Beruflich Dokumente
Kultur Dokumente
2
the Head and Neck
L. Roy Eversole, DDS, MSD, MA, and Sol Silverman, Jr, MA, DDS
Salivary glands, 13
Vital signs, 7
Respiration, 8
Pulse, 8
Larynx, 16
Neck, 17
External eyes, 10
Temporomandibular joint, 17
Ears, 11
Cranial nerves, 19
Suggested reading, 26
Upon completion of the history, a physical examination is conducted for the assessment of patients with
complaints relevant to oral medicine problems. This
examination involves assessment of vital signs and
clinical evaluation of the tissues in the head and neck
region, including the anatomic areas listed in Table
21. Visual inspection, palpation, and auscultation
assessments of the head and neck tissues are made in a
sequential manner. During this procedure, various
anomalies or lesions are recorded in the patients
chart. Recording of abnormalities can also be assisted
by procurement of clinical photographs and other
forms of imaging, including radiographs, computed
Table 21
Vital signs
Hair and facial skin
External eyes (lids, conjunctiva, iris)
Ear (external, tympanic membrane)
Oral cavity and oropharynx
Dental and periodontal tissues
Temporomandibular joint
Facial muscles
Nasal cavity and nasopharynx (endoscopy)
Larynx (endoscopy)
Major salivary glands
Anterior neck (thyroid)
Lateral neck
Posterior neck
Supraclavicular notch
Cranial nerve function
Finding
Hair
Skin
Mucosa
Deep tissue
Craniofacial
TMJ
Tympanic membrane
Neurologic
Table 23
mirror. Visualization of sequestered areas requires special instruments, such as the otoscope, ophthalmoscope,
nasopharyngoscope, or fiber optic laryngoscope.
Masses of the deeper tissue are usually detected by palpation. The stethoscope can be used with auscultation
to assess the carotid artery, temporomandibular joint
(TMJ), and larynx.
The primary elements of the physical diagnosis in
dentistry are the following:
1.
2.
3.
4.
5.
6.
Vital signs
The first phase of the physical examination is the evaluation of a patients vital signs, which include respiratory rate, heart rate, and blood pressure. Height,
CHAPTER 2
Respiration
Respiration rate is determined by sitting next to or standing behind the patient seated in the dental chair and looking down at the patients chest. Count the number of
times the chest rises and falls for 30 seconds and then
multiply by 2. A normal respiratory rate is 12 to 15 respirations per minute. Hyperpnea occurs in acidosis when
an increase in carbon dioxide exhalation occurs as a
physiologic compensatory process to increase blood pH.
Increased shallow respirations, tachypnea, may be
encountered in anxious patients. Metabolic alkalosis
results in a decreased rate of respiration.
Pulse
Cardiac rate, rhythm, and strength are assessed by taking the radial or carotid artery pulse. The first two measures are objective and easy to learn; a measure of pulse
strength is subjective and is learned after evaluating the
pulse of numerous subjects. To undertake these measures of cardiac function, one uses digital means. For
the carotid pulse, the first two fingers are placed just
anterior to the sternomastoid muscle, posterior to the
larynx, and below the angle of the mandible in the
region of the carotid bulb (Figure 22). Only light pressure is applied until pulsations are readily detectable.
Excess adipose tissue of the lateral and anterior neck in
obese patients may preclude a reliable examination, and
it may be more prudent to attempt to take a radial
Figure 23
pulse. This is accomplished by placing the first two fingers in the slight trough produced by a tissue depression
between the radius and the flexor tendons located on
the ventral wrist just proximal to the thumbs thenar
eminence (Figure 23). Only light pressure is exerted
until pulsations are perceived.
The cardiac rate is determined by counting the number of beats during 15 seconds and multiplying by 4.
Normal heart rate is 60 to 80 beats per minute. Bradycardia occurs in dedicated athletes yet can also be
pathologic. Tachycardia occurs in anxious subjects and
in a variety of metabolic and cardiac diseases. The
rhythm is assessed after or while taking the pulse rate.
A normal pulse should be steady with equal intervals
between pulsations. Rapid beats followed by delayed
intervals are indicative of cardiac conduction disturbances, as may occur in myocardial ischemia and
myocarditis or from various metabolic disorders. Pulse
strength, as mentioned previously, is a subjective measure and is learned after repeated palpation of the
carotid or radial artery on many patients. A strong
pulse is indicative of high cardiac output, whereas a
weak pulse occurs during low contractility.
Blood pressure and body temperature
Figure 22 Placement of the fingers over the carotid artery, just anterior
to the sternomastoid muscle to assess cardiac rate, rhythm, and strength.
applied pressure continues to be decreased until pulsations are no longer detected. This level of pressure, the
diastolic, varies normally from 70 to 90 mm Hg.
To measure blood pressure, an inflatable sphygmomanometer cuff is placed around the upper arm (Figure
24). For children there are small cuffs and for adults
with large arms there are oversized cuffs. A stethoscope
with a flat diaphragm is placed in the antecubital notch.
The precise location of the brachial artery varies somewhat, so it might be advisable to first palpate the area
B
Figure 24 Blood pressure measurement. A, Pressure cuff with stethoscope over the antecubital fossa; B, sphygmomanometer showing a
high diastolic pressure reading; C, digital readout gives systolic and diastolic pressures as well as heart rate. Elevated diastolic pressure is a sign
of increased peripheral resistance (hardening of the arteries or arteriosclerosis). High systolic pressure is also indicative of hypertension.
10
CHAPTER 2
external aspects of the eye are observed. The eyebrows are first examined followed by the skin surfaces of the upper and lower lids and then the eyelashes. The inner mucosal surfaces of the eyelids
(palpebral conjunctivae) are examined by inverting
the lids. The lower lid is easily inverted by placing the
thumb or forefinger on the center of the lid skin and
sliding it inferiorly. The upper lid does not retract as
easily, and to clearly visualize the mucosa, a match
stick or blunted toothpick can be placed longitudinally along the upper lid and with light pressure of
the finger, the lid can be rolled back over the stick.
The white portion of the globe of the eye, the sclera, is
covered by bulbar conjunctiva, a mucosal membrane
with fine vascular channels (Figure 25). The conjunctivae are examined for dryness, erosions, telangiectasias, scars, and nodules. A scar band that traverses the bulbar and palpebral conjunctivae is
referred to as a symblepharon. A slit-like defect in the
eyelid is termed coloboma. The iris, or pigmented
ring, surrounds the black pupil and is covered by a
convex transparent cornea. A slit in the iris, giving a
keyhole appearance, is termed iridial coloboma. The
iris can dilate and constrict, varying the diameter of
the pupil, depending upon the focal distance of the
eye and the amount of light. In neurologic disorders
and drug overdose, the papillary diameter is altered.
An overly dilated pupil (over 6 mm) is termed mydriasis whereas an overly contracted pupil (less than 2
mm) is called miosis. The pupillary reflex is checked
during the cranial nerve function assessment. The
cornea is examined for opacifications, which usually
represent cataracts.
External eyes
Visual acuity, peripheral vision, visual fields, pupillary reflex, and retinal integrity (funduscopy) can be
tested when conducting the cranial nerve assessment.
At this point in the physical examination, only the
Figure 25
11
Ears
Cartilage gives shape to the external ear (Figure 26).
Its structure helps to funnel sound waves into the external auditory meatus. The outer curvature is the helix,
which terminates inferiorly as the lobe. The cartilage
flap just anterior to the external canal is the tragus. Skin
cancers can arise on any of these sun-exposed areas,
especially the superior helix or pinna.
Examination of the tympanic membranes (TM) or
eardrums requires the use of an otoscope (Figure 27).
This visualization instrument consists of a batterycontaining handle, a light source, a magnification lens,
and a funnel-shaped speculum. Since individuals have
external ear canals of varying diameters, the ear speculums vary in size. To allow visualization of the TM the
external auditory meatus must be free of cerumin (earwax). A Q-tip will usually suffice, although in some
patients, small ear curettes must be employed to clear the
canal of wax. To examine the TM, the pinna should be
grasped with the thumb and forefinger and pulled up and
back. The speculum is inserted slowly and gently into the
canal with a slight anterior angulation. The canal does
not extend straight at a perpendicular angle to the side of
the head. The speculum is inserted just short of the hub,
and at this point, the examiner looks through the lens. If
the TM is not readily visualized, the speculum can be
rotated and angulated slightly while the examiner continues to gaze through the lens. The membrane is whitish
and taut, like the head of a drum (Figure 28). The upper
region is opaque and referred to as the pars flaccida,
whereas the lower portion, the pars tensa is translucent.
Fine vascular markings may be present over the surface.
At the junction of the two regions is an inferiorly directed
linear structure that represents attachment of a middle
ear ossicle, the malleus, on the opposite (middle ear) side
of the membrane. During the examination, one should
check for telangiectasia, bulging, and erythema, surface
white plaques, and perforations.
Figure 26
Figure 27
meatus.
12
CHAPTER 2
Pars flaccida
Malleus
Short process
Incus-stapes junction
Manubrium
Umbro
Pars tensa
Figure 28
13
Salivary glands
While still gloved from the oral examination, the practitioner can assess salivary function. Milking the glands
will give a crude estimate of salivary flow, and one can
determine whether an obstruction of the duct is present
(Figure 214). For the parotid glands, a gauze square is
used to dry the buccal mucosa over the parotid papilla
(see Figure 214, A). The mouth must be wide open
with the cheek stretched taut. All four fingers are placed
flat on the face, over the parotid gland, which is found
in the preauricular region. The gland is milked by plac-
D
Figure 29 Visual examination of, A, the tuberosity with the dental
mirror; B, the anterior mandibular gingiva; C, the buccal mucosa; D, the
everted lower lip, showing the mucosal surface and the sulcus; E,
retracted upper lip showing the gingiva, lip mucosa, and vestibule.
14
CHAPTER 2
Figure 210 A, The anterior aspect of the hard palate and rugae; B, dorsum of the tongue; C, lateral border of the tongue; D, anterior floor of the
mouth, lingual frenum, and carunculae.
Figure 211
fauces.
Figure 212
15
angiocath sleeve. (Note: This procedure is contraindicated in patients with allergies to iodine or radiographic
contrast media.) Once the patient is positioned for the
procurement of radiographs of the gland under study,
the patient is instructed that upon injection of the dye,
he or she will experience pressure and fullness. The
patient is instructed to raise the hand as a signal when
this fullness turns into a stinging pain sensation. Begin
slowly filling the duct tree with radiopaque contrast
media, never force the plunger (Figure 215). When the
patient raises the hand, deliver an additional 0.5 to 1
mL, let go of the syringe and move out of the way so
that a radiographic exposure can be made immediately.
Take another backup film then remove the angiocath. A
post-fill film should then be obtained 5 minutes later.
Sialography is used sparingly and is not free from the
risk of ductal perforations.
B
Figure 213 A, Bidigital palpation of the anterior floor of mouth contents. B, Palpation of posterior floor of the mouth.
B
Figure 214 A, Wiping saliva away from Stensens duct prior to milking the parotid gland. B, Milking saliva from the parotid gland.
16
CHAPTER 2
Figure 215
lar duct.
Larynx
Examination of the supraglottic larynx is performed with
either a rigid or a flexible laryngoscope. The vocal structures can also be viewed indirectly using a headlamp and
a laryngeal mirror, but gagging is problematic, and fiber
optic endoscopes are much easier on both examiner and
B
Figure 216
17
As with the nasopharyngoscope, the laryngoscopic equipment can be attached to a video system. This allows for
procurement of a permanent record.
Neck
The neck should be initially examined by visualization,
searching for any masses, surface skin lesions, jugular
vein distention, and asymmetry. Palpation of the neck
proceeds from the anterior to the posterior triangles.
Beginning with the anterior triangle, the body of the larynx is grasped between the thumb and forefinger. A
stethoscope is placed anteriorly, and the trachea is
moved from side to side. Audible crepitus should be
noted. Next, the stethoscope is placed over the carotid
bulb just anterior to the sternomastoid and below the
angle of the mandible (Figure 219). The patient is asked
to take and hold a breath while the clinician auscultates
both sides, listening for a bruit or thrill (a chugging or
slush sound), which can be indicative of aneurysm.
The thyroid is not normally palpable. To examine for
enlargement, place the grouped fingers on one side of the
larynx and push laterally while palpating the opposite
side. Next, bidigitally palpate down the course of the
anterior sternomastoid, burying the fingers into the
trough between the muscle and the anterolateral neck
(Figure 220). The area is palpated from the carotid bulb
where carotid-body tumors can arise, down to the clavicle, along the cervical lymph node chain. End by pushing fingers into the supraclavicular notch, a region where
upper intestinal tract malignancies may metastasize (signal node) (Figure 221). Repeat the palpation examination for the opposite lateral neck. Lastly, the postauricular, retrosternomastoid region should be palpated along
with the back of the neck.
Temporomandibular joint
The temporomandibular joint (TMJ) is examined by
palpation and auscultation. First, the interincisal maxi-
C
Figure 217 A, Insertion of fiber optic laryngoscope; B, scope is
placed high, deflecting the soft palate superiorly. C, Once the scope is in
place, the larynx is visualized through the ocular.
18
CHAPTER 2
Tongue base
Epiglottis
Pyriform sinus
Aryepiglottic fold
Cartilages
Figure 218
Figure 219
scope.
Figure 220
Auscultation of the carotid bulb region with the stethoBidigital palpation of the lateral neck.
Figure 221
19
Figure 223
Figure 222
Figure 224
sounds.
Cranial nerves
20
CHAPTER 2
rently extant. If in fact the patient responds in the affirmative to any of these questions, objective assessment is
undertaken or the patient may be referred to an internist
or neurologist for in-depth examination.
The first cranial nerve (olfactory) can be tested by
having the patient occlude one nostril while allowing
specific aromas contained in liquid form within a vial to
enter the open nostril. Commonly tested aromas include
coffee, vanilla, perfumes, and hydrogen sulfide. Failure
to detect odors is termed anosmia. Dysosmia is mistaking a common odor for something else. Nasal obstruction, trauma to the cribriform plate, or lesions of the
olfactory tract may be present. The second cranial nerve
(optic) can be tested objectively by using an eye chart
for visual acuity and by examining visual fields. The latter is performed with an electronic view chamber or can
be screened by having the patient gaze straight ahead
while the examiner introduces an object or fingers
around the periphery of the visual fields. One eye at a
time is tested, beginning with placing the peripheral
object above the forehead and progressively dropping it
until it is perceived. This procedure is then repeated for
the lateral, medial, and inferior aspects of peripheral
vision, noting any restrictions. Rapid movement of the
eyes is referred to as nystagmus; strabismus is a deviant
position of one eye, usually either laterally or medially.
Diplopia refers to double vision. Funduscopic examination is performed to assess the retina. Eyegrounds, or
retinal vessel disease connote hypertension and diabetic
microangiopathy. Retinal detachments, hemorrhages,
and pigmentations are also visualized. In an oral medicine practice, a retinal examination is rarely performed,
because the pupil must be dilated pharmacologically to
achieve accurate observations.
Table 24
Cranial Nerves
Subgroup
Nerve
Special senses
Smell
Seeing
Hearing
Taste
Olfactory
Optic
Vestibulocochlear
Facial, glossopharyngeal
1st
2nd
8th
7th, 9th
Function
Nerves of smell
Nerve of sight
Nerves of hearing
Taste fibers
Somatic sensory
Trigeminal
Facial, auricular
Glossopharyngeal
5th
7th
9th
Motor
Oculomotor
Trochlear
Trigeminal
Abducens
Facial
Vagus
Spinal accessory
Hypoglossal
3rd
4th
5th
6th
7th
10th
11th
12th
Moves eyes up, down, and medially; elevates lid, pupillary reflex
Moves eyes inferolaterally
Muscles of mastication
Moves eyes laterally
Muscles of facial expression
Gag reflex, speech
Superior movement of shoulders
Tongue movements
21
a dental explorer for perception of pain (pin-prick sensation) (Figure 227). The cotton tip is pulled out to a
thin whisp and is applied gently to the facial skin to test
the sensory component of the fifth cranial nerve
(trigeminal). For pin-prick testing, the examinar should
first lightly touch the dental explorer to the back of the
patients hand, to orient him or her as to the sensation
prior to using this sharp object on the face. Both light
touch and pin-prick are tested over the forehead (V1),
the malar region (V2), and the chin (V3) on each side of
the face. Intraoral sensory perception can be assessed by
using both light touch and pin-prick on the hard palate,
maxillary gingiva, mandibular gingiva, and lateral
tongue. Sensory fibers of the seventh cranial nerve
(facial) innervate the tissues of the external ear that lie
adjacent to the auditory meatus. This region is also
tested by light touch and pin-prick. The ninth cranial
nerve (glossopharyngeal) is sensory for the oropharynx
and can be tested over the fauces and the posterior
aspect of the soft palate. Altered sensations are paresthesias; loss of sensation is hypesthesia. These sensory
deficits may be attributable to trauma, such as injury to
the inferior alveolar nerve during third molar extraction
or jaw fracture; however, when there is no history of
injury, a malignancy must be considered.
Motor nerve testing involves observing movements.
The three nerves that supply the extraocular muscles are
tested by having the patient move the eyes in five directions: up, down, left, right, and down and out. The
patient focuses on the examiners finger as it is moved in
various directions, and the examiner makes note of the
patients eye movements (Figure 228). The motor nerves
that control eye movement are tested together by having
Figure 225
the patient move his or her eyes up and down and side to
side. The third cranial nerve (oculomotor) moves the eyes
up and down and medially; the sixth cranial nerve
(abducens) moves them laterally. The examiner then asks
the subject to follow the finger as it is moved down and
out for each eye, a test for the fourth cranial nerve
(trochlear) function. Failure to complete these movements is referred to as ophthalmoplegia, a condition that
can be caused by extraocular muscle injury or a neurologic lesion along the course of these motor nerves. The
third cranial nerve also regulates in part, pupillary diameter. This is tested in two ways. First a light beam is
directed at the pupil; this stimulus should cause pupillary
constriction (Figure 229). When the light stimulus is
directed into the right eye, the left pupil constricts as well,
in consensual response. The pupils also respond to
accommodation. The subject is asked to gaze across the
room, then to focus on a card with lettering held 2 feet
from the eye. The pupil will dilate if normal. Anisocoria
represents constriction of a single pupil and may be a sign
22
CHAPTER 2
B
Figure 227 A, Soft touch sensory perception testing; B, pin-prick sensory perception testing.
C
Figure 228 A and B, Testing the oculomotor (nerve III) and abducens
(nerve VI) by lateral eye movement. C, Testing the trochlear (nerve IV)
for down and out eye movement.
23
Figure 229
24
CHAPTER 2
Figure 232 The oculomotor nerve, like a pillar, raises the upper lid;
the facial nerve, like a hook, closes the lid.
Figure 234
B
Figure 233 Testing the spinal branch of the eleventh cranial nerve
(accessory nerve).
Figure 235 Venipuncture. A, Application of tourniquet; B, placement of needle into vein and compression of vacutainer tube.
25
A
A
C
Figure 236 Patch test. A, Application of test materials to tape; B,
placement of tape with allergens to skin; C, a zone of erythema indicates delayed-type hypersensitivity.
C
Figure 237 Punch biopsy. A, Obtaining a core with a 5-mm punch
instrument; B, removing the punch biopsy tissue fragment with curved
scissors; C, placing the tissue in formalin.
26
CHAPTER 2
Figure 238
Figure 239 Brush biopsy. The brush is rotated or twirled over the
area to be sampled.
Suggested reading
Alexander MM, Brown MS. Physical examination. Part 17:
neurological examination. Nursing 1976;6:3843.
Bates B. A guide to physical examination. 4th Ed. Philadelphia: Lippincott, 1987.
Hicks JL. Important landmarks of the orofacial complex.
Emerg Med Clin North Am 2000;18:37991.
Mulliken RA, Casner MJ. Oral manifestations of systemic disease. Emerg Med Clin North Am 2000;18:56575.
Seidel HM, Ball JW, Dains JE, Benedict GW. Mosbys guide to
physical examination. 2nd Ed. St. Louis: Mosby Year
Book, 1991.
Tanaka TT. Recognition of the pain formula for head, neck,
and TMJ disorders: the general physical examination.
CDA J 1984;12:439.