1. Physical Exam of the Head & Neck A Lect
Physical Exam of the Head & Neck A Lect. of Clin Skills for Med Students (Nepalese Class)
Dr. Xiu J Li

2. Part I
PE of the Head

3. All through the approach of PE in general involves 4
Steps Sequentially:
Inspection
Palpation
Percussion
Auscultation

4. the 1st one (inspection) is esp, important and useful for PE of head
This is because many traits or findings from the head,
esp, the face, is so attractively draw our attention
when we firstly look at the pt
For Ex, the emotional reactions:

5. expressive/unexpressive, keen/dull; nutritional status palor, puffiness of the faces, Plethora, Xanthoma, over growth of facial hair of a woman, and facial asymmetries, all highly pathogenomonic for a peculiar illness

7. General appearance (faces)

8. Thyrotoxic faces The pt is often thin and wasting, accompanied by an
alert, startled, flushed and anxious appearance.

9. Eye signs of Graves’ disease

11. This is characterized by protrusion of one or both eyes (exophthalmos) associated with retraction of the upper eyelids, (“lid lag”) which results in exposure of the white conjunctiva above the cornea (Von-Gravef’s Sign)
Other eye signs including……

12. Cachectic/Hippocratic faces
Sharp nose, sunken eyes, drooping eyelids, hollow temples and cheeks, and dry roughened skin, usu. seening in highly wasting disease as malignancy, indicative of approaching death.

13. f. hepatica
A thin face with sunken eyeballs, sallow complexion, and yellow conjunctivae, characteristic of certain chronic disorders of liver (cirrhosis)

14. Cushingoid f.
Features moon f. plethora, acne, hirsutism (over-growth of body hair, esp. mustache of a woman)

16. Mitral f. / mitrotricuspid f.
The appearance of the f. of some pts with mitral stenosis of long duration, marked by rosy, flushed cheeks and dilated capillaries.

17. Other faces
Cretin’s f.
dull, yellow appearance with thick lips, enlarged tongue, puffy eyelids, wrinkled forehead.
Nephritic f.Edematous eyelid and pale appearance.

20. Acromegalic face A typical appearance characterized by a
prominent forehead and large nose,

21. Other signs of the face

22. Paralysis of facial n
Asymmetry of the f. esp. the loss of the normal nasolabial fold, indicating the paralysis of facial n. This changes become most obvious if you let the pt try to smile or show his / or her teeth.

23. Paralysis of facial n.

24. The ability to wrinkle pt’s forchead on
the affected side helps to identify the
type of the lesion.
A: How to distinguish?

26. Color and pigmentation
Vitiligo—Absence of pigm of the f. skin. occurring in patches.
Mask of pregnancy—yellowish brown pigm symmetrically on the forehead, cheeks, and neck of some woman during pregnancy. or taking contraceptive pills. (due to hormonal changes)

27. Hyperpigmentation
appearing as a diffuse brown, tan, and darkening of the facial skin, and esp, the unexposed parts, such as the gum, or buccal mucosa or other areas, as the nipples, creases of the hand, etc. added weakness, fatigability, loss of appetide, nausea / vomiting, and hypotension strongly points to adrenocortical insufficiency (hypocortisolism or Addison’s disease).

30.  Systemic lupus erythematosis (SLE)
the skin lesion with pigm (facial rash) is distributed in a butterfly shape over the cheeks and the surfaces and bridge of the nose)
 Jaundice yellowish pigm
mild degree of jaundice can be found by carefully check the sclerae in daynight. (may not be visible in artificial light).

31. Jaundice should not be confused with carotenemia, resulting from excessive ingestion of carrots or be secondary to increased serum levels of carotene in the setting of hypothyroidism and nephrosis.

32.  Cyanosis
A bluish cast to the skin, that is easily seen in the tip of the nose, lips, cheeks, oral nucosa, conjunctivae, tongue, and the nail beds. usu. caused by↑amount of unoxygenated Hb in the circulation fr a nunmber of clinical conditions

33. Sudden obstruction of the airway
COPD
Pneumonia (critical SARS)
HF (esp CHF)
Congenital heart disease (with the shunt of R→L）
Note cyanosis may not occur in case that Hb is less than 5g/dl even through all Hb became HHb

34.  Xanthoma This is circumscribed collections of
lipid material in the eyelids, a flat /
elevated yellowish patch vary in size
from 1mm to 2cm.
(associated with ↑ TC and DM)

36. Facial hair
Excessive growth of hormone-dependent hair (hair on cheeks or upper lip, chin) in women, suggesting hirsutism, and verified by associated androgenism, such as the ↑levels of male hormones, muscularity, and an enlarging clitoris.

37.  Adenoma / carcinoma of adrenal glands
This is seeing in androgen-secreting tumors, such as
 Polycystic ovaries
 Adenoma / carcinoma of adrenal glands
 Drugs (androgen, contraceptive pills)

38.  Loss of facial hair growth, on the other hand, in a man may imply some disorders related to hypogonadism (Klinefelter’s syndrome, Kallmann’s syn) and hypopituitarism(Sheehan’s syn)

39. Nasal ale flag/short of breath seeing in acute obstruction of airway in children, asthma, pneumonia and acute heart failure
Nasal discharge(thick, yellow)
neso/sinus inflammation
The study of Oro-eye-ENT Exam in detail is available in related Div/Dept of Medicine

40. Deformities of skull (cranium)
Microcephaly a congenitally small skull resulting fr failure of the brain
Macrocephalus is an abnormally large head due to hydrocephalus, Paget’s disease(osteitis deformans), and acromegaly
Oxycephaly (steeple skull) characterized by a long anteroposterior axis, narrow in width, and pointed at the vertex.
The is caused by premature union of the cranial sutures

41. Neck Inspection The neck is inspected for Asymmetry
Limitation of motion
Abnormal pulsations
Goiter
Masses
Neck scar (thyroidectomy,tracheotomy)

42. Anatomy

43. Palpation Palpation of the neck
Should be done with the pt seated in a chair while the physician examines the neck for both behind and in front of the pt

44. A systematic approach to examination is followed
First to have the pt’s nk relaxed by asking that pt chin down. Then the posterior lateral nk are palpated for lymph nodes and masses

45. Followed by checking of the front cervical triangle searching for enlarged lymph nodes and tumors, then the parotid, salivary glands, and the pre-auricular lymph nodes.Then, the tracheal position is determined for deviation.

50. Palpation of the thyroid
Should be done with the pt seated in a chair while the physician examines the neck for both behind and in front
of the pt

52. Auscultation Bruit Put the stethoscope over the thyroid
gland, and listen carefully. If a systolic
bruit heard over the thyroid is almost
diagnostic of diffuse toxic goiter (↑
blood flow to the thyroid).

53. A&Q Questions  What are the facial feature of esetinism?
 How to distinguish central Vs peripheral paralysis of the facial nerve?
 What are the common causes of cyanosis?
 What is the cliniacal implication of virchow’s lymph node?
 Briefly depict the skill for the palpation of thyroid gland.

54. References
 History and Examination. Edited by James Marsh Pages 77,97-98,112,137 and Mosby,2002
 Physical Diagnosis. Edited by prior JA and Silberstein J.S. 5th ed. Ch7,8,9,10 C.v.Mosby,1977.
 Swarz M H:Textbook of Physical Diagnosis 4th de,Ch8,P ,2002,W.B.Saunder W.