion.

Big nose acromegaly.

Rhinophyma is an enlarged nose, with rough surface
(potato nose).
Saddle nose congenital syphilis.
Asymmetric nose; after injuries.
Epistaxis (profuse nose bleeding)
injuries,
uncontrolled hypertension
haemorrhagic diathesis or rhinitis.
 Nose:
Redness in tip:
alcoholism, mitral stenosis and cold weather
Working ala nasi:
pneumonia, toxemia,nervousness,
bronchial asthma and respiratory failure.
Nasolabial fold:
vitamin B2 deficiency sulphur granules.
Any discharge from the nostrils.
Inflammation:Furuncle close to the nostrils.
 Lips
symmetric, pink, smooth, and moist.
Asymmetric lips ;paresis of the facial nerve
defective teeth.

Pallor: anemia.
Cyanotic lips
Dry lips Dehydration
Inflamed lips Cheilitis; thiamine deficiency.
Herpes labialis.
Anguli infectiosi vitamin B2 deficiency
insufficient hygiene
immunodeficiency.
Equipment
Assure that you have all the supplies
necessary to complete an oral
examination
Mirror
Tissue retractor (tongue blade)
Dry gauze
 Exam: Tongue
Wrap the tongue in
a dry gauze and
gently pull it from
side to side to
observe the lateral
borders
Retract the tongue
to view the inferior
tissues
 Oral cavity
Mucous membrane of oral cavity is pink, shiny, without
pathological changes.
Pale; anaemia.
Erythematous ;stomatitis.
Black spots of melanin pigmentation; Addison's
diseas.
Petechial hg; haemorrhagic diathesis.
Erosion, ulcers; agranulocytosis or acute leukaemia.
Soor (thrush) whitish fur on mucous membrane;
antibiotic therapy
elderly people
immunodeficiency.
 Tongue
sticks out in medial line, it is pink and wet.
Deviation ;cerebral apoplexy
Dry tongue ;dehydration
breathing through the mouth
saliva is decreased.
uremia,
intestinal obstruction
Coated tongue ;
diseases of the oral cavity
systemic diseases.
Leucoplakia ;blue-white
(pre-cancer state).
 Tongue
Atrophy of papillae
(Hunter's glossitis);
pernicious anemia
iron deficiency anemia
pellagra.
Bitten tongue ;
big epileptic seizure.
Macroglosia;
acromegaly, myxoedema,
angioneurotic oedema,
and glossitis.
 Tongue:
Tumor
Pallor:
severe anemia.
Cyanosis:
congenital heart diseases, cor pulmonale,
heart failur and arteriovenous fistula.
Tremors:
nervousness, thyrotoxicosis and parkinsonism.
Absence of fur;
heavy smokers and fungus infection.
lingual varicosities
Exam:
Gums
Hard palate
Soft palate
tonsilar pillars,
tonsils,
oropharynx
 Gums
pink, strong, without bleeding signs.
Erythematous; gingivitis.
Bleeding; (scurvy).
Coloured edge of greyish;
chronic intoxication by heavy metals
(lead, bismuth).
 Oral Cavity
Teeth are fully developed, healthy.
Teeth: nicotine stains.
Decayed teeth
Defective teeth
Dentures (prosthesis)
Buccal Mucosa
Observe color,
Lesions
Amalgam tattoo
Palpate tissue
Observe Stensons duct opening
for inflammation or signs of
blockage
 Floor Of The Mouth

Must dry to observe

Visualize
Whartons duct
Palpate bimanually
Squamous cell carcinoma

Floor of mouth
 Tonsils
Missing;
tonsillectomy.
Hypertrophied with furrows;
chronic tonsillitis
Enlarged, erythematous;
acute tonsillitis.
Asymmetric, bulging;
retrotonsillar abscess or tumour.
 Pharynx Soft palate;
Pharynx;
symmetrical, mucous membrane is pink,
Soft palate;
Yellowish or yellow palate
Erythematous - in respiratory infections.
 Breath:
Diabetic ketoacidosis
acetone smell.
Uremia
ammonia smell.
Hepatic failure
fetor hepaticus (mossy smell).
Suppurative lung diseases
putrid smell.
 Parotids:

Mumps.
Parotid tumors.
Parotid stones.
Liver cirrhosis.
Endemic parotiditis
 Ears
Shape
external auditory canal
pressure on tragus are painless
palpation on processus mastoideus are painless.
1. Gouty tophi; on auricle are yellowish
subcutaneous deposits of urates.
2. Secretion in the auditory meatus; meatus
inflammation or otitis media.
3. Bleeding from the auditory meatus; trauma.
4. Pain; when pulling the auricle, pressing on the tragus,
and percussion onto processus mastoideus occur in
case of otitis media or mastoiditis.
 Examination of the neck
inspection, palpation, and auscultation
Inspection; The shape and length of neck are
proportional to the body.
Slim neck; cachexia; the supraclavicular areas
are notably sunken.
Strong neck; obese people.
Pulsations of carotid; visible in skinny people
,exertion, hypertension, hyperthyrodism, aortic
insufficiency.
Horizontal scar state after thyroidectomy,
 Neck
Describe the enlargement if present.
Goitre
enlarged lymphatic nodes
filling of neck veins
Post-radiation changes on the skin of
the neck; after radiotherapy
Movement; is free in all directions.
Change of posture;
1. Deviation to the side result of bleeding into the neck
muscles
muscle rupturefibrositis, or reflex spasm of muscles.
2.Opisthotonus inversion to the back in case of
tetanus.
 Palpation
Carotid artery ;
Weakened or not palpable pulsation;
contraction
complete obstruction of the vessel lumen.

