EXAMINATION OF

HEENT
 Common HEENT complaint
•Head ache •Vertigo - refers to the

•Eye discharge perception that the patient

or the environment is
•Blurring of vision rotating or spinning.
•Ear discharge •Rhinorrhea
•Epistaxis
•Earache or otalgia
•Sore tongue or sore throat
•Tinnitus
• Gum bleeding
•Hoarseness
Techniques of Examination

The Head
• Ask if the pt. has noticed anything wrong with the scalp or hair. If
there is a wig-remove it.
• Examine:
• The hair - Quantity, distribution, pattern of loss and texture
• The scalp - Part the hair and examine for scaliness, lumps,
tenderness
• The skull
• Observe general size and contour
• Note any deformities, lumps, tenderness
• The face
• Note facial expressions and contours
• Observe for asymmetry, involuntary movements, edema
and masses
• The skin
• Observe the skin noting it’s color, pigmentation, texture,
thickness, hair distribution
• Example
• Acne in adolescents
• Hirsutism (excessive facial hair) occurs in some women
with polycystic ovary syndrome.
The Eyes
• Sclera
• Cornea
• Limbus
• Iris
• Pupil
• Eyelid
• Lacrimal system
• The upper eyelid covers a portion of the iris but does not
normally overlay the pupil. The opening between the eyelids is
called the palpebral fissure.
Visual Fields
• A visualfield is the entire area seen by an eye when it looks at a
central point.
• Eachvisual field, shown by the white areas below, is divided into
quadrants.
• Note that the fields extend farthest on the temporal sides.
• Visualfields are normally limited by the brows above, the cheeks
below, and the nose medially.
• A lack of retinal receptors at the optic disc produces an oval
blind spot in the normal field of each eye, 15° temporal to the
line of gaze.
• When a person is using both eyes, the two visual fields overlap in an
area of binocular vision but laterally, vision is monocular.
VF
 Visual Pathways
• To see an image, light reflected from the image must pass
through the pupil and be focused on sensory neurons in the
retina.
• The image projected there is upside down and reversed right to
left. E.g. An image from the upper nasal VF - strikes the lower
temporal quadrant of the retina.
Nerve impulses, stimulated by light, are conducted
through the following structures:

Retina
OpticNerve
Optic Tract

Optic Radiation
Occipital Lobe
•Pupillary Reactions
• Pupillary size changes in response to light and to the effort of focusing on a near
object.

•The Light Reaction

• A light beam shining onto one retina causes pupillary constriction in both that eye,
termed the direct reaction to light, and in the opposite eye, the consensual
reaction.

• The oculomotor nerve, CN III - the constrictor muscles of

the iris of each eye.
The coordinated action of six muscles, the four rectus
and two oblique, control the eye.
If one of these muscles is paralyzed, the eye will
deviate from its normal position in that direction of
gaze and the eyes will no longer appear conjugate, or
parallel.
Visual Acuity
• VA is a measurement of central vision only and assessment of total visual system
from cornea to occipital cortex using a Snellen eye chart.
• Position the patient 20 feet from the chart.
• Patients who use glasses other than for reading should put them on.
• Ask the patient to cover one eye with a card (to prevent peeking through the
fingers) and to read the smallest line of print possible.
• A patient who cannot read the largest letter should be positioned closer to the chart;
note the intervening distance.
• Determine the smallest line of print from which the patient can identify more than
half the letters.
• Record the visual acuity designated at the side of this line, along with use of
glasses, if any.
• Visual acuity is expressed as two numbers (e.g., 20/30): the first indicates the
distance of the patient from the chart, and the second, the distance at which a
normal eye can read the line of letters.
Visual fields by confrontation : Used to assess peripheral
vision
• Start screening in the temporal fields
• Ask the patient to look with both eyes into your eyes
• While you return the patient’s gaze, place hands
about 2 feet apart lateral to patients ears
• Instruct the patient to point to your fingers as soon
as they are seen
• Repeat this pattern in upper and lower temporal
quadrants
Field defects that are all or partly
temporal include
• If you find a defect, try to establish its boundaries.
• Test one eye at a time.
• E.g. If you suspect a temporal defect in the left
visual field, for example, ask the patient to cover the
right eye and, with the left one, to look into your eye
directly opposite. Then slowly move your wiggling
fingers from the defective area toward the better
vision, noting where the patient first responds.
Repeat this at several levels to define the border.
• Position and alignment of eyes
• Stand in front of the patient and survey eyes for
position and alignment
Observe inward or outward deviation
Abnormal protrusion
• Eyebrows
• Inspect eyebrows noting quantity and distribution
 Xanthelasma – irregular, slightly raised yellow peri-
orbital lesions may suggest lipid disorder
• Eyelids
• Note the position of the lids in relation to the eyeballs
• Inspect
• Width of the palpebral fissure (When the eye is open this fissure measures
about 30mm in width or horizontally and 12 to 15mm in height or vertically.)
• Edema of the lids
• Color of the lids
• Lesions
• Condition and direction of eyelashes
• Adequacy with which eyelids close
Ptosis(TOH-sis)- if upper lid covers part of pupil (muscle weakness or
neurologic lesion).
 Ectropion (lid turned out) or Entropion (lid turned in).
• Lacrimal apparatus
• Inspect the regions of lacrimal gland and lacrimal sac for swelling
• Conjunctiva and Sclera
• Ask patient to look up as you depress both lower lids with your
thumbs
• Inspect the sclera and palpebral conjunctiva for color
• Eg. pale conjunctiva in anemia and Yellow sclera indicates jaundice
• Look for nodules and swelling
Conjunctivitis- inflammation from infection, allergy...
Pterygium (ter-IG-ee-um)- growth of conjunctiva over cornea
If you need a fuller view of the eye, rest your thumb and finger
on the bones of the cheek and brow, respectively, and spread
the lids.
 Ask the patient to look to each side and down.
 This technique gives you a good view of the sclera and bulbar
conjunctiva, but not of the palpebral conjunctiva of the upper lid.
 For this purpose, you need to evert the lid.
•Cornea and lens
• With oblique lighting, inspect the cornea of each eye
for opacities.
• Note any opacities in the lens that may be visible
through the pupil.
• Inspect the iris
• Pupils
• Inspect size, shape, symmetry
• Test pupillary reaction to light
• Ask the patient to look into the distance
• Shine a bright light obliquely into each pupil
• Look for
• Direct reaction
• Consensual reaction

• Accommodation (papillary constriction with near focus) – an increased

convexity of the lenses caused by contraction of the ciliary muscles.

• Ask patient to look at finger held several feet from face, then to look at finger

brought just beyond the end of the patient's nose.

Findings:
Miosis (my-OH-sis) if <2mm (narcotic use,
elderly)
Mydriasis (mi-DRY-ah-sis) if >6mm (head
injury, drugs)
Anisocoria - unequal pupil size, may be
normal variation
• Extra ocular muscles
 From about 2 feet directly in front of the patient, shine a light
into the patient’s eyes, ask the patient to look at it- inspect
reflections in the corneas
 They should be visible slightly nasal to the center of the pupils.
 Asymmetry of the corneal reflections indicates a deviation from
normal ocular alignment.
 E.g. A temporal light reflection on one cornea, for example,
indicates a nasal deviation of that eye.
• Assess extra ocular movements looking for
 Normal conjugate movements of the eyes, any deviation
from normal
 Nystagmus, a fine rhythmic oscillation of the eyes
 Lid lag, as the eyes move from above downward which is
commonly seen in hyperthyroidism
 Ask the patient to follow your finger as you move it slowly from
up to down- a rim of sclera is visible above the iris with
downward gaze and a lid should overlap the iris slightly
throughout this movement.
• Nerve supply
• Superior oblique – CN IV
• Lateral rectus – CN VI
• The rest – CN III

• Actions: rotate eye ball around 3 axes

• Superior rectus – elevates and rotates medially
• Inferior rectus – depress and rotate medially
• Medial rectus – medial rotation (adduct)
• Lateral rectus – lateral rotation (abduct)
• Superior oblique – downward rotation and laterally
• Inferior oblique – upward rotation and laterally

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36
 Superior Oblique/Trochlear Muscle
Eye Muscles
Left eye Superior Rectus Muscle

Medial Rectus Muscle

Lateral Rectus Muscle

Inferior Rectus Muscle

Inferior Oblique Muscle

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In paralysis of the CN
VI, illustrated below,
the eyes are conjugate
in right lateral gaze but
not in left lateral gaze.
Proptosis, an abnormal protrusion of the eyeball in hyperthyroidism,
leading to a characteristic “stare” on frontal gaze.
•Ophthalmoscope examination
Inspect optic disk, retina
The Ears
•The auricle
• Inspect for deformities, lumps, skin lesions
• Inspect position and shape
• Position: Top of auricle should be above line drawn between
outer canthus of eye and occipital protuberance.
• Low set auricle may signify chromosomal abnormality
• Move the auricle up and down, press the tragus, press
firmly behind the ear if pain, discharge or inflammation
is present
• Some abnormalities
• Tophi-   deposits of uric acid crystals found in patients

with gout
• Chondritis- infection of cartilage, often caused by
piercing
• "Cauliflower"-repeated trauma causes cartilage necrosis
• Otitis externa- "swimmer's ear", pulling on lobe often
painful
• Skin cancer - often nodular, with indurations, scaling
and superficial ulceration.
• Ear canal and drum
• Use an otoscope
• Inspect the ear canal
• Note any discharge, foreign bodies, redness of skin and cerumen
• Inspect the ear drum
• Note the color and contour
Hearing tests

