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
Color of skin 2. Symmetrical 3. Edema of the face. 4. Hair: deficiency, excess. Hirsutism tumour of adrenal glands and ovaries
1.

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.

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

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
1. Shape external auditory canal pressure on tragus are painless palpation on processus mastoideus are painless. 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 postauricular occipital tonsillar submandibular submental

superficial anterior cervical deep cervical posterior cervical 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

 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.

deep cervical

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