Thyroid gland;
normally neither visible nor palpable.
Goitre; diffuse or nodal.
 Auscultation
Carotids;
systolic murmur;
Aortic stenosis(bilateral audibility)
carotid artery stenosis (asymmetric
audibile).

Goitre;
The murmur can also be audible above.
 Trachea:
Shifted to site of lesion:
Lung or pleural fibrosis
lung collapse.
Shifted to opposite side:
Pleural effusion,
Pneumothorax,
Lung tumors
Thyroid swelling.
 Lymph Nodes
Head and Neck
preauricular superficial
postauricular anterior cervical
occipital deep cervical
tonsillar posterior
submandibular cervical
submental supraclavicular
infraclavicular
 Cervical LN location
Preauricular - In front of the ear
Postauricular - Behind the ear
Occipital - At the base of the skull
Tonsillar - At the angle of the jaw
Submandibular - Under the jaw on the
side
Submental - Under the jaw in the midline
Superficial (Anterior) Cervical - Over and
in front of the sternomastoid muscle
Supraclavicular - In the angle of the
sternomastoid and the clavicle
 Regional lymphatic nodes
Enlargement of inflamed node;
Single node;
chronic tonsillitis, nasopharyngitis, gingivitis, and dental
affections.
Multiple nodes;
tuberculosis, sarcoidosis, toxoplasmosis, infectious
mononucleosis, and others.
Enlargement of tumorous node;
Single node; rigid solitary metastasis, e.g. Virchow's
node in stomach carcinoma.
Multiple nodes; multiple metastases (thyroid gland
carcinoma), haematological diseases (chronic
lymphatic leukaemia, lymphomas).
 Lymph Nodes

Submental
Drains:
Lower 2 incisors
Tip of tongue
Center of lower lip
Center of mandible
Submandibular
Drains:
Submental glands
Ant. 2/3 of tongue, except tip
Remainder of lower lip
not drained by submental
Dentition
Upper, lower deep cervical
Location: top and bottom of SCM.
Upper and lower groups.
Both drains:
Ant. neck inf. to hyoid.
Tongue
Dentition
Paratracheal nodes
Superior drains:
Upper hard palate
 deep cervical
The deep cervical chain of lymph nodes
lies below the sternomastoid and cannot
be palpated without getting underneath the
muscle:
Inform the patient that this procedure will
cause some discomfort.
Hook your fingers under the anterior edge
of the sternomastoid muscle.
Ask the patient to bend their neck toward
the side you are examining.
Move the muscle backward and palpate
for the deep nodes underneath.
Preauricular
Drains:
Ant. of meatus
2 finger widths ant. of ear
Postauricular
Drains:
Pinna
Nearby scalp
Occipital
Supraclavicular
Dx is Virchow's node, usually Lt one:
Classically, stomach CA
GI CA
Pelvic CA
Other CAs

Infraclavicular
Location: inferior to clavicle, in groove
between pec major and deltoid.
Paratracheal
Location;lateral to trachea
Drains:
Neck deep tissues
associated with recurrent laryngeal
Lymph nodes of the head and neck,
and the regions that they drain
 Pallor:
detected in mucus membranes of lips, lower lids
(not upper lids because of trachoma) and palms:
Anemia.
Malignancy.
Blood diseases.
Infective endocarditis.
Parasitic infestations.
Malnutrition.
Chronic infections.
 Jaundice:
yellow discoloration of the sclera and mucus membranes,
apparent clinically when serum bilirubin exceeds 2-3 mg/
1. Cardiac; (due to liver congestion):
Right sided heart failure.
Constrictive pericarditis.
TS and TI.
2.Chest causes:
Pulmonary infarction (hemolysis of blood).
Liver affection secondary to antituberculous drugs.
Cor pulmonale.
N.B: Rifampicin changes color of body secretion to oran
3Liver causes.
4.Blood causes
as hemolytic anemia
 Cyanosis:
It is bluish discoloration of the lips and mucus
membranes due to raised level of reduced
HB in capillaries more than 5 gm/dl (normally 1-2 gm/dl),
so dont say cyanosis with pallor. Normally:
O2 saturation of arterial blood 95-99%.
O2 saturation of venous blood 70%.
Cyanosis is apparent clinically when O2
saturation is below 80%.
Types of cyanosis:
Central cyanosis:
Peripheral cyanosis
 Hydration
Sunken orbits.
Mucus membrane dryness.
Skin turgor [pinch skin: normal returns immediately]
Postural hypotension [less BP when sit, stand].
Peripheral perfusion [press nose, time capillary retur
Examine weight loss over hours.
 Lower limbs:
Edema:
Unilateral or bilateral.
Pitting or non-pitting.

Tender calf muscles;

DVT
peripheral neuritis.
Rashes.
Clubbing, spooning and cyanosis(nails).
Pulsations.
Hairs: loss of hairs chronic ischemia.
 Differential
Idiopathic
Vascular
Infectious
Neoplastic
Degenerative
Inflammatory
Congenital
Autoimmune
Trauma
Endocrine and metabolic
Allergic
Iatrogenic
Drugs