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Approach to the ENT Patient Head and Neck Exam By: Christine B. Taylor, MD
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LEARNING OBJECTIVES After reviewing this module, the student will have the ability to: - Develop a systematic approach to interviewing and examining the ENT patient - Gain understanding of all components of the comprehensive head and neck physical exam - Learn about what special tools are used in Otolaryngology to examine the patient
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History Chief complaint: Ear? Nose? Throat? Neck? HPI: Onset, frequency, duration Associated symptoms What has the patient already tried? Pertinent positives and negatives Always think: “Could this be related to underlying malignancy or something more serious?” Previous work-up, testing, imaging, or interventions What has already been done or tried for this?
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History Past Medical History: Allergies? Asthma? Neurologic or rheumatologic disorders? Past Surgical History: Head and neck procedures? Allergies- Aspirin Sensitivity? Meds- Is this problem medication-related? Social History - Smoker? Alcohol use? Family History- Does this run in the patient’s family? Remember: The patient may not know their full medical history. Often, you will have to ask specific and directed questions to get the information you are looking for Sampter Triad: Allergies + Asthma + Aspirin sensitivity Familial/genetic syndromes, such as MEN (which may have concurrent thryoid or parathyroid carcinoma, pheochromocytoma, or typical physical features
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ENT Review of Systems Gen: fever/chills/weight changes Ear: tinnitus/ vertigo/ hearing loss/ otalgia/ otorrhea Nose: congestion/ rhinorrhea/ epistaxis/ decreased smell Throat: pain/ dysphagia/ odynophagia Larynx: hoarseness/ voice changes/ noisy breathing/ difficulty breathing / pain with speaking (odynophonia) Trachea: noisy or difficulty breathing Neck: lymphadenopathy/ new lumps or bumps/ pain/ swelling Face: sinus pain/ pressure/ swelling/ numbness
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Physical Exam Tips: Remember that you will be approaching the patient very closely and are examining the head and face so be careful not to invade the patient’s personal space. (Also, check your breath and monitor the volume of your voice accordingly!) Try to go in the same order each time you examine the patient Tools: Pen light, tongue blades, nasal speculum (or otoscope for nasal exam if speculum not available), otoscope Your eyes and hands
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Initial Exam First, start by looking at the skin of the face Look for scars, any concerning lesions Check for symmetry, is there muscle weakness? Does the patient have tell-tale signs? Nasal crease in allergies Noisy nasal breathing? Listen to the patient’s voice as they give the history/answer questions Is it breathy? Nasal? Does the patient have stridor? Be observant. Most of this can be done within the first few minutes in the exam room You can also usually get a sense within a few moments if the patient is acutely ill or whether their problem is more chronic in nature
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Face/Cranial Nerves CN VII Bilateral muscles of facial expression Asymmetry or weakness CN V Bilateral sensation in all distributions (V1-V3) Extraocular Muscles (CN III, IV, VI) CN VIII – hearing (see ear exam) CN X - palate rise, voice CN XI - shoulder shrug, head turn CN XII- tongue protrusion Facial muscle function is graded from 1-6 using the House-Brackmann classification. A score of 1 denotes full motion while 6 indicates no mobility. Each side is graded individually when there is asymmetry between sides.
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Ears External exam Deformities? Preauricular pits? Ulcers or lesions? Otoscopy External Auditory Canal erythema, stenosis, debris or discharge Tympanic Membrane Normal: Shiny, translucent, visible light reflex Tympanosclerosis (white) Erythema, bulging, dull, retractions Perforations Pneumatic otoscopy Mobility of TM
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Ears Microscopy: 3D image Tuning fork exam Rinne: Air vs. bone conduction Just outside to EAC vs. over mastoid Normal: AC > BC Weber: Tuning fork on top/center of head Normal: equal on both sides Does the sound lateralize?
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Video- Ear exam American Academy of Otolaryngology ENT EXAM videos Episode 1: The Ear Exam http://www.entnet.org/EducationAndResearch/The-ENT-EXAM.cfm
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Nose Eternal exam Deformities, symmetry, size/patency of nares Nasal speculum (anterior rhinoscopy) Septum, inferior turbinates Septal deviation, boggy or pale turbinates/ mucosa, hypertrophy of inferior turbinates, rhinorrhea, masses, prominent vessels Rigid or flexible nasal endoscopy Vasoconstriction + decongest with Afrin (oxymetazolone) Exam of sinus openings, mucosa, middle turbinates
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Video- Face and Nose Exam American Academy of Otolaryngology ENT EXAM videos Episode 3: The Face and Nose Exam http://www.entnet.org/EducationAndResearch/The-ENT-EXAM.cfm
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Mouth *Use your tongue blades! Teeth, gums, alveolar ridge Edentulous, dentures (remove), caries, bite Mucosa Buccal mucosa, palatal mucosa, lingual mucosa, vestibule (between teeth and lips) Retromolar trigone Tongue surfaces, including sides; examine bulk/atrophy, fasciculations, strength Floor of mouth: look under the tongue! Palpation: feel for masses on tongue/floor of mouth
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Salivary Glands Palpate for masses, stones Check for salivary duct patency Stenson’s duct (parotid gland opening on buccal mucosa) Wharton’s duct (submandibular and sublingual gland, located on floor of mouth)
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Oral Cavity and Oropharynx *Use your tongue blade here too! Palate and uvula Tonsils Enlarged, symmetry, exudates, masses Grading tonsils Posterior pharyngeal wall Erythema, drainage, purulence, exudates
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Video- Oral Cavity and Neck Exam American Academy of Otolaryngology ENT EXAM videos Episode 2: The Oral Cavity and Neck Exam http://www.entnet.org/EducationAndResearch/The-ENT-EXAM.cfm
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Neck External Exam Lymphadenopathy Thyroid Range of motion Masses Exact location, size, mobility, depth, tenderness, texture, firmness, fluctuance Larynx and trachea
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Fiberoptic Nasopharyngoscopy What is it? Exam of nasal passages, nasopharynx, oropharynx, hypopharynx, larynx Use afrin/lidocaine before exam to decongest, vasoconstrict, and provide local anesthesia Indications? Voice changes, neck masses, shortness of breath/noisy breathing, concern for mass anywhere along the aerodigestive tract (from nose down to larynx)
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Take-Home Points All new patients should have full Head andNeck exam Always be on the lookout for signs/symptoms of malignancy Good lighting and the right tools are essential Thorough exam is essential, especially when considering consultation/referral to a specialist
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Acknowledgements/Resources Photo credits – Thank you to Megan M. Gaffey, MD and Lauren Thomas for participating in physical exam. Primary Care Otolaryngology, 3rd edition. Edited by Mark K. Wax. (Available through the American Academy of Otolaryngology- Head and Neck Surgery Website- http://www.entnet.org) American Academy of Otolarynoglogy Website (www.entnet.org); ENT EXAM videos: http://www.entnet.org/EducationAndResearch/The-ENT-EXAM.cfm Thank you to Christian Stallworth, MD for overseeing this project and providing advisory support. Editing and input: Jeanne Hatcher MD, John Morehead MD