1. Rinne test(1855) : A 512Hz tuning fork

firmly held with its stem .
Place the base of a lightly vibrating tuning fork on the
mastoid bone, behind the ear and level with the canal. When
the patient can no longer hear the sound, quickly place the
fork close to the ear canal and ascertain whether the sound
can be heard again.
Rinne +ve : Normally AC Better than BC
(AC>BC ) .
Rinne -ve : Conductive deafness BC better than
AC ( BC>AC)
Rinne equal : Some times both AC&BC In equal
intensities.
Hearing tests

2. Weber test: Place the base of the lightly vibrating tuning

fork firmly on top of the patient's head or on the mid forehead.
. Normal persons : Sound is heard in both ears equally or in
the center of the head.
. Conductive deafness : The sound is lateralized to the
affected ear, or the worse ear if both ears are involved.
. SNHL : The sound is lateralized to normal ear or better ear
if both are involved.
• 3. Auditory acuity
• Occlude one ear
• Standing 1-2 feet away whisper softly toward the
unconcluded ear.
The Nose and Paranasal sinuses
• Inspect the anterior and inferior surfaces of the
nose
• Gentle pressure on the tip of the nose with your thumb
widens the nostrils
• Note any asymmetry or deformity

• Test for nasal obstruction

• Press on each ala nasi in turn and ask the patient to breathe
in.
• Inspect
the inside of the nose with an otoscpe and largest ear
speculum available
• Tilt patients head back a bit
• Insert speculum gently into the vestibule
• Observe
• The nasal mucosa
• Note color, swelling, bleeding, or exudate
• Bluish, swollen mucosa-  allergies
• Generalized redness-   infection
• Bleeding-   often from Kiesselbach plexus, on anterior septum
• The nasal septum
• Note any deviation, inflammation, perforation
• Any abnormalities-ulcers, polyps
• Palpate for sinus tenderness
• Press up the frontal sinus from under the bony brows
• Press up on the maxillary sinus
The Mouth and Pharynx
• Inspect the following
• The lips
• Observe color and moisture,
• Note any lumps and ulcers, cracking or scaliness
• The oral mucosa
• Inspect the color, look for ulcers, white patches and nodules
• The gums and teeth
• Note color of the gums
• Inspect the gum margins and inter dental papillae
• Inspect the teeth- missing, discolored
• The roof of the mouth
• Color and architecture of the hard palate
• The tongue and floor of the mouth
• Ask the patient to put out the tongue
• Look for symmetry
• Note the color and texture
•Inspect
sides and undersurface of the
tongue and the floor of the mouth
• Noteany white or reddened areas, nodules or
ulcerations
•Palpate
• Ask the patient to protrude his tongue
and grasp the tip of the tongue with a
gauze
•Gently pull it to the patients left
•Inspect the side of the tongue and palpate
it
• Angular cheilitis (key-LY-tis) - fissures at corners of mouth
• Angioedema - allergic swelling
• Herpes labialis- "cold sore"
• Carcinoma

Colors:
Pale-     anemia
Blue-    cyanosis
Red-     CO poisoning
Buccal Mucosa:
Thrush- adherent white patches
• The Pharynx
• With the patient’s mouth open, and tongue not protruded ask the patient to
say ‘ah’
• Inspect the soft palate, anterior and posterior pillars, uvula, tonsils and
pharynx
Examination of the Neck

Inspection
• Note symmetry, any masses or scars
• Look for enlargement of parotid or submandibular
glands
• Note any visible lymph nodes
Lymph nodes
• Inspect
• Palpate using the pads of your index and middle fingers
• Note their size, shape, delimitation( discrete or matted together)
mobility, consistency, tenderness
• Their drainage sites should be examined in case of abnormalities
The trachea
• Inspect for any deviation
• Palpate for any deviation
• Place your finger along one side of the trachea
and note the space between it and the
sternomastoid
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Thank
you!