HEENT: Head & Neck: Eyes: Ears: Nose, Face, Mouth & Throat

Head: Symmetry of skull and face

Neck: Structure, movement, trachea, thyroid, vessels and lymph
nodes
Eyes: ision, placement, e!ternal and internal fundoscopic e!am
Ears: Hearin", e!ternal, ear canal and otoscopic e!am of tympanic
mem#rane
Nose: E!am of nose and sinuses
Mouth: Structures of mouth, teeth and pharyn!
Head: $ey %oints
Head &ircumference 'H&(: Frontal )ccipital &ircumference 'F)&(
Fontannels*sutures: +nterior closes at ,-.,/ months, posterior #y 0
months
Symmetry & shape: Face & skull
1ruits: Temporal #ruits may #e si"ni2cant after 3 yrs
Hair: %atterns, loss, hy"iene, pediculosis in school a"ed child
Sinuses: %alpate for tenderness in older children
Facial e!pression: Saddness, si"ns of a#use, aller"y, fati"ue
+#normal facies: 45ia"nostic facies6 of common syndromes or
illnesses
Head: ariations
Neonates: Moldin" 'suture overlap( resolve 0 days
&apput succedaneum 'scalp s7ellin"( resolve 0 days
&ephalohematoma 'su#periosteal hemorrha"e( resolve 7ks*months
Fontannels: Tense and #ul"in" 7ith increased intracranial pressure
'8&%(
5epressed 7ith dehydration
9ar"e H&*8&%: 8ncreased H& due to increased 8&% '#efore suture
closure(,
tense & #ul"in" fontannels, dilated head veins, 4sunset si"n:6
Head may tranilluminate:
May indicate hydrocephalus, intraventricular hemorrha"e, trauma,
menin"itis or tumors:
8n older child, after cranial sutures close, 8&% increases are more like
adult si"ns ' headache, vomitin", 1% increases, chan"e in 9)&(
Small H&: May indicate microcephaly or craniosynostosis
&raniosynostosis: +symmetric head shape due to premature
closure of sutures:
Sur"ical separation corrects defect:
&raniota#es: 4%in".pon"6 e;ect 7ith pressure over temporo.
parietal.occipital
areas: May #e <N9, or result of hydrocephaly, rickets or infection
Mace7en=s si"n: 4&racked pot6 sound 7ith tappin" over parietal
#one:
May #e <N9 in infants, or associated 7ith 8&% & suture separation
'i:e: lead encephalopathy, tumor(
&hevostek=s si"n: Spasm of facial muscle 7ith percussion over
>y"omatic #one in front of
ear: May #e associated 7ith hypocalcemic tetany and tetanus:
Flattened head areas: Especially occipital ?attenin" 7ith hair loss,
may indicate persistent
placement of #a#y in same position:/
Eyes: $ey %oints
ision: @ed re?e! & #link in neonate
isual follo7in" at 3.A 7ks
,/- de"ree trackin" at B months
E chart & stra#ismus check for preschool child
Snellen charts for older children
8rritations & infections
%E@@9+
+m#lyopia 'la>y eye(: &orneal li"ht re?e!, #inocular vision, cover.
uncover test
E)Ms: trackin" A 2elds of vision
Fundoscopic e!am of internal eye & retina
Eyes: ariations
%lacement & symmetry: <ide set: hypertelorism C 5o7n syndrome
&lose set: hypotelorism
Epicanthal folds or up7ard slants C ethnicity, 5o7n s:
&haracter of eye#ro7s
Eyelids: %tosis, lid la", #lepharitis 'stye(, s7ellin"
5acryocystitis '#locked tear duct( may cause rednnes,
s7ellin" and dischar"e
4+ller"ic shinner6 'dark circles( may indicate aller"y
%eror#ital edema may indicate renal pro#lems
Sunken eyes may indicate dehydration
&onDunctive: 8n?ammation, pallor 'anemia(,
&o##lestone appearance may indicate aller"y
Sclera: Eaundice 'liver disease(, inDection 'conDunctivitis(,
Hemorrha"e, #lue color 'osteo"enesis imperfecta(
&ornea: Smooth, mo ist,clear 'not inDected 7ith conDunctivitis red
eye(
%upil & 8ris: 1rush2eld=s spots 'li"ht specklin" of iris( seen in 5o7n
s:
&olo#oma 'notch at outer ed"e or iris( may indicate visual
2eld defect:
)thalmoscope: %artial or dark red re?e! indicates patholo"y,
various retinal
anomalies or opacities of cornea, anterior cham#er or lens
'i:e: cataract(
<hite retinal re?e! indicates patholo"y 'i:e:, retino#lastoma,
@etinal detachment chorioretinitis(
@etinal hemorrha"e is patholo"ical, associated 7ith a variety
of causes: 8s a speci2c dia"nostic criteria in 4shaken #a#y6
syndrome:
%apilledema of increased 8&% more likely in olde child, 7ith
closed cranial suturesF
Ears: $ey %oints
E!am last 8n youn"er children
@estrain Goun" children in lap, head #raced a"ainst parent=s chest
Hearin": Especially if lan"ua"e delay or freHuent otitis media
)toscope e!am: %ull auricle do7n & #ack for infants, toddlers,
preschoolers
%ull auricle up &#ack for school a"ed & adolescents
&erumen removal may #e necessary
Ise pneumatic otoscopy
Tunin" fork: <e#er & @inne tests to di;erentiate conductive vs
sensorineural
hearin" loss are not e;ective 7ith youn"er children
Ears: ariations
E!ternal: Malformed auricle*pinna, or lo7.set or o#liHuely.set ears
may #e
+ssociated 7ith many syndromes, or "enitourinary & chromosomal
a#normalities:
)titis e!terna: %ain 7ith movement of auricle or tra"us, dischar"e
in canal, occurs
More often in summer '4s7immer=s ear6(
)titis media: %roper position & holdin" of otoscope facilitates
comforta#le
+s middle ear pressure or ?uid increases, the tympanic mem#rane
'TM( #ecomes less mo#ile 7ith pneumatic otoscopy:
E!am of TM:
TM: 5ull, "ray, retracted, loss of li"ht re?e!, landmarks may #e
more diJcult to see, 7ith possi#le superior inDection near
short process of malleus is associated 7ith #locked or
o#structed eustachian tu#es:
TM: 5ull, #ul"in", "ray or 7ith some inDection is associated 7ith
pressure, ?uid or pus accumulatin" in the middle ear:
TM: @ed, dull*thick*#ul"in", 7ith landmarks not visi#le is
associated 7ith acute otitis media:
TM: )ran"e.am#er color, 7ith*7ithout #u##les*?uid lines is
associated 7ith serous otitis media 7ith e;usion, often
associated 7ith viral I@8s, or pressure chan"es, such as divin"
or ?yin": TM may #e retracted, 7ith landmarks easier to see:
Nose: $ey %oints
E!am nose & mouth after ears 'after cryin" from ear e!am(
)#serve shape & structural deviations
Nares: ' check patency, mucous mem#ranes, dischar"e, inferior
tur#inates, #leedin"(
Septum: 'check for deviation(
8nfants are o#li"ate nose #reathers
Nasal ?arin" is associated 7ith respiratory distress,-
Nose: ariations
+ller"y: %ale, #o""y mucous mem#ranes & interior tur#inates,
7atery
dischar"e, mouth #reathin" & 4aller"ic salute6 line across nose:
8nfection: Erythematous, edematous mucous mem#ranes, 7ith
purulent yello7
or "reen nasal dischar"e
Forei"n #ody: Foul odor or unilateral dischar"e
E!coriation: 8rritatin" dischar"e, freHuent 7ipin" or nose pickin"
Structure variations: )#serve ?attened nose or nasola#ial folds
that may indicate
con"enital anomolies:
+symmetry of nasola#ial folds may indicate facial nerve impairment
or
1ell=s palsy:
Sinuses: $ey %oints
%alpate ma!illary & frontal sinus areas for tenderness of sinusitis in
older children
5evelopment of facial sinuses and location of sinus pain is listed
#elo7:
Sinus %ain 9ocation +"e of 5evelopment
Ma!illary cheek & upper teeth present K #irth
Ethmoid medial & deep to eye present K #irth
Frontal forehead & a#ove eye#ro7 appro!imately L years
Sphenoid deep #ehnd eye in occiput adolescence
Mouth & %haryn!: $ey %oints
8nspect lips for color, symmetry, moisture, s7ellin", sores, 2ssures
:
8nspect #uccal mucosa, "in"ivae, ton"ue & palate for moisture,
color, intactness, #leedin",
lesions:
8nspect ton"ue & frenulum for movement, si>e & te!ture
&ount teeth & inspect for caries, malocclusion and loose teeth:
0- deciduous teeth, #e"in eruption at A months & continue addin"
appro!imately ,*month
M0 permanent teeth, erupt from A to 03 years, 7ith molar eruption
from ,to 03 years
8nspect uvula for symmetrical movement or #i2d uvula 'indicatin"
cleft palate or <N9
)#serve for Huality of voice
)#serve infants for rootin" and suckin" re?e!es, Epstein pearls &
thrush
)#serve #reath for halitosis,,
Mouth & %haryn!: ariations
Ne7#orn cysts: <hite retention epitheleal cysts occur in the
ne7#orn:
Epstein=s pearls occur alon" midline of palate:
1ohn=s nodules occur alon" "um line, resem#lin" teeth:
esicular eruptions: &an occur on lips, #uccal mucosa & ton"ue,
due to viral infections,
such as herpes simple! cold sores or aphthous stomatitis:
Fissure*cracked lips: May #e due to harsh climate or vitamin
de2ciencies:
&olor variations: &entral cyanosis can #e o#served in lips &
mucosa::
%allor may indicate anemia:
&herry red coloration may #e seen in acidosis:
<hite patches: <hite ulcerated sores on mucosa ae cankers,
related to mild trauma,
viral infection, mild trauma or local irritants:
$oplik=s spots, small 7hite, red rimmed eruptions on #uccal mucosa
ne!t to 2rst & second molars, appear and disappear #efore the
onset of
Measles 'ru#eola( rash:
<hite curdy patches that cannot #e scraped a7ay, may #e oral
candidiasis 'thrush(, and is common in infants, especially follo7in"
anti#iotic therapy:
Ton"ue variations: + smooth, red ton"ue may #e related to vitamin
de2ciencies
:
4Stra7#erry6 and 4@asp#erry6 ton"ue are seem in scarlet fever:
+ short frenulum 7ith ina#ility to touch ton"ue to upper "um rid"e
'4ton"ue tie6 or ankylo"lossia( may lead to later speech pro#lems:
%alate & uvula: <ith "a" re?e!, deviation of uvula to one side
su""ests either
Nlossopharyn"eal or va"us nerve involvement or infection of
peritonsillar or retropharyn"eal a#cess:
+n a#sent or #i2d 'notched( uvula may indicate su#mucosal or soft
palate cleft:
Tooth markin"s: 1ro7n & #lack spots may indicate caries:
41a#y #ottle6 caries appear on teeth at "um line and are
due to #a#ies takin" a #ottle to #ed, and milk pools around the
teeth:
1ro7n.7hite mottlin" may indicte e!cessive ?uoride intake:
Nreen & #lack stainin" may indicate oral iron intake contactin"
teeth
+n increase in tooth decay or evidence or eroded enamel may
indicate
freHuent, self.induced vomitin", especially in adolescent "irls:
&allous
marks on 2n"ers*knuckles mi"ht also #e o#served,0
%haryn!: 9ar"e tonsils, due to developmental lymph tissue
hypertrophy
+re common in school a"ed children & adolescents
9ar"e red tonsils covered 7ith 7hite e!udate are su""estive of
streptococcal tonsillitis, especially if palatal petichiae & red uvula
are
present:
Thick, "ray e!udate may indicate diptheric tonsititis
+ "ray, necrotic discoloration of tonsillar tissue may su""est
infeftious
mononucleosis:
+ unilateral, red, enlar"ed tonsil su""ests peritonsillar a#cess:
oice Huality: Nasal voice may indicate enlar"ed adenoids
Hoarse cry may indicate croup, cretinism or tetany:
Shrill, hi"h.pitched cry may indicate increased 8&%, such as
head inDury or menin"itis:
Neck: $ey %oints
&heck for position, lymph nodes, masses, cysts or 2stulas*clefts
Suppleness & @an"e of Motion '@)M(
&heck clavicle in ne7#orn
Head control in infant
Trachea & thyroid in midline
&arotid arteries '#ruits(
Torticollis
<e##in"
Menin"eal irritation
Neck: ariations
Head la": Si"ni2cant la" after A months may indicate cere#ral
palsy
Torticollis: 4Sti; neck6 7ith resistance to lateral head turn as result
of inDury to
sternocleidomastoid muscle, more often seen in ne7#orn
&lavicle: &heck for fracture in ne7#orn, associated 7ith shortenin",
#reak in contour,
&repitus at fracture site, and decreased motion of arm
<e##in": Feature of 4Turner=s syndrome6 or other con"enital
a#normalities
Menin"eal: 8rritation indicated #y nuchal ri"idiy, opisthotonos,
tripod position 7ith sittin",
%ositive 1rud>inski=s si"n '7ith patient supine, neck ?e!ion produces
pain and
?e!ion of hips and knees(:
%ositive $erni"=s si"n '7ith patient supine, hip & knee ?e!ed,
e!tension of knee
%roduces pain & resistance
Nodes: 9ymphadenopathy common 7ith infection in older children,
upper neck areas,
and #elo7 an"le of Da7, usually #ilateral: Should not #e deep
cervical or
clavicular:,M
Mumps: %arotitis produces s7ellin" over an"le of Da7, usually
unilateral,
7ith redness & s7ellin" of Stensen=s parotid duct in mouth & pain
7ith
sour tastes:
Thyroid +scends 7ith s7allo7in" 'not normally palpa#le in youn"
child(:
&heck #ruits, nodules or "oiter '& accelerated "ro7th, starin" eyes(
9ymph Nodes: $ey %oints
8nspect & palpate lymph nodes for si>e, color, location,
temperature, consistency, tenderness,
2rmness & mo#ility:
Nodes are proportionately lar"e in older children & adolescents,
and smaller in the elderly:
9ymphadenopathy in the head & upper neck area are common 7ith
various infections:
')cciptal, pre & post auricular, super2cial anterior cervical, posterior
cervical, tonsillar,
su#mandi#ular, su#ma!illary, su#mental, su#lin"ual(
8n"uinal lymphadenopathy may #e o#served in some diapered
children, #ut not usually
other7ise:
5eep cervical, supraclavicular, infraclavicular, a!illary &
epitrochlear lymphadenopathy may
indicate patholo"y: