A comprehensive head and neck exam includes the eyes, ears, nose, mouth, throat, and neck. In the clinic, the head and neck examination is often more limited and tailored to the patient’s history and presenting concern. Experienced clinicians may also test the cranial nerves as part of the HEENT exam, depending on the chief concern.

The HEENT exam is usually performed in the seated position but in the hospital, it may be done reclining.

To prepare for the Head and Neck Physical Exam Lab, view the landmarks and prepare to perform each of the maneuvers by either watching the Exam Video OR reading carefully through the list of exam maneuvers.

A short demonstration of the exam in class will be followed by time to practice.

Immersion: Landmarks

Immersion: Exam Maneuvers

Perform an integrated skin exam as you complete the following maneuvers.

Measure visual acuity in each eye

Normal visual acuity is 20/20, meaning your patient can read print at 20 feet that someone with normal vision can read at 20 feet. As visual acuity decreases, the denominator goes up – Visual acuity of 20/80 indicates that a patient can recognize at 20 feet a symbol that a person with normal acuity can recognize at 80 ft.

Hold a pocket vision screener or smartphone app the indicated distance away from your patient.  Ask them to cover one eye and read the lowest line they can with the other, then switch eyes and repeat.

Inspect the external eye

Carefully observe eyelids and eyelashes, conjunctiva, sclera, cornea, anterior chamber, and iris. Note any differences in symmetry, redness or swelling of the eyes and surrounding tissues.

Observe the corneal light reflex

Hold your penlight directly in front of your patient, about 12 inches away. The light should appear in the same spot in both eyes, indicating that they are normally aligned. An asymmetric corneal light reflex indicates that your patient has strabismus, which can cause long term vision problems in children.

Assess pupil symmetry & reactivity

Observe the size of the pupils, which are typically equal in size.  Anisocoria of < 0.5 mm is common and is considered normal if the pupils react to light. 

Next, assess the reactivity of the pupils by observing pupillary constriction with direct and consensual light. In people with dark brown irises, pupils may be easier to see if the light is shone from below.

Perform fundoscopy

Fundoscopy (also called direct ophthalmoscopy) allows you to view the interior structures of the eye: the retina, retinal vessels, macula and optic disc, also called the fundus. In Immersion, you will only be expected to be able to demonstrate the red reflex (steps 1-3). We will return to examine the retina later on.

1. Position your patient so that your eyes are at the same level.
2. Have the patient gaze at a distant object in a darkened room.
3. Starting with a 0 lens, focus on the lashes from 124 inches away, and look for the red reflex. The red reflex should be symmetric and without spots, indicating that light is reflecting equally off of each retina.
4. Hold the ophthalmoscope in the R hand and use your R eye to examine the patient’s R eye. Switch hands/eyes to examine the patient’s L eye.
5. Moving in at an angle of 15 degrees lateral to the patient’s line of vision, focus on the retina by rotating the lenses until the retinal vessels are clearly visible.  Follow the vessels until you see the optic disk.  Carefully examine as much of the retina as you can.

Inspect the auricle and mastoid

Observe for swelling, erythema, and skin lesions – the ear is a common site for skin cancers.

Assess hearing

Hold your fingers an equal distance from each ear and rub the fingers on one side together, asking which ear they can hear the sound in. Compare one side to the other and to your ability to hear the sound. This is an insensitive test for loss of hearing but can easily be done at the bedside.

Perform otoscopy

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  Stand on the patient’s left to examine the left ear

• With your right hand, gently pull the left ear up and back to straighten the ear canal.
• Hold the otoscope in your left hand with the thumb and first two fingers, like a pen, or around the barrel. To stabilize your hand, brace your little finger against your patient’s forehead so that your hand moves with the head if it moves.
• Place the otoscope partway into the external auditory canal.
• Examine the canal and the tympanic membrane

Repeat for the right ear, switching sides and holding the otoscope in your right hand

Observe the external nose for symmetry and discharge

Inspect the oral cavity and posterior pharynx

With a penlight and the mouth opened as widely as comfortable, examine:

• Teeth, tongue, and hard palate
• Buccal mucosa and lateral teeth. Ask your patient to pull their own cheek out slightly, or with permission, gently use a tongue blade.
• Floor of the mouth.  Ask your patient to place the tip of the tongue on the roof of the mouth.
• Posterior pharynx. If the clinical situation requires a careful exam, ask your patient to say “aaah” to raise the soft palate.  If necessary, you can also use a tongue depressor held gently on the tongue.

Palpate the parotid and submandibular salivary glands

 The parotid glands are anterior to the angle of the jaw and the ear.  The submandibular glands are on the underside of the lower jaw, midway between the angle of the jaw and the chin. They may feel slightly lumpy, but there should be no dominant masses

Palpate the temporomandibular joint (TMJ)

With your fingers placed just anterior to the ear, palpate as your patient opens and closes the jaw, feeling for crepitus (crackling) or tenderness.

Inspect the neck for symmetry and masses

Palpate the lymph nodes

Moving the pads of your fingertips in small circular motions, attempt to roll the nodes under your fingertips, checking the area of the anterior and posterior cervical chains and the supraclavicular nodes. Normal lymph nodes are mobile and less than 1 centimeter in size but it is common to have mildly enlarged nodes in the anterior and posterior cervical chains.

Inspect and palpate the thyroid

Inspect the lower neck.  The outline of the lobes of the thyroid may be visible, more often in females than in males.

Because the thyroid exam can be triggering for those with a history of trauma, provide a clear explanation of what you will do, ensure comfort and perform the exam from beside or in front of your patient rather than from behind. You may also skip this exam in those with a history of trauma and no symptoms of thyroid disease.

Identify the thyroid and cricoid cartilages. The isthmus of the thyroid lies just below the cricoid. With the neck flexed slightly, place your index finger just below the cricoid and as your patient swallows a sip of water, feel for the isthmus.  After locating the isthmus, move the fingers to either side of the trachea.  As the patient swallows again, palpate each lobe of the thyroid gland, observing for enlargement or masses.

Each lobe of the thyroid is normally about the size of the distal phalanx of the thumb.  Because it lies partly under the sternocleidomastoid, the thyroid may be difficult to feel in some people. If you palpate carefully and cannot identify it, move on.

Palpate and auscultate each carotid artery

Gently palpate each carotid artery one at a time, assessing the strength of the pulse. As the patient briefly breath-holds, place your stethoscope lightly over each carotid artery, listening for radiation of heart murmurs or bruits, which can indicate narrowing of the artery.

Immersion: Exam Video

Immersion: Documenting the Exam

Practice using precise and descriptive language to describe your exam findings. Although you may eventually present normal findings more concisely, you will still need to provide this level of detail for body regions or organ systems that might be involved in a patient’s presenting concern.

Immersion: Knowledge Check

Term 2: Hypothesis Driven Maneuvers

Weber and Rinne tests

The Weber and Rinne tests are used to differentiate conductive and sensorineural hearing loss.  Conductive hearing loss is caused by problems with the external or middle ear, which amplify and conduct sound to the inner ear.  Sensorineural hearing loss is caused by problems with the cochlea, auditory nerve, or brain. Differentiating them can be clinically useful – conductive hearing loss is often caused by cerumen impaction, which can be treated in the clinic, while sudden onset of sensorineural hearing loss suggests the need for an urgent ENT referral.

The Weber test is performed on patients with asymmetric hearing.  Strike the 512 Hz tuning fork against your knee to make it vibrate, then place it on your patient’s head in the midline. The bones of the skull will conduct the sound to the inner ears.  Ask your patient which ear hears the sound best.

If the ‘bad’ ear hears the sound better, there is conductive hearing loss in that ear.  The relative lack of sound conducted from the outside world to the inner ear makes the tuning fork sound louder – try it on yourself by blocking one ear with your finger.

If the ‘good’ ear hears the sound better, it means the ‘bad’ ear is affected by sensorineural hearing loss.

For the Rinne test, the vibrating tuning fork is placed on the mastoid process, testing conduction of sound through bone. It is then held just lateral to the ear testing conduction of sound through air. The patient is asked which position produces the loudest sound. Normally, air conduction should be better than bone conduction.

• In sensorineural hearing loss, air conduction is also better than bone conduction.
• In conductive hearing loss, bone conduction is better than air conduction.

Inspect the nasal mucosa

If you suspect sinusitis, allergies, or nasal polyps, inspect the inside of the nose with the otoscope.  Place the largest available speculum that will comfortably fit inside the nostril.  Gently elevate the tip of the nose to better see the nasal cavity.  Direct the speculum posteriorly and superiorly as you inspect the nasal cavity.  Pale nasal mucosa suggests allergies as the cause of post-nasal drip. In sinusitis, you may be able to see purulent nasal secretions.

Palpate the sinuses in suspected sinusitis

In suspected sinusitis, many providers palpate the paranasal sinuses above the eyes (frontal sinuses) and over the malar eminences (maxillary sinuses).  Sinus tenderness is a sensitive but not a specific finding of acute bacterial sinusitis.

Term 3: Problem Focused Eye Exam

For patients with a vision concern, a complete exam would include:

1. Testing visual acuity
2. Assessing visual fields
3. Inspection of the external eye
4. Assessment of corneal light reflex and extraocular movements
5. Assessment of pupillary symmetry and assessment reactivity
6. Inspection of cornea and iris
7. Fundoscopy

Step 1. Measure visual acuity in each eye

Normal visual acuity is 20/20, meaning your patient can read print at 20 feet that someone with normal vision can read at 20 feet. As visual acuity decreases, the denominator goes up – Visual acuity of 20/80 indicates that a patient can recognize at 20 feet a symbol that a person with normal acuity can recognize at 80 ft.

The best measure of acuity is distance visual acuity, which is typically tested at 20 feet. Test one eye at a time, occluding the other eye with an opaque occluder or the palm of your hand. Have the patient wear their own distance correction (glasses or contacts) if possible. Ask the patient to read the smallest line in which he or she can distinguish at least half of the letters. Record the acuity measurement as a notation (eg 20/20) in which the numerator represents the distance at which the test is performed, and the denominator represents the numeric designation of the line read. Repeat for each eye individually.

If the visual acuity is 20/40 or worse in either eye, repeat the test with the patient viewing the test chart through a pinhole occluder, as this can help identify if there is a problem with refractive error (needing glasses) or a surface or lens problem.

If the patient cannot see the largest Snellen letters:

1. Move the patient closer to the chart and record the new distance as the numerator of the acuity designation (eg 5/200 if the patient is 5 ft from the chart and is only able to read the 20/200 size letters).
2. If they are unable to see the largest Snellen letter at 3 feet, hold up 1 hand, extend 2 or more fingers and ask the patient to count the number of fingers, recording the distance at which counting fingers is done accurately (eg, CF 1ft).
3. If the patient cannot count fingers, determine whether they can correctly determine the direction of hand motion (eg HM 2ft).
4. If the patient cannot detect hand motion, use a bright light to determine whether they can detect the direction or perception of light. Use a bright light in a dim room, and ask the patient: “let me know when you see the light on,” and “let me know when the light disappears”, determining whether they are LP (light perception) or NLP (no light perception).

Near visual acuity testing is performed if a patient has a complaint about near vision or if distance testing is difficult, such as at bedside. Use a patient’s reading glasses if they use those for reading. Hold a pocket vision screener or smartphone app the indicated distance away from your patient. Ask them to cover one eye and read the lowest line they can with the tested eye, then switch eyes and repeat.

Step 2. Perform a confrontation visual field test for each eye

This test grossly examines for visual field deficits. Place yourself approximately 1 meter away from the patient. Ask the patient to cover the left eye while covering your right eye in order to use your own left eye as a reference in assessing the patient’s field of view. Ask your patient to look at your uncovered left eye and count your fingers in each of the 4 quadrants of the visual field. Use 1, 2, or 5 fingers in this test. Wiggling the fingers may be less sensitive. Repeat the procedure with the patient’s left eye.

Step 3. Inspect the eyelids, surrounding tissues, conjunctival and sclera

Carefully observe eyelids, lashes, bulbar & palpebral conjunctiva, sclera, cornea, anterior chamber, and iris. Inspection of the conjunctival and sclera is facilitated by using a penlight and having the patient look up while retracting the lower eyelid or look down raising the upper eyelid. Palpation of the orbital rim and eyelids if there is concern for trauma or mass lesion.

Upper eyelid eversion is sometimes required to search for conjunctival foreign bodies. Ask the patient to look down and grasp the eyelashes of the upper eyelid between the thumb and index finger. Use a cotton tipped applicator to press gently downward over the superior aspect of the tarsal plate as you pull the eyelid margin upward by the lashes.

Step 4. Observe the corneal light reflex and extraocular movements

Hold your penlight directly in front of your patient, about 12 inches away. The light should appear in the same spot in both eyes, indicating that they are normally aligned. An asymmetric corneal light reflex indicates that your patient has strabismus, which can cause long term vision problems in children.

Step 5. Assess ocular motility

To test ocular motility, ask the patient to follow an object or your finger in 6 directions, the cardinal fields of gaze. You can have them follow your finger in the “H” pattern. This enables you to systematically test each muscle in its primary field of action.

Step 5. Assess pupil symmetry & reactivity

Observe the size and shape of the pupils in ambient room light. Anisocoria of < 1 mm is common (up to 20% of the population) and is considered normal if the pupils react to light similarly. For differences >1mm, the difference in pupil size should be recorded both in very bright and very dim lighting.

Assess the reactivity of the pupils by observing pupillary constriction with direct and consensual light. Keep the room illumination dim and have the patient look at a distant object. Direct the penlight at the patient’s right eye to see if the pupil constricts. Repeat for the left. To test for consensual pupillary reaction, direct the penlight at the right eye and watch the left pupil to see if it constricts with the right pupil. Repeat the same for the left pupil while watching the right.

Conduct a swinging flashlight test to detect a relative afferent pupillary defect (RAPD), which is present when there is a difference in the strength of the pupillary reflex between the two eyes. Perform the test for the pupillary light reflex, except that the light is rhythmically swung between the 2 eyes to compare the intensity of the light reflex. The light must be shone into each eye for equal amounts of time and from the same angle, typically for 3 seconds each eye, repeated several times. The pupils should remain the same size or constrict slightly as the light is swung between the two eyes. A RAPD is present when there is repeatable dilation of both pupils without initial constriction as the light is swung from the normal eye to the abnormal eye. A RAPD indicates a lesion in the optic nerve or retina on the affected side. A RAPD never causes anisocoria and cannot be bilateral.

Step 6. Inspect the cornea and iris. Assess the anterior chamber for depth and clarity.

Use a penlight to illuminate the cornea and observe for any opacities. If a patient complains of eye pain or foreign body sensation, use fluorescein staining to diagnose defects of the cornea. Fluorescein is applied by moistening a sterile filter paper strip with a drop of sterile saline, water, or topical anesthetic and touching it to the palpebral conjunctiva. Viewing the eye under cobalt blue light or using a Wood lamp enhances the visibility of the fluorescence.

The anterior chamber is typically deep and the iris has a flat contour. The anterior chamber should be clear, such that iris details can be seen. Note if there is blood (hyphema) or purulence (hypopyon) in the anterior chamber. If the iris appears to be bowed forward, the chamber may be shallow, indicating narrow angle glaucoma.

Step 7. Perform fundoscopy

The ophthalmoscope allows you to view the interior structures of the eye: the retina, retinal vessels, macula and optic disc, also called the fundus. In Immersion, you will only be expected to be able to demonstrate the red reflex (steps 1-3). Adequate ophthalmoscopy typically requires dilation of a patient’s pupils.

1. Position your patient so that your eyes are at the same level.
2. Have the patient gaze at a distant object in a darkened room.
3. Starting with a 0 lens, set the aperture wheel to select the large, white light. Focus on the lashes from 12 inches away, and look for the red reflex. The red reflex should be symmetric and evenly colored without shadows, indicating that light is reflecting equally off of each retina.
4. Hold the ophthalmoscope in the R hand and use your R eye to examine the patient’s R eye. Switch hands/eyes to examine the patient’s L eye.
5. Moving in at an angle of 15 degrees lateral to the patient’s line of vision, focus on the retina by rotating the lenses until the retinal vessels are clearly visible. Follow the vessels until you see the optic disc. Carefully examine as much of the retina as you